American College of Radiology
ACR Appropriateness Criteria®

Stage I Breast Cancer: Initial Workup and Surveillance for Local Recurrence and Distant Metastases in Asymptomatic Women

Variant 1: Newly diagnosed. Stage I breast cancer. Asymptomatic. Rule out bone metastases. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
FDG-PET/CT whole body Usually not appropriate Strong ☢☢☢☢ 10-30 mSv 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
6 (27422453) 4
12 (15668281) 3
13 (20516453) 3
14 (21969709) 3
15 (21076343) 2
16 (29025377) 4
Tc-99m bone scan whole body Usually not appropriate Moderate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
11 (3338047) 4
17 (8427400) 3
18 (3373314) 3
19 (3565316) 4
20 (4064511) 4
21 (213852) 3
22 (7848404) 1
Radiography skeletal survey Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
11 (3338047) 4
Variant 2: Newly diagnosed. Stage I breast cancer. Asymptomatic. Rule out thoracic metastases. Initial imaging.
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 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
27 (21298335) 3
CT chest 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
27 (21298335) 3
CT chest without and with 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
27 (21298335) 3
FDG-PET/CT whole body Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
6 (27422453) 4
12 (15668281) 3
16 (29025377) 4
Radiography chest Usually not appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
11 (3338047) 4
12 (15668281) 3
23 (8164036) 4
24 (12000220) 3
25 (2714345) 4
26 (8182811) 1
Variant 3: Newly diagnosed. Stage I breast cancer. Asymptomatic. Rule out abdominal metastases. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT abdomen with 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
27 (21298335) 3
29 (3490743) 4
CT abdomen 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
27 (21298335) 3
29 (3490743) 4
CT abdomen without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
27 (21298335) 3
29 (3490743) 4
MRI abdomen without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
29 (3490743) 4
MRI abdomen without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
29 (3490743) 4
FDG-PET/CT whole body Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
6 (27422453) 4
12 (15668281) 3
16 (29025377) 4
US abdomen Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
11 (3338047) 4
26 (8182811) 1
30 (6258861) 4
31 (7208864) 4
32 (11387916) 4
Variant 4: Newly diagnosed. Stage I breast cancer. Asymptomatic. Rule out brain metastases. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI head without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
33 (3317495) 2
37 (3275962) 4
38 (1902031) 4
MRI head without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
33 (3317495) 2
37 (3275962) 4
38 (1902031) 4
FDG-PET/CT whole body Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
6 (27422453) 4
12 (15668281) 3
16 (29025377) 4
CT head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
35 (3341548) 4
36 (22740201) 4
CT head without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
35 (3341548) 4
36 (22740201) 4
CT head without and 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
35 (3341548) 4
36 (22740201) 4
Variant 5: Surveillance. Stage I breast cancer. Asymptomatic. Rule out bone, thoracic, abdominal, and brain metastases. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
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
7 (26314782) 4
8 (-3146467) 4
9 (-3146470) 4
10 (23601761) 4
CT abdomen without 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
7 (26314782) 4
8 (-3146467) 4
9 (-3146470) 4
10 (23601761) 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
7 (26314782) 4
8 (-3146467) 4
9 (-3146470) 4
10 (23601761) 4
CT chest 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
7 (26314782) 4
8 (-3146467) 4
9 (-3146470) 4
10 (23601761) 4
CT chest without 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
7 (26314782) 4
8 (-3146467) 4
9 (-3146470) 4
10 (23601761) 4
CT chest without and 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
7 (26314782) 4
8 (-3146467) 4
9 (-3146470) 4
10 (23601761) 4
CT head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
7 (26314782) 4
8 (-3146467) 4
9 (-3146470) 4
10 (23601761) 4
CT head without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
7 (26314782) 4
8 (-3146467) 4
9 (-3146470) 4
10 (23601761) 4
CT head without and 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
7 (26314782) 4
8 (-3146467) 4
9 (-3146470) 4
10 (23601761) 4
MRI abdomen without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
7 (26314782) 4
8 (-3146467) 4
9 (-3146470) 4
10 (23601761) 4
MRI abdomen without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
7 (26314782) 4
8 (-3146467) 4
9 (-3146470) 4
10 (23601761) 4
MRI head without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
7 (26314782) 4
8 (-3146467) 4
9 (-3146470) 4
10 (23601761) 4
MRI head without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
7 (26314782) 4
8 (-3146467) 4
9 (-3146470) 4
10 (23601761) 4
Tc-99m bone scan whole body 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
7 (26314782) 4
8 (-3146467) 4
9 (-3146470) 4
10 (23601761) 4
FDG-PET/CT whole body Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
7 (26314782) 4
8 (-3146467) 4
9 (-3146470) 4
10 (23601761) 4
US abdomen Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
7 (26314782) 4
8 (-3146467) 4
9 (-3146470) 4
10 (23601761) 4
Radiography chest Usually not appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
7 (26314782) 4
8 (-3146467) 4
9 (-3146470) 4
10 (23601761) 4
Radiography skeletal survey Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
7 (26314782) 4
8 (-3146467) 4
9 (-3146470) 4
10 (23601761) 4
Variant 6: Surveillance. Stage I breast cancer. Asymptomatic. Rule out local recurrence.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Mammography diagnostic bilateral Usually appropriate Limited ☢☢ 0.1-1mSv 9 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
6 (27422453) 4
Digital breast tomosynthesis diagnostic Usually appropriate Strong ☢☢ 0.1-1mSv 9 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
6 (27422453) 4
57 (23345348) 2
58 (23620367) 2
59 (23255766) 3
60 (23844366) 3
Mammography screening Usually appropriate Limited ☢☢ 0.1-1mSv 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
8 (-3146467) 4
39 (17033037) 4
48 (18206623) 0
49 (22692036) 0
50 (17548838) 4
51 (16409580) 4
52 (18368477) 4
Digital breast tomosynthesis screening Usually appropriate Strong ☢☢ 0.1-1mSv 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
53 (23175484) 2
54 (24354377) 2
55 (24484063) 1
56 (24475859) 3
MRI breast without and with IV contrast bilateral May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
61 (23889950) 3
62 (22476755) 4
63 (17392385) 4
64 (20651211) 3
65 (28655029) 4
US breast bilateral May be appropriate Moderate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
68 (18477782) 1
MRI breast without IV contrast bilateral Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
61 (23889950) 3
62 (22476755) 4
63 (17392385) 4
64 (20651211) 3
65 (28655029) 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.