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Appropriateness Criteria

Variant 1: Indeterminate renal mass. No contraindication to either iodinated CT contrast or gadolinium-based MR intravenous contrast. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US abdomen with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
18 (28429490) 3
68 (26971426) 2
66 (25919803) 2
17 (25209216) 2
67 (24768490) 3
65 (18806171) 2
16 (24475802) 3
19 (17097844) 3
MRI abdomen without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
44 (28651987) 4
54 (27845847) 3
63 (28095036) 2
53 (26919441) 2
24 (27729042) 3
60 (26486936) 3
61 (27275530) 3
49 (26797358) 2
25 (25681121) 2
58 (24359883) 2
50 (23883215) 4
29 (15128983) 4
51 (12202701) 3
52 (15215544) 2
59 (22344404) 3
56 (19276322) 3
57 (21877173) 3
55 (20160001) 2
62 (19244046) 3
64 (29390196) 2
7 (31210616) 4
CT abdomen without and with IV contrast Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
32 (25905961) 2
31 (22106359) 3
15 (28705069) 3
24 (27729042) 3
13 (27043480) 3
35 (26587925) 2
36 (25799334) 4
25 (25681121) 2
30 (24766033) 4
26 (24450674) 3
38 (23382290) 2
14 (23352763) 2
29 (15128983) 4
2 (22528901) 4
28 (16040900) 4
1 (17456870) 4
34 (14990834) 3
37 (21940539) 3
27 (19559352) 2
33 (21555349) 3
US kidneys retroperitoneal May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
69 (28678573) 2
70 (28609114) 4
MRI abdomen without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
44 (28651987) 4
54 (27845847) 3
63 (28095036) 2
53 (26919441) 2
24 (27729042) 3
60 (26486936) 3
61 (27275530) 3
49 (26797358) 2
25 (25681121) 2
58 (24359883) 2
50 (23883215) 4
29 (15128983) 4
51 (12202701) 3
52 (15215544) 2
59 (22344404) 3
56 (19276322) 3
57 (21877173) 3
55 (20160001) 2
62 (19244046) 3
64 (29390196) 2
7 (31210616) 4
CT abdomen with IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
32 (25905961) 2
31 (22106359) 3
15 (28705069) 3
24 (27729042) 3
13 (27043480) 3
35 (26587925) 2
36 (25799334) 4
25 (25681121) 2
30 (24766033) 4
26 (24450674) 3
38 (23382290) 2
14 (23352763) 2
29 (15128983) 4
2 (22528901) 4
28 (16040900) 4
1 (17456870) 4
34 (14990834) 3
37 (21940539) 3
27 (19559352) 2
33 (21555349) 3
CT abdomen without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
32 (25905961) 2
31 (22106359) 3
15 (28705069) 3
24 (27729042) 3
13 (27043480) 3
35 (26587925) 2
36 (25799334) 4
25 (25681121) 2
30 (24766033) 4
26 (24450674) 3
38 (23382290) 2
14 (23352763) 2
29 (15128983) 4
2 (22528901) 4
28 (16040900) 4
1 (17456870) 4
34 (14990834) 3
37 (21940539) 3
27 (19559352) 2
33 (21555349) 3
CTU without and with IV contrast May be appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
39 (22451550) 2
Arteriography kidney Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Radiography intravenous urography Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Image-guided biopsy renal mass Usually not appropriate Limited Varies Varies 3 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
42 (21992727) 4
48 (21704449) 4
44 (28651987) 4
43 (27112777) 4
40 (22633318) 4
47 (18707712) 3
41 (16643475) 3
45 (22088331) 4
46 (20720070) 4
MRU without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Indeterminate renal mass. Contraindication to both iodinated CT and gadolinium-based MR intravenous contrast. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US abdomen with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
18 (28429490) 3
68 (26971426) 2
66 (25919803) 2
17 (25209216) 2
67 (24768490) 3
65 (18806171) 2
16 (24475802) 3
19 (17097844) 3
US kidneys retroperitoneal Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
69 (28678573) 2
70 (28609114) 4
MRI abdomen without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
54 (27845847) 3
53 (26919441) 2
71 (-3132600) 4
72 (16431890) 4
56 (19276322) 3
57 (21877173) 3
55 (20160001) 2
CT abdomen without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
71 (-3132600) 4
2 (22528901) 4
1 (17456870) 4
Arteriography kidney Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Radiography intravenous urography Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Image-guided biopsy renal mass Usually not appropriate Limited Varies Varies 3 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
42 (21992727) 4
48 (21704449) 4
44 (28651987) 4
43 (27112777) 4
40 (22633318) 4
47 (18707712) 3
41 (16643475) 3
45 (22088331) 4
46 (20720070) 4
MRI abdomen without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
54 (27845847) 3
53 (26919441) 2
71 (-3132600) 4
72 (16431890) 4
56 (19276322) 3
57 (21877173) 3
55 (20160001) 2
MRU without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT abdomen with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
71 (-3132600) 4
2 (22528901) 4
1 (17456870) 4
CT abdomen without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
71 (-3132600) 4
2 (22528901) 4
1 (17456870) 4
CTU without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Indeterminate renal mass. Contraindication only to iodinated CT intravenous contrast. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US abdomen with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 1 6 8 2
References Study Quality
18 (28429490) 3
68 (26971426) 2
66 (25919803) 2
17 (25209216) 2
67 (24768490) 3
16 (24475802) 3
MRI abdomen without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 3 2 12
References Study Quality
44 (28651987) 4
54 (27845847) 3
63 (28095036) 2
53 (26919441) 2
24 (27729042) 3
60 (26486936) 3
61 (27275530) 3
25 (25681121) 2
58 (24359883) 2
29 (15128983) 4
51 (12202701) 3
52 (15215544) 2
59 (22344404) 3
56 (19276322) 3
57 (21877173) 3
55 (20160001) 2
62 (19244046) 3
64 (29390196) 2
US kidneys retroperitoneal May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 3 7 5 1 0
References Study Quality
69 (28678573) 2
70 (28609114) 4
MRI abdomen without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 1 4 2 4 4 0 0 0
References Study Quality
44 (28651987) 4
54 (27845847) 3
63 (28095036) 2
53 (26919441) 2
24 (27729042) 3
60 (26486936) 3
61 (27275530) 3
25 (25681121) 2
58 (24359883) 2
29 (15128983) 4
51 (12202701) 3
52 (15215544) 2
59 (22344404) 3
56 (19276322) 3
57 (21877173) 3
55 (20160001) 2
62 (19244046) 3
64 (29390196) 2
CT abdomen without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 0 2 9 3 2 0 0
References Study Quality
71 (-3132600) 4
2 (22528901) 4
1 (17456870) 4
Arteriography kidney Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 1 0 0 0 0 0 0
Radiography intravenous urography Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 15 0 2 0 0 0 0 0 0
Image-guided biopsy renal mass Usually not appropriate Limited Varies Varies 2 2 4 4 4 2 0 0 0 1 0
References Study Quality
42 (21992727) 4
48 (21704449) 4
44 (28651987) 4
43 (27112777) 4
40 (22633318) 4
47 (18707712) 3
41 (16643475) 3
45 (22088331) 4
46 (20720070) 4
MRU without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 2 3 8 1 0 0 0 1 0
CT abdomen with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 1 2 0 0 0 0 0 0
References Study Quality
71 (-3132600) 4
2 (22528901) 4
1 (17456870) 4
CT abdomen without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 14 1 2 0 0 0 0 0 0
References Study Quality
71 (-3132600) 4
2 (22528901) 4
1 (17456870) 4
CTU without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 15 1 1 0 0 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.