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Variant 1: Evaluation of saline breast implants. Asymptomatic patient. Any age. 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 15 0 0 0 0 0 0 1 0
Digital breast tomosynthesis screening Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 15 0 1 0 0 0 0 0 0
References Study Quality
21 (29101979) 4
Mammography screening Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 15 0 0 0 1 0 0 0 0
References Study Quality
21 (29101979) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 15 1 0 0 0 0 0 0 0
References Study Quality
22 (24792659) 4
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 15 1 0 0 0 0 0 0 0
References Study Quality
22 (24792659) 4
Variant 2: Evaluation of saline breast implants. Clinical examination equivocal for implant rupture. Age younger than 30 years. 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 Expert Consensus O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 1 0 1 4 10
Digital breast tomosynthesis diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 3 3 3 4 3 2 3 1 0 0 0
References Study Quality
22 (24792659) 4
23 (16579024) 4
Mammography diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 3 3 3 4 3 3 2 1 0 0 0
References Study Quality
22 (24792659) 4
23 (16579024) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 14 1 0 0 0 0 0 1 0
References Study Quality
22 (24792659) 4
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 0 0 0 1 0
References Study Quality
22 (24792659) 4
Variant 3: Evaluation of saline breast implants. Clinical examination equivocal for implant rupture. Age 30-39 years. 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 Expert Consensus O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 0 4 4 7
Digital breast tomosynthesis diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 8 8 0 0 1 0 2 0 4 4 5
References Study Quality
22 (24792659) 4
23 (16579024) 4
Mammography diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 8 8 0 0 0 2 1 0 5 3 5
References Study Quality
22 (24792659) 4
23 (16579024) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 14 1 0 0 0 0 1 0 0
References Study Quality
22 (24792659) 4
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 14 1 0 0 0 0 0 1 0
References Study Quality
22 (24792659) 4
Variant 4: Evaluation of saline breast implants. Clinical examination equivocal for implant rupture. Age 40 years or older. 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 9 9 0 0 1 0 1 0 0 3 11
References Study Quality
22 (24792659) 4
23 (16579024) 4
Mammography diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 1 1 0 0 4 10
References Study Quality
22 (24792659) 4
23 (16579024) 4
US breast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 0 0 1 1 9 4 0 1 0
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 0 0 0 1 0
References Study Quality
22 (24792659) 4
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 0 0 0 1 0
References Study Quality
22 (24792659) 4
Variant 5: Evaluation of silicone breast implants. Asymptomatic patient. Any age. 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 3 1 0 0 0 0 1 0
References Study Quality
25 (22743887) 4
7 (18090814) 4
8 (23623260) 4
9 (21427311) 4
13 (25028829) 3
24 (23928244) 4
Digital breast tomosynthesis screening Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 13 1 0 0 2 0 0 0 0
References Study Quality
21 (29101979) 4
Mammography screening Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 13 1 1 0 1 0 0 0 0
References Study Quality
21 (29101979) 4
MRI breast without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 11 2 1 0 1 0 1 0 0
References Study Quality
13 (25028829) 3
14 (15257358) 2
15 (15664285) 2
18 (21364405) M
26 (18349629) 4
27 (17898620) 2
29 (16874191) 3
28 (17051096) 3
30 (22751081) 1
21 (29101979) 4
MRI breast without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 9 3 2 0 1 0 0 1 0
References Study Quality
13 (25028829) 3
14 (15257358) 2
15 (15664285) 2
18 (21364405) M
26 (18349629) 4
27 (17898620) 2
29 (16874191) 3
28 (17051096) 3
30 (22751081) 1
21 (29101979) 4
Variant 6: Evaluation of silicone breast implants. Suspected implant complication. Age younger than 30 years. 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 1 0 2 0 5 1 7
References Study Quality
25 (22743887) 4
7 (18090814) 4
8 (23623260) 4
9 (21427311) 4
10 (22328687) 2
11 (23668948) 3
12 (19054000) 3
13 (25028829) 3
14 (15257358) 2
24 (23928244) 4
31 (23622796) 4
MRI breast without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 1 0 2 4 8
References Study Quality
22 (24792659) 4
19 (22430679) 3
7 (18090814) 4
9 (21427311) 4
10 (22328687) 2
13 (25028829) 3
14 (15257358) 2
15 (15664285) 2
18 (21364405) M
31 (23622796) 4
Digital breast tomosynthesis diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 10 1 3 1 0 1 0 0 0
References Study Quality
7 (18090814) 4
8 (23623260) 4
9 (21427311) 4
24 (23928244) 4
31 (23622796) 4
Mammography diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 10 2 1 1 1 1 0 0 0
References Study Quality
7 (18090814) 4
8 (23623260) 4
9 (21427311) 4
24 (23928244) 4
31 (23622796) 4
MRI breast without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 1 0 0 0 0
References Study Quality
22 (24792659) 4
19 (22430679) 3
7 (18090814) 4
9 (21427311) 4
10 (22328687) 2
13 (25028829) 3
14 (15257358) 2
15 (15664285) 2
18 (21364405) M
31 (23622796) 4
Variant 7: Evaluation of silicone breast implants. Suspected implant complication. Age 30-39 years. 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] 7 7 0 0 0 0 3 1 5 1 6
References Study Quality
25 (22743887) 4
7 (18090814) 4
8 (23623260) 4
9 (21427311) 4
10 (22328687) 2
11 (23668948) 3
12 (19054000) 3
13 (25028829) 3
14 (15257358) 2
24 (23928244) 4
31 (23622796) 4
Digital breast tomosynthesis diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 7 7 0 0 0 0 1 1 9 2 3
References Study Quality
7 (18090814) 4
8 (23623260) 4
9 (21427311) 4
24 (23928244) 4
31 (23622796) 4
Mammography diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 7 7 0 0 1 1 3 2 3 3 3
References Study Quality
7 (18090814) 4
8 (23623260) 4
9 (21427311) 4
24 (23928244) 4
31 (23622796) 4
MRI breast without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 1 0 0 1 1 3 9
References Study Quality
22 (24792659) 4
19 (22430679) 3
7 (18090814) 4
9 (21427311) 4
10 (22328687) 2
18 (21364405) M
31 (23622796) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 12 3 0 0 0 0 1 0 0
References Study Quality
22 (24792659) 4
19 (22430679) 3
7 (18090814) 4
9 (21427311) 4
10 (22328687) 2
18 (21364405) M
31 (23622796) 4
Variant 8: Evaluation of silicone breast implants. Suspected implant complication. Age 40 years or older. 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 0 0 0 1 7 4 4
References Study Quality
7 (18090814) 4
8 (23623260) 4
9 (21427311) 4
24 (23928244) 4
31 (23622796) 4
Mammography diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 7 7 0 0 1 1 3 0 4 3 4
References Study Quality
7 (18090814) 4
8 (23623260) 4
9 (21427311) 4
24 (23928244) 4
31 (23622796) 4
MRI breast without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 1 3 2 9
References Study Quality
22 (24792659) 4
19 (22430679) 3
7 (18090814) 4
9 (21427311) 4
10 (22328687) 2
18 (21364405) M
31 (23622796) 4
US breast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 0 2 0 6 0 6 0 1
References Study Quality
25 (22743887) 4
7 (18090814) 4
8 (23623260) 4
9 (21427311) 4
10 (22328687) 2
11 (23668948) 3
12 (19054000) 3
13 (25028829) 3
14 (15257358) 2
24 (23928244) 4
31 (23622796) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 12 3 0 0 0 1 0 0 0
References Study Quality
22 (24792659) 4
19 (22430679) 3
7 (18090814) 4
9 (21427311) 4
10 (22328687) 2
18 (21364405) M
31 (23622796) 4
Variant 9: Evaluation of unexplained axillary adenopathy. Silicone breast implants (current or prior). Age younger than 30 years. 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 1 0 1 14
References Study Quality
8 (23623260) 4
Digital breast tomosynthesis diagnostic Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 2 2 4 5 3 2 2 0 0 0 0
Mammography diagnostic Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 2 2 5 5 2 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 3 0 1 1 0 0 1 0
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 4 3 0 0 1 0 1 0
Variant 10: Evaluation of unexplained axillary adenopathy. Silicone breast implants (current or prior). Age 30-39 years. 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 1 3 0 12
References Study Quality
8 (23623260) 4
Digital breast tomosynthesis diagnostic Usually appropriate Expert Consensus ☢☢ 0.1-1mSv 9 9 0 0 1 0 2 1 3 1 8
Mammography diagnostic Usually appropriate Expert Consensus ☢☢ 0.1-1mSv 9 9 0 0 1 1 2 0 3 1 8
MRI breast without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 3 0 2 1 0 0 1 0
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 5 2 0 0 1 0 1 0
Variant 11: Evaluation of unexplained axillary adenopathy. Silicone breast implants (current or prior). Age 40 years or older. 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 1 1 4 10
References Study Quality
8 (23623260) 4
Digital breast tomosynthesis diagnostic Usually appropriate Expert Consensus ☢☢ 0.1-1mSv 9 9 0 0 1 0 1 0 1 1 12
Mammography diagnostic Usually appropriate Expert Consensus ☢☢ 0.1-1mSv 9 9 0 0 0 1 1 0 1 2 11
MRI breast without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 4 0 1 1 0 0 1 0
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 5 2 0 0 1 0 1 0
Variant 12: 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). Any age. 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 0 1 0 0 0 1 2 12
References Study Quality
1 (25073777) 3
Digital breast tomosynthesis diagnostic May be appropriate Limited ☢☢ 0.1-1mSv 5 5 0 0 1 2 7 4 1 0 1
References Study Quality
1 (25073777) 3
Mammography diagnostic May be appropriate (Disagreement) Expert Opinion ☢☢ 0.1-1mSv 5 5 0 0 2 2 6 4 1 0 1
References Study Quality
1 (25073777) 3
MRI breast without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 2 1 5 1 3 2 1 1 0
References Study Quality
1 (25073777) 3
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 9 5 1 0 0 0 0 1 0
References Study Quality
1 (25073777) 3
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.