American College of Radiology
ACR Appropriateness Criteria®

Follow-up of Malignant or Aggressive Musculoskeletal Tumors

Variant 1: Lower-risk patient (low grade). Evaluation for metastatic disease to the lung from musculoskeletal primary. Baseline examination at time of diagnosis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT chest without IV contrast Usually appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body May be appropriate ☢☢☢☢ 10-30 mSv 5 n/a 0 0 0 0 0 0 0 0 0
Radiography chest Usually not appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
CT chest without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT chest with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Lower-risk patient (low grade). Evaluation for metastatic disease to the lung from musculoskeletal primary. Follow-up examination 3–6 months after treatment or surgery.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT chest without IV contrast Usually appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body May be appropriate ☢☢☢☢ 10-30 mSv 4 n/a 0 0 0 0 0 0 0 0 0
Radiography chest Usually not appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
CT chest without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT chest with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Higher-risk patient (high grade). Evaluation for metastatic disease to the lung from musculoskeletal primary. Baseline examination at time of diagnosis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest Usually not appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually appropriate ☢☢☢☢ 10-30 mSv 7 n/a 0 0 0 0 0 0 0 0 0
CT chest without IV contrast Usually appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
CT chest without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT chest with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Higher-risk patient (high grade). Evaluation for metastatic disease to the lung from musculoskeletal primary. Follow-up examination 3–6 months after treatment or surgery.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest Usually not appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body May be appropriate ☢☢☢☢ 10-30 mSv 5 n/a 0 0 0 0 0 0 0 0 0
CT chest without IV contrast Usually appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
CT chest without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT chest with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Evaluation for osseous metastatic disease from musculoskeletal primary. Asymptomatic. Baseline and follow-up examination.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
FDG-PET/CT whole body Usually not appropriate ☢☢☢☢ 10-30 mSv 2 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan whole body Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
MRI whole body without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
MRI whole body without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
Variant 6: Evaluation for osseous metastatic disease from musculoskeletal primary. Symptomatic. Baseline and follow-up examination.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Tc-99m bone scan whole body May be appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
MRI whole body without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
MRI whole body without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually appropriate ☢☢☢☢ 10-30 mSv 7 n/a 0 0 0 0 0 0 0 0 0
Variant 7: Osseous tumor, without significant hardware present. Local recurrence.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT area of interest with IV contrast Usually not appropriate Varies Varies Varies 3 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast May be appropriate Varies Varies Varies 4 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without IV contrast May be appropriate Varies Varies Varies 4 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body May be appropriate ☢☢☢☢ 10-30 mSv 4 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
US area of interest Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Radiography area of interest Usually appropriate Varies Varies Varies 9 n/a 0 0 0 0 0 0 0 0 0
Variant 8: Osseous tumor, with significant hardware present. Local recurrence.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT area of interest with IV contrast May be appropriate Varies Varies Varies 5 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Varies Varies Varies 2 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without IV contrast May be appropriate Varies Varies Varies 5 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body May be appropriate ☢☢☢☢ 10-30 mSv 5 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
US area of interest Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
Radiography area of interest Usually appropriate Varies Varies Varies 9 n/a 0 0 0 0 0 0 0 0 0
Variant 9: Soft-tissue tumors. Local recurrence surveillance. Follow-up examination 3–6 months after treatment or surgery.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI area of interest without and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body May be appropriate ☢☢☢☢ 10-30 mSv 6 n/a 0 0 0 0 0 0 0 0 0
CT area of interest with IV contrast May be appropriate Varies Varies Varies 5 n/a 0 0 0 0 0 0 0 0 0
US area of interest May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Varies Varies Varies 2 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without IV contrast Usually not appropriate Varies Varies Varies 2 n/a 0 0 0 0 0 0 0 0 0
Radiography area of interest Usually not appropriate Varies Varies Varies 2 n/a 0 0 0 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.