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Appropriateness Criteria

Variant 1: Nontraumatic chest wall pain. No history of malignancy. 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 Strong ☢ <0.1 mSv ☢ <0.03 mSv [ped] 8 8 0 0 0 0 1 1 3 3 7
References Study Quality
19 (30646757) 2
18 (29427301) 1
17 (28716296) 2
16 (24209723) 4
US chest May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 1 1 4 9 1 0 0 0
References Study Quality
15 (21466934) 4
24 (29202259) 4
23 (26815671) 2
25 (30612161) 2
22 (27748231) 4
Radiography rib views May be appropriate Limited ☢☢☢ 1-10 mSv 6 6 0 1 0 0 4 4 3 2 1
References Study Quality
11 (26207003) 4
20 (25690384) 1
21 (24648235) 3
16 (24209723) 4
MRI chest without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 4 0 7 0 3 1 0 0 0
References Study Quality
15 (21466934) 4
MRI chest without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 4 2 4 1 3 1 0 0 0
References Study Quality
15 (21466934) 4
Bone scan whole body Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 4 3 2 0 5 0 0 1 0
References Study Quality
9 (29538096) 2
CT chest with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 5 4 2 1 0 0 0 0
References Study Quality
12 (26226916) 1
11 (26207003) 4
13 (25680714) 4
14 (24707937) 4
10 (31054749) 4
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 2 1 1 0 1 0 0 0
References Study Quality
12 (26226916) 1
11 (26207003) 4
13 (25680714) 4
14 (24707937) 4
10 (31054749) 4
CT chest without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 6 5 2 1 0 0 0 0
References Study Quality
12 (26226916) 1
11 (26207003) 4
13 (25680714) 4
14 (24707937) 4
10 (31054749) 4
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 2 2 1 0 0 0 0 0
WBC scan chest Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 11 1 2 0 1 0 0 0 0
Variant 2: Nontraumatic chest wall pain. Known or suspected malignancy. Secondary evaluation after normal chest radiograph. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Bone scan whole body Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 1 0 0 0 1 0 11 3 0
References Study Quality
26 (30484853) 4
CT chest with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 0 0 2 12 2
References Study Quality
29 (21862774) 4
15 (21466934) 4
27 (27494286) 4
31 (24585297) 3
32 (21900839) 2
30 (21571655) 4
28 (19931110) 4
CT chest without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 1 0 1 0 11 2 1
References Study Quality
29 (21862774) 4
15 (21466934) 4
27 (27494286) 4
31 (24585297) 3
32 (21900839) 2
30 (21571655) 4
28 (19931110) 4
Radiography rib views May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 1 2 1 3 9 0 0 0 0
References Study Quality
16 (24209723) 4
MRI chest without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 3 10 2 1 0 0
References Study Quality
29 (21862774) 4
41 (18373824) 3
15 (21466934) 4
42 (11128398) 2
27 (27494286) 4
38 (29613963) 4
40 (24947314) 3
39 (23206603) 4
30 (21571655) 4
28 (19931110) 4
MRI chest without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 1 5 8 1 1 0 0
References Study Quality
29 (21862774) 4
41 (18373824) 3
15 (21466934) 4
42 (11128398) 2
27 (27494286) 4
38 (29613963) 4
39 (23206603) 4
30 (21571655) 4
28 (19931110) 4
FDG-PET/CT skull base to mid-thigh May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 0 3 7 2 1 2 0
References Study Quality
37 (21354739) Good
36 (28884133) 4
33 (22850222) 3
32 (21900839) 2
34 (17954662) 4
35 (24361174) 3
US chest Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 4 2 4 2 4 0 0 0 0
References Study Quality
43 (25911140) 1
27 (27494286) 4
44 (25038014) 2
39 (23206603) 4
46 (22675711) 2
32 (21900839) 2
45 (17951616) 1
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 3 0 0 0 0 0 0 0
References Study Quality
29 (21862774) 4
15 (21466934) 4
27 (27494286) 4
31 (24585297) 3
30 (21571655) 4
28 (19931110) 4
WBC scan chest Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 14 2 0 0 0 0 0 0 0
Variant 3: Nontraumatic chest wall pain. Suspected infectious or inflammatory condition. Secondary evaluation after normal chest radiograph. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT chest with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 0 0 2 10 4
References Study Quality
51 (25742551) 2
50 (20878342) 3
52 (28363377) 4
48 (24515885) 4
53 (22119315) 1
54 (21834915) 1
CT chest without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 2 1 12 1 0
References Study Quality
51 (25742551) 2
50 (20878342) 3
52 (28363377) 4
48 (24515885) 4
53 (22119315) 1
54 (21834915) 1
US chest May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 1 2 0 5 7 1 0 0 0
References Study Quality
48 (24515885) 4
MRI chest without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 1 1 9 0 3 2 0
References Study Quality
58 (20558917) 4
52 (28363377) 4
48 (24515885) 4
49 (22798267) 2
59 (22226453) 1
53 (22119315) 1
MRI chest without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 1 1 2 7 3 2 0 0
References Study Quality
58 (20558917) 4
52 (28363377) 4
48 (24515885) 4
49 (22798267) 2
59 (22226453) 1
53 (22119315) 1
Bone scan whole body May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 2 0 0 7 4 3 0 0
References Study Quality
51 (25742551) 2
50 (20878342) 3
48 (24515885) 4
6 (23678156) 2
49 (22798267) 2
26 (30484853) 4
47 (24416624) 2
FDG-PET/CT skull base to mid-thigh May be appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 2 0 1 1 10 1 1 0 0
References Study Quality
56 (25917543) 4
57 (30205705) Not Assessed
55 (23359660) 4
34 (17954662) 4
WBC scan chest May be appropriate Limited ☢☢☢☢ 10-30 mSv 6 6 0 1 0 2 4 5 3 1 0
References Study Quality
60 (25475377) 4
56 (25917543) 4
61 (29452615) 4
55 (23359660) 4
Radiography rib views Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 4 9 2 0 1 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 3 0 1 0 0 0 0 0
References Study Quality
51 (25742551) 2
50 (20878342) 3
52 (28363377) 4
48 (24515885) 4
53 (22119315) 1
54 (21834915) 1
Variant 4: Nontraumatic chest wall pain. History of prior chest intervention. Secondary evaluation after normal chest radiograph. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT chest with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 0 0 2 11 3
References Study Quality
66 (26129745) 4
71 (23415550) 2
8 (22821673) 2
69 (30850215) 4
73 (30403979) 2
70 (25910220) 4
74 (23558226) 4
72 (22815325) 4
65 (21995807) 1
67 (19775906) 4
64 (30300004) 4
68 (15627194) 2
CT chest without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 1 2 10 3 0
References Study Quality
66 (26129745) 4
71 (23415550) 2
8 (22821673) 2
69 (30850215) 4
73 (30403979) 2
70 (25910220) 4
74 (23558226) 4
72 (22815325) 4
65 (21995807) 1
67 (19775906) 4
64 (30300004) 4
68 (15627194) 2
US chest May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 1 2 2 3 6 1 0 0 0
References Study Quality
70 (25910220) 4
MRI chest without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 1 2 7 4 1 1 0
References Study Quality
27 (27494286) 4
63 (26351442) 4
69 (30850215) 4
79 (30443994) 4
MRI chest without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 1 2 1 7 4 0 1 0
References Study Quality
27 (27494286) 4
63 (26351442) 4
69 (30850215) 4
79 (30443994) 4
FDG-PET/CT skull base to mid-thigh May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 2 1 1 7 4 1 0 0 0
References Study Quality
75 (26756408) 2
77 (30196022) 1
76 (22228342) 4
78 (31456858) 2
Radiography rib views Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 8 6 1 0 1 0 0 0 0
Bone scan whole body Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 2 4 0 1 0 1 0 0
References Study Quality
62 (23585956) 4
63 (26351442) 4
64 (30300004) 4
CT chest without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 0 0 1 0 0 0 0 0
References Study Quality
66 (26129745) 4
71 (23415550) 2
8 (22821673) 2
69 (30850215) 4
73 (30403979) 2
70 (25910220) 4
74 (23558226) 4
72 (22815325) 4
65 (21995807) 1
67 (19775906) 4
64 (30300004) 4
68 (15627194) 2
WBC scan chest Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 2 5 3 2 1 3 1 0 0 0
References Study Quality
80 (11973486) 2
81 (8462208) 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.