American College of Radiology
ACR Appropriateness Criteria®

Follow-up and Retreatment of Brain Metastases

Variant 1: 70-year-old man with non-small-cell lung cancer status post lobectomy 3 years ago with a single brain metastasis 6 months ago treated with radiosurgery. Now with new contralateral metastasis in nondominant temporal lobe measuring 2 cm. No extracranial disease present. Mild neurologic symptoms. KPS 80.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Surgical resection alone Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
SRS alone Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
20 Gy/5 fractions Usually not appropriate TBD TBD 3 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
37.5 Gy/15 fractions Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
40 Gy/20 fractions Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
WBRT and SRS Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Surgery and postop WBRT Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Surgery and postop SRS Usually not appropriate 3 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy only Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Supportive care Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Variant 2: 60-year-old man with renal cancer history, status post-surgical resection of 2 cerebellar metastases and postoperative WBRT (35 Gy in 14 fractions) 18 months ago. Now with new 3-cm left frontal metastasis without edema. KPS 90. No other signs of recurrence. No neurological symptoms.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Surgical resection alone May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
SRS alone Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
20 Gy/5 fractions Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
25 Gy/10 fractions Usually not appropriate 1 n/a 0 0 0 0 0 0 0 0 0
30 Gy/10 fractions Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
37.5 Gy/15 fractions Usually not appropriate 1 n/a 0 0 0 0 0 0 0 0 0
40 Gy/20 fractions Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
WBRT and SRS Usually not appropriate 1 n/a 0 0 0 0 0 0 0 0 0
Surgery and postop WBRT Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Surgery and postop SRS May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy only Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Supportive care Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Variant 3: 44-year-old woman with breast cancer (negative ER/PR, Her2neu receptors) and multiple brain metastases 9 months ago, status post WBRT (30 Gy in 10 fractions). Now with recurrence of 2 asymptomatic well-separated bilateral anterior frontal masses, 1–2 cm in diameter each. No extracranial disease present. KPS 80.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Surgical resection alone Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
SRS alone Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
20 Gy/5 fractions Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
25 Gy/10 fractions Usually not appropriate 1 n/a 0 0 0 0 0 0 0 0 0
30 Gy/10 fractions Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
37.5 Gy/15 fractions Usually not appropriate 1 n/a 0 0 0 0 0 0 0 0 0
40 Gy/20 fractions Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
WBRT and SRS Usually not appropriate 1 n/a 0 0 0 0 0 0 0 0 0
Surgery and postop WBRT Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Surgery and postop SRS Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy only Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Supportive care Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Variant 4: 49-year-old woman with melanoma, status post WBRT (30 Gy in 10 fractions) for multiple metastases 6 months ago. Now with recurrence of one 3.5-cm right parietal metastasis with edema causing weakness. No extracranial disease present. KPS 70.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Surgical resection alone Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
SRS alone May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
20 Gy/5 fractions Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
25 Gy/10 fractions Usually not appropriate 1 n/a 0 0 0 0 0 0 0 0 0
30 Gy/10 fractions Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
37.5 Gy/15 fractions Usually not appropriate 1 n/a 0 0 0 0 0 0 0 0 0
40 Gy/20 fractions Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
WBRT and SRS Usually not appropriate 1 n/a 0 0 0 0 0 0 0 0 0
Surgery and postop WBRT Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Surgery and postop SRS Usually not appropriate 3 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy alone Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Supportive care Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Variant 5: 73-year-old man with progressing metastatic lung cancer who was previously treated with whole brain radiation for multiple brain metastases 9 months earlier. Now with 3 new slightly symptomatic brain metastasis. KPS 50.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Surgical resection alone Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
SRS alone Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
20 Gy/5 fractions Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
25 Gy/10 fractions Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
30 Gy/10 fractions Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
37.5 Gy/15 fractions Usually not appropriate 1 n/a 0 0 0 0 0 0 0 0 0
40 Gy/20 fractions Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
WBRT and SRS Usually not appropriate 1 n/a 0 0 0 0 0 0 0 0 0
Surgery and postop WBRT Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Surgery and postop SRS Usually not appropriate 1 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy alone Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Supportive care Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Variant 6: Follow-up after treatment of brain metastases. No extracranial disease present. KPS 90. Follow-up for 1–2 years.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Initial MRI head ≤3 months Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Subsequent MRI head every 3–6 months Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
FDG-PET head only if MRI or CT abnormality suggests recurrence after radiosurgery or WBRT May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Subsequent MRI head when symptomatic on physical examination only Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Subsequent CT head every 4-6 months Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Subsequent FDG-PET head every 4-6 months Usually not appropriate TBD TBD 1 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.