American College of Radiology
ACR Appropriateness Criteria®

Thyroid Disease

Variant 1: Palpable thyroid nodule. Not goiter. Euthyroid. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US thyroid Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 0 0 16
References Study Quality
8 (28372962) 4
16 (26462967) 4
CT neck with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 4 0 3 3 5 1 0 0 0
References Study Quality
7 (25456025) 4
CT neck without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 4 2 2 7 1 0 0 0 0
References Study Quality
7 (25456025) 4
MRI neck without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 7 1 2 3 2 1 1 0 0
MRI neck without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 4 1 7 2 2 0 0 0 0
I-123 radionuclide uptake and scan neck Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 7 5 3 0 2 0 0 0 0
I-131 radionuclide uptake and Tc-99m pertechnetate scan neck Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 2 2 6 6 4 0 1 0 0 0 0
CT neck without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 1 2 1 1 0 1 0 0
References Study Quality
7 (25456025) 4
FDG-PET/CT neck Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 3 0 0 0 0 1 0 0
Variant 2: Suspected goiter. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US thyroid Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 0 0 16
References Study Quality
8 (28372962) 4
16 (26462967) 4
CT neck without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 7 7 1 0 0 1 3 2 6 1 3
References Study Quality
17 (24295043) 4
CT neck with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 0 1 0 2 8 2 1 2 0
References Study Quality
17 (24295043) 4
I-123 radionuclide uptake and scan neck May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 2 2 1 3 8 0 0 0 0
References Study Quality
18 (4685532) 2
16 (26462967) 4
MRI neck without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 1 1 3 6 4 1 0 0 0
MRI neck without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 1 3 1 8 3 0 0 0 0
I-131 radionuclide uptake and Tc-99m pertechnetate scan neck May be appropriate Limited ☢☢☢☢ 10-30 mSv 4 4 5 0 3 4 3 2 0 0 0
References Study Quality
18 (4685532) 2
16 (26462967) 4
CT neck without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 1 2 0 1 0 0 1 0
References Study Quality
17 (24295043) 4
FDG-PET/CT neck Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 0 0 0 0 0 1 0
Variant 3: Thyrotoxicosis. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US thyroid Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 9 9 0 1 0 0 0 1 2 1 12
References Study Quality
19 (27521067) 4
21 (17381355) 4
22 (17437515) 4
23 (16356088) 2
24 (22440986) 4
I-123 radionuclide uptake and scan neck Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 1 0 0 0 2 0 1 6 7
References Study Quality
19 (27521067) 4
25 (26926973) 4
26 (21825836) 4
16 (26462967) 4
I-131 radionuclide uptake and Tc-99m pertechnetate scan neck Usually appropriate Limited ☢☢☢☢ 10-30 mSv 7 7 0 1 0 0 2 2 6 3 3
References Study Quality
19 (27521067) 4
25 (26926973) 4
26 (21825836) 4
16 (26462967) 4
CT neck with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 8 8 0 0 0 0 0 0 0
CT neck without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 7 2 0 3 3 1 1 0 0
MRI neck without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 1 3 3 1 0 0 0 1
MRI neck without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 2 2 1 3 0 0 0 1
CT neck without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 2 1 1 1 0 0 0 1
FDG-PET/CT neck Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 1 0 0 0 0 0 0 1
Variant 4: Primary hypothyroidism. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT neck with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 14 0 1 0 0 0 2 0 0
CT neck without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 13 1 0 1 1 0 0 1 0
CT neck without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 1 1 0 0 0 1
MRI neck without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 1 0 0 0 0 0 1
MRI neck without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 2 0 0 0 0 0 1
FDG-PET/CT neck Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 0 0 0 0 0 0 0 1
I-123 radionuclide uptake and scan neck Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 0 0 0 1 0 0 0 0
I-131 radionuclide uptake and Tc-99m pertechnetate scan neck Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 16 0 0 0 1 0 0 0 0
US thyroid Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 2 0 0 1 0 0 1
Variant 5: Preoperative evaluation of differentiated thyroid cancer.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US thyroid Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 1 0 0 0 0 2 3 11
References Study Quality
28 (14668727) 2
29 (19696304) 2
31 (27007092) 2
30 (18358074) 2
32 (22863305) 2
33 (23554058) 2
CT neck with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 8 8 0 0 0 1 0 0 2 6 8
References Study Quality
16 (26462967) 4
30 (18358074) 2
33 (23554058) 2
32 (22863305) 2
34 (25188202) 4
11 (24295076) 4
12 (22827435) 3
MRI neck without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 1 0 0 0 5 5 2 4 0
CT neck without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 0 0 0 8 8 0 0 0 0
References Study Quality
30 (18358074) 2
33 (23554058) 2
34 (25188202) 4
32 (22863305) 2
11 (24295076) 4
12 (22827435) 3
MRI neck without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 1 0 1 12 2 0 0 0 0
FDG-PET/CT whole body Usually not appropriate Strong ☢☢☢☢ 10-30 mSv 3 3 4 2 7 3 0 0 0 0 0
References Study Quality
35 (16918964) 1
36 (19158200) 1
CT neck without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 2 3 0 2 1 0 0 1
References Study Quality
30 (18358074) 2
33 (23554058) 2
32 (22863305) 2
34 (25188202) 4
I-123 scan whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 1 0 0 1 0 1 0 0
I-131 scan whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 14 1 0 0 0 1 1 0 0
In-111 somatostatin receptor scintigraphy whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 14 2 0 0 0 0 1 0 0
Variant 6: Early imaging after treatment of differentiated thyroid cancer.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US thyroid Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 0 16
References Study Quality
16 (26462967) 4
I-123 scan whole body May be appropriate Limited ☢☢☢ 1-10 mSv 6 6 1 0 0 0 5 8 0 1 1
References Study Quality
16 (26462967) 4
CT neck with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 1 2 3 2 1 5 2 0 0
I-131 scan whole body May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv 5 5 1 0 1 1 8 2 2 1 0
References Study Quality
16 (26462967) 4
MRI neck without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 3 1 3 2 7 0 0 0 0
CT neck without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 3 4 3 6 0 0 0 0 0
MRI neck without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 6 1 2 7 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 2 2 6 3 1 1 5 0 0 0 0
CT neck without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 1 1 0 0 0 0 0 0
In-111 somatostatin receptor scintigraphy whole body Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 1 1 16 0 0 0 0 0 0 0 0
References Study Quality
16 (26462967) 4
Variant 7: Suspected recurrence of differentiated thyroid cancer.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT neck with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 9 9 0 0 0 1 1 0 1 5 9
References Study Quality
29 (19696304) 2
33 (23554058) 2
48 (18408961) 2
11 (24295076) 4
12 (22827435) 3
US thyroid Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 1 0 0 0 1 0 15
References Study Quality
28 (14668727) 2
I-123 scan whole body Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 0 0 0 0 2 2 2 10 0
References Study Quality
16 (26462967) 4
40 (22310247) 2
41 (11139058) 4
MRI neck without and with IV contrast Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 4 2 8 1 0
CT chest with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 3 2 8 3 0 0
References Study Quality
16 (26462967) 4
CT chest without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 3 3 7 3 0 0
References Study Quality
16 (26462967) 4
FDG-PET/CT whole body May be appropriate Strong ☢☢☢☢ 10-30 mSv 6 6 0 0 1 1 3 7 4 0 1
References Study Quality
6 (21118976) 2
49 (21220972) 4
50 (22985118) 2
36 (19158200) 1
I-131 scan whole body May be appropriate Limited ☢☢☢☢ 10-30 mSv 6 6 0 0 0 1 3 8 4 0 0
References Study Quality
16 (26462967) 4
40 (22310247) 2
41 (11139058) 4
CT neck without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 1 0 2 2 7 3 1 0 0
References Study Quality
29 (19696304) 2
33 (23554058) 2
48 (18408961) 2
MRI neck without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 1 0 0 5 9 0 1 0 0
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 1 0 0 2 0 0 0 0
References Study Quality
16 (26462967) 4
CT neck without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 0 0 0 0 0 0 0
References Study Quality
29 (19696304) 2
33 (23554058) 2
48 (18408961) 2
In-111 somatostatin receptor scintigraphy whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 14 2 0 0 0 0 1 0 0
Variant 8: Suspected recurrence of medullary thyroid cancers.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US thyroid Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 1 0 0 1 0 15
References Study Quality
51 (12771918) 3
52 (25368270) 3
53 (17726071) 1
CT neck with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 8 8 0 0 1 0 1 0 0 8 7
References Study Quality
52 (25368270) 3
54 (25810047) 4
CT chest with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 3 5 2 5 1
References Study Quality
53 (17726071) 1
MRI neck without and with IV contrast Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 3 2 9 1 2
CT abdomen with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 1 0 1 6 8 0 0 0
References Study Quality
54 (25810047) 4
CT abdomen without and with IV contrast May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 6 6 1 0 0 0 3 11 1 0 0
References Study Quality
54 (25810047) 4
MRI abdomen without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 5 7 4 0 0
References Study Quality
53 (17726071) 1
55 (27682648) 4
56 (26494385) 4
MRI complete spine without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 2 7 5 3 0
References Study Quality
53 (17726071) 1
57 (15572422) 4
Tc-99m bone scan whole body May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 1 4 8 3 1 0
References Study Quality
16 (26462967) 4
CT chest without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 4 4 5 2 0 0
References Study Quality
53 (17726071) 1
CT neck without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 1 0 2 5 7 1 0 0 0
References Study Quality
52 (25368270) 3
54 (25810047) 4
MRI abdomen without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 3 1 1 3 7 2 0 0 0
References Study Quality
53 (17726071) 1
55 (27682648) 4
56 (26494385) 4
MRI complete spine without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 3 10 3 0 0 0
References Study Quality
53 (17726071) 1
57 (15572422) 4
FDG-PET/CT whole body May be appropriate Strong ☢☢☢☢ 10-30 mSv 5 5 1 0 0 2 7 4 3 0 0
References Study Quality
58 (22527889) Good
59 (18375923) 1
60 (17401085) 2
61 (11801705) 3
62 (17892923) 4
63 (19156423) 4
64 (22223169) 2
65 (23081996) 3
MRI neck without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 1 0 0 9 3 3 0 0 0
CT abdomen without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 2 10 1 1 0 0 0 0
References Study Quality
54 (25810047) 4
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 2 0 0 0 0 0 0
References Study Quality
53 (17726071) 1
CT neck without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 1 1 0 0 0 0 0 0
I-123 scan whole body Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 11 3 2 0 0 0 1 0 0
References Study Quality
61 (11801705) 3
62 (17892923) 4
66 (8683310) 4
I-131 scan whole body Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 1 1 11 2 3 0 0 0 0 1 0
References Study Quality
61 (11801705) 3
62 (17892923) 4
66 (8683310) 4
Ga-68 DOTATATE PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 1 1 9 1 6 0 0 0 0 0 0
References Study Quality
67 (25369749) 3
69 (28429044) 2
In-111 somatostatin receptor scintigraphy whole body Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 1 1 11 3 1 0 2 0 0 0 0
References Study Quality
61 (11801705) 3
66 (8683310) 4
62 (17892923) 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.