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Appropriateness Criteria

Variant 1: Palpable thyroid nodule. Not goiter. Euthyroid. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US thyroid Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 0 0 16
References Study Quality
16 (26462967) 4
8 (28372962) 4
CT neck with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 4 0 3 3 5 1 0 0 0
References Study Quality
7 (25456025) 4
CT neck without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 4 2 2 7 1 0 0 0 0
References Study Quality
7 (25456025) 4
MRI neck without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 4 1 7 2 2 0 0 0 0
MRI neck without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 7 1 2 3 2 1 1 0 0
CT neck without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 1 2 1 1 0 1 0 0
References Study Quality
7 (25456025) 4
I-123 uptake scan neck Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 7 5 3 0 2 0 0 0 0
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 3 0 0 0 0 1 0 0
I-131 uptake scan and Tc-99m pertechnetate scan neck Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 2 2 6 6 4 0 1 0 0 0 0
Variant 2: Suspected goiter. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US thyroid Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 0 0 16
References Study Quality
16 (26462967) 4
8 (28372962) 4
CT neck without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 7 7 1 0 0 1 3 2 6 1 3
References Study Quality
17 (24295043) 4
MRI neck without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 1 3 1 8 3 0 0 0 0
MRI neck without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 1 1 3 6 4 1 0 0 0
CT neck with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 0 1 0 2 8 2 1 2 0
References Study Quality
17 (24295043) 4
I-123 uptake scan neck May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 2 2 1 3 8 0 0 0 0
References Study Quality
16 (26462967) 4
18 (4685532) 2
I-131 uptake scan and Tc-99m pertechnetate scan neck May be appropriate Limited ☢☢☢☢ 10-30 mSv 4 4 5 0 3 4 3 2 0 0 0
References Study Quality
16 (26462967) 4
18 (4685532) 2
CT neck without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 1 2 0 1 0 0 1 0
References Study Quality
17 (24295043) 4
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 0 0 0 0 0 1 0
Variant 3: Thyrotoxicosis. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US thyroid Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 9 9 0 1 0 0 0 1 2 1 12
References Study Quality
24 (22440986) 4
21 (17381355) 4
22 (17437515) 4
19 (27521067) 4
23 (16356088) 2
I-123 uptake scan neck Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 1 0 0 0 2 0 1 6 7
References Study Quality
16 (26462967) 4
25 (26926973) 4
26 (21825836) 4
19 (27521067) 4
I-131 uptake scan and Tc-99m pertechnetate scan neck Usually appropriate Limited ☢☢☢☢ 10-30 mSv 7 7 0 1 0 0 2 2 6 3 3
References Study Quality
16 (26462967) 4
25 (26926973) 4
26 (21825836) 4
19 (27521067) 4
MRI neck without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 2 2 1 3 0 0 0 1
MRI neck without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 1 3 3 1 0 0 0 1
CT neck with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 8 8 0 0 0 0 0 0 0
CT neck without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 2 1 1 1 0 0 0 1
CT neck without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 7 2 0 3 3 1 1 0 0
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 1 0 0 0 0 0 0 1
Variant 4: Primary hypothyroidism. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US thyroid Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 2 0 0 1 0 0 1
MRI neck without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 2 0 0 0 0 0 1
MRI neck without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 1 0 0 0 0 0 1
CT neck with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 14 0 1 0 0 0 2 0 0
CT neck without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 1 1 0 0 0 1
CT neck without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 13 1 0 1 1 0 0 1 0
I-123 uptake scan neck Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 0 0 0 1 0 0 0 0
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 0 0 0 0 0 0 0 1
I-131 uptake scan and Tc-99m pertechnetate scan neck Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 16 0 0 0 1 0 0 0 0
Variant 5: Preoperative evaluation of differentiated thyroid cancer.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US thyroid Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 1 0 0 0 0 2 3 11
References Study Quality
31 (27007092) 2
29 (19696304) 2
30 (18358074) 2
28 (14668727) 2
32 (22863305) 2
33 (23554058) 2
CT neck with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 8 8 0 0 0 1 0 0 2 6 8
References Study Quality
16 (26462967) 4
34 (25188202) 4
30 (18358074) 2
32 (22863305) 2
33 (23554058) 2
12 (22827435) 3
11 (24295076) 4
MRI neck without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 1 0 0 0 5 5 2 4 0
MRI neck without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 1 0 1 12 2 0 0 0 0
CT neck without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 0 0 0 8 8 0 0 0 0
References Study Quality
34 (25188202) 4
30 (18358074) 2
32 (22863305) 2
33 (23554058) 2
12 (22827435) 3
11 (24295076) 4
CT neck without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 2 3 0 2 1 0 0 1
References Study Quality
34 (25188202) 4
30 (18358074) 2
32 (22863305) 2
33 (23554058) 2
I-123 scan whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 1 0 0 1 0 1 0 0
FDG-PET/CT whole body Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 4 2 7 3 0 0 0 0 0
References Study Quality
36 (19158200) 1
35 (16918964) 1
I-131 scan whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 14 1 0 0 0 1 1 0 0
Octreotide scan whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 14 2 0 0 0 0 1 0 0
Variant 6: Early imaging after treatment of differentiated thyroid cancer.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US thyroid Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 0 16
References Study Quality
16 (26462967) 4
MRI neck without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 3 1 3 2 7 0 0 0 0
CT neck with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 1 2 3 2 1 5 2 0 0
I-123 scan whole body May be appropriate Limited ☢☢☢ 1-10 mSv 6 6 1 0 0 0 5 8 0 1 1
References Study Quality
16 (26462967) 4
I-131 scan whole body May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv 5 5 1 0 1 1 8 2 2 1 0
References Study Quality
16 (26462967) 4
MRI neck without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 6 1 2 7 0 0 0 0 0
CT neck without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 1 1 0 0 0 0 0 0
CT neck without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 3 4 3 6 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 3 1 1 5 0 0 0 0
Octreotide scan whole body Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 1 1 16 0 0 0 0 0 0 0 0
References Study Quality
16 (26462967) 4
Variant 7: Suspected recurrence of differentiated thyroid cancer.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US thyroid Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 1 0 0 0 1 0 15
References Study Quality
28 (14668727) 2
MRI neck without and with IV contrast Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 4 2 8 1 0
CT neck with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 9 9 0 0 0 1 1 0 1 5 9
References Study Quality
29 (19696304) 2
33 (23554058) 2
12 (22827435) 3
11 (24295076) 4
48 (18408961) 2
I-123 scan whole body Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 0 0 0 0 2 2 2 10 0
References Study Quality
16 (26462967) 4
40 (22310247) 2
41 (11139058) 4
MRI neck without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 1 0 0 5 9 0 1 0 0
CT chest with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 3 2 8 3 0 0
References Study Quality
16 (26462967) 4
CT chest without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 3 3 7 3 0 0
References Study Quality
16 (26462967) 4
CT neck without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 1 0 2 2 7 3 1 0 0
References Study Quality
29 (19696304) 2
33 (23554058) 2
48 (18408961) 2
FDG-PET/CT whole body May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 1 1 3 7 4 0 1
References Study Quality
36 (19158200) 1
50 (22985118) 2
6 (21118976) 2
49 (21220972) 4
I-131 scan whole body May be appropriate Limited ☢☢☢☢ 10-30 mSv 6 6 0 0 0 1 3 8 4 0 0
References Study Quality
16 (26462967) 4
40 (22310247) 2
41 (11139058) 4
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 1 0 0 2 0 0 0 0
References Study Quality
16 (26462967) 4
CT neck without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 0 0 0 0 0 0 0
References Study Quality
29 (19696304) 2
33 (23554058) 2
48 (18408961) 2
Octreotide scan whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 14 2 0 0 0 0 1 0 0
Variant 8: Suspected recurrence of medullary thyroid cancers.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US thyroid Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 1 0 0 1 0 15
References Study Quality
53 (17726071) 1
52 (25368270) 3
51 (12771918) 3
MRI neck without and with IV contrast Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 3 2 9 1 2
CT chest with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 3 5 2 5 1
References Study Quality
53 (17726071) 1
CT neck with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 8 8 0 0 1 0 1 0 0 8 7
References Study Quality
54 (25810047) 4
52 (25368270) 3
MRI abdomen without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 5 7 4 0 0
References Study Quality
56 (26494385) 4
53 (17726071) 1
55 (27682648) 4
MRI abdomen without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 3 1 1 3 7 2 0 0 0
References Study Quality
56 (26494385) 4
53 (17726071) 1
55 (27682648) 4
MRI complete spine without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 2 7 5 3 0
References Study Quality
53 (17726071) 1
57 (15572422) 4
MRI complete spine without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 3 10 3 0 0 0
References Study Quality
53 (17726071) 1
57 (15572422) 4
MRI neck without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 1 0 0 9 3 3 0 0 0
Bone scan whole body May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 1 4 8 3 1 0
References Study Quality
16 (26462967) 4
CT abdomen with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 1 0 1 6 8 0 0 0
References Study Quality
54 (25810047) 4
CT chest without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 4 4 5 2 0 0
References Study Quality
53 (17726071) 1
CT neck without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 1 0 2 5 7 1 0 0 0
References Study Quality
54 (25810047) 4
52 (25368270) 3
CT abdomen without and with IV contrast May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 6 6 1 0 0 0 3 11 1 0 0
References Study Quality
54 (25810047) 4
FDG-PET/CT whole body May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 0 2 7 4 3 0 0
References Study Quality
58 (22527889) Good
59 (18375923) 1
62 (17892923) 4
61 (11801705) 3
60 (17401085) 2
63 (19156423) 4
64 (22223169) 2
65 (23081996) 3
CT abdomen without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 2 10 1 1 0 0 0 0
References Study Quality
54 (25810047) 4
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 2 0 0 0 0 0 0
References Study Quality
53 (17726071) 1
CT neck without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 1 1 0 0 0 0 0 0
DOTATATE PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 9 1 6 0 0 0 0 0 0
References Study Quality
67 (25369749) 3
69 (28429044) 2
I-123 scan whole body Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 11 3 2 0 0 0 1 0 0
References Study Quality
62 (17892923) 4
61 (11801705) 3
66 (8683310) 4
I-131 scan whole body Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 1 1 11 2 3 0 0 0 0 1 0
References Study Quality
62 (17892923) 4
61 (11801705) 3
66 (8683310) 4
Octreotide scan whole body Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 1 1 11 3 1 0 2 0 0 0 0
References Study Quality
62 (17892923) 4
61 (11801705) 3
66 (8683310) 4
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.