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Appropriateness Criteria

Variant 1: Indeterminate adrenal mass, less than 1 cm on initial imaging. No diagnostic benign imaging features. No history of malignancy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Image-guided biopsy adrenal gland Usually not appropriate Limited Varies Varies 1 1 15 0 1 0 0 0 1 0 0
References Study Quality
27 (9167965) 4
28 (10732267) 4
29 (10690869) 4
30 (9267279) 3
MRI abdomen without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 8 4 4 0 0 1 0 0 0
References Study Quality
4 (8495301) 4
5 (1745970) 4
6 (18430826) 4
MRI abdomen without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 7 6 1 0 1 1 0 1 0
References Study Quality
4 (8495301) 4
5 (1745970) 4
6 (18430826) 4
CT abdomen with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 3 2 0 1 0 0 0 0
References Study Quality
4 (8495301) 4
5 (1745970) 4
6 (18430826) 4
CT abdomen without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 3 5 1 1 0 0 1 0
References Study Quality
4 (8495301) 4
5 (1745970) 4
6 (18430826) 4
CT abdomen without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 8 3 4 0 0 0 0 2 0
References Study Quality
4 (8495301) 4
5 (1745970) 4
6 (18430826) 4
FDG-PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 2 1 0 1 0 0 0 0
References Study Quality
4 (8495301) 4
5 (1745970) 4
6 (18430826) 4
26 (15585482) 3
25 (21330566) Good
Variant 2: Indeterminate adrenal mass, 1 to 2 cm on initial imaging. No diagnostic benign imaging features. No history of malignancy. Follow-up imaging in 12 months.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI abdomen without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 1 0 0 2 5 3 6 0
References Study Quality
57 (11441561) 4
50 (2773732) 4
59 (15118113) 3
60 (14994299) 4
51 (1410337) 4
52 (8430178) 3
53 (7785642) 3
56 (12760936) 3
54 (7484585) 4
58 (17056891) 4
61 (20093571) 3
62 (19097108) 3
20 (26233268) 2
18 (24951201) 3
19 (17466481) 3
CT abdomen without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 1 0 0 2 6 4 5 1
References Study Quality
43 (24647823) 2
34 (9648789) 4
36 (14975968) 4
35 (2014283) 2
37 (9490968) 3
40 (9275981) 4
38 (11044054) 4
39 (14628882) 3
41 (9577483) 2
42 (17517932) 2
CT abdomen without and with IV contrast Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 7 7 0 0 0 0 0 4 6 8 1
References Study Quality
43 (24647823) 2
34 (9648789) 4
36 (14975968) 4
35 (2014283) 2
37 (9490968) 3
40 (9275981) 4
38 (11044054) 4
39 (14628882) 3
41 (9577483) 2
42 (17517932) 2
MRI abdomen without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 1 0 2 3 10 2 1 0
References Study Quality
57 (11441561) 4
50 (2773732) 4
59 (15118113) 3
60 (14994299) 4
51 (1410337) 4
52 (8430178) 3
53 (7785642) 3
56 (12760936) 3
54 (7484585) 4
55 (7645474) 2
58 (17056891) 4
61 (20093571) 3
62 (19097108) 3
20 (26233268) 2
18 (24951201) 3
19 (17466481) 3
Image-guided biopsy adrenal gland Usually not appropriate Limited Varies Varies 1 1 12 1 2 1 1 0 0 0 0
References Study Quality
46 (8497619) 3
7 (3871150) 4
47 (1910990) 4
27 (9167965) 4
45 (1643776) 4
28 (10732267) 4
29 (10690869) 4
30 (9267279) 3
48 (19451490) 4
49 (24836548) 3
CT abdomen with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 5 2 6 1 1 1 1 0 0
References Study Quality
43 (24647823) 2
34 (9648789) 4
36 (14975968) 4
35 (2014283) 2
37 (9490968) 3
40 (9275981) 4
38 (11044054) 4
39 (14628882) 3
41 (9577483) 2
42 (17517932) 2
FDG-PET/CT skull base to mid-thigh Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 3 4 0 0 1 0 0 0
References Study Quality
4 (8495301) 4
5 (1745970) 4
6 (18430826) 4
26 (15585482) 3
21 (16391184) 3
44 (18566816) 2
25 (21330566) Good
Variant 3: Indeterminate adrenal mass, greater than 2 cm and less than 4 cm on initial imaging. No diagnostic benign imaging features. No history of malignancy. Adrenal specific imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI abdomen without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 1 1 0 1 1 6 5 2
References Study Quality
57 (11441561) 4
50 (2773732) 4
59 (15118113) 3
60 (14994299) 4
51 (1410337) 4
52 (8430178) 3
53 (7785642) 3
56 (12760936) 3
54 (7484585) 4
55 (7645474) 2
58 (17056891) 4
61 (20093571) 3
62 (19097108) 3
MRI abdomen without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 1 0 1 1 5 5 4 0
References Study Quality
57 (11441561) 4
50 (2773732) 4
59 (15118113) 3
60 (14994299) 4
51 (1410337) 4
52 (8430178) 3
53 (7785642) 3
56 (12760936) 3
54 (7484585) 4
55 (7645474) 2
58 (17056891) 4
61 (20093571) 3
62 (19097108) 3
CT abdomen without and with IV contrast Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 8 8 0 0 0 0 1 3 2 10 3
References Study Quality
43 (24647823) 2
34 (9648789) 4
36 (14975968) 4
35 (2014283) 2
37 (9490968) 3
40 (9275981) 4
38 (11044054) 4
39 (14628882) 3
41 (9577483) 2
42 (17517932) 2
CT abdomen without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 1 0 0 2 7 2 7 0
References Study Quality
43 (24647823) 2
34 (9648789) 4
36 (14975968) 4
35 (2014283) 2
37 (9490968) 3
40 (9275981) 4
38 (11044054) 4
39 (14628882) 3
41 (9577483) 2
42 (17517932) 2
Image-guided biopsy adrenal gland Usually not appropriate Limited Varies Varies 1 1 9 5 2 0 0 0 1 0 0
References Study Quality
46 (8497619) 3
7 (3871150) 4
47 (1910990) 4
27 (9167965) 4
45 (1643776) 4
28 (10732267) 4
29 (10690869) 4
30 (9267279) 3
48 (19451490) 4
49 (24836548) 3
CT abdomen with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 4 3 6 2 1 0 1 0 0
References Study Quality
43 (24647823) 2
34 (9648789) 4
36 (14975968) 4
35 (2014283) 2
37 (9490968) 3
40 (9275981) 4
38 (11044054) 4
39 (14628882) 3
41 (9577483) 2
42 (17517932) 2
FDG-PET/CT skull base to mid-thigh Usually not appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 6 2 0 0 1 0 0 0
References Study Quality
4 (8495301) 4
64 (15181132) 4
5 (1745970) 4
6 (18430826) 4
26 (15585482) 3
21 (16391184) 3
44 (18566816) 2
65 (15197504) 3
25 (21330566) Good
Variant 4: Indeterminate adrenal mass, greater than or equal to 4 cm on initial imaging. No diagnostic benign imaging features. No history of malignancy. Adrenal specific imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Image-guided biopsy adrenal gland Usually not appropriate Limited Varies Varies 3 3 6 2 6 2 0 0 0 1 0
References Study Quality
46 (8497619) 3
7 (3871150) 4
47 (1910990) 4
27 (9167965) 4
45 (1643776) 4
28 (10732267) 4
29 (10690869) 4
30 (9267279) 3
48 (19451490) 4
49 (24836548) 3
MRI abdomen without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 4 3 3 4 1 2 0 0 0
References Study Quality
27 (9167965) 4
28 (10732267) 4
29 (10690869) 4
30 (9267279) 3
MRI abdomen without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 6 2 3 4 0 0 1 1 0
References Study Quality
27 (9167965) 4
28 (10732267) 4
29 (10690869) 4
30 (9267279) 3
CT abdomen with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 2 5 1 0 1 1 0 0
References Study Quality
27 (9167965) 4
28 (10732267) 4
29 (10690869) 4
30 (9267279) 3
CT abdomen without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 2 3 3 1 0 0 1 0
References Study Quality
27 (9167965) 4
28 (10732267) 4
29 (10690869) 4
30 (9267279) 3
CT abdomen without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 1 3 13 1 0 0 1 0 0
References Study Quality
27 (9167965) 4
28 (10732267) 4
29 (10690869) 4
30 (9267279) 3
FDG-PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 3 4 2 2 0 0 0 0
References Study Quality
64 (15181132) 4
21 (16391184) 3
44 (18566816) 2
65 (15197504) 3
Variant 5: Adrenal mass, less than 4 cm on initial imaging. No diagnostic benign imaging features. History of malignancy. Adrenal specific imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI abdomen without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 1 0 0 3 2 6 5 2
References Study Quality
57 (11441561) 4
50 (2773732) 4
59 (15118113) 3
60 (14994299) 4
51 (1410337) 4
52 (8430178) 3
53 (7785642) 3
56 (12760936) 3
58 (17056891) 4
61 (20093571) 3
62 (19097108) 3
83 (10652932) 4
82 (9314970) 3
CT abdomen without and with IV contrast Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 8 8 0 0 0 1 0 1 0 8 7
References Study Quality
43 (24647823) 2
34 (9648789) 4
36 (14975968) 4
35 (2014283) 2
37 (9490968) 3
40 (9275981) 4
38 (11044054) 4
39 (14628882) 3
41 (9577483) 2
42 (17517932) 2
FDG-PET/CT skull base to mid-thigh Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 2 1 11 5 0
References Study Quality
78 (9857995) 4
64 (15181132) 4
80 (18941099) 3
77 (9144854) 4
26 (15585482) 3
21 (16391184) 3
79 (11752075) 3
44 (18566816) 2
65 (15197504) 3
Image-guided biopsy adrenal gland May be appropriate Limited Varies Varies 6 6 0 0 0 0 5 9 5 0 0
References Study Quality
46 (8497619) 3
7 (3871150) 4
47 (1910990) 4
81 (15039183) 4
45 (1643776) 4
48 (19451490) 4
49 (24836548) 3
MRI abdomen without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 1 1 3 13 1 0 0
References Study Quality
57 (11441561) 4
50 (2773732) 4
59 (15118113) 3
60 (14994299) 4
51 (1410337) 4
52 (8430178) 3
53 (7785642) 3
56 (12760936) 3
58 (17056891) 4
61 (20093571) 3
62 (19097108) 3
83 (10652932) 4
82 (9314970) 3
CT abdomen without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 1 0 0 4 0 6 5 0 1
References Study Quality
43 (24647823) 2
34 (9648789) 4
36 (14975968) 4
35 (2014283) 2
37 (9490968) 3
40 (9275981) 4
38 (11044054) 4
39 (14628882) 3
41 (9577483) 2
42 (17517932) 2
CT abdomen with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 4 3 6 1 1 1 1 0 0
References Study Quality
43 (24647823) 2
34 (9648789) 4
36 (14975968) 4
35 (2014283) 2
37 (9490968) 3
40 (9275981) 4
38 (11044054) 4
39 (14628882) 3
41 (9577483) 2
42 (17517932) 2
76 (23151828) 4
Variant 6: Adrenal mass, greater than or equal to 4 cm on initial imaging. No diagnostic benign imaging features. History of malignancy. Adrenal specific imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Image-guided biopsy adrenal gland Usually appropriate Limited Varies Varies 7 7 0 0 1 0 0 3 7 4 2
References Study Quality
46 (8497619) 3
7 (3871150) 4
47 (1910990) 4
81 (15039183) 4
45 (1643776) 4
48 (19451490) 4
49 (24836548) 3
FDG-PET/CT skull base to mid-thigh Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 1 1 1 2 9 3
References Study Quality
78 (9857995) 4
64 (15181132) 4
80 (18941099) 3
77 (9144854) 4
26 (15585482) 3
21 (16391184) 3
79 (11752075) 3
44 (18566816) 2
65 (15197504) 3
MRI abdomen without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 3 6 8 1 0 0 0 1 0
MRI abdomen without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 3 8 7 0 0 0 1 0 0
CT abdomen with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 4 3 0 1 1 0 0 0
CT abdomen without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 3 3 3 0 1 1 0 0
CT abdomen without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 3 4 9 1 0 0 1 1 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.