American College of Radiology
ACR Appropriateness Criteria®

Clinically Suspected Adnexal Mass, No Acute Symptoms

Variant 1: Clinically suspected adnexal mass, no acute symptoms. Premenopausal. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler pelvis 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
23 (10739694) 3
34 (21211896) 3
35 (20973268) 3
36 (9646799) 2
37 (9618853) 3
38 (19244062) 3
39 (19574775) 3
40 (8497367) 2
41 (7814654) 3
42 (15032283) 3
43 (22648861) 3
US pelvis transvaginal Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
7 (28266033) 4
10 (20823748) 4
27 (12962948) 4
28 (15672002) 4
29 (7938766) 4
30 (11717074) 4
33 (24327552) Good
US pelvis transabdominal Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
MRI pelvis without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
42 (15032283) 3
44 (24183731) 4
45 (15710137) 2
46 (12704041) 2
47 (16928938) 2
48 (25153677) 3
MRI pelvis without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
15 (22095438) 2
49 (7824738) 2
CT pelvis with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
50 (15018172) 4
CT pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
50 (15018172) 4
CT pelvis without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
50 (15018172) 4
FDG-PET/CT skull base to mid-thigh 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 2: Clinically suspected adnexal mass, no acute symptoms. Postmenopausal. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler pelvis 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
23 (10739694) 3
34 (21211896) 3
35 (20973268) 3
36 (9646799) 2
37 (9618853) 3
38 (19244062) 3
39 (19574775) 3
41 (7814654) 3
42 (15032283) 3
43 (22648861) 3
US pelvis transvaginal Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
5 (16126262) 4
27 (12962948) 4
28 (15672002) 4
29 (7938766) 4
30 (11717074) 4
32 (11169340) 4
51 (18536617) 4
52 (1509047) 4
US pelvis transabdominal Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
MRI pelvis without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
42 (15032283) 3
44 (24183731) 4
45 (15710137) 2
46 (12704041) 2
47 (16928938) 2
48 (25153677) 3
MRI pelvis without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
15 (22095438) 2
49 (7824738) 2
CT pelvis with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
50 (15018172) 4
CT pelvis without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
50 (15018172) 4
CT pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
50 (15018172) 4
FDG-PET/CT skull base to mid-thigh 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: Adnexal mass, likely benign, no acute symptoms. Premenopausal. Initial follow-up.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler pelvis Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
US pelvis transvaginal Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
53 (16024535) 4
54 (2188180) 4
US pelvis transabdominal Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
MRI pelvis without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
MRI pelvis without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
15 (22095438) 2
49 (7824738) 2
CT pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
CT pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
CT pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh 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 4: Adnexal mass, likely benign, no acute symptoms. Postmenopausal. Initial follow-up.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US pelvis transvaginal Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
52 (1509047) 4
54 (2188180) 4
US duplex Doppler pelvis Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
US pelvis transabdominal Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
MRI pelvis without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
MRI pelvis without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
15 (22095438) 2
49 (7824738) 2
CT pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
CT pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
CT pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh 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 5: Adnexal mass, indeterminate, no acute symptoms. Premenopausal. Initial follow-up.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US pelvis transvaginal Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 0 2 16
References Study Quality
7 (28266033) 4
US duplex Doppler pelvis Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 8 8 0 1 0 0 1 3 2 4 8
US pelvis transabdominal Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 8 8 0 1 0 1 0 1 3 6 7
MRI pelvis without and with IV contrast Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 1 5 5 6 1
MRI pelvis without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 1 4 6 3 4 1 0
References Study Quality
15 (22095438) 2
49 (7824738) 2
CT pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 3 11 0 1 0 1 0 0 0
CT pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 7 4 1 0 2 0 0 0
CT pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 3 9 1 0 1 2 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 15 3 0 0 0 0 0 1 0
Variant 6: Adnexal mass, indeterminate, no acute symptoms. Postmenopausal. Initial follow-up.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US pelvis transvaginal Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 2 2 14
References Study Quality
51 (18536617) 4
52 (1509047) 4
US duplex Doppler pelvis Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 8 8 0 1 0 1 0 2 2 4 9
US pelvis transabdominal Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 8 8 0 1 0 1 0 1 4 5 7
MRI pelvis without and with IV contrast Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 7 7 0 0 1 1 0 4 5 5 3
MRI pelvis without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 4 1 10 0 0 1
References Study Quality
49 (7824738) 2
CT pelvis without and with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 2 3 10 0 0 0 2 0 1 0
CT pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 3 11 0 0 0 1 0 1 0
CT pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 9 0 1 0 0 0 1 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 15 1 0 0 1 1 0 1 0
Variant 7: Adnexal mass, highly suspicious for malignancy, no acute symptoms. Premenopausal and postmenopausal. Initial follow-up.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 1 0 1 1 0 8 6
References Study Quality
6 (29724422) 4
MRI pelvis without and with IV contrast Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 7 7 0 0 0 2 2 2 9 0 1
US pelvis transabdominal May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 0 0 0 2 4 7 1 0 2
US pelvis transvaginal May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 0 0 0 2 4 6 1 0 3
CT pelvis with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 6 2 1 3 1 1 1 6 1 0
CT pelvis without and with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 2 2 3 1 0 5 2 1 0
MRI pelvis without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 0 0 2 6 6 1 0 0 1
FDG-PET/CT skull base to mid-thigh May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 5 5 0 1 0 4 7 3 0 1 0
References Study Quality
20 (12034950) 2
US duplex Doppler pelvis May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 6 0 0 0 3 4 6 1 0 2
CT abdomen and pelvis without IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 1 7 5 4 0 0 0 0
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 4 4 2 5 1 0 1 0 0
References Study Quality
6 (29724422) 4
CT pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 4 8 1 0 0 0 1 0
Variant 8: Clinically suspected adnexal mass, no acute symptoms. Pregnant. Initial imaging and follow-up.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler pelvis Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 1 0 1 1 13
References Study Quality
23 (10739694) 3
34 (21211896) 3
35 (20973268) 3
36 (9646799) 2
37 (9618853) 3
38 (19244062) 3
39 (19574775) 3
40 (8497367) 2
41 (7814654) 3
42 (15032283) 3
43 (22648861) 3
57 (9583073) 3
US pelvis transabdominal Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 1 0 0 0 2 3 3 10
References Study Quality
53 (16024535) 4
54 (2188180) 4
US pelvis transvaginal Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 0 2 16
References Study Quality
2 (26800772) 2
5 (16126262) 4
27 (12962948) 4
28 (15672002) 4
29 (7938766) 4
30 (11717074) 4
33 (24327552) Good
MRI pelvis without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 3 12 0 1 0
References Study Quality
58 (28668416) 2
MRI pelvis without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 2 6 6 0 1 1 0 0 0
References Study Quality
58 (28668416) 2
CT pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 6 2 0 0 0 0 0 1
CT pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 7 0 1 0 0 0 0 1
CT pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 5 2 0 0 0 0 0 1
FDG-PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 15 1 1 0 0 1 0 0 1
References Study Quality
20 (12034950) 2
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.