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Appropriateness Criteria

Variant 1: Adult. Rectal cancer. Locoregional staging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI pelvis without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 2 0 2 1 4 4
References Study Quality
86 (30354269) 3
85 (25652254) 3
81 (31062058) 4
82 (30993392) 4
83 (24127411) 2
84 (25497874) 4
77 (29785540) 4
78 (29337774) 3
76 (29043428) 4
75 (25615776) 2
79 (27125200) 3
73 (8724412) 2
80 (34584334) 3
74 (15550372) 3
45 (33170102) 2
MRI pelvis without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 1 2 10 3
References Study Quality
72 (36069323) 2
71 (28497665) 3
67 (21926843) 3
68 (21327602) 3
70 (28900855) 4
69 (36800203) 3
59 (17504336) M
60 (17504337) 3
62 (22426259) 2
63 (21913017) 4
65 (32488420) 3
66 (32020526) 3
61 (34491607) 4
64 (35218137) 4
51 (21802588) 1
43 (21674192) 2
44 (22271205) M
50 (23049209) 2
52 (22156868) 2
53 (20464422) 3
54 (22434494) 3
55 (23571146) 1
56 (17329685) 1
57 (19388124) 2
58 (17463134) 3
49 (32113887) 2
45 (33170102) 2
47 (33369829) 4
48 (34842978) 3
46 (35026621) 3
40 (21225363) 3
41 (21135417) 2
42 (21671218) 3
FDG-PET/MRI skull base to mid-thigh May be appropriate Moderate ☢☢☢ 1-10 mSv 4 4 0 3 4 2 6 0 0 0 0
References Study Quality
39 (35086111) 3
38 (35705874) Good
36 (36063201) 3
37 (33034673) 4
FDG-PET/CT skull base to mid-thigh May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 4 2 3 2 2 0 0 0
References Study Quality
35 (30899056) 3
34 (26828149) 3
33 (29378659) 4
US pelvis transrectal Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 0 1 7 2 4 1 0 0 0
References Study Quality
95 (9276704) 4
94 (17674104) 3
90 (21920011) 3
92 (21795480) 3
93 (21550864) 3
91 (30736712) 3
87 (23280021) 3
28 (20103950) 3
88 (21176897) 3
89 (17294198) 3
51 (21802588) 1
27 (18697365) 4
CT abdomen and pelvis with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 0 0 8 0 5 2 0 0 0
References Study Quality
32 (22271004) 3
31 (22281979) 2
28 (20103950) 3
27 (18697365) 4
30 (22100372) 3
29 (33686499) 4
15 (19571705) 2
23 (9568652) 1
22 (15376205) 3
24 (19949791) 3
25 (21110194) 2
26 (31305437) 4
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 6 2 0 1 0 0 0 0
CT abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 7 3 1 0 1 0 0 0 1
Variant 2: Adult. Rectal cancer. Staging for distant metastases.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI abdomen and pelvis without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 2 3 1 4 2
References Study Quality
144 (31855148) 1
143 (31080095) 1
140 (32239338) 3
141 (33902498) 1
142 (34563410) 2
139 (30616608) 2
132 (17515386) 4
131 (19789256) 2
133 (20143461) 4
134 (31340755) 2
138 (30353920) 1
135 (28803449) 3
136 (25286324) 1
137 (29951340) 3
98 (20392584) 2
128 (22487067) 4
130 (22976920) 2
126 (18058107) 1
125 (22652037) 2
99 (21293130) 3
127 (22556405) 2
129 (22167501) 2
CT abdomen and pelvis with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 2 3 8
References Study Quality
104 (23150701) 2
103 (21263087) 2
101 (15841734) 3
97 (11152779) 2
96 (15044747) 2
102 (16484347) 2
98 (20392584) 2
100 (1914737) 3
99 (21293130) 3
CT chest with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 1 0 0 1 1 1 11 1
References Study Quality
110 (22169348) 4
109 (20607759) 4
108 (20175945) 4
106 (20151212) 4
105 (27779994) 3
107 (34119380) 4
CT chest without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 1 0 0 0 2 0 7 0 3
References Study Quality
110 (22169348) 4
109 (20607759) 4
108 (20175945) 4
106 (20151212) 4
105 (27779994) 3
107 (34119380) 4
FDG-PET/MRI skull base to mid-thigh May be appropriate Strong ☢☢☢ 1-10 mSv 5 5 0 0 1 3 3 3 2 1 0
References Study Quality
38 (35705874) Good
124 (29279157) 4
123 (9377498) 3
122 (37143144) Good
FDG-PET/CT skull base to mid-thigh May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 1 1 4 4 3 0 0
References Study Quality
121 (32213686) 3
120 (34775402) 4
116 (17195075) 2
117 (28687025) 3
119 (32034769) 3
118 (30928334) Good
114 (21867996) 3
111 (21431987) 2
112 (17610107) 4
115 (19486092) 2
113 (28169837) 3
MRI abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 1 2 6 2 1 1 0 0 0
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 2 6 2 1 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 4 3 0 1 0 0 0 1
CT abdomen and pelvis without and with IV contrast Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 4 3 9 0 0 0 0 0 0
References Study Quality
26 (31305437) 4
25 (21110194) 2
101 (15841734) 3
102 (16484347) 2
Variant 3: Adult. Rectal cancer. Locoregional staging. Post neoadjuvant therapy and during watch and wait.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI pelvis without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 1 0 0 2 1 2 4 3
References Study Quality
193 (22101743) 3
85 (25652254) 3
81 (31062058) 4
82 (30993392) 4
MRI pelvis without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 0 1 11 3
References Study Quality
192 (30280248) 3
191 (27959622) 3
187 (31490825) 3
189 (30403572) 3
188 (29668301) 3
190 (32813028) 3
185 (27055660) 3
180 (31386575) 3
179 (30844347) 4
183 (25243543) 3
184 (19403848) 4
186 (19830503) 4
182 (33573925) 3
181 (30483843) 3
164 (21876084) 2
165 (21590453) 3
166 (21509631) 2
167 (21475011) 4
169 (31939890) Good
177 (30327166) 3
178 (28786006) 3
175 (28237642) 3
170 (27331883) 4
163 (26953983) 3
171 (27489868) 3
172 (21343320) 2
173 (36971272) 2
176 (34803147) 3
174 (33319450) 3
168 (35550803) 4
15 (19571705) 2
57 (19388124) 2
78 (29337774) 3
76 (29043428) 4
161 (28177989) 4
162 (26747329) 4
20 (36073323) 4
CT abdomen and pelvis with IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 2 4 1 6 2 0 0 0
References Study Quality
150 (26855391) 3
149 (25448648) 4
145 (20452636) 3
146 (22497951) 4
147 (18589355) 3
148 (26130666) 4
15 (19571705) 2
28 (20103950) 3
24 (19949791) 3
25 (21110194) 2
30 (22100372) 3
31 (22281979) 2
32 (22271004) 3
FDG-PET/MRI skull base to mid-thigh May be appropriate Limited ☢☢☢ 1-10 mSv 4 4 0 2 5 5 3 0 0 0 0
References Study Quality
159 (36412686) 3
160 (31842163) 4
FDG-PET/CT skull base to mid-thigh May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 2 0 13 1 0 0 0
References Study Quality
158 (25181962) 2
157 (31229791) 3
153 (18424814) 3
154 (31833807) 4
155 (20190455) 4
156 (34435447) 3
150 (26855391) 3
152 (26711129) 4
151 (22644560) 3
US pelvis transrectal Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 0 5 3 4 3 0 0 0 0
References Study Quality
195 (29944579) 2
194 (27858916) Good
93 (21550864) 3
198 (29848812) 3
196 (26323642) 3
197 (36575373) 2
92 (21795480) 3
27 (18697365) 4
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 3 4 6 0 0 0 0 0 0
CT abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 4 4 3 0 1 0 0 0 1
Variant 4: Adult. Rectal cancer. Systemic disease monitoring after curative resection or during watch and wait or during palliation. Follow-up imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI abdomen and pelvis without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 1 0 2 2 1 4 3
References Study Quality
144 (31855148) 1
143 (31080095) 1
140 (32239338) 3
141 (33902498) 1
142 (34563410) 2
139 (30616608) 2
132 (17515386) 4
131 (19789256) 2
133 (20143461) 4
134 (31340755) 2
138 (30353920) 1
135 (28803449) 3
136 (25286324) 1
137 (29951340) 3
98 (20392584) 2
128 (22487067) 4
130 (22976920) 2
126 (18058107) 1
125 (22652037) 2
99 (21293130) 3
127 (22556405) 2
129 (22167501) 2
CT abdomen and pelvis with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 1 5 7
References Study Quality
104 (23150701) 2
103 (21263087) 2
101 (15841734) 3
97 (11152779) 2
96 (15044747) 2
102 (16484347) 2
98 (20392584) 2
87 (23280021) 3
100 (1914737) 3
99 (21293130) 3
CT chest with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 1 0 1 0 2 5 4
References Study Quality
88 (21176897) 3
CT chest without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 1 0 0 0 2 2 7 0 1
References Study Quality
30 (22100372) 3
110 (22169348) 4
108 (20175945) 4
106 (20151212) 4
109 (20607759) 4
107 (34119380) 4
FDG-PET/MRI skull base to mid-thigh May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 0 1 2 3 5 1 1 0 0
References Study Quality
93 (21550864) 3
FDG-PET/CT skull base to mid-thigh May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 1 0 1 13 1 0 0 0
References Study Quality
116 (17195075) 2
115 (19486092) 2
114 (21867996) 3
92 (21795480) 3
111 (21431987) 2
112 (17610107) 4
89 (17294198) 3
90 (21920011) 3
91 (30736712) 3
36 (36063201) 3
MRI abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 2 2 4 1 3 1 0 0 0
CT abdomen and pelvis without IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 3 6 0 2 0 0 0 0
References Study Quality
25 (21110194) 2
26 (31305437) 4
101 (15841734) 3
102 (16484347) 2
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 3 3 1 1 0 0 0 1
CT abdomen and pelvis without and with IV contrast Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 3 4 9 0 0 0 0 0 0
References Study Quality
25 (21110194) 2
26 (31305437) 4
101 (15841734) 3
102 (16484347) 2
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.