Preview

Variant: 1 Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Known breast cancer. Initial determination of tumor size and extent within the breast prior to neoadjuvant chemotherapy. Initial imaging.

Procedure	Appropriateness Category
US breast	Usually Appropriate
Digital breast tomosynthesis diagnostic	Usually Appropriate
Mammography diagnostic	Usually Appropriate
MRI breast without and with IV contrast	Usually Appropriate
MRI breast without IV contrast	Usually Not Appropriate
Sestamibi MBI	Usually Not Appropriate
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate

Variant: 2 Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Known breast cancer. Imaging of the breast after initiation or completion of neoadjuvant chemotherapy. Initial imaging.

Procedure	Appropriateness Category
US breast	Usually Appropriate
Digital breast tomosynthesis diagnostic	Usually Appropriate
Mammography diagnostic	Usually Appropriate
MRI breast without and with IV contrast	Usually Appropriate
MRI breast without IV contrast	Usually Not Appropriate
Sestamibi MBI	Usually Not Appropriate
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate

Variant: 3 Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Known breast cancer, clinically node-negative. Axillary evaluation prior to neoadjuvant chemotherapy. Initial imaging.

Procedure	Appropriateness Category
US axilla	Usually Appropriate
US-guided core biopsy axillary node	Usually Not Appropriate
US-guided fine needle aspiration biopsy axillary node	Usually Not Appropriate
Digital breast tomosynthesis diagnostic	Usually Not Appropriate
Mammography diagnostic	Usually Not Appropriate
MRI breast without and with IV contrast	Usually Not Appropriate
MRI breast without IV contrast	Usually Not Appropriate
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate

Variant: 4 Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Known breast cancer, clinically node-positive. Axillary evaluation prior to neoadjuvant chemotherapy. Initial imaging.

Procedure	Appropriateness Category
US axilla	Usually Appropriate
MRI breast without and with IV contrast	May Be Appropriate
FDG-PET/CT skull base to mid-thigh	May Be Appropriate
US-guided core biopsy axillary node	Usually Not Appropriate
US-guided fine needle aspiration biopsy axillary node	Usually Not Appropriate
Digital breast tomosynthesis diagnostic	Usually Not Appropriate
Mammography diagnostic	Usually Not Appropriate
MRI breast without IV contrast	Usually Not Appropriate

Variant: 5 Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Known breast cancer, clinically node-negative. Axillary evaluation after completion of neoadjuvant chemotherapy, axilla not previously evaluated. Initial imaging.

Procedure	Appropriateness Category
US axilla	Usually Not Appropriate
US-guided core biopsy axillary node	Usually Not Appropriate
US-guided fine needle aspiration biopsy axillary node	Usually Not Appropriate
Digital breast tomosynthesis diagnostic	Usually Not Appropriate
Mammography diagnostic	Usually Not Appropriate
MRI breast without and with IV contrast	Usually Not Appropriate
MRI breast without IV contrast	Usually Not Appropriate
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate

Variant: 6 Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Known breast cancer with clinical suspicion of metastatic disease. Staging or assessment of response to neoadjuvant chemotherapy. Initial imaging.

Procedure	Appropriateness Category
Bone scan whole body	Usually Appropriate
CT chest abdomen pelvis with IV contrast	Usually Appropriate
FDG-PET/CT skull base to mid-thigh	Usually Appropriate
MRI chest abdomen pelvis without and with IV contrast	Usually Not Appropriate
MRI chest abdomen pelvis without IV contrast	Usually Not Appropriate
CT chest abdomen pelvis without and with IV contrast	Usually Not Appropriate
CT chest abdomen pelvis without IV contrast	Usually Not Appropriate

Variant: 7 Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Known axillary lymph node-positive breast cancer on prior mammography, US, or MRI. Axillary evaluation after completion of neoadjuvant chemotherapy, axilla previously evaluated. Next imaging study.

Procedure	Appropriateness Category
US axilla	Usually Appropriate
US breast	Usually Not Appropriate
US-guided core biopsy axillary node	Usually Not Appropriate
US-guided fine needle aspiration biopsy axillary node	Usually Not Appropriate
Digital breast tomosynthesis diagnostic	Usually Not Appropriate
Mammography diagnostic	Usually Not Appropriate
MRI breast without and with IV contrast	Usually Not Appropriate
MRI breast without IV contrast	Usually Not Appropriate
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate

Variant: 8 Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Known breast cancer. Axillary imaging suspicious for metastatic disease on mammography, US, or MRI during initial evaluation. Next imaging study.

Procedure	Appropriateness Category
US-guided core biopsy axillary node	Usually Appropriate
US-guided fine needle aspiration biopsy axillary node	Usually Appropriate
Digital breast tomosynthesis diagnostic	Usually Not Appropriate
Mammography diagnostic	Usually Not Appropriate
MRI breast without and with IV contrast	Usually Not Appropriate
MRI breast without IV contrast	Usually Not Appropriate

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

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The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination

Monitoring Response to Neoadjuvant Systemic Therapy for Breast Cancer