ACR Appropriateness Criteria® Palpable Breast Masses: 2022 Update

Expert Panel on Breast Imaging, Katherine A. Klein, Maddi Kocher, Ana P. Lourenco, Bethany L. Niell, Debbie L. Bennett, Alison Chetlen, Phoebe Freer, Lillian K. Ivansco, Maxine S. Jochelson, Mallory E. Kremer, Sharp F. Malak, Marion McCrary, Tejas S. Mehta, Colleen H. Neal, Andrea Porpiglia, Gary A. Ulaner, Linda Moy

Research output: Contribution to journalArticlepeer-review


Palpable masses in women are the most common symptom associated with breast cancer. This document reviews and evaluates the current evidence for imaging recommendations of palpable masses in women less than 30 to over 40 years of age. There is also a review of several different scenarios and recommendations after initial imaging. Ultrasound is usually the appropriate initial imaging for women under 30 years of age. If ultrasound findings are suspicious or highly suggestive of malignancy (BIRADS 4 or 5), it is usually appropriate to continue with diagnostic tomosynthesis or mammography with image-guided biopsy. No further imaging is recommended if the ultrasound is benign or negative. The patient under 30 years of age with a probably benign ultrasound may undergo further imaging; however, the clinical scenario plays a role in the decision to biopsy. For women between 30 to 39 years of age, ultrasound, diagnostic mammography, tomosynthesis, and ultrasound are usually appropriate. Diagnostic mammography and tomosynthesis are the appropriate initial imaging for women 40 years of age or older, as ultrasound may be appropriate if the patient had a negative mammogram within 6 months of presentation or immediately after mammography findings are suspicious or highly suggestive of malignancy. If the diagnostic mammogram, tomosynthesis, and ultrasound findings are probably benign, no further imaging is necessary unless the clinical scenario indicates a biopsy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Original languageEnglish
Pages (from-to)S146-S163
JournalJournal of the American College of Radiology
Issue number5
StatePublished - May 2023


  • AUC
  • Appropriate Use Criteria
  • Appropriateness Criteria
  • breast cancer
  • digital breast tomosynthesis
  • mammography
  • palpable breast mass
  • ultrasound


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