American College of Radiology
ACR Appropriateness Criteria®

Noninvasive Clinical Staging of Primary Lung Cancer

Variant 1: Noninvasive initial clinical staging of non–small-cell lung carcinoma.
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 Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 1 1 2 9
References Study Quality
11 (23649440) 4
12 (12527573) 4
13 (16731115) 3
14 (18291191) 2
15 (28651988) 4
FDG-PET/CT skull base to mid-thigh Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 9 9 0 0 0 0 0 2 1 1 9
References Study Quality
11 (23649440) 4
13 (16731115) 3
16 (11380213) 2
17 (14688710) 3
18 (15197196) 1
19 (11978336) 1
20 (10478250) 2
21 (14693872) 2
22 (19571281) 1
23 (16151765) 1
24 (15620991) Good
25 (21587082) 2
26 (24082283) 3
27 (26013292) 4
28 (-3127897) 4
29 (18024539) 3
30 (17588407) 3
31 (21330566) Good
32 (9724372) 2
33 (15140545) 3
34 (21354739) Good
35 (19144446) 3
36 (12665681) 4
37 (9636830) 3
MRI head without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 3 2 3 5
References Study Quality
11 (23649440) 4
40 (14568686) 3
39 (17762336) 4
41 (10189463) 2
42 (6094117) 4
CT chest without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 1 0 0 2 2 3 3 2
References Study Quality
11 (23649440) 4
12 (12527573) 4
13 (16731115) 3
14 (18291191) 2
15 (28651988) 4
CT abdomen and pelvis with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 1 0 3 5 1 0 3
References Study Quality
11 (23649440) 4
CT head with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 6 6 0 0 1 0 5 4 3 0 0
References Study Quality
11 (23649440) 4
43 (1902031) 4
44 (10084481) 3
CT head without and with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 2 1 8 2 0 0 0
References Study Quality
11 (23649440) 4
43 (1902031) 4
44 (10084481) 3
MRI abdomen without and with IV contrast May be appropriate Moderate O 0 mSv O 0 mSv [ped] 5 5 1 0 1 1 9 1 0 0 0
References Study Quality
49 (23549390) 4
31 (21330566) Good
MRI chest without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 1 1 2 2 5 2 0 0 0
References Study Quality
45 (18349458) 4
46 (18373824) 3
47 (16028243) 3
48 (23593186) 2
MRI head without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 4 1 5 3 0 0 0
References Study Quality
11 (23649440) 4
40 (14568686) 3
Tc-99m bone scan whole body May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 1 4 5 2 0 0 0
References Study Quality
34 (21354739) Good
35 (19144446) 3
38 (21094027) Good
CT abdomen and pelvis without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 2 0 3 3 5 0 0 0 0
References Study Quality
11 (23649440) 4
CT abdomen and pelvis without and with IV contrast May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 4 4 1 0 3 3 4 2 0 0 0
References Study Quality
11 (23649440) 4
MRI abdomen without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 1 0 3 5 4 0 0 0 0
CT head without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 3 1 6 1 2 0 0 0 0
References Study Quality
11 (23649440) 4
43 (1902031) 4
44 (10084481) 3
MRI chest without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 2 1 4 4 1 1 0 0 0
References Study Quality
45 (18349458) 4
46 (18373824) 3
47 (16028243) 3
48 (23593186) 2
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 2 2 0 0 0 0 1 0
References Study Quality
11 (23649440) 4
12 (12527573) 4
13 (16731115) 3
14 (18291191) 2
15 (28651988) 4
Radiography chest Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 7 1 4 0 0 0 0 1 0
Variant 2: Noninvasive initial clinical staging of small-cell lung carcinoma.
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 Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 1 1 2 9
References Study Quality
50 (25310425) 4
51 (23649448) 4
MRI head without and with IV contrast Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 4 8
FDG-PET/CT skull base to mid-thigh Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 9 9 0 0 0 0 0 0 2 2 9
References Study Quality
31 (21330566) Good
33 (15140545) 3
34 (21354739) Good
37 (9636830) 3
51 (23649448) 4
52 (23307985) 4
55 (3034008) 3
56 (21409347) 3
57 (19921339) 3
58 (15057156) 3
59 (15310768) 2
60 (15258700) 2
CT abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 3 3 1 0 6
References Study Quality
55 (3034008) 3
CT chest without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 1 4 3 2 1 2
References Study Quality
50 (25310425) 4
51 (23649448) 4
CT head with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 0 0 0 1 7 4 1 0 0
References Study Quality
51 (23649448) 4
MRI abdomen without and with IV contrast May be appropriate Moderate O 0 mSv O 0 mSv [ped] 5 5 1 0 1 0 5 5 1 0 0
References Study Quality
49 (23549390) 4
31 (21330566) Good
MRI head without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 0 0 3 3 6 1 0 0 0
Tc-99m bone scan whole body May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 1 4 5 2 0 0 0
References Study Quality
51 (23649448) 4
62 (10473359) 4
63 (27877227) 3
CT abdomen and pelvis without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 2 0 1 7 2 1 0 0 0
References Study Quality
55 (3034008) 3
CT abdomen and pelvis without and with IV contrast May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 4 4 1 0 4 3 3 2 0 0 0
References Study Quality
55 (3034008) 3
CT head without and with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 1 4 3 4 1 0 0 0
References Study Quality
51 (23649448) 4
MRI abdomen without IV contrast May be appropriate Moderate O 0 mSv O 0 mSv [ped] 4 4 2 0 2 3 4 2 0 0 0
References Study Quality
49 (23549390) 4
31 (21330566) Good
MRI chest without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 4 4 1 0 2 5 5 0 0 0 0
References Study Quality
45 (18349458) 4
46 (18373824) 3
47 (16028243) 3
48 (23593186) 2
64 (6290145) 4
CT head without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 2 0 7 2 1 1 0 0 0
References Study Quality
51 (23649448) 4
MRI chest without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 1 3 4 3 1 1 0 0 0
References Study Quality
45 (18349458) 4
46 (18373824) 3
47 (16028243) 3
48 (23593186) 2
Radiography chest Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 2 2 6 5 1 0 0 0 0 1 0
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 7 3 2 0 0 0 0 1 0
References Study Quality
50 (25310425) 4
51 (23649448) 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.