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Appropriateness Criteria

Variant 1: Adult greater than or equal to 35 years of age. Incidentally detected indeterminate pulmonary nodule on 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 without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 1 3 5 9
References Study Quality
20 (25658477) 4
27 (27639313) 4
25 (10682770) 4
3 (18195376) 4
Radiography chest May be appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 4 4 0 0 2 8 6 2 0 0 0
References Study Quality
25 (10682770) 4
5 (23460160) 4
Image-guided transthoracic needle biopsy Usually not appropriate Expert Consensus Varies Varies 1 1 16 0 1 0 0 1 0 0 0
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 4 1 1 0 0 0 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 4 1 1 0 0 0 0
CT chest with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 7 3 1 1 1 0 0 0
References Study Quality
27 (27639313) 4
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 9 6 3 0 0 0 0 0 0
References Study Quality
27 (27639313) 4
FDG-PET/MRI whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 1 1 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 3 0 2 0 1 0 0 0
Variant 2: Adult greater than or equal to 35 years of age. Incidentally detected indeterminate pulmonary nodule less than 6 mm on chest 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
CT chest without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 1 0 3 9 4 1 0 0
References Study Quality
20 (25658477) 4
27 (27639313) 4
Radiography chest Usually not appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 13 3 1 0 1 0 0 0 0
References Study Quality
5 (23460160) 4
Image-guided transthoracic needle biopsy Usually not appropriate Expert Consensus Varies Varies 1 1 12 1 3 2 0 0 0 0 0
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 3 0 0 0 0 0 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 2 1 0 0 0 0 0
CT chest with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 5 2 3 3 0 0 0 0
References Study Quality
27 (27639313) 4
CT chest without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 9 2 2 2 2 1 0 0 0
References Study Quality
31 (15304661) 2
30 (10644104) 2
29 (16244276) 2
FDG-PET/MRI whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 1 2 1 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 3 1 1 2 0 0 0 0
References Study Quality
32 (16513614) 2
5 (23460160) 4
1 (24630316) 4
Variant 3: Adult greater than or equal to 35 years of age. Incidentally detected indeterminate pulmonary nodule equal to or greater than 6 mm on chest 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
CT chest without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 1 1 6 7 3
References Study Quality
27 (27639313) 4
20 (25658477) 4
FDG-PET/CT whole body Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 1 0 1 3 4 5 2 2
References Study Quality
45 (24801058) 2
40 (27179906) 2
44 (25247519) Good
43 (20822650) 2
42 (12192561) 2
41 (9574618) 4
36 (17056930) 2
32 (16513614) 2
27 (27639313) 4
5 (23460160) 4
1 (24630316) 4
Image-guided transthoracic needle biopsy May be appropriate Strong Varies Varies 5 5 0 1 1 1 10 4 1 0 0
References Study Quality
52 (32976266) Good
53 (31206453) 2
56 (27108299) Good
55 (26545460) Good
54 (29573050) 4
Radiography chest Usually not appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 11 4 2 0 0 1 0 0 0
References Study Quality
5 (23460160) 4
MRI chest without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 5 3 7 2 1 0 0 0 0
References Study Quality
66 (24173597) 2
65 (15215548) 2
64 (25658478) 4
54 (29573050) 4
MRI chest without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 6 4 5 2 1 0 0 0 0
References Study Quality
63 (26447872) 2
58 (25545835) 2
62 (30480492) Good
61 (21696559) 2
60 (16177419) 2
59 (28263700) 2
57 (29775663) 2
54 (29573050) 4
CT chest with IV contrast Usually not appropriate Moderate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 6 4 0 2 1 0 0 0
References Study Quality
38 (18796658) 3
37 (10644105) 2
CT chest without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 5 2 0 0 0 0 0 0
References Study Quality
36 (17056930) 2
35 (27161068) 2
34 (27161059) 2
32 (16513614) 2
31 (15304661) 2
30 (10644104) 2
29 (16244276) 2
5 (23460160) 4
FDG-PET/MRI whole body Usually not appropriate Strong ☢☢☢ 1-10 mSv 2 2 6 5 3 2 1 0 1 0 0
References Study Quality
47 (33415433) 2
49 (27424217) 4
50 (26514173) 2
46 (27516448) 4
Variant 4: Adult greater than or equal to 35 years of age. Incidentally detected indeterminate pulmonary nodule on incomplete thoracic CT (eg, CT abdomen, neck, spine, etc). 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 without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 2 2 5 5 4
References Study Quality
27 (27639313) 4
20 (25658477) 4
Radiography chest Usually not appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 12 1 3 1 1 0 0 0 0
References Study Quality
5 (23460160) 4
Image-guided transthoracic needle biopsy Usually not appropriate Expert Consensus Varies Varies 2 2 9 2 2 1 3 0 1 0 0
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 2 4 2 0 0 0 0 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 1 4 2 1 0 0 0 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 5 2 2 0 1 1 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 6 0 0 1 0 0 0 0
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 3 2 1 2 1 0 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.