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Appropriateness Criteria

Variant 1: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Known breast cancer. Initial determination of tumor size and extent within the breast prior to neoadjuvant chemotherapy. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US breast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 4 10
References Study Quality
41 (16684323) 3
15 (16142441) 3
14 (14533601) 3
13 (15865110) 3
12 (11720669) 2
11 (14652148) 2
10 (15486214) 3
Digital breast tomosynthesis diagnostic Usually appropriate Strong ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 0 0 15
References Study Quality
27 (16733676) 4
26 (31639053) 3
25 (30964425) 3
24 (23255766) 3
23 (23620367) 2
22 (23345348) 2
21 (23844366) 3
20 (25188431) 3
19 (24896197) 3
18 (23969151) 2
17 (25313245) 2
16 (23901124) 3
15 (16142441) 3
14 (14533601) 3
13 (15865110) 3
12 (11720669) 2
11 (14652148) 2
10 (15486214) 3
Mammography diagnostic Usually appropriate Strong ☢☢ 0.1-1mSv 9 9 0 0 0 0 1 0 1 2 11
References Study Quality
27 (16733676) 4
26 (31639053) 3
25 (30964425) 3
24 (23255766) 3
23 (23620367) 2
22 (23345348) 2
21 (23844366) 3
20 (25188431) 3
19 (24896197) 3
18 (23969151) 2
17 (25313245) 2
16 (23901124) 3
15 (16142441) 3
14 (14533601) 3
13 (15865110) 3
12 (11720669) 2
11 (14652148) 2
10 (15486214) 3
MRI breast without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 3 0 12
References Study Quality
37 (17392300) 1
36 (16286912) 2
35 (15728611) 2
34 (23297042) Inadequate
33 (19333654) 3
32 (18474876) 4
31 (23359240) 4
30 (22623692) 1
27 (16733676) 4
1 (25727555) 4
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 11 2 2 0 0 0 0 0 0
References Study Quality
38 (29742918) 3
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 6 6 2 1 0 0 0 0 0
References Study Quality
40 (31166752) 3
39 (24152645) 2
FDG-PET/CT skull base to mid-thigh Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 3 0 0 0 0 0 0 0
References Study Quality
29 (19075273) 2
28 (16897427) 2
Variant 2: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Known breast cancer. Imaging of the breast after initiation or completion of neoadjuvant chemotherapy. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US breast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 1 3 7 3
References Study Quality
107 (30103213) 3
106 (23062366) 2
105 (22476757) 3
104 (24169359) 3
103 (20359567) 3
102 (21947594) 3
101 (15765374) 4
100 (15972702) 2
99 (16154816) 4
27 (16733676) 4
Digital breast tomosynthesis diagnostic Usually appropriate Strong ☢☢ 0.1-1mSv 7 7 1 0 0 0 2 3 4 4 1
References Study Quality
50 (28526187) 3
49 (29110671) 2
48 (25056851) 4
47 (25287438) 3
46 (8596826) 3
45 (10769724) 4
44 (26495873) 3
43 (11026579) 4
42 (16432360) 3
27 (16733676) 4
14 (14533601) 3
13 (15865110) 3
12 (11720669) 2
11 (14652148) 2
10 (15486214) 3
Mammography diagnostic Usually appropriate Strong ☢☢ 0.1-1mSv 7 7 1 0 0 0 2 3 4 3 2
References Study Quality
50 (28526187) 3
49 (29110671) 2
48 (25056851) 4
47 (25287438) 3
46 (8596826) 3
45 (10769724) 4
44 (26495873) 3
43 (11026579) 4
42 (16432360) 3
27 (16733676) 4
14 (14533601) 3
13 (15865110) 3
12 (11720669) 2
11 (14652148) 2
10 (15486214) 3
MRI breast without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 1 13
References Study Quality
93 (20851939) 2
92 (22566277) 3
91 (18384182) 2
90 (24535214) 2
89 (21127880) 2
88 (21929557) 3
87 (30179110) 1
86 (31026118) 2
85 (15522553) 2
84 (18000804) 2
83 (17851879) 2
82 (23463090) 3
81 (26357493) 2
80 (12558665) 4
79 (15024602) 3
78 (23652844) 3
77 (25805427) 3
76 (21947592) 3
75 (20494311) 4
74 (14986052) 2
73 (23436342) 3
72 (24166728) 2
71 (26624971) 3
70 (29708782) 3
69 (18941065) 3
68 (16677795) 2
67 (26650831) 3
66 (20224378) 3
65 (26063880) 4
64 (20566826) M
63 (18436185) 3
62 (17018307) 2
42 (16432360) 3
35 (15728611) 2
34 (23297042) Inadequate
33 (19333654) 3
31 (23359240) 4
30 (22623692) 1
1 (25727555) 4
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 10 2 3 0 0 0 0 0 0
References Study Quality
38 (29742918) 3
Sestamibi MBI Usually not appropriate Strong ☢☢☢ 1-10 mSv 1 1 8 5 2 0 0 0 0 0 0
References Study Quality
40 (31166752) 3
98 (30620672) 3
97 (25501326) 2
96 (24671359) 3
95 (15637688) 2
94 (22391702) 2
FDG-PET/CT skull base to mid-thigh Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 1 3 1 2 0 0 0 0
References Study Quality
61 (25915099) 3
60 (11032590) 2
59 (22241914) 3
58 (24647576) 3
57 (23942075) 2
56 (24092940) 1
55 (17579854) 3
54 (8683314) 2
53 (29758503) Good
52 (19877158) 3
51 (22734080) Inadequate
Variant 3: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Known breast cancer, clinically node-negative. Axillary evaluation prior to neoadjuvant chemotherapy. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US axilla Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 1 0 0 3 2 2 3 4
References Study Quality
116 (28130619) 3
115 (-3194381) 4
108 (35550807) 4
US-guided core biopsy axillary node Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 9 2 2 0 1 0 0 0 1
References Study Quality
2 (16079956) 3
117 (25797740) 2
US-guided fine needle aspiration biopsy axillary node Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 10 1 2 0 2 0 0 0 0
References Study Quality
2 (16079956) 3
117 (25797740) 2
Digital breast tomosynthesis diagnostic Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 11 2 1 0 1 0 0 0 0
Mammography diagnostic Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 11 2 1 0 1 0 0 0 0
MRI breast without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 6 4 2 1 2 0 0 0 0
References Study Quality
114 (27956116) 3
113 (20143266) 2
112 (23846781) 3
65 (26063880) 4
64 (20566826) M
63 (18436185) 3
62 (17018307) 2
42 (16432360) 3
35 (15728611) 2
34 (23297042) Inadequate
31 (23359240) 4
30 (22623692) 1
1 (25727555) 4
108 (35550807) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 2 0 0 1 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 2 4 1 0 0 0 0 0
References Study Quality
111 (22872522) 2
110 (14722036) 1
109 (24744045) 2
108 (35550807) 4
Variant 4: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Known breast cancer, clinically node-positive. Axillary evaluation prior to neoadjuvant chemotherapy. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US axilla Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 4 11
References Study Quality
2 (16079956) 3
119 (31500785) 3
117 (25797740) 2
115 (-3194381) 4
108 (35550807) 4
MRI breast without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 1 2 2 9 1 0 0 0
References Study Quality
114 (27956116) 3
113 (20143266) 2
112 (23846781) 3
65 (26063880) 4
64 (20566826) M
63 (18436185) 3
62 (17018307) 2
42 (16432360) 3
35 (15728611) 2
34 (23297042) Inadequate
31 (23359240) 4
30 (22623692) 1
1 (25727555) 4
108 (35550807) 4
FDG-PET/CT skull base to mid-thigh May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 1 3 3 3 5 0 0 0
References Study Quality
118 (23456316) 2
116 (28130619) 3
111 (22872522) 2
110 (14722036) 1
109 (24744045) 2
108 (35550807) 4
US-guided core biopsy axillary node Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 0 0 0 0 0
References Study Quality
2 (16079956) 3
117 (25797740) 2
US-guided fine needle aspiration biopsy axillary node Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 0 0 0 0 0
References Study Quality
2 (16079956) 3
117 (25797740) 2
Digital breast tomosynthesis diagnostic Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 12 2 0 0 1 0 0 0 0
Mammography diagnostic Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 12 2 0 0 1 0 0 0 0
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 2 1 0 0 0 0 0 0
Variant 5: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Known breast cancer, clinically node-negative. Axillary evaluation after completion of neoadjuvant chemotherapy, axilla not previously evaluated. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US axilla Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 5 3 2 4 0 1 0 0 0
References Study Quality
126 (29381381) 1
125 (31407967) 3
124 (31605348) 4
123 (31740186) 3
112 (23846781) 3
US-guided core biopsy axillary node Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 2 0 0 0 0 1 0 0
US-guided fine needle aspiration biopsy axillary node Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 2 0 0 1 0 0 0 0
Digital breast tomosynthesis diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 10 4 0 0 0 0 0 1 0
References Study Quality
108 (35550807) 4
Mammography diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 10 4 0 0 0 0 0 1 0
References Study Quality
108 (35550807) 4
MRI breast without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 6 3 3 2 1 0 0 0 0
References Study Quality
122 (28919579) 3
121 (27451892) 2
120 (31583546) 4
114 (27956116) 3
113 (20143266) 2
112 (23846781) 3
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 3 0 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 2 6 0 0 0 0 0 0
References Study Quality
118 (23456316) 2
111 (22872522) 2
110 (14722036) 1
109 (24744045) 2
108 (35550807) 4
Variant 6: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Known breast cancer with clinical suspicion of metastatic disease. Staging or assessment of response to neoadjuvant chemotherapy. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Bone scan whole body Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 1 4 10
References Study Quality
127 (20516453) 3
CT chest abdomen pelvis with IV contrast Usually appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 1 6 8
References Study Quality
128 (19664478) 4
127 (20516453) 3
FDG-PET/CT skull base to mid-thigh Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 0 5 10
References Study Quality
134 (25971426) 4
133 (21057787) 1
132 (21880576) 3
131 (23220901) 4
130 (29923514) 3
129 (23725991) 4
127 (20516453) 3
MRI chest abdomen pelvis without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 2 0 0 2 0 0 0 0
MRI chest abdomen pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 0 0 0 0 0
CT chest abdomen pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 15 0 0 0 0 0 0 0 0
CT chest abdomen pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 1 0 0 1 0 0 0 0
Variant 7: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Known axillary lymph node-positive breast cancer on prior mammography, US, or MRI. Axillary evaluation after completion of neoadjuvant chemotherapy, axilla previously evaluated. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US axilla Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 2 3 4 5
References Study Quality
126 (29381381) 1
125 (31407967) 3
124 (31605348) 4
112 (23846781) 3
108 (35550807) 4
US breast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 12 2 0 1 0 0 0 0 0
References Study Quality
136 (28423171) 3
US-guided core biopsy axillary node Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 10 2 1 1 0 0 1 0 0
References Study Quality
141 (26727919) 4
140 (24101169) 3
139 (28766234) 3
138 (26811528) 2
137 (22772869) 3
119 (31500785) 3
112 (23846781) 3
US-guided fine needle aspiration biopsy axillary node Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 10 2 1 1 1 0 0 0 0
References Study Quality
141 (26727919) 4
140 (24101169) 3
139 (28766234) 3
138 (26811528) 2
137 (22772869) 3
119 (31500785) 3
112 (23846781) 3
Digital breast tomosynthesis diagnostic Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 11 2 0 0 1 1 0 0 0
Mammography diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 11 2 0 0 1 1 0 0 0
References Study Quality
108 (35550807) 4
MRI breast without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 2 2 4 1 5 1 0 0 0
References Study Quality
122 (28919579) 3
121 (27451892) 2
120 (31583546) 4
114 (27956116) 3
113 (20143266) 2
112 (23846781) 3
108 (35550807) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 3 0 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 4 5 1 2 0 0 0 0
References Study Quality
135 (21308372) 2
112 (23846781) 3
Variant 8: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Known breast cancer. Axillary imaging suspicious for metastatic disease on mammography, US, or MRI during initial evaluation. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US-guided core biopsy axillary node Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 1 2 4 8
References Study Quality
2 (16079956) 3
32 (18474876) 4
142 (29972239) Good
141 (26727919) 4
139 (28766234) 3
138 (26811528) 2
119 (31500785) 3
117 (25797740) 2
108 (35550807) 4
US-guided fine needle aspiration biopsy axillary node Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 1 2 5 6
References Study Quality
2 (16079956) 3
145 (27896640) 3
144 (17985188) 3
143 (23244481) 4
142 (29972239) Good
141 (26727919) 4
139 (28766234) 3
138 (26811528) 2
119 (31500785) 3
117 (25797740) 2
108 (35550807) 4
Digital breast tomosynthesis diagnostic Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 13 2 0 0 0 0 0 0 0
Mammography diagnostic Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 13 2 0 0 0 0 0 0 0
MRI breast without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 7 3 4 0 1 0 0 0 0
References Study Quality
1 (25727555) 4
113 (20143266) 2
112 (23846781) 3
65 (26063880) 4
64 (20566826) M
63 (18436185) 3
62 (17018307) 2
42 (16432360) 3
35 (15728611) 2
34 (23297042) Inadequate
31 (23359240) 4
30 (22623692) 1
108 (35550807) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 4 0 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.