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Appropriateness Criteria

Variant 1: Adult female. Clinically suspected adnexal mass, no acute symptoms. Premenopausal or postmenopausal. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler pelvis Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 1 1 4 1 7
References Study Quality
25 (7839975) 3
24 (11176291) 4
23 (18504770) 3
22 (31687921) 4
21 (9646799) 2
20 (10739694) 3
19 (9618853) 3
US pelvis transabdominal Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 4 5 4 1
US pelvis transabdominal and US pelvis transvaginal Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 2 1 11
References Study Quality
37 (30149950) 4
44 (31770022) 3
43 (28727500) 3
42 (23358210) 3
41 (31549945) 4
36 (25320247) 3
35 (14529661) 3
34 (30303910) 3
33 (20505067) 4
32 (19244063) 3
31 (12634641) 4
30 (32736853) 4
29 (34474226) 4
28 (27776067) 4
27 (10586480) 3
26 (10201081) 3
23 (18504770) 3
22 (31687921) 4
39 (11169340) 4
45 (32809166) 2
38 (24937676) 3
40 (36520422) 3
US pelvis transvaginal Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 2 2 10
MRI pelvis without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 1 3 3 6 0 1 0
References Study Quality
15 (31482379) 3
16 (35040672) 4
MRI pelvis without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 1 0 3 2 4 3 0 1 0
References Study Quality
18 (33725187) 3
17 (7824738) 2
CT pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 3 5 2 1 2 1 0 0 0
CT pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 5 3 0 0 0 0 0 0
CT pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 5 3 0 2 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 0 1 0 0 0 0 0 0
Variant 2: Adult female. Adnexal mass, likely benign, no acute symptoms. Premenopausal. Follow-up imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler pelvis Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 1 4 3 5
US pelvis transabdominal Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 4 6 3 1
US pelvis transabdominal and US pelvis transvaginal Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 1 1 1 11
References Study Quality
55 (29702449) Good
54 (35315722) 3
53 (29112653) 3
52 (21351179) 3
51 (27282774) 3
50 (30737137) 2
49 (23583217) 4
48 (30419104) 3
47 (21762355) 3
46 (20096820) 4
45 (32809166) 2
41 (31549945) 4
24 (11176291) 4
22 (31687921) 4
34 (30303910) 3
33 (20505067) 4
US pelvis transvaginal Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 3 2 9
MRI pelvis without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 1 0 0 8 5 1 1 0 0
References Study Quality
15 (31482379) 3
16 (35040672) 4
MRI pelvis without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 0 0 1 8 4 1 0 0 0
References Study Quality
17 (7824738) 2
18 (33725187) 3
CT pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 3 8 2 0 0 0 1 0 0
CT pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 7 1 0 0 0 0 0 0
CT pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 6 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] 1 1 11 2 1 0 0 0 0 0 0
Variant 3: Adult female. Adnexal mass, likely benign, no acute symptoms. Postmenopausal. Follow-up Imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler pelvis Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 2 0 5 1 6
US pelvis transabdominal Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 0 2 7 3 1
US pelvis transabdominal and US pelvis transvaginal Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 2 11
References Study Quality
34 (30303910) 3
41 (31549945) 4
59 (20503240) 3
58 (12962948) 4
57 (31396641) 3
56 (23001924) 3
55 (29702449) Good
48 (30419104) 3
47 (21762355) 3
46 (20096820) 4
US pelvis transvaginal Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 3 2 9
MRI pelvis without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 4 8 0 1 0
References Study Quality
16 (35040672) 4
15 (31482379) 3
MRI pelvis without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 1 6 4 3 0 0 0
References Study Quality
17 (7824738) 2
18 (33725187) 3
CT pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 3 7 1 1 0 2 0 0 0
CT pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 7 1 0 0 0 0 0 0
CT pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 5 2 0 1 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 2 2 0 0 0 0 0 0
Variant 4: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Premenopausal or postmenopausal. Next imaging study for characterization.
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] 9 9 0 0 0 0 0 1 1 1 11
References Study Quality
16 (35040672) 4
43 (28727500) 3
85 (27583370) 3
84 (29467113) 3
83 (32715577) 2
82 (33484725) 4
81 (19214523) 3
80 (18972356) 3
79 (21193596) 2
78 (18581400) 3
77 (22105841) 3
76 (22814827) 3
75 (27367786) 3
74 (20419493) 3
73 (22095438) 2
72 (31977064) 3
71 (33929901) 4
70 (23468574) 2
69 (24183731) 4
68 (27770228) 4
MRI pelvis without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 4 10 1 0 0
References Study Quality
86 (30177450) 4
72 (31977064) 3
70 (23468574) 2
18 (33725187) 3
17 (7824738) 2
16 (35040672) 4
CT pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 4 3 0 2 1 0 0 0
CT pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 3 3 0 1 0 0 0 0
CT pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 5 1 0 3 1 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 1 4 0 0 0 0 0 0
References Study Quality
67 (20093590) 4
66 (18423470) 3
65 (24463640) 3
64 (29399968) 3
63 (15599527) 4
62 (34112736) 4
Variant 5: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Premenopausal. Follow-up imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler pelvis Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 8 8 0 0 1 0 1 1 3 2 6
US pelvis transabdominal and US pelvis transvaginal Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 1 0 0 0 2 2 9
References Study Quality
16 (35040672) 4
22 (31687921) 4
44 (31770022) 3
60 (29480762) 3
72 (31977064) 3
US pelvis transvaginal Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 9 9 0 0 1 0 0 1 3 2 7
MRI pelvis without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 1 1 1 4 5 2
References Study Quality
16 (35040672) 4
US pelvis transabdominal May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 1 0 0 0 2 5 5 1 0
MRI pelvis without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 1 4 1 6 2 0 0
References Study Quality
86 (30177450) 4
72 (31977064) 3
70 (23468574) 2
18 (33725187) 3
17 (7824738) 2
16 (35040672) 4
CT pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 3 2 2 1 0 0 0 0
CT pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 5 2 0 0 0 0 0 0
CT pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 3 2 1 2 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 2 0 0 0 0 0 0 0
Variant 6: Adult female. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Postmenopausal. Follow-up imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler pelvis Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 2 1 1 3 7
US pelvis transabdominal Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 1 5 5 0 2
US pelvis transabdominal and US pelvis transvaginal Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 1 1 3 9
References Study Quality
16 (35040672) 4
44 (31770022) 3
60 (29480762) 3
72 (31977064) 3
91 (28118296) 4
90 (27876070) 3
89 (33992598) 3
88 (25068555) 3
US pelvis transvaginal Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 2 1 4 7
MRI pelvis without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 0 6 3 4
References Study Quality
16 (35040672) 4
87 (25273949) 3
MRI pelvis without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 3 11 2 0 0
References Study Quality
86 (30177450) 4
72 (31977064) 3
70 (23468574) 2
18 (33725187) 3
17 (7824738) 2
16 (35040672) 4
CT pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 4 3 1 1 0 1 0 0
CT pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 4 3 0 0 0 0 0 0
CT pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 3 2 0 3 0 1 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 2 1 0 0 1 0 0 0
Variant 7: Adult female. Adnexal mass, suspicious for malignancy on pelvic US, no acute symptoms. Premenopausal or postmenopausal. Next imaging study for characterization.
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] 9 9 0 0 0 0 0 1 2 0 13
References Study Quality
16 (35040672) 4
22 (31687921) 4
23 (18504770) 3
94 (35230183) 3
79 (21193596) 2
78 (18581400) 3
77 (22105841) 3
76 (22814827) 3
75 (27367786) 3
74 (20419493) 3
73 (22095438) 2
72 (31977064) 3
70 (23468574) 2
68 (27770228) 4
61 (21156740) 3
60 (29480762) 3
54 (35315722) 3
44 (31770022) 3
36 (25320247) 3
33 (20505067) 4
MRI pelvis without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 1 2 2 6 4 1 0
References Study Quality
86 (30177450) 4
72 (31977064) 3
70 (23468574) 2
18 (33725187) 3
17 (7824738) 2
16 (35040672) 4
CT pelvis without and with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 5 1 7 0 0 1 0 0 2
CT pelvis with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 4 4 6 0 0 0 1 1 0
References Study Quality
92 (29724422) 4
CT pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 2 2 0 1 0 1 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 7 0 5 0 3 1 0 0 0
References Study Quality
93 (23988417) 2
Variant 8: Female. Clinically suspected adnexal mass, no acute symptoms. Pregnant. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler pelvis Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 0 6 3 4
References Study Quality
25 (7839975) 3
24 (11176291) 4
23 (18504770) 3
22 (31687921) 4
21 (9646799) 2
20 (10739694) 3
19 (9618853) 3
US pelvis transabdominal Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 2 5 5 1
US pelvis transabdominal and US pelvis transvaginal Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 2 2 10
References Study Quality
28 (27776067) 4
113 (34902893) 4
112 (33671023) 3
111 (11127014) 4
110 (27484484) 4
109 (24496773) 4
108 (26482730) 3
107 (10411786) 4
106 (15863550) 3
105 (16310839) 4
104 (21194826) 4
103 (33515746) Good
102 (10214838) 3
101 (32347749) 4
100 (9315194) 4
US pelvis transvaginal Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 1 2 4 7
MRI pelvis without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 1 6 5 3 1 0 0
References Study Quality
17 (7824738) 2
16 (35040672) 4
15 (31482379) 3
18 (33725187) 3
95 (-3188538) 4
MRI pelvis without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 5 1 5 1 1 0 1 0 0
References Study Quality
99 (28668416) 2
98 (-3195845) 4
97 (27599330) 3
96 (22003244) 3
95 (-3188538) 4
CT pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 3 0 0 0 0 0 0 0
CT pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 3 0 0 0 0 0 0 0
CT pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 2 0 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] 1 1 14 0 0 0 0 0 0 0 0
Variant 9: Female . Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Pregnant. Next imaging study for characterization.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI pelvis without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 4 2 8
References Study Quality
16 (35040672) 4
18 (33725187) 3
114 (27130065) 3
110 (27484484) 4
108 (26482730) 3
95 (-3188538) 4
86 (30177450) 4
72 (31977064) 3
70 (23468574) 2
61 (21156740) 3
60 (29480762) 3
MRI pelvis without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 1 0 8 5 1 0 1 0 0
References Study Quality
99 (28668416) 2
98 (-3195845) 4
97 (27599330) 3
96 (22003244) 3
95 (-3188538) 4
CT pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 3 0 0 0 1 0 0 0
CT pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 3 0 1 0 0 0 0 0
CT pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 2 0 0 0 1 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 0 1 0 0 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.