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Appropriateness Criteria

Variant 1: Adult or child. Primary hyperparathyroidism. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US parathyroid Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 3 3 15
References Study Quality
67 (25475790) 4
31 (30475247) 2
90 (21178047) 2
88 (26274755) 2
70 (21710322) Good
18 (30938239) 4
7 (26898682) 4
58 (26646659) 2
85 (29281866) Not Assessed
20 (20338394) 4
86 (30103649) 2
89 (19774444) 3
87 (21463783) 2
8 (31002214) 4
91 (16585862) 2
2 (27532368) 4
Sestamibi scan and pertechnetate thyroid scan Usually appropriate Strong 7 7 0 0 0 0 0 0 15 4 1
References Study Quality
64 (25525929) 1
82 (25299470) 2
54 (22566587) 2
17 (29461661) 4
80 (23531879) 2
45 (26447369) 2
81 (23102932) 4
59 (29319134) 2
65 (12458389) 1
CT neck without and with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 1 0 1 2 4 13
References Study Quality
44 (26359149) 1
31 (30475247) 2
30 (26024308) 2
36 (24674300) 2
39 (22135127) 2
35 (21367374) 2
34 (27329424) 2
29 (23868155) 2
45 (26447369) 2
41 (27590748) 2
42 (21955750) 1
43 (28705526) 3
37 (21184187) 2
38 (25518904) 2
40 (29063298) 2
32 (30835187) 2
Sestamibi dual-phase scan neck Usually appropriate Strong ☢☢☢ 1-10 mSv 7 7 0 0 0 0 0 6 7 4 4
References Study Quality
66 (20625763) 2
53 (23759694) 2
67 (25475790) 4
64 (25525929) 1
52 (23153996) 2
54 (22566587) 2
55 (21576603) 2
17 (29461661) 4
56 (21076888) 2
57 (29877611) 1
45 (26447369) 2
58 (26646659) 2
59 (29319134) 2
60 (23748916) 2
61 (19893394) 2
62 (25642803) Good
63 (30239472) 2
65 (12458389) 1
Sestamibi dual-phase scan with SPECT or SPECT/CT neck Usually appropriate Strong ☢☢☢ 1-10 mSv 9 9 0 0 0 0 0 2 2 5 12
References Study Quality
70 (21710322) Good
71 (26932954) 2
68 (22454482) 4
73 (26825209) 2
72 (20466104) 4
61 (19893394) 2
62 (25642803) Good
69 (18794320) 4
32 (30835187) 2
Sestamibi scan and I-123 thyroid scan Usually appropriate Strong ☢☢☢ 1-10 mSv 7 7 0 0 0 0 0 0 14 5 1
References Study Quality
64 (25525929) 1
74 (26584615) 3
54 (22566587) 2
77 (22437201) 2
75 (24152647) 2
15 (19471928) 4
45 (26447369) 2
76 (26732668) 2
59 (29319134) 2
65 (12458389) 1
Sestamibi scan and I-123 thyroid scan with SPECT or SPECT/CT neck Usually appropriate Strong ☢☢☢ 1-10 mSv 8 8 0 0 0 0 0 0 4 9 7
References Study Quality
74 (26584615) 3
68 (22454482) 4
78 (25637075) 2
75 (24152647) 2
45 (26447369) 2
79 (28984813) 2
69 (18794320) 4
Sestamibi scan and pertechnetate thyroid scan with SPECT or SPECT/CT neck Usually appropriate Strong ☢☢☢ 1-10 mSv 7 7 1 0 1 0 1 4 4 5 5
References Study Quality
68 (22454482) 4
83 (30556441) 2
84 (20615139) 2
69 (18794320) 4
MRI neck with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 1 0 2 5 7 4 0 1 0
References Study Quality
46 (21982525) 2
47 (21623148) 2
50 (29736849) 2
52 (23153996) 2
49 (21879264) 2
48 (27318765) 2
51 (32165367) 2
MRI neck without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 4 10 4 2 0
References Study Quality
46 (21982525) 2
47 (21623148) 2
50 (29736849) 2
52 (23153996) 2
49 (21879264) 2
48 (27318765) 2
51 (32165367) 2
CT neck with IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 6 6 0 0 0 2 6 8 3 1 0
References Study Quality
44 (26359149) 1
31 (30475247) 2
30 (26024308) 2
36 (24674300) 2
39 (22135127) 2
35 (21367374) 2
34 (27329424) 2
29 (23868155) 2
45 (26447369) 2
41 (27590748) 2
42 (21955750) 1
43 (28705526) 3
37 (21184187) 2
38 (25518904) 2
40 (29063298) 2
32 (30835187) 2
Venous sampling parathyroid Usually not appropriate Strong Varies Varies 2 2 9 4 7 0 0 0 0 0 0
References Study Quality
94 (20372897) 2
96 (30193297) 4
95 (19958928) 2
92 (27643800) 3
93 (20870706) 4
8 (31002214) 4
MRI neck without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 5 2 4 3 5 1 1 0 0
References Study Quality
46 (21982525) 2
47 (21623148) 2
50 (29736849) 2
52 (23153996) 2
49 (21879264) 2
48 (27318765) 2
51 (32165367) 2
CT neck without IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 7 5 4 2 3 0 0 0 0
References Study Quality
44 (26359149) 1
31 (30475247) 2
30 (26024308) 2
36 (24674300) 2
39 (22135127) 2
35 (21367374) 2
34 (27329424) 2
29 (23868155) 2
45 (26447369) 2
41 (27590748) 2
42 (21955750) 1
43 (28705526) 3
37 (21184187) 2
38 (25518904) 2
40 (29063298) 2
32 (30835187) 2
Variant 2: Adult or child. Primary hyperparathyroidism, recurrent or persistent after parathyroid surgery. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US parathyroid Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 1 2 1 4 12
References Study Quality
101 (29484563) 3
48 (27318765) 2
100 (22184303) 3
10 (30070413) 4
Sestamibi scan and pertechnetate thyroid scan Usually appropriate Expert Consensus 7 7 0 0 0 0 2 2 13 2 1
CT neck without and with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 1 0 1 2 3 14
References Study Quality
36 (24674300) 2
97 (25454737) 2
34 (27329424) 2
29 (23868155) 2
40 (29063298) 2
Sestamibi dual-phase scan neck Usually appropriate Expert Consensus ☢☢☢ 1-10 mSv 7 7 0 0 0 0 0 3 14 1 2
Sestamibi dual-phase scan with SPECT or SPECT/CT neck Usually appropriate Strong ☢☢☢ 1-10 mSv 8 8 0 0 0 0 0 0 2 9 9
References Study Quality
48 (27318765) 2
99 (20957360) 2
Sestamibi scan and I-123 thyroid scan Usually appropriate Expert Consensus ☢☢☢ 1-10 mSv 7 7 0 0 0 0 2 2 12 3 1
Sestamibi scan and I-123 thyroid scan with SPECT or SPECT/CT neck Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 0 0 0 0 0 3 5 7 5
References Study Quality
100 (22184303) 3
Sestamibi scan and pertechnetate thyroid scan with SPECT or SPECT/CT neck Usually appropriate Expert Consensus ☢☢☢ 1-10 mSv 8 8 0 0 0 0 0 1 7 7 5
Venous sampling parathyroid May be appropriate Strong Varies Varies 6 6 0 0 0 2 8 10 0 0 0
References Study Quality
96 (30193297) 4
97 (25454737) 2
92 (27643800) 3
104 (25868412) 2
102 (19590890) 4
103 (23554505) 2
93 (20870706) 4
8 (31002214) 4
10 (30070413) 4
105 (27384174) 2
MRI neck with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 1 1 7 9 1 0 1 0
References Study Quality
98 (22695787) 2
48 (27318765) 2
MRI neck without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 1 0 0 1 2 8 4 5 0
References Study Quality
98 (22695787) 2
48 (27318765) 2
CT neck with IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 6 6 0 0 0 3 7 9 0 1 0
References Study Quality
36 (24674300) 2
97 (25454737) 2
34 (27329424) 2
29 (23868155) 2
40 (29063298) 2
MRI neck without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 7 3 2 5 3 1 0 0 0
References Study Quality
98 (22695787) 2
48 (27318765) 2
CT neck without IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 7 5 3 4 2 0 0 0 0
References Study Quality
36 (24674300) 2
97 (25454737) 2
34 (27329424) 2
29 (23868155) 2
40 (29063298) 2
Variant 3: Adult or child. Secondary hyperparathyroidism. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US parathyroid Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 2 3 3 6 2 5
References Study Quality
14 (25409841) 3
13 (24626889) 2
110 (29154082) 2
112 (19111413) 2
111 (20414855) 2
85 (29281866) Not Assessed
12 (20091692) 2
CT neck without and with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 1 0 0 1 3 2 5 6 3
References Study Quality
107 (31602011) 2
106 (26665124) 2
Sestamibi dual-phase scan neck Usually appropriate Limited ☢☢☢ 1-10 mSv 7 7 1 0 0 0 2 1 17 0 0
References Study Quality
12 (20091692) 2
Sestamibi dual-phase scan with SPECT or SPECT/CT neck Usually appropriate Strong ☢☢☢ 1-10 mSv 8 8 0 0 0 0 0 3 7 6 4
References Study Quality
110 (29154082) 2
109 (29233127) 2
108 (24370142) 2
Sestamibi scan and I-123 thyroid scan with SPECT or SPECT/CT neck Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 0 0 0 1 2 4 3 7 3
References Study Quality
14 (25409841) 3
Sestamibi scan and pertechnetate thyroid scan with SPECT or SPECT/CT neck Usually appropriate Expert Consensus ☢☢☢ 1-10 mSv 8 8 0 0 0 0 2 5 3 7 3
Sestamibi scan and pertechnetate thyroid scan May be appropriate (Disagreement) Expert Opinion 5 5 0 0 0 3 3 2 9 2 1
MRI neck with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 1 0 1 10 6 1 0 1 0
MRI neck without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 0 0 0 2 7 8 2 1 0
CT neck with IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 6 6 0 0 0 2 7 10 0 1 0
References Study Quality
107 (31602011) 2
106 (26665124) 2
Sestamibi scan and I-123 thyroid scan May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv 5 5 0 0 1 3 2 2 8 3 1
Venous sampling parathyroid Usually not appropriate Expert Consensus Varies Varies 2 2 8 6 4 1 1 1 0 0 0
MRI neck without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 9 4 4 3 1 0 0 0 0
CT neck without IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 8 9 3 0 0 0 0 0 0
References Study Quality
107 (31602011) 2
106 (26665124) 2
Variant 4: Adult or child. Tertiary hyperparathyroidism. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US parathyroid Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 2 9 3 6
References Study Quality
14 (25409841) 3
13 (24626889) 2
110 (29154082) 2
Sestamibi scan and pertechnetate thyroid scan Usually appropriate Expert Consensus 7 7 0 0 0 2 3 2 9 3 1
CT neck without and with IV contrast Usually appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 1 0 11 5 3
Sestamibi dual-phase scan neck Usually appropriate Expert Consensus ☢☢☢ 1-10 mSv 7 7 0 0 0 0 3 3 10 3 1
Sestamibi dual-phase scan with SPECT or SPECT/CT neck Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 0 0 0 0 0 2 3 11 4
References Study Quality
110 (29154082) 2
Sestamibi scan and I-123 thyroid scan with SPECT or SPECT/CT neck Usually appropriate Expert Consensus ☢☢☢ 1-10 mSv 8 8 0 0 0 0 2 4 2 8 4
Sestamibi scan and pertechnetate thyroid scan with SPECT or SPECT/CT neck Usually appropriate Expert Consensus ☢☢☢ 1-10 mSv 8 8 0 0 0 0 3 3 2 8 4
MRI neck with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 1 1 1 7 9 0 0 1 0
MRI neck without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 0 0 0 3 7 8 1 1 0
CT neck with IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 6 6 0 0 0 3 7 9 0 1 0
Sestamibi scan and I-123 thyroid scan May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv 5 5 0 0 0 3 3 1 9 3 1
Venous sampling parathyroid Usually not appropriate Limited Varies Varies 2 2 7 6 3 2 2 1 0 0 0
References Study Quality
96 (30193297) 4
93 (20870706) 4
MRI neck without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 4 4 2 3 0 0 0 0
CT neck without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 11 4 3 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.