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Appropriateness Criteria

Variant 1: Adult or child. Suspected primary bone tumor. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography area of interest Usually appropriate Strong Varies Varies 9 9 1 0 0 0 0 0 0 1 12
References Study Quality
17 (9308471) 3
10 (5846856) 4
11 (7323290) 4
12 (7323291) 4
13 (7323292) 4
14 (16247641) 3
15 (27070373) 3
16 (26220916) 2
US area of interest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 1 0 1 0 0 1 0
MRI area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 2 2 2 0 1 1 0 0
MRI area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 2 2 2 0 2 0 0 0
Bone scan whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 3 2 0 2 0 0 1 0
Bone scan whole body with SPECT or SPECT/CT area of interest Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 3 3 0 0 0 0 1 0
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 1 3 1 0 0 0 1 0
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 2 2 7 2 3 0 1 1 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 2 2 7 3 2 1 0 1 0 0 0
CT area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 2 2 6 2 3 0 2 1 0 0 0
Variant 2: Adult or child. Suspected primary bone tumor. No lesions on radiographs. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI area of interest without and with IV contrast Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 3 4 7
MRI area of interest without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 1 1 0 3 5 4
References Study Quality
18 (2120933) 2
Bone scan whole body May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 1 1 1 9 2 0 0 0 0
References Study Quality
18 (2120933) 2
Bone scan whole body with SPECT or SPECT/CT area of interest May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 3 0 0 9 2 0 0 0 0
CT area of interest with IV contrast May be appropriate (Disagreement) Expert Opinion Varies Varies 5 5 3 2 1 5 0 3 0 0 0
References Study Quality
4 (37606571) 4
7 (35147726) 2
8 (34601617) 2
CT area of interest without IV contrast May be appropriate (Disagreement) Expert Opinion Varies Varies 5 5 0 0 0 5 3 3 1 2 0
References Study Quality
19 (12886126) 3
22 (27101076) 3
21 (29323547) 3
20 (32755207) 2
US area of interest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 3 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 6 1 3 1 1 2 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 3 3 4 2 5 2 0 1 0 0 0
Variant 3: Adult or child. Suspected primary bone tumor. Lesion on radiographs. Benign appearance. Not osteoid osteoma. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI area of interest without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 1 0 0 1 3 4 3 0 2
References Study Quality
23 (-3145589) 4
25 (34436624) 2
24 (36745072) 2
MRI area of interest without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 1 0 0 1 4 3 3 2 0
References Study Quality
23 (-3145589) 4
CT area of interest without IV contrast May be appropriate Expert Consensus Varies Varies 5 5 0 0 0 3 8 2 0 1 0
US area of interest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 1 0 0 0 0 1 0
Image-guided biopsy area of interest Usually not appropriate Expert Consensus Varies Varies 2 2 7 3 2 0 1 0 0 0 1
Bone scan whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 0 2 1 2 0 0 0 1
Bone scan whole body with SPECT or SPECT/CT area of interest Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 1 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 1 3 0 1 0 0 1 0
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 2 2 7 2 4 1 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 2 2 6 2 1 2 1 1 0 1 0
Variant 4: Adult or child. Suspected primary bone tumor. Osteoid osteoma suspected on radiographs or osteoid osteoma suspected based on clinical presentation with no lesions on radiographs. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI area of interest without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 2 3 2 3 1 3
References Study Quality
33 (12773675) 2
CT area of interest without IV contrast Usually appropriate Limited Varies Varies 8 8 1 0 0 0 0 0 2 5 6
References Study Quality
29 (2119115) 4
30 (8134575) 3
MRI area of interest without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 1 0 0 2 5 2 3 1 0
References Study Quality
34 (12324824) 4
33 (12773675) 2
30 (8134575) 3
CT area of interest with IV contrast May be appropriate Expert Consensus Varies Varies 5 5 0 0 0 6 7 0 1 0 0
CT area of interest without and with IV contrast May be appropriate Limited Varies Varies 5 5 1 0 0 5 4 3 1 0 0
References Study Quality
28 (24631034) 4
US area of interest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 1 0 0 0 0 1 0
Image-guided biopsy area of interest Usually not appropriate Limited Varies Varies 3 3 4 1 5 0 2 2 0 0 0
References Study Quality
31 (34573895) 3
32 (33563522) Good
Bone scan whole body Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 6 3 0 0 0 0 0 0
References Study Quality
27 (24751704) 3
Bone scan whole body with SPECT or SPECT/CT area of interest Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 5 1 2 1 4 1 0 0 0
References Study Quality
27 (24751704) 3
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 2 5 0 0 0 0 0 0
Variant 5: Adult or child. Suspected primary bone tumor. Lesion on radiographs. Indeterminate or aggressive appearance for malignancy. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI area of interest without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 1 0 0 1 4 8
References Study Quality
56 (7529935) 2
55 (1853820) 4
60 (8058957) 3
54 (16436820) 2
57 (10671608) 3
59 (25656545) 4
58 (32429792) 4
MRI area of interest without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 1 1 5 3 3
References Study Quality
29 (2119115) 4
64 (3055041) 3
63 (1737596) 3
69 (20566784) 3
39 (14530882) 4
38 (19277645) 4
40 (14512511) 4
41 (8988217) 2
61 (12652336) 4
70 (26388466) 3
62 (24035342) 4
14 (16247641) 3
16 (26220916) 2
65 (26724650) 3
59 (25656545) 4
66 (26162578) 3
67 (26559290) Good
68 (22210011) Good
FDG-PET/CT whole body Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 2 0 0 8 4 0
References Study Quality
49 (15286325) 2
43 (11376267) 3
45 (8657920) 2
51 (15937711) 3
44 (18278491) 3
47 (18756363) 3
50 (18309481) 3
46 (26356700) Good
48 (22072239) Good
53 (30953476) Good
52 (31887730) Good
Bone scan whole body with SPECT or SPECT/CT area of interest May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 0 4 10 0 0 0 0
References Study Quality
37 (22865157) 3
CT area of interest with IV contrast May be appropriate Expert Consensus Varies Varies 4 4 0 0 0 9 5 0 0 0 0
CT area of interest without and with IV contrast May be appropriate Expert Consensus Varies Varies 4 4 1 0 0 9 4 0 0 0 0
CT area of interest without IV contrast May be appropriate Strong Varies Varies 6 6 0 0 1 1 1 5 4 2 0
References Study Quality
39 (14530882) 4
38 (19277645) 4
40 (14512511) 4
41 (8988217) 2
42 (26002126) 3
22 (27101076) 3
21 (29323547) 3
20 (32755207) 2
US area of interest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 1 1 0 0 0 1 0
Image-guided biopsy area of interest Usually not appropriate Limited Varies Varies 3 3 3 1 4 2 3 0 1 0 0
References Study Quality
31 (34573895) 3
Bone scan whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 5 2 5 2 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.