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Appropriateness Criteria

Variant 1: Clinically suspected mediastinal mass. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest Usually appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 7 7 0 0 0 1 2 1 3 1 4
References Study Quality
85 (21424313) 4
86 (3612915) 4
87 (9587766) 4
88 (17234997) 4
MRI chest without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 0 8 0 4
References Study Quality
70 (24177751) 2
48 (18373824) 3
45 (16028243) 3
60 (1410337) 4
80 (17145404) 3
67 (24157619) 4
69 (29324329) 4
79 (29143106) 2
55 (26272529) 2
21 (25952512) 4
24 (25575742) 2
61 (25105246) 2
110 (25518038) 4
77 (24646161) 4
76 (22573298) 4
75 (21940535) 4
20 (21700977) 4
59 (20462094) 4
22 (17463136) 2
74 (16282916) 4
58 (25950727) 4
19 (2117345) 4
23 (25478741) 1
46 (11128398) 2
47 (19945190) 2
49 (27494286) 4
50 (2916014) 4
51 (25798006) 4
52 (10988179) 2
62 (22707094) 4
63 (24555628) 3
64 (3753623) 4
65 (27449453) 4
66 (30951437) 4
68 (22786993) 4
71 (24877982) 2
72 (12100322) 4
73 (10730236) 4
78 (25556605) 4
81 (18637703) 4
82 (20705944) 3
83 (7862995) 2
84 (11368935) 4
MRI chest without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 3 3 2 2 3
References Study Quality
70 (24177751) 2
48 (18373824) 3
45 (16028243) 3
60 (1410337) 4
67 (24157619) 4
79 (29143106) 2
55 (26272529) 2
21 (25952512) 4
24 (25575742) 2
77 (24646161) 4
76 (22573298) 4
75 (21940535) 4
20 (21700977) 4
59 (20462094) 4
22 (17463136) 2
74 (16282916) 4
58 (25950727) 4
19 (2117345) 4
46 (11128398) 2
47 (19945190) 2
49 (27494286) 4
50 (2916014) 4
51 (25798006) 4
52 (10988179) 2
62 (22707094) 4
63 (24555628) 3
64 (3753623) 4
65 (27449453) 4
66 (30951437) 4
68 (22786993) 4
71 (24877982) 2
72 (12100322) 4
73 (10730236) 4
78 (25556605) 4
83 (7862995) 2
84 (11368935) 4
CT chest with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 1 1 2 8
References Study Quality
48 (18373824) 3
45 (16028243) 3
24 (25575742) 2
41 (23820175) 2
43 (19820808) 4
40 (9308448) 4
42 (30887749) 2
44 (8134583) 4
46 (11128398) 2
47 (19945190) 2
49 (27494286) 4
50 (2916014) 4
51 (25798006) 4
52 (10988179) 2
CT chest without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 4 2 6 1 0
References Study Quality
48 (18373824) 3
45 (16028243) 3
41 (23820175) 2
43 (19820808) 4
25 (28238381) 4
40 (9308448) 4
42 (30887749) 2
44 (8134583) 4
46 (11128398) 2
47 (19945190) 2
49 (27494286) 4
50 (2916014) 4
51 (25798006) 4
52 (10988179) 2
US chest Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 5 0 5 1 1 0 0 0 0
References Study Quality
89 (30027639) 4
90 (25881598) 1
Image-guided transthoracic needle biopsy Usually not appropriate Expert Consensus Varies Varies 1 1 9 1 1 0 0 0 1 0 0
CT chest without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 5 0 0 0 0 0 0 0
References Study Quality
48 (18373824) 3
45 (16028243) 3
41 (23820175) 2
43 (19820808) 4
25 (28238381) 4
40 (9308448) 4
42 (30887749) 2
44 (8134583) 4
46 (11128398) 2
47 (19945190) 2
49 (27494286) 4
50 (2916014) 4
51 (25798006) 4
52 (10988179) 2
FDG-PET/CT skull base to mid-thigh Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 6 2 0 0 0 0 0 0
References Study Quality
53 (29437755) 2
56 (28123154) 3
55 (26272529) 2
57 (19501523) 2
42 (30887749) 2
54 (19443604) 4
Variant 2: Indeterminate mediastinal mass on radiography. 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 chest without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 1 0 2 1 2 1 5
References Study Quality
70 (24177751) 2
48 (18373824) 3
45 (16028243) 3
60 (1410337) 4
80 (17145404) 3
69 (29324329) 4
79 (29143106) 2
55 (26272529) 2
21 (25952512) 4
24 (25575742) 2
61 (25105246) 2
77 (24646161) 4
76 (22573298) 4
75 (21940535) 4
20 (21700977) 4
59 (20462094) 4
22 (17463136) 2
74 (16282916) 4
58 (25950727) 4
19 (2117345) 4
46 (11128398) 2
47 (19945190) 2
49 (27494286) 4
50 (2916014) 4
51 (25798006) 4
52 (10988179) 2
63 (24555628) 3
64 (3753623) 4
65 (27449453) 4
71 (24877982) 2
72 (12100322) 4
73 (10730236) 4
78 (25556605) 4
100 (31464819) 4
81 (18637703) 4
82 (20705944) 3
83 (7862995) 2
84 (11368935) 4
MRI chest without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 2 2 3 4 2
References Study Quality
70 (24177751) 2
60 (1410337) 4
80 (17145404) 3
69 (29324329) 4
79 (29143106) 2
55 (26272529) 2
21 (25952512) 4
24 (25575742) 2
61 (25105246) 2
77 (24646161) 4
76 (22573298) 4
75 (21940535) 4
20 (21700977) 4
59 (20462094) 4
22 (17463136) 2
74 (16282916) 4
58 (25950727) 4
19 (2117345) 4
46 (11128398) 2
47 (19945190) 2
49 (27494286) 4
50 (2916014) 4
51 (25798006) 4
52 (10988179) 2
63 (24555628) 3
64 (3753623) 4
65 (27449453) 4
71 (24877982) 2
72 (12100322) 4
73 (10730236) 4
78 (25556605) 4
100 (31464819) 4
81 (18637703) 4
82 (20705944) 3
83 (7862995) 2
84 (11368935) 4
CT chest with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 0 1 11
References Study Quality
48 (18373824) 3
45 (16028243) 3
24 (25575742) 2
41 (23820175) 2
43 (19820808) 4
40 (9308448) 4
42 (30887749) 2
44 (8134583) 4
46 (11128398) 2
47 (19945190) 2
49 (27494286) 4
50 (2916014) 4
51 (25798006) 4
52 (10988179) 2
CT chest without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 1 1 8 3 0
References Study Quality
48 (18373824) 3
45 (16028243) 3
24 (25575742) 2
41 (23820175) 2
43 (19820808) 4
40 (9308448) 4
42 (30887749) 2
44 (8134583) 4
46 (11128398) 2
47 (19945190) 2
49 (27494286) 4
50 (2916014) 4
51 (25798006) 4
52 (10988179) 2
US chest Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 4 0 5 2 1 0 0 0 0
References Study Quality
89 (30027639) 4
90 (25881598) 1
Image-guided transthoracic needle biopsy Usually not appropriate Expert Consensus Varies Varies 1 1 7 2 2 0 0 0 1 0 0
CT chest without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 5 0 0 0 0 0 0 0
References Study Quality
48 (18373824) 3
45 (16028243) 3
24 (25575742) 2
41 (23820175) 2
43 (19820808) 4
40 (9308448) 4
44 (8134583) 4
46 (11128398) 2
47 (19945190) 2
49 (27494286) 4
50 (2916014) 4
51 (25798006) 4
52 (10988179) 2
FDG-PET/CT skull base to mid-thigh Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 3 5 5 0 0 0 0 0 0
References Study Quality
95 (29720487) 2
53 (29437755) 2
96 (28634685) 4
56 (28123154) 3
94 (27130796) 1
98 (24724780) 4
55 (26272529) 2
92 (26089397) 4
93 (25205600) 2
91 (24799481) 2
99 (20639307) 4
57 (19501523) 2
42 (30887749) 2
97 (25841712) 4
54 (19443604) 4
Variant 3: Indeterminate mediastinal mass on CT. 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 chest without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 1 0 2 2 7
References Study Quality
70 (24177751) 2
60 (1410337) 4
67 (24157619) 4
69 (29324329) 4
79 (29143106) 2
55 (26272529) 2
21 (25952512) 4
24 (25575742) 2
61 (25105246) 2
77 (24646161) 4
76 (22573298) 4
75 (21940535) 4
20 (21700977) 4
59 (20462094) 4
22 (17463136) 2
74 (16282916) 4
58 (25950727) 4
19 (2117345) 4
25 (28238381) 4
46 (11128398) 2
47 (19945190) 2
50 (2916014) 4
51 (25798006) 4
52 (10988179) 2
62 (22707094) 4
63 (24555628) 3
64 (3753623) 4
65 (27449453) 4
66 (30951437) 4
68 (22786993) 4
71 (24877982) 2
72 (12100322) 4
73 (10730236) 4
78 (25556605) 4
100 (31464819) 4
83 (7862995) 2
84 (11368935) 4
MRI chest without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 2 2 2 4 1
References Study Quality
70 (24177751) 2
48 (18373824) 3
45 (16028243) 3
60 (1410337) 4
80 (17145404) 3
67 (24157619) 4
69 (29324329) 4
79 (29143106) 2
55 (26272529) 2
21 (25952512) 4
24 (25575742) 2
61 (25105246) 2
77 (24646161) 4
76 (22573298) 4
75 (21940535) 4
20 (21700977) 4
59 (20462094) 4
22 (17463136) 2
74 (16282916) 4
58 (25950727) 4
19 (2117345) 4
25 (28238381) 4
46 (11128398) 2
47 (19945190) 2
50 (2916014) 4
51 (25798006) 4
52 (10988179) 2
62 (22707094) 4
63 (24555628) 3
64 (3753623) 4
65 (27449453) 4
66 (30951437) 4
68 (22786993) 4
71 (24877982) 2
72 (12100322) 4
73 (10730236) 4
78 (25556605) 4
100 (31464819) 4
81 (18637703) 4
82 (20705944) 3
83 (7862995) 2
84 (11368935) 4
Image-guided transthoracic needle biopsy May be appropriate Strong Varies Varies 6 6 0 0 0 1 4 3 2 2 0
References Study Quality
109 (26402427) 4
108 (29581992) 2
111 (26604114) 3
102 (26397325) 4
103 (25763320) 4
110 (25518038) 4
106 (25261906) 4
104 (24263776) 2
105 (22039020) 1
101 (25978277) 4
107 (20938161) 2
FDG-PET/CT skull base to mid-thigh May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 1 4 2 3 2 0
References Study Quality
95 (29720487) 2
53 (29437755) 2
96 (28634685) 4
56 (28123154) 3
94 (27130796) 1
98 (24724780) 4
55 (26272529) 2
92 (26089397) 4
93 (25205600) 2
91 (24799481) 2
99 (20639307) 4
57 (19501523) 2
42 (30887749) 2
97 (25841712) 4
54 (19443604) 4
US chest Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 6 2 1 1 1 1 0 0 0
References Study Quality
89 (30027639) 4
90 (25881598) 1
Radiography chest Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 9 2 0 1 0 0 0 0 0
Variant 4: Indeterminate mediastinal mass on FDG-PET/CT. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Image-guided transthoracic needle biopsy Usually appropriate Strong Varies Varies 7 7 0 0 0 0 4 1 3 3 1
References Study Quality
109 (26402427) 4
108 (29581992) 2
111 (26604114) 3
102 (26397325) 4
103 (25763320) 4
110 (25518038) 4
106 (25261906) 4
104 (24263776) 2
105 (22039020) 1
101 (25978277) 4
107 (20938161) 2
MRI chest without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 1 0 2 2 7
References Study Quality
70 (24177751) 2
48 (18373824) 3
45 (16028243) 3
60 (1410337) 4
80 (17145404) 3
67 (24157619) 4
69 (29324329) 4
79 (29143106) 2
55 (26272529) 2
21 (25952512) 4
61 (25105246) 2
77 (24646161) 4
76 (22573298) 4
75 (21940535) 4
20 (21700977) 4
59 (20462094) 4
22 (17463136) 2
74 (16282916) 4
58 (25950727) 4
19 (2117345) 4
25 (28238381) 4
46 (11128398) 2
47 (19945190) 2
49 (27494286) 4
50 (2916014) 4
51 (25798006) 4
52 (10988179) 2
62 (22707094) 4
63 (24555628) 3
64 (3753623) 4
65 (27449453) 4
66 (30951437) 4
68 (22786993) 4
71 (24877982) 2
72 (12100322) 4
73 (10730236) 4
78 (25556605) 4
100 (31464819) 4
81 (18637703) 4
82 (20705944) 3
83 (7862995) 2
84 (11368935) 4
MRI chest without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 3 1 2 5 0
References Study Quality
70 (24177751) 2
48 (18373824) 3
45 (16028243) 3
60 (1410337) 4
80 (17145404) 3
67 (24157619) 4
69 (29324329) 4
79 (29143106) 2
55 (26272529) 2
21 (25952512) 4
61 (25105246) 2
77 (24646161) 4
76 (22573298) 4
75 (21940535) 4
20 (21700977) 4
59 (20462094) 4
22 (17463136) 2
74 (16282916) 4
58 (25950727) 4
19 (2117345) 4
25 (28238381) 4
46 (11128398) 2
47 (19945190) 2
49 (27494286) 4
50 (2916014) 4
51 (25798006) 4
52 (10988179) 2
62 (22707094) 4
63 (24555628) 3
64 (3753623) 4
65 (27449453) 4
66 (30951437) 4
68 (22786993) 4
71 (24877982) 2
72 (12100322) 4
73 (10730236) 4
78 (25556605) 4
100 (31464819) 4
81 (18637703) 4
82 (20705944) 3
83 (7862995) 2
84 (11368935) 4
CT chest with IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 1 3 6 3 0 0
US chest Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 6 2 2 0 1 1 0 0 0
References Study Quality
89 (30027639) 4
90 (25881598) 1
Radiography chest Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 9 1 1 0 1 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 5 1 0 1 0 0 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 3 2 0 0 1 1 0 0
Variant 5: Indeterminate mediastinal mass on MRI. Next imaging study or surveillance.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Image-guided transthoracic needle biopsy Usually appropriate Strong Varies Varies 8 8 0 0 0 0 2 1 2 2 5
References Study Quality
109 (26402427) 4
108 (29581992) 2
111 (26604114) 3
102 (26397325) 4
103 (25763320) 4
110 (25518038) 4
106 (25261906) 4
104 (24263776) 2
105 (22039020) 1
101 (25978277) 4
107 (20938161) 2
MRI chest without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 1 3 4 4 0
References Study Quality
70 (24177751) 2
48 (18373824) 3
45 (16028243) 3
60 (1410337) 4
80 (17145404) 3
67 (24157619) 4
69 (29324329) 4
79 (29143106) 2
55 (26272529) 2
21 (25952512) 4
24 (25575742) 2
61 (25105246) 2
77 (24646161) 4
76 (22573298) 4
75 (21940535) 4
20 (21700977) 4
59 (20462094) 4
22 (17463136) 2
74 (16282916) 4
58 (25950727) 4
19 (2117345) 4
25 (28238381) 4
46 (11128398) 2
47 (19945190) 2
49 (27494286) 4
50 (2916014) 4
51 (25798006) 4
52 (10988179) 2
62 (22707094) 4
63 (24555628) 3
64 (3753623) 4
65 (27449453) 4
66 (30951437) 4
68 (22786993) 4
71 (24877982) 2
72 (12100322) 4
73 (10730236) 4
78 (25556605) 4
100 (31464819) 4
81 (18637703) 4
82 (20705944) 3
83 (7862995) 2
84 (11368935) 4
MRI chest without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 5 1 5 1 0
References Study Quality
70 (24177751) 2
48 (18373824) 3
45 (16028243) 3
60 (1410337) 4
80 (17145404) 3
67 (24157619) 4
69 (29324329) 4
79 (29143106) 2
55 (26272529) 2
21 (25952512) 4
24 (25575742) 2
61 (25105246) 2
77 (24646161) 4
76 (22573298) 4
75 (21940535) 4
20 (21700977) 4
59 (20462094) 4
22 (17463136) 2
74 (16282916) 4
58 (25950727) 4
19 (2117345) 4
25 (28238381) 4
46 (11128398) 2
47 (19945190) 2
49 (27494286) 4
50 (2916014) 4
51 (25798006) 4
52 (10988179) 2
62 (22707094) 4
63 (24555628) 3
64 (3753623) 4
65 (27449453) 4
66 (30951437) 4
68 (22786993) 4
71 (24877982) 2
72 (12100322) 4
73 (10730236) 4
78 (25556605) 4
100 (31464819) 4
81 (18637703) 4
82 (20705944) 3
83 (7862995) 2
84 (11368935) 4
CT chest with IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 0 5 7 1 0 0
CT chest without IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 0 7 4 1 0 0
FDG-PET/CT skull base to mid-thigh May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 1 0 2 0 5 3 1 0
References Study Quality
95 (29720487) 2
53 (29437755) 2
96 (28634685) 4
56 (28123154) 3
94 (27130796) 1
98 (24724780) 4
55 (26272529) 2
92 (26089397) 4
93 (25205600) 2
91 (24799481) 2
99 (20639307) 4
57 (19501523) 2
42 (30887749) 2
97 (25841712) 4
54 (19443604) 4
US chest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 7 3 1 0 0 1 0 0 0
Radiography chest Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 8 3 0 0 1 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 5 0 0 1 0 1 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.