Imaging after Breast Surgery

Variant: 1 Female. Age 40 years or older. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Digital breast tomosynthesis screening	Usually Appropriate	☢☢
Mammography screening	Usually Appropriate	☢☢
MRI breast without and with IV contrast	May Be Appropriate	O
US breast	Usually Not Appropriate	O
Digital breast tomosynthesis diagnostic	Usually Not Appropriate	☢☢
Mammography diagnostic	Usually Not Appropriate	☢☢
MRI breast without IV contrast	Usually Not Appropriate	O
FDG-PET breast dedicated	Usually Not Appropriate	☢☢☢
Sestamibi MBI	Usually Not Appropriate	☢☢☢

Variant: 2 Female. Age 30 to 39 years. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Digital breast tomosynthesis screening	May Be Appropriate	☢☢
Mammography screening	May Be Appropriate	☢☢
MRI breast without and with IV contrast	May Be Appropriate	O
US breast	Usually Not Appropriate	O
Digital breast tomosynthesis diagnostic	Usually Not Appropriate	☢☢
Mammography diagnostic	Usually Not Appropriate	☢☢
MRI breast without IV contrast	Usually Not Appropriate	O
FDG-PET breast dedicated	Usually Not Appropriate	☢☢☢
Sestamibi MBI	Usually Not Appropriate	☢☢☢

Variant: 3 Adult female younger than 30 years of age. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US breast	Usually Not Appropriate	O
Digital breast tomosynthesis diagnostic	Usually Not Appropriate	☢☢
Digital breast tomosynthesis screening	Usually Not Appropriate	☢☢
Mammography diagnostic	Usually Not Appropriate	☢☢
Mammography screening	Usually Not Appropriate	☢☢
MRI breast without and with IV contrast	Usually Not Appropriate	O
MRI breast without IV contrast	Usually Not Appropriate	O
FDG-PET breast dedicated	Usually Not Appropriate	☢☢☢
Sestamibi MBI	Usually Not Appropriate	☢☢☢

Variant: 4 Adult female. Postsurgical excision for breast cancer. Positive margins. Asymptomatic. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Digital breast tomosynthesis diagnostic	May Be Appropriate (Disagreement)	☢☢
Mammography diagnostic	May Be Appropriate	☢☢
MRI breast without and with IV contrast	May Be Appropriate	O
US breast	Usually Not Appropriate	O
Digital breast tomosynthesis screening	Usually Not Appropriate	☢☢
Mammography screening	Usually Not Appropriate	☢☢
MRI breast without IV contrast	Usually Not Appropriate	O
FDG-PET breast dedicated	Usually Not Appropriate	☢☢☢
Sestamibi MBI	Usually Not Appropriate	☢☢☢

Variant: 5 Adult female. Surveillance following completion of breast conservation therapy for breast cancer. Negative margins. With or without radiation. Asymptomatic.

Procedure	Appropriateness Category	Relative Radiation Level
Digital breast tomosynthesis diagnostic	Usually Appropriate	☢☢
Digital breast tomosynthesis screening	Usually Appropriate	☢☢
Mammography diagnostic	Usually Appropriate	☢☢
Mammography screening	Usually Appropriate	☢☢
US breast	May Be Appropriate	O
MRI breast without and with IV contrast	May Be Appropriate	O
MRI breast without IV contrast	Usually Not Appropriate	O
FDG-PET breast dedicated	Usually Not Appropriate	☢☢☢
Sestamibi MBI	Usually Not Appropriate	☢☢☢

Panel Members

Summary of Literature Review

Introduction/Background

Initial Imaging Definition

Discussion of Procedures by Variant

Variant 1: Female. Age 40 years or older. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.

Variant 1: Female. Age 40 years or older. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
A. Digital Breast Tomosynthesis Diagnostic

Variant 1: Female. Age 40 years or older. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
B. Digital Breast Tomosynthesis Screening

Variant 1: Female. Age 40 years or older. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
C. FDG-PET Breast Dedicated

Variant 1: Female. Age 40 years or older. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
D. Mammography Diagnostic

Variant 1: Female. Age 40 years or older. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
E. Mammography Screening

Variant 1: Female. Age 40 years or older. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
F. MRI Breast Without and With IV Contrast

Variant 1: Female. Age 40 years or older. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
G. MRI Breast Without IV Contrast

Variant 1: Female. Age 40 years or older. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
H. Sestamibi MBI

Variant 1: Female. Age 40 years or older. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
I. US Breast

Variant 2: Female. Age 30 to 39 years. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.

Variant 2: Female. Age 30 to 39 years. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
A. Digital Breast Tomosynthesis Diagnostic

Variant 2: Female. Age 30 to 39 years. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
B. Digital Breast Tomosynthesis Screening

Variant 2: Female. Age 30 to 39 years. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
C. FDG-PET Breast Dedicated

Variant 2: Female. Age 30 to 39 years. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
D. Mammography Diagnostic

Variant 2: Female. Age 30 to 39 years. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
E. Mammography Screening

Variant 2: Female. Age 30 to 39 years. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
F. MRI Breast Without and With IV Contrast

Variant 2: Female. Age 30 to 39 years. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
G. MRI Breast Without IV Contrast

Variant 2: Female. Age 30 to 39 years. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
H. Sestamibi MBI

Variant 2: Female. Age 30 to 39 years. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
I. US Breast

Variant 3: Adult female younger than 30 years of age. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.

Variant 3: Adult female younger than 30 years of age. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
A. Digital Breast Tomosynthesis Diagnostic

Variant 3: Adult female younger than 30 years of age. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
B. Digital Breast Tomosynthesis Screening

Variant 3: Adult female younger than 30 years of age. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
C. FDG-PET Breast Dedicated

Variant 3: Adult female younger than 30 years of age. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
D. Mammography Diagnostic

Variant 3: Adult female younger than 30 years of age. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
E. Mammography Screening

Variant 3: Adult female younger than 30 years of age. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
F. MRI Breast Without and With IV Contrast

Variant 3: Adult female younger than 30 years of age. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
G. MRI Breast Without IV Contrast

Variant 3: Adult female younger than 30 years of age. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
H. Sestamibi MBI

Variant 3: Adult female younger than 30 years of age. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging.
I. US Breast

Variant 4: Adult female. Postsurgical excision for breast cancer. Positive margins. Asymptomatic. Initial imaging.

Variant 4: Adult female. Postsurgical excision for breast cancer. Positive margins. Asymptomatic. Initial imaging.
A. Digital Breast Tomosynthesis Diagnostic

Variant 4: Adult female. Postsurgical excision for breast cancer. Positive margins. Asymptomatic. Initial imaging.
B. Digital Breast Tomosynthesis Screening

Variant 4: Adult female. Postsurgical excision for breast cancer. Positive margins. Asymptomatic. Initial imaging.
C. FDG-PET Breast Dedicated

Variant 4: Adult female. Postsurgical excision for breast cancer. Positive margins. Asymptomatic. Initial imaging.
D. Mammography Diagnostic

Variant 4: Adult female. Postsurgical excision for breast cancer. Positive margins. Asymptomatic. Initial imaging.
E. Mammography Screening

Variant 4: Adult female. Postsurgical excision for breast cancer. Positive margins. Asymptomatic. Initial imaging.
F. MRI Breast Without and With IV Contrast

Variant 4: Adult female. Postsurgical excision for breast cancer. Positive margins. Asymptomatic. Initial imaging.
G. MRI Breast Without IV Contrast

Variant 4: Adult female. Postsurgical excision for breast cancer. Positive margins. Asymptomatic. Initial imaging.
H. Sestamibi MBI

Variant 4: Adult female. Postsurgical excision for breast cancer. Positive margins. Asymptomatic. Initial imaging.
I. US Breast

Variant 5: Adult female. Surveillance following completion of breast conservation therapy for breast cancer. Negative margins. With or without radiation. Asymptomatic.

Variant 5: Adult female. Surveillance following completion of breast conservation therapy for breast cancer. Negative margins. With or without radiation. Asymptomatic.
A. Digital Breast Tomosynthesis Diagnostic

Variant 5: Adult female. Surveillance following completion of breast conservation therapy for breast cancer. Negative margins. With or without radiation. Asymptomatic.
H. Sestamibi MBI

Variant 5: Adult female. Surveillance following completion of breast conservation therapy for breast cancer. Negative margins. With or without radiation. Asymptomatic.
I. US Breast

Summary of Recommendations

Supporting Documents

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 Names and Definitions

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.

Relative Radiation Level Information

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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