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Appropriateness Criteria

Variant 1: Adult. Primary liver cancer. Screening.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US abdomen Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 8 8 0 0 0 1 0 0 6 4 6
References Study Quality
16 (27775821) 3
15 (29981779) 4
14 (15042359) 1
13 (11592607) 4
4 (29624699) 4
MRI abdomen without and with IV contrast May be appropriate Moderate O 0 mSv O 0 mSv [ped] 6 6 0 0 0 2 1 5 6 0 0
References Study Quality
11 (31524775) 3
10 (25714281) 2
9 (27657493) 3
8 (29268722) 4
MRI abdomen without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 1 1 0 8 2 2 0 0 0
References Study Quality
8 (29268722) 4
12 (27558976) 3
CT abdomen with IV contrast multiphase May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 0 0 1 1 6 4 2 0 0
References Study Quality
4 (29624699) 4
US abdomen with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 5 2 7 0 0 0 0 0 0
MRI abdomen without and with IV contrast with MRCP Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 7 0 3 3 2 1 1 0 0
MRI abdomen without IV contrast with MRCP Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 6 2 3 6 0 0 0 0 0
CT abdomen with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 2 5 3 4 1 0 0 0
References Study Quality
4 (29624699) 4
CT abdomen without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 4 2 0 0 0 0 0 0
CT abdomen without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 2 2 9 1 0 0 0 0 0
References Study Quality
4 (29624699) 4
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 5 2 0 0 0 0 0 0
Variant 2: Adult. Primary liver cancer. Staging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI abdomen without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 0 7 1 5
References Study Quality
23 (28859233) 4
4 (29624699) 4
CT abdomen with IV contrast multiphase Usually appropriate Limited ☢☢☢☢ 10-30 mSv 9 9 0 0 0 0 2 1 3 1 7
References Study Quality
4 (29624699) 4
MRI abdomen without and with IV contrast with MRCP May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 1 1 5 3 2 2 0 0 0
Bone scan whole body May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 2 2 5 3 2 0 0 0
CT abdomen and pelvis with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 1 6 1 3 2 1 0 0
CT chest with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 1 1 1 1 0 6 3 1
CT chest without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 2 0 1 1 1 10 0 0
CT pelvis with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 2 1 7 2 2 1 0 0
US abdomen transabdominal Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 2 3 0 0 0 0 0 0
US abdomen with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 9 2 1 0 1 1 0 0 0
MRI abdomen without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 3 5 1 0 0 0 0 0
MRI abdomen without IV contrast with MRCP Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 3 5 0 0 0 0 1 0
CT abdomen and pelvis without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 5 2 0 1 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 4 2 1 1 1 0 0 0
CT pelvis without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 3 5 5 0 1 0 0 0 0
FDG-PET/MRI skull base to mid-thigh Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 2 2 7 0 2 0 0 1 0
References Study Quality
21 (10845666) 3
20 (29518452) 3
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 3 2 3 4 0 1 1 0 0
CT pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 4 4 1 1 0 0 0 0
Variant 3: Adult. Primary liver cancer. Liver observations under active surveillance.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI abdomen without and with IV contrast Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 2 11
CT abdomen with IV contrast multiphase Usually appropriate Moderate ☢☢☢☢ 10-30 mSv 9 9 0 0 0 0 0 0 1 4 9
MRI abdomen without and with IV contrast with MRCP May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 1 0 4 3 3 3 0 0 0
CT abdomen without and with IV contrast May be appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 4 4 0 3 4 2 4 0 1 0 0
US abdomen transabdominal Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 3 6 2 2 1 0 0 0 0
References Study Quality
6 (27158749) 4
US abdomen with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 1 6 4 1 2 0 0 0 0
MRI abdomen without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 4 5 4 1 0 0 0 0 0
MRI abdomen without IV contrast with MRCP Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 3 5 5 0 1 0 0 0 0
CT abdomen with IV contrast Usually not appropriate Moderate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 1 3 5 4 1 0 0 0 0
CT abdomen without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 1 2 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 4 2 1 1 0 0 0 0
Variant 4: Adult. Primary liver cancer. Posttreatment evaluation after liver directed therapy or neoadjuvant chemotherapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI abdomen without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 3 11
References Study Quality
4 (29624699) 4
24 (33596330) 3
25 (-3197194) 4
CT abdomen with IV contrast multiphase Usually appropriate Limited ☢☢☢☢ 10-30 mSv 8 8 0 0 0 0 0 0 1 7 6
References Study Quality
4 (29624699) 4
24 (33596330) 3
CT abdomen without and with IV contrast Usually appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 7 7 1 0 0 0 1 0 8 4 0
MRI abdomen without and with IV contrast with MRCP May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 2 1 2 5 3 1 0 0 0
US abdomen transabdominal Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 2 3 0 0 0 0 0 0
US abdomen with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 3 2 4 2 3 0 0 0 0
MRI abdomen without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 7 3 4 0 0 0 0 0 0
MRI abdomen without IV contrast with MRCP Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 4 3 0 1 0 0 0 0
CT abdomen with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 1 9 0 1 0 0 0 0
CT abdomen without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 2 3 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 5 2 6 0 1 0 0 0 0
Variant 5: Adult. Primary liver cancer. Treated. Routine surveillance.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI abdomen without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 4 10
References Study Quality
24 (33596330) 3
CT abdomen with IV contrast multiphase Usually appropriate Limited ☢☢☢☢ 10-30 mSv 9 9 0 0 0 0 0 0 1 3 10
References Study Quality
24 (33596330) 3
MRI abdomen without and with IV contrast with MRCP May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 2 0 1 3 6 2 0 0 0
CT abdomen without and with IV contrast May be appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 5 5 2 0 1 4 5 1 1 0 0
US abdomen transabdominal Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 2 2 0 0 0 0 0 0
US abdomen with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 5 2 0 0 0 0 0 0
MRI abdomen without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 5 6 3 0 0 0 0 0 0
MRI abdomen without IV contrast with MRCP Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 4 3 0 0 0 0 0 0
CT abdomen with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 5 1 3 3 1 1 0 0 0
CT abdomen without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 1 4 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 4 5 0 1 0 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.