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Appropriateness Criteria

Variant 1: Breast cancer screening during lactation. 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 screening Usually appropriate Limited ☢☢ 0.1-1mSv 8 8 0 1 0 0 4 1 1 2 7
References Study Quality
10 (23345354) 4
9 (18180221) 4
7 (24485752) 3
13 (23881348) 4
14 (15960763) 2
24 (21382187) 4
38 (17189838) 4
37 (29101979) 4
Mammography screening Usually appropriate Limited ☢☢ 0.1-1mSv 8 8 1 0 0 0 5 0 2 4 4
References Study Quality
10 (23345354) 4
9 (18180221) 4
7 (24485752) 3
13 (23881348) 4
14 (15960763) 2
24 (21382187) 4
38 (17189838) 4
37 (29101979) 4
US breast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 1 1 2 8 4 0 0 0
References Study Quality
39 (25329763) 3
40 (23116728) 2
MRI breast without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 5 2 3 0 4 2 0 0 0
References Study Quality
10 (23345354) 4
33 (-3132600) 4
3 (17872711) 4
7 (24485752) 3
34 (16244250) 3
35 (12752635) 4
41 (23062742) 4
42 (10924585) 3
38 (17189838) 4
19 (28609163) 2
MRI breast without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 15 0 1 0 0 0 0 0 0
References Study Quality
10 (23345354) 4
33 (-3132600) 4
3 (17872711) 4
7 (24485752) 3
34 (16244250) 3
35 (12752635) 4
41 (23062742) 4
42 (10924585) 3
38 (17189838) 4
19 (28609163) 2
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 0 0 0 0 0 0 0
Variant 2: Breast cancer screening during pregnancy. Age younger than 30 at high risk. 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 screening Usually appropriate Limited ☢☢ 0.1-1mSv 7 7 1 0 0 0 3 3 3 3 3
References Study Quality
28 (21343518) 3
44 (-3112876) 4
7 (24485752) 3
24 (21382187) 4
25 (21782123) 4
26 (12751860) 3
27 (8134581) 3
43 (22403117) 4
45 (9653462) 4
Mammography screening Usually appropriate Limited ☢☢ 0.1-1mSv 7 7 0 0 0 0 2 0 8 2 4
References Study Quality
28 (21343518) 3
44 (-3112876) 4
7 (24485752) 3
24 (21382187) 4
25 (21782123) 4
26 (12751860) 3
27 (8134581) 3
43 (22403117) 4
45 (9653462) 4
US breast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 1 1 10 4 0 0 0
References Study Quality
10 (23345354) 4
9 (18180221) 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
33 (-3132600) 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
33 (-3132600) 4
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 0 0 0 0 0 0 0
Variant 3: Breast cancer screening during pregnancy. Age 30 to 39 years at elevated risk (intermediate or high risk). 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 screening Usually appropriate Limited ☢☢ 0.1-1mSv 7 7 1 0 0 0 1 4 3 3 4
References Study Quality
28 (21343518) 3
44 (-3112876) 4
7 (24485752) 3
24 (21382187) 4
25 (21782123) 4
26 (12751860) 3
27 (8134581) 3
43 (22403117) 4
45 (9653462) 4
Mammography screening Usually appropriate Limited ☢☢ 0.1-1mSv 7 7 0 0 0 0 1 1 7 3 4
References Study Quality
28 (21343518) 3
44 (-3112876) 4
7 (24485752) 3
24 (21382187) 4
25 (21782123) 4
26 (12751860) 3
27 (8134581) 3
43 (22403117) 4
45 (9653462) 4
US breast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 1 1 2 10 2 0 0 0
References Study Quality
10 (23345354) 4
9 (18180221) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 16 0 0 0 0 0 0 0 0
References Study Quality
33 (-3132600) 4
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 16 0 0 0 0 0 0 0 0
References Study Quality
33 (-3132600) 4
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 0 0 0 0 0 0 0 0
Variant 4: Breast cancer screening during pregnancy. Age 40 years or older, any risk level. 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 screening Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 1 0 0 2 13
References Study Quality
28 (21343518) 3
44 (-3112876) 4
7 (24485752) 3
24 (21382187) 4
25 (21782123) 4
26 (12751860) 3
27 (8134581) 3
43 (22403117) 4
45 (9653462) 4
Mammography screening Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 1 0 1 3 11
References Study Quality
28 (21343518) 3
44 (-3112876) 4
7 (24485752) 3
24 (21382187) 4
25 (21782123) 4
26 (12751860) 3
27 (8134581) 3
43 (22403117) 4
45 (9653462) 4
US breast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 1 1 3 1 8 2 0 0 0
References Study Quality
10 (23345354) 4
9 (18180221) 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
33 (-3132600) 4
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 16 0 0 0 0 0 0 0 0
References Study Quality
28 (21343518) 3
44 (-3112876) 4
7 (24485752) 3
24 (21382187) 4
25 (21782123) 4
26 (12751860) 3
27 (8134581) 3
43 (22403117) 4
45 (9653462) 4
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 0 0 0 0 0 0 0 0
Variant 5: Pregnant women with a palpable breast mass. 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 0 0 0 0 0 0 16
References Study Quality
10 (23345354) 4
9 (18180221) 4
44 (-3112876) 4
7 (24485752) 3
23 (15969981) 4
24 (21382187) 4
25 (21782123) 4
26 (12751860) 3
46 (16311748) 3
47 (16502483) 4
36 (28473077) 4
Digital breast tomosynthesis diagnostic May be appropriate Limited ☢☢ 0.1-1mSv 5 5 0 0 0 0 9 5 2 0 0
References Study Quality
28 (21343518) 3
44 (-3112876) 4
7 (24485752) 3
24 (21382187) 4
25 (21782123) 4
26 (12751860) 3
27 (8134581) 3
43 (22403117) 4
Mammography diagnostic May be appropriate Limited ☢☢ 0.1-1mSv 5 5 0 0 0 0 10 4 1 1 0
References Study Quality
28 (21343518) 3
44 (-3112876) 4
7 (24485752) 3
24 (21382187) 4
25 (21782123) 4
26 (12751860) 3
27 (8134581) 3
43 (22403117) 4
Image-guided core biopsy breast Usually not appropriate Expert Consensus Varies Varies 1 1 12 1 1 0 0 2 0 0 0
Image-guided fine needle aspiration breast Usually not appropriate Expert Consensus Varies Varies 1 1 12 1 2 1 0 0 0 0 0
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 16 0 0 0 0 0 0 0 0
References Study Quality
33 (-3132600) 4
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 15 0 0 0 1 0 0 0 0
References Study Quality
33 (-3132600) 4
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 0 0 0 1 0 0 0 0
Variant 6: Clinically suspicious nipple discharge during pregnancy. 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 0 0 0 1 0 3 12
References Study Quality
48 (-3112883) 4
Digital breast tomosynthesis diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 7 7 0 0 0 0 3 4 4 3 2
References Study Quality
28 (21343518) 3
44 (-3112876) 4
7 (24485752) 3
24 (21382187) 4
25 (21782123) 4
43 (22403117) 4
Mammography diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 7 7 0 0 0 0 3 4 3 4 2
References Study Quality
28 (21343518) 3
44 (-3112876) 4
7 (24485752) 3
24 (21382187) 4
25 (21782123) 4
43 (22403117) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 16 0 0 0 0 0 0 0 0
References Study Quality
33 (-3132600) 4
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 16 0 0 0 0 0 0 0 0
References Study Quality
33 (-3132600) 4
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 0 0 0 0 0 0 0 0
Variant 7: Locoregional staging of newly diagnosed breast cancer during pregnancy. 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 2 1 1 1 11
References Study Quality
51 (16484353) 3
Digital breast tomosynthesis diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 1 0 0 0 0 1 2 12
References Study Quality
44 (-3112876) 4
43 (22403117) 4
Mammography diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 1 1 0 0 0 2 12
References Study Quality
44 (-3112876) 4
43 (22403117) 4
US breast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 3 2 6 1 2 1 1 0 0
References Study Quality
25 (21782123) 4
51 (16484353) 3
52 (27955877) 2
54 (25013439) 3
53 (15486214) 3
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 15 0 1 0 0 0 0 0 0
References Study Quality
33 (-3132600) 4
19 (28609163) 2
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 15 0 0 0 0 0 1 0 0
References Study Quality
33 (-3132600) 4
19 (28609163) 2
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 0 1 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.