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Appropriateness Criteria

Variant 1: Malignant or aggressive primary musculoskeletal tumor. Initial staging. Evaluation for pulmonary metastasis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT chest without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 1 1 2 13
References Study Quality
9 (26472138) 2
11 (16410133) 2
12 (21513852) 4
FDG-PET/CT whole body May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 0 2 10 4 0 0 0
References Study Quality
16 (22745027) 2
6 (30953476) Good
13 (19352275) 3
15 (22134535) 3
14 (23251096) 3
Radiography chest Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 14 0 1 0 0 1 0 0 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 0 6 0 0 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 1 4 0 0 1 0 0 0
FDG-PET/MRI whole body Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 1 3 1 1 1 0 0 0
References Study Quality
17 (27951459) 3
Variant 2: Malignant or aggressive primary musculoskeletal tumor. Initial staging. Evaluation for extrapulmonary metastasis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
FDG-PET/CT whole body Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 2 0 4 4 7
References Study Quality
37 (18048826) 3
34 (16951929) 2
36 (21716019) 2
33 (11418435) 2
22 (25539251) 3
32 (14693872) 2
30 (31601386) 2
35 (31016339) 2
6 (30953476) Good
31 (29189489) 4
15 (22134535) 3
MRI whole body without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 0 1 1 10 0 0 2 1
References Study Quality
34 (16951929) 2
33 (11418435) 2
32 (14693872) 2
29 (30915559) 4
42 (31447287) 4
35 (31016339) 2
44 (26831007) 3
40 (29558901) 4
41 (29275455) 4
43 (20369068) 4
Bone scan whole body May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 0 2 7 5 1 0 0 1
References Study Quality
22 (25539251) 3
28 (20224457) 2
23 (25533313) 2
29 (30915559) 4
24 (23995264) 3
25 (9779715) 3
26 (12750613) 3
27 (19542943) 4
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 2 1 7 6 0 0 0
References Study Quality
30 (31601386) 2
FDG-PET/MRI whole body May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 3 11 0 1 0 0
References Study Quality
38 (24309383) 3
17 (27951459) 3
Fluoride PET/CT whole body May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 3 0 4 2 4 3 0 0 0
References Study Quality
39 (28798033) 2
US area of interest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 0 0 1 0 0 0 0
Radiography area of interest Usually not appropriate Expert Consensus Varies Varies 1 1 14 1 0 0 0 0 0 0 1
MRI whole body without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 1 5 2 0 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 11 0 4 1 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 11 0 5 0 0 0 0 0 0
CT area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 11 0 5 0 0 0 0 0 0
Variant 3: Malignant or aggressive primary musculoskeletal tumor with no suspected or known recurrence. Surveillance for pulmonary metastasis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT chest without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 1 0 0 1 2 13
References Study Quality
56 (21537873) 3
55 (17438474) 3
9 (26472138) 2
45 (31377411) 4
54 (24249538) 2
12 (21513852) 4
53 (29437071) 2
FDG-PET/CT whole body May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 0 1 13 1 1 0 0
References Study Quality
16 (22745027) 2
15 (22134535) 3
Radiography chest Usually not appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 10 3 3 0 0 0 0 0 0
References Study Quality
57 (10674442) 3
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 0 2 2 0 1 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 1 2 1 0 0 0 0 0
FDG-PET/MRI whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 0 4 2 0 1 0 0 0
Variant 4: Malignant or aggressive primary bone tumor. Surveillance for local recurrence.
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 Expert Consensus Varies Varies 9 9 1 0 0 0 0 2 1 1 12
MRI area of interest without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 1 15
References Study Quality
67 (23246334) 3
68 (9285993) 4
MRI area of interest without IV contrast Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 7 7 1 0 1 0 2 3 6 3 1
FDG-PET/CT whole body May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 0 0 9 2 4 1 0
References Study Quality
64 (23558689) 3
65 (29261626) 3
66 (25431093) 2
CT area of interest with IV contrast May be appropriate Expert Consensus Varies Varies 5 5 0 0 1 1 10 3 0 1 0
US area of interest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 2 1 2 1 1 0 0 0
Bone scan whole body Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 2 4 0 0 0 0 0 0
References Study Quality
22 (25539251) 3
23 (25533313) 2
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 8 3 2 2 1 0 1 0 0
FDG-PET/MRI whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 3 2 0 0 0 0 0 0
Fluoride PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 2 3 1 1 1 1 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 9 1 2 2 1 1 0 0 0
CT area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 9 0 2 2 3 0 0 0 0
Variant 5: Malignant or aggressive primary soft tissue tumor. Surveillance for local recurrence.
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] 9 9 0 0 0 0 0 0 0 1 16
References Study Quality
82 (27060189) 3
77 (30352764) 3
83 (19744809) 3
67 (23246334) 3
68 (9285993) 4
MRI area of interest without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 2 0 11 2 0
References Study Quality
82 (27060189) 3
77 (30352764) 3
83 (19744809) 3
67 (23246334) 3
68 (9285993) 4
US area of interest May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 2 0 1 3 7 3 0 0 0
References Study Quality
84 (25794664) 3
FDG-PET/MRI whole body May be appropriate Moderate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 1 5 7 1 1 0 0
References Study Quality
81 (28567495) 2
FDG-PET/CT whole body May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 0 1 9 4 2 0 0
References Study Quality
79 (23233156) 2
80 (27488833) 2
CT area of interest with IV contrast May be appropriate Expert Consensus Varies Varies 6 6 0 0 0 0 7 4 4 1 1
Radiography area of interest Usually not appropriate Expert Consensus Varies Varies 1 1 10 1 0 3 1 1 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 2 2 8 3 2 2 1 0 0 0 0
CT area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 11 1 1 2 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.