ACR Appropriateness

Question 1

Breast Cancer Screening:

Variant 1: High risk women

Who does this include?

Answer 1

BRCA
(+ untested 1st degree relatives),
History of chest radiation,
Risk model shows 20% or greater lifetime risk

Question 2

Breast Cancer Screening:

Variant 1: High risk women

What imaging appropriate? (And #)

Answer 2

Mammo (9)
Tomo (9)
MRI (9)

Question 3

Breast Cancer Screening:

Variant 1: High risk women

When start screening exams?

Answer 3

• Beginning at age 25-30, OR
• 10 years before age of first degree relative with breast cancer
• 8 years after radiation therapy (but not before age 25)

Question 4

Breast Cancer Screening:

Variant 1: High risk women

Should you do mammography AND MRI?

Answer 4

Yes. They are complementary exams and both should be performed.

Question 5

Breast Cancer Screening:

Variant 2: Medium risk women

Who fits this category?

Answer 5

• personal history of breast CA
• lobular hyperplasia,
• atypical ductal hyperplasia, or
• risk model shows 15-20% lifetime risk

Question 6

Breast Cancer Screening:

Variant 2: Medium risk women

What imaging (and appropriateness score)?

Answer 6

Mammo (9)
Tomo (9)
MRI (7)*****

Mammography + MRI? They are complementary exams, MRI should NOT replace mammography.

Question 7

Breast Cancer Screening:

Variant 3: Average risk women

Who?

Answer 7

<15% lifetime risk

Question 8

Breast Cancer Screening:

Variant 3: Average risk women

Imaging (and appropriateness score)?

Answer 8

Mammo (9)
Tomo (9)

MRI is a 3–NOT appropriate

Question 9

Breast Pain

Variant 1: Cyclical, Unilateral or Bilateral, Age < 40

Imaging (and scores)?

Answer 9

No imaging is appropriate!!

Ultrasound is least inappropriate, and it’s a 2..

Question 10

Breast Pain:

Variant 2: Cyclical, Unilateral or Bilateral, Age > 40

Imaging (and score)?

Answer 10

No imaging is appropriate!!!

Ultrasound, mammo, and tomo are the least inappropriate and are all 2s…

Question 11

Breast Pain:

Variant 3: NON-Cyclical, Unilateral or Bilateral, Age < 40

Imaging (and score)?

Answer 11

Ultrasound (5)

Might be appropriate

Question 12

Stage 1 Breast CA: Initial workup and surveillance (NO symptoms)

Newly diagnosed: rule out mets to bone, chest, liver, and/or brain

Imaging ?

Answer 12

NO imaging is appropriate

CT, MRI, PET, etc…not indicated with initial stage 1

Question 13

Stage 1 Breast CA: Initial workup and surveillance (NO symptoms)

Surveillance—rule out local recurrence

Imaging (and scores)?

Answer 13

Diagnostic Mammo or Tomo (9)

Ultrasound (5)—maybe
MRI (5)—maybe

Question 14

Symptomatic Male Breast:

Variant 1: Any age, physical exam + history consistent with gynecomastia or pseudogynecomastia

Imaging?

Answer 14

NO imaging is appropriate

Question 15

Symptomatic Male Breast:

Variant 2: Age <25, with indeterminate palpable

Imaging?

Answer 15

Ultrasound (8)

Mammo (5)—maybe
only if Ultrasound doesn’t answer your question

Question 16

Symptomatic Male Breast:

Variant 3: Age>25, with indeterminate palpable

Imaging?

Answer 16

Mammo (8)

Ultrasound (5)—maybe

(Note: opposite of same issue in age<25)

Question 17

Symptomatic Male Breast:

Variant 4: Age >25, with indeterminate palpable. Mammogram indeterminate or suspicious.

Imaging?

Answer 17

Ultrasound (9)

Question 18

Symptomatic Male Breast:

Variant 5: Physical Exam highly concerning for cancer. (Dude has ulcerative mass, axillary nodes, nipple retraction, etc…)

Imaging?

Answer 18

Mammo (9)

Ultrasound (8)—to stage breast and axilla just like female breast CA workup.

Question 19

Woman >40 with palpable

Imaging?

Answer 19

Mammo (9)

Question 20

Woman >40, mammo suspicious for CA

Imaging?

Answer 20

Ultrasound (9)

Question 21

Woman >40, mammo findings of lipoma at site of palpable

Imaging?

Answer 21

NO imaging appropriate

Question 22

Woman >40 with palpable, mammo negative

Imaging?

Answer 22

Ultrasound (9)

Question 23

Woman <30, initial evaluation

Imaging?

Answer 23

Ultrasound (9)

Question 24

Woman 30-39, initial evaluation

Imaging?

Answer 24

Ultrasound (8)

Mammo (8)

Question 25

Woman <30, Ultrasound suspicious for CA

Imaging?

Answer 25

Core Biopsy (9)
Mammo (8)

Question 26

Woman <30, Ultrasound negative

Imaging?

Answer 26

NO imaging is appropriate

Question 27

Woman <30, Ultrasound has a B9 finding (like a cyst)

Imaging?

Answer 27

NO imaging is appropriate

Question 28

Woman <30, Ultrasoundis BR3 able—example fibroadenoma

Imaging?

Answer 28

Short interval follow-up—usually q6 months x 2 years