American College of Radiology
ACR Appropriateness Criteria®

Non-Spine Bone Metastases

Variant 1: 52-year-old man with a history of a T1N0M0 non–small-cell lung cancer. Two years after lobectomy, he is found to have a painful metastasis in the right femoral neck. The lesion is 3.5 cm in size with greater than 50% erosion of the medial bone cortex. Karnofsky performance status (KPS) 90. No other metastatic disease is found. He has had no previous therapy other than lobectomy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Surgical intervention followed by EBRT, then systemic therapy Usually appropriate 9 n/a 0 0 0 0 0 0 0 0 0
Surgical intervention followed by systemic therapy alone May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
EBRT alone Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
EBRT followed by systemic therapy Usually not appropriate 3 n/a 0 0 0 0 0 0 0 0 0
Surgical intervention alone Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Hospice after treatment of the femur Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy alone (may include biologic agents, bisphosphonates, and/or chemotherapy) Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
Observation Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Direct hospice placement Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
8 Gy/1 fraction May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
20 Gy/5 fractions May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
24 Gy/6 fractions May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
30 Gy/10 fractions Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
35 Gy/14 fractions May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
40 Gy/20 fractions May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
Clinical simulation May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
Fluoroscopic simulation or 2-D RT Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
CT simulation Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
AP/PA Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
3-D CRT Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
SBRT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Proton therapy to the bone metastasis Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Variant 2: 62-year-old woman with estrogen-receptor positive/progesterone-receptor positive breast cancer, Her-2/neu nonamplified. She develops a painful lytic bone metastasis in the right humerus after 4 years of a single-line of adjuvant hormonal therapy. There is minimal invasion of bone cortex, and the lesion is thought to have a low fracture risk per orthopedic surgery consult. KPS is 90. Bone scan demonstrates a few other asymptomatic bone metastases.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
EBRT followed by systemic therapy Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy alone (hormonal therapy and bisphosphonates or RANK ligand inhibitor) May be appropriate 4 n/a 0 0 0 0 0 0 0 0 0
EBRT alone Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Radiopharmaceuticals Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Surgical intervention Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Direct hospice placement Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Hospice after treatment of the humerus Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
8 Gy/1 fraction Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
20 Gy/5 fractions Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
24 Gy/6 fractions Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
30 Gy/10 fractions Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
35 Gy/14 fractions May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
40 Gy/20 fractions Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Clinical simulation May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
Fluoroscopic simulation or 2-D RT Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
CT simulation Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
AP/PA Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
3-D CRT Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
SBRT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Proton therapy to the bone metastasis Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Variant 3: 65-year-old woman with metastatic hormone-receptor positive breast cancer currently on hormonal and bisphosphonate therapy for skeletal-dominant metastatic disease. She received palliative radiation (30 Gy/10 fractions) to a painful lesion in the right humerus 3 years ago with good pain relief but now has recurrent pain at this site. Radiographs show a lytic lesion with no radiographic evidence of impending fracture. She has several other asymptomatic skeletal lesions and a new 1.5-cm lung metastasis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
EBRT reirradiation to symptomatic lesion Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Consider changes to systemic therapy only May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Radiopharmaceuticals Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Surgical intervention Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Direct hospice placement Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Hospice after treatment of the humerus Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
8 Gy/1 fraction Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
20 Gy/5 fractions Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
24 Gy/6 fractions Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
30 Gy/10 fractions Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
35 Gy/14 fractions May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
40 Gy/20 fractions Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Clinical simulation May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
3-D CRT Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
CT simulation Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Fluoroscopic simulation or 2-D RT Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
CT simulation Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
AP/PA Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
SBRT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Proton therapy to the bone metastasis Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Variant 4: 66-year-old man with metastatic hormone-refractory prostate cancer. He has widespread osteoblastic skeletal disease with increasingly painful lesions in the lumbar spine, hips, and extremities. Prior therapy has included hormonal therapy, bisphosphonates, docetaxel chemotherapy, and EBRT to one of his painful hip lesions.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiopharmaceuticals and EBRT to symptomatic lesions Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Radiopharmaceuticals Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
EBRT to most symptomatic lesions Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Direct hospice placement May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
Consider changes to systemic therapy only May be appropriate 4 n/a 0 0 0 0 0 0 0 0 0
Medical pain management only May be appropriate 4 n/a 0 0 0 0 0 0 0 0 0
8 Gy/1 fraction Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
20 Gy/5 fractions Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
24 Gy/6 fractions Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
30 Gy/10 fractions Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
35 Gy/14 fractions May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
40 Gy/20 fractions Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Clinical simulation May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
Fluoroscopic simulation or 2-D RT Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
CT simulation Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
3-D CRT Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
SBRT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Proton therapy to the bone metastasis Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Variant 5: 47-year-old man with a history of malignant melanoma, now with a painful metastatic lesion in the left scapula. KPS is 70. He has had no prior therapy for metastatic disease. Staging scans show an asymptomatic 3-cm liver metastasis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
EBRT and consideration of systemic therapy Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy alone May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
EBRT alone Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Hospice after treatment of the scapula metastasis Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
Direct hospice placement Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Radiopharmaceuticals Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
8 Gy/1 fraction Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
20 Gy/5 fractions Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
24 Gy/6 fractions Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
30 Gy/10 fractions Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
30 Gy/5 fractions Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
35 Gy/14 fractions May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
40 Gy/20 fractions Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Clinical simulation May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
CT simulation Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Fluoroscopic simulation or 2-D RT Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
CT simulation Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
3-D CRT Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
SBRT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Proton therapy to the bone metastasis Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.