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Appropriateness Criteria

Variant 1: Adult of any age. Female or transfeminine. Evaluation of saline breast implants. Asymptomatic. 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 not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 0 0 0 0 0 0 0
Digital breast tomosynthesis screening Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 11 0 2 1 0 0 0 0 1
References Study Quality
14 (29101979) 4
15 (34794604) 4
Mammography screening Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 12 0 1 0 0 0 1 0 1
References Study Quality
14 (29101979) 4
15 (34794604) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 0 0 1 0 0 0 0 1
References Study Quality
16 (24792659) 4
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 1 0 1 0 0 0 0 0
References Study Quality
16 (24792659) 4
Variant 2: Adult younger than 30 years of age. Female or transfeminine. Evaluation of saline breast implants. Clinical examination equivocal for implant rupture. 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 Limited O 0 mSv O 0 mSv [ped] 8 8 0 1 0 1 1 0 2 4 6
References Study Quality
18 (28186859) 4
Digital breast tomosynthesis diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 9 0 3 0 1 0 0 0 0
References Study Quality
16 (24792659) 4
17 (16579024) 4
Mammography diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 3 3 7 0 4 0 3 0 0 0 1
References Study Quality
16 (24792659) 4
17 (16579024) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 0 0 0 2 0 0 0 0
References Study Quality
16 (24792659) 4
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 0 0 0 2 0 0 0 0
References Study Quality
16 (24792659) 4
Variant 3: Adult 30 to 39 years of age. Female or transfeminine. Evaluation of saline breast implants. Clinical examination equivocal for implant rupture. 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 Limited O 0 mSv O 0 mSv [ped] 8 8 0 1 0 0 2 0 3 4 5
References Study Quality
18 (28186859) 4
Digital breast tomosynthesis diagnostic May be appropriate (Disagreement) Expert Opinion ☢☢ 0.1-1mSv 5 5 0 0 2 0 3 2 0 6 0
References Study Quality
16 (24792659) 4
17 (16579024) 4
Mammography diagnostic May be appropriate (Disagreement) Expert Opinion ☢☢ 0.1-1mSv 5 5 0 0 2 0 3 2 0 6 0
References Study Quality
16 (24792659) 4
17 (16579024) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 0 0 0 2 0 0 0 0
References Study Quality
16 (24792659) 4
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 12 0 1 0 2 0 0 0 0
References Study Quality
16 (24792659) 4
Variant 4: Adult age 40 years or older. Female or transfeminine. Evaluation of saline breast implants. Clinical examination equivocal for implant rupture. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Digital breast tomosynthesis diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 8 8 0 0 1 0 0 0 1 7 4
References Study Quality
16 (24792659) 4
17 (16579024) 4
Mammography diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 8 8 0 0 1 0 0 1 1 6 4
References Study Quality
16 (24792659) 4
17 (16579024) 4
US breast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 4 3 0 5 1
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 0 0 0 2 0 0 0 0
References Study Quality
16 (24792659) 4
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 0 0 0 2 0 0 0 0
References Study Quality
16 (24792659) 4
Variant 5: Adult of any age. Female or transfeminine. Evaluation of silicone breast implants. Asymptomatic. Less than 5 years after implant placement. 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 not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 11 0 1 0 0 0 0 1 0
References Study Quality
1 (-3195188) 4
Digital breast tomosynthesis diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 12 0 0 0 0 0 1 0 0
References Study Quality
20 (23928244) 4
19 (15900139) 4
18 (28186859) 4
15 (34794604) 4
14 (29101979) 4
Mammography diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 12 0 0 0 0 1 0 0 0
References Study Quality
20 (23928244) 4
19 (15900139) 4
18 (28186859) 4
15 (34794604) 4
14 (29101979) 4
MRI breast without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 0 0 0 0 0 0 0
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 12 0 1 0 0 0 0 0 0
References Study Quality
1 (-3195188) 4
Variant 6: Adult of any age. Female or transfeminine. Evaluation of silicone breast implants. Asymptomatic. Initial imaging at 5 to 6 years after implant placement and follow-up imaging every 2 to 3 years after initial negative 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] 7 7 0 0 0 0 3 2 3 2 3
References Study Quality
34 (19054000) 3
33 (23668948) 3
32 (22328687) 2
31 (21427311) 4
30 (23623260) 4
29 (18090814) 4
27 (25028829) 3
26 (15257358) 2
18 (28186859) 4
1 (-3195188) 4
14 (29101979) 4
15 (34794604) 4
MRI breast without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 1 1 0 1 9
References Study Quality
28 (15664285) 2
27 (25028829) 3
26 (15257358) 2
25 (22751081) 1
24 (16874191) 3
23 (17051096) 3
22 (17898620) 2
21 (18349629) 4
16 (24792659) 4
1 (-3195188) 4
Digital breast tomosynthesis diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 12 0 0 0 0 0 1 0 0
References Study Quality
20 (23928244) 4
19 (15900139) 4
18 (28186859) 4
15 (34794604) 4
14 (29101979) 4
Mammography diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 12 0 0 0 0 1 0 0 0
References Study Quality
20 (23928244) 4
19 (15900139) 4
18 (28186859) 4
15 (34794604) 4
14 (29101979) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 0 0 0 0 0 0 0 0
References Study Quality
1 (-3195188) 4
14 (29101979) 4
15 (34794604) 4
Variant 7: Adult younger than 30 years of age. Female or transfeminine. Evaluation of silicone breast implants. Suspected implant complication. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI breast without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 1 1 0 4 8
References Study Quality
16 (24792659) 4
38 (22430679) 3
29 (18090814) 4
31 (21427311) 4
32 (22328687) 2
27 (25028829) 3
26 (15257358) 2
28 (15664285) 2
37 (21364405) M
35 (23622796) 4
1 (-3195188) 4
US breast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 1 0 1 7 1 1 1 1
References Study Quality
29 (18090814) 4
30 (23623260) 4
31 (21427311) 4
32 (22328687) 2
33 (23668948) 3
34 (19054000) 3
27 (25028829) 3
26 (15257358) 2
20 (23928244) 4
35 (23622796) 4
39 (34063687) 2
18 (28186859) 4
36 (-3112870) 4
15 (34794604) 4
14 (29101979) 4
1 (-3195188) 4
Digital breast tomosynthesis diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 12 0 1 0 0 0 0 0 0
References Study Quality
29 (18090814) 4
31 (21427311) 4
20 (23928244) 4
35 (23622796) 4
19 (15900139) 4
1 (-3195188) 4
36 (-3112870) 4
15 (34794604) 4
14 (29101979) 4
Mammography diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 12 0 1 0 0 0 0 0 0
References Study Quality
29 (18090814) 4
31 (21427311) 4
20 (23928244) 4
35 (23622796) 4
19 (15900139) 4
36 (-3112870) 4
15 (34794604) 4
14 (29101979) 4
1 (-3195188) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 11 1 1 0 0 0 0 0 0
References Study Quality
36 (-3112870) 4
15 (34794604) 4
14 (29101979) 4
1 (-3195188) 4
Variant 8: Adult 30 to 39 years of age. Female or transfeminine. Evaluation of silicone breast implants. Suspected implant complication. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI breast without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 1 0 0 0 2 0 1 5 6
References Study Quality
16 (24792659) 4
38 (22430679) 3
29 (18090814) 4
31 (21427311) 4
32 (22328687) 2
37 (21364405) M
35 (23622796) 4
28 (15664285) 2
27 (25028829) 3
26 (15257358) 2
1 (-3195188) 4
US breast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 1 0 1 7 1 2 2 0
References Study Quality
29 (18090814) 4
30 (23623260) 4
31 (21427311) 4
32 (22328687) 2
33 (23668948) 3
34 (19054000) 3
27 (25028829) 3
26 (15257358) 2
20 (23928244) 4
35 (23622796) 4
39 (34063687) 2
18 (28186859) 4
36 (-3112870) 4
15 (34794604) 4
14 (29101979) 4
1 (-3195188) 4
Digital breast tomosynthesis diagnostic May be appropriate (Disagreement) Expert Opinion ☢☢ 0.1-1mSv 5 5 2 0 2 1 4 1 1 1 1
References Study Quality
19 (15900139) 4
1 (-3195188) 4
14 (29101979) 4
15 (34794604) 4
36 (-3112870) 4
Mammography diagnostic May be appropriate (Disagreement) Expert Opinion ☢☢ 0.1-1mSv 5 5 2 0 2 1 4 1 1 1 1
References Study Quality
29 (18090814) 4
31 (21427311) 4
20 (23928244) 4
35 (23622796) 4
19 (15900139) 4
1 (-3195188) 4
14 (29101979) 4
15 (34794604) 4
36 (-3112870) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 12 0 1 0 1 0 1 0 0
References Study Quality
1 (-3195188) 4
14 (29101979) 4
15 (34794604) 4
36 (-3112870) 4
Variant 9: Adult age 40 years or older. Female or transfeminine. Evaluation of silicone breast implants. Suspected implant complication. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI breast without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 1 0 1 4 8
References Study Quality
16 (24792659) 4
38 (22430679) 3
29 (18090814) 4
31 (21427311) 4
32 (22328687) 2
37 (21364405) M
35 (23622796) 4
28 (15664285) 2
27 (25028829) 3
26 (15257358) 2
1 (-3195188) 4
US breast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 1 0 1 7 1 2 2 0
References Study Quality
29 (18090814) 4
30 (23623260) 4
31 (21427311) 4
32 (22328687) 2
33 (23668948) 3
34 (19054000) 3
27 (25028829) 3
26 (15257358) 2
20 (23928244) 4
35 (23622796) 4
39 (34063687) 2
36 (-3112870) 4
15 (34794604) 4
14 (29101979) 4
1 (-3195188) 4
Digital breast tomosynthesis diagnostic May be appropriate (Disagreement) Expert Opinion ☢☢ 0.1-1mSv 5 5 2 0 1 1 2 1 3 1 2
References Study Quality
29 (18090814) 4
30 (23623260) 4
31 (21427311) 4
20 (23928244) 4
35 (23622796) 4
19 (15900139) 4
36 (-3112870) 4
15 (34794604) 4
14 (29101979) 4
1 (-3195188) 4
Mammography diagnostic May be appropriate (Disagreement) Expert Opinion ☢☢ 0.1-1mSv 5 5 2 0 1 1 2 1 3 1 2
References Study Quality
29 (18090814) 4
30 (23623260) 4
31 (21427311) 4
20 (23928244) 4
35 (23622796) 4
19 (15900139) 4
36 (-3112870) 4
15 (34794604) 4
14 (29101979) 4
1 (-3195188) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 12 0 1 0 1 0 1 0 0
References Study Quality
36 (-3112870) 4
15 (34794604) 4
14 (29101979) 4
1 (-3195188) 4
Variant 10: Adult younger than 30 years of age. Female or transfeminine. Evaluation of unexplained axillary adenopathy. Silicone breast implants (current or prior). 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 Limited O 0 mSv O 0 mSv [ped] 9 9 0 1 0 0 1 0 1 2 10
References Study Quality
30 (23623260) 4
Digital breast tomosynthesis diagnostic Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 2 2 7 3 1 2 1 0 0 0 1
Mammography diagnostic Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 8 2 1 2 2 0 0 0 0
MRI breast without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 1 1 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 10 2 1 0 0 0 0 0 0
Variant 11: Adult 30 to 39 years of age. Female or transfeminine. Evaluation of unexplained axillary adenopathy. Silicone breast implants (current or prior). 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 Limited O 0 mSv O 0 mSv [ped] 9 9 0 1 0 0 1 0 2 3 8
References Study Quality
30 (23623260) 4
39 (34063687) 2
Digital breast tomosynthesis diagnostic Usually appropriate Expert Consensus ☢☢ 0.1-1mSv 8 8 0 0 0 0 0 0 3 6 4
Mammography diagnostic Usually appropriate Expert Consensus ☢☢ 0.1-1mSv 8 8 0 0 0 0 0 0 3 6 4
MRI breast without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 7 4 0 1 1 0 0 0 0
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 6 1 0 0 0 1 0 0
Variant 12: Adult age 40 years or older. Female or transfeminine. Evaluation of unexplained axillary adenopathy. Silicone breast implants (current or prior). 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 Limited O 0 mSv O 0 mSv [ped] 9 9 0 1 0 0 2 0 2 2 8
References Study Quality
30 (23623260) 4
39 (34063687) 2
Digital breast tomosynthesis diagnostic Usually appropriate Expert Consensus ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 3 2 8
Mammography diagnostic Usually appropriate Expert Consensus ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 3 2 8
MRI breast without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 4 0 1 2 0 0 0 0
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 7 4 1 0 0 0 1 0 0
Variant 13: Adult of any age. Female or transfeminine. Suspected breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) (delayed seroma, swelling, mass, pain, but no erythema, warmth, or skin changes that would raise concern for inflammatory breast cancer or mastitis). Breast implant of any type. 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 Limited O 0 mSv O 0 mSv [ped] 9 9 0 1 0 0 0 0 1 2 11
References Study Quality
11 (25073777) 3
49 (26598546) 3
48 (25490539) 4
47 (28402426) 4
46 (26936251) 4
45 (-3195205) 4
44 (21441845) 4
43 (33554880) 4
13 (32302264) 4
9 (33234792) 4
8 (28184418) 4
4 (28918365) 4
Digital breast tomosynthesis diagnostic May be appropriate Limited ☢☢ 0.1-1mSv 5 5 0 0 0 1 8 2 2 0 0
References Study Quality
11 (25073777) 3
13 (32302264) 4
41 (33222158) 4
Mammography diagnostic May be appropriate Limited ☢☢ 0.1-1mSv 5 5 0 0 0 1 8 2 2 0 0
References Study Quality
11 (25073777) 3
13 (32302264) 4
41 (33222158) 4
MRI breast without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 2 2 0 0 4 4 1 0 0
References Study Quality
11 (25073777) 3
9 (33234792) 4
42 (33989039) 4
43 (33554880) 4
MRI breast without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 6 2 2 1 0 0 1 0 1
References Study Quality
13 (32302264) 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.