ACR logo

Appropriateness Criteria

Variant 1: Female. Breast cancer screening. History of cancer, mastectomy side(s), no reconstruction.
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 8 1 3 3 0 0 0 0 0
References Study Quality
20 (23131395) 3
19 (20422455) 3
18 (17354188) 3
16 (8327698) 3
Digital breast tomosynthesis screening Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 11 1 1 0 0 0 1 0 0
Mammography screening Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 10 2 1 0 0 0 1 0 0
References Study Quality
8 (8273633) 4
16 (8327698) 3
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 8 1 3 0 0 1 1 0 0
References Study Quality
17 (29371086) 4
18 (17354188) 3
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 0 0 0 0 1 0 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 0 0 0 1 0 0 0
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 0 0 0 1 0 0 0
Variant 2: Female. Breast cancer screening. History of cancer, autologous reconstruction side(s) with or without implant.
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 May be appropriate Strong ☢☢ 0.1-1mSv 4 4 2 2 2 2 6 0 0 1 0
References Study Quality
23 (24316152) 1
26 (23623721) 1
22 (25058084) 3
21 (24918774) 3
25 (24582915) 1
24 (23175484) 2
Mammography screening May be appropriate Limited ☢☢ 0.1-1mSv 5 5 2 1 1 3 7 0 0 1 0
References Study Quality
28 (25059787) 3
10 (30129903) 4
29 (18539887) 3
27 (12091685) 3
US breast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 0 1 0 0 1 0 0
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 4 3 7 0 1 0 0 0 0
References Study Quality
17 (29371086) 4
30 (26143679) 4
31 (12664117) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 0 1 0 0 1 0 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 0 1 0 0 1 0 0 0
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 2 0 0 0 1 0 0 0
Variant 3: Female. Breast cancer screening. History of cancer, nonautologous (implant) reconstruction sides(s).
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 11 1 1 0 0 0 1 0 0
Digital breast tomosynthesis screening Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 11 1 1 0 0 0 1 0 0
Mammography screening Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 11 1 1 0 0 0 1 0 0
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 7 0 4 0 1 1 1 0 0
References Study Quality
17 (29371086) 4
33 (21337876) 4
34 (30511241) 3
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 0 0 0 0 1 0 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 1 0 0 0 1 0 0 0
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 1 0 0 0 1 0 0 0
Variant 4: Female. Breast cancer screening. High-risk, bilateral prophylactic mastectomy, no reconstruction.
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 0 1 1 0 0 0 0 0
Digital breast tomosynthesis screening Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 12 1 0 1 0 0 0 0 0
Mammography screening Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 12 1 0 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 11 4 0 0 0 0 0 0 0
References Study Quality
35 (31196476) 3
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 0 0 0 0 1 0 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 0 0 0 1 0 0 0
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 0 0 0 1 0 0 0
Variant 5: Female. Breast cancer screening. High-risk, bilateral prophylactic mastectomy with autologous reconstructions.
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 1 0 0 0 0 0 0
Digital breast tomosynthesis screening Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 9 3 0 1 0 0 0 1 0
Mammography screening Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 10 3 0 0 0 0 0 1 0
References Study Quality
10 (30129903) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 7 1 3 1 1 0 0 1 0
References Study Quality
33 (21337876) 4
35 (31196476) 3
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 0 1 0 0 0 0 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 1 0 1 0 0 0 0 0
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 1 0 1 0 0 0 0 0
Variant 6: Female. Breast cancer screening. High-risk, bilateral prophylactic mastectomy with nonautologous (implant) reconstructions.
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 0 1 1 0 0 0 0 0
Digital breast tomosynthesis screening Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 12 2 0 0 0 0 0 0 0
Mammography screening Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 12 2 0 0 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 8 1 3 0 2 0 0 0 0
References Study Quality
33 (21337876) 4
34 (30511241) 3
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 0 1 0 0 0 0 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 1 0 0 0 0 0 0 0
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 1 0 0 0 0 0 0
Variant 7: Female. Palpable lump or clinically significant pain on the side of the mastectomy without reconstruction. 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 1 0 0 0 0 0 0 2 11
References Study Quality
41 (22302210) 3
39 (31039027) 3
Digital breast tomosynthesis diagnostic May be appropriate Limited ☢☢ 0.1-1mSv 5 5 4 0 2 0 8 1 0 0 0
References Study Quality
36 (23620367) 2
37 (23255766) 3
38 (23844366) 3
Mammography diagnostic May be appropriate Limited ☢☢ 0.1-1mSv 5 5 3 1 2 0 8 1 0 0 0
References Study Quality
39 (31039027) 3
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 6 0 4 0 4 0 0 0 0
References Study Quality
18 (17354188) 3
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 0 0 1 0 0 0 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 2 1 0 0 0 0 0 0
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 7 4 3 0 0 0 0 0 0
References Study Quality
40 (20965904) 3
Variant 8: Female. Palpable lump or clinically significant pain on the side of the mastectomy with reconstruction (autologous or nonautologous). 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 1 5 7
References Study Quality
42 (12732703) 4
39 (31039027) 3
Digital breast tomosynthesis diagnostic May be appropriate Limited ☢☢ 0.1-1mSv 5 5 2 0 1 1 9 1 0 0 1
References Study Quality
36 (23620367) 2
37 (23255766) 3
38 (23844366) 3
Mammography diagnostic May be appropriate Limited ☢☢ 0.1-1mSv 5 5 0 1 1 1 10 1 0 0 1
References Study Quality
42 (12732703) 4
39 (31039027) 3
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 4 1 8 0 2 0 0 0 0
References Study Quality
43 (15371609) 4
44 (-3158507) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 0 0 0 1 0 0 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 3 0 0 0 0 0 0 0
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 10 3 0 1 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.