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
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.