American College of Radiology
ACR Appropriateness Criteria®

Multiple Brain Metastases

Variant 1: 70-year-old man with four newly diagnosed, asymptomatic, surgically accessible supratentorial brain metastases on MRI. All brain metastases 1 to 3 cm in maximum diameter. KPS 50. Newly diagnosed T3 N2 adenocarcinoma of lung. Bone and liver metastases also present.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
20 Gy/5 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
37.5 Gy/15 fractions May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
40 Gy/20 fractions Usually not appropriate TBD TBD 2 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
SRS + WBRT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Excise dominant lesion(s) Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Excise all lesions Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Radiosensitizer + WBRT Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Observation May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
Variant 2: 50-year-old man with six newly diagnosed, asymptomatic, supratentorial brain metastases on MRI (three surgically accessible, three inaccessible). KPS 90. Primary completely resected (T2 N0 adenocarcinoma of lung). No other systemic metastases present.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
20 Gy/5 fractions May be appropriate TBD TBD 4 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
37.5 Gy/15 fractions Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
40 Gy/20 fractions Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
SRS alone Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
SRS + WBRT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Excise dominant lesion(s) Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Excise all lesions Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Radiosensitizer + WBRT Usually not appropriate TBD TBD 1 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
Variant 3: 50-year-old man with two newly diagnosed, surgically accessible, supratentorial brain metastases on MRI. KPS 90. One brain metastasis 3 cm in maximum diameter in right frontal area. Other one <1 cm in maximum diameter in lateral cerebellum. No hydrocephalus. Primary completely resected 6 months ago (T2 N0 adenocarcinoma of lung). No other systemic metastases.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
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 3 n/a 0 0 0 0 0 0 0 0 0
SRS alone May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
SRS + WBRT Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Excise dominant lesion(s) Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Excise all lesions Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Radiosensitizer + WBRT Usually not appropriate TBD TBD 1 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
Variant 4: 47-year-old woman with two newly diagnosed, surgically accessible, supratentorial brain metastases on MRI. KPS 80. Mild symptoms related to 2 cm lesion in right parietal area. Other metastasis in left frontal region measuring 1 cm in maximum diameter. Two years status/post right modified radical mastectomy and adjuvant chemotherapy for T2 N1 adenocarcinoma of breast. Newly diagnosed pulmonary nodules also present.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
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 3 n/a 0 0 0 0 0 0 0 0 0
SRS alone May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
SRS + WBRT Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Excise dominant lesion(s) Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Excise all lesions Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Surgery + WBRT May be appropriate TBD TBD 5 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
Radiosensitizer + WBRT Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Variant 5: 35-year-old woman with two newly diagnosed, asymptomatic, surgically accessible, supratentorial brain metastases, <3 cm in size on MRI. KPS 100. Status/post wide local excision of Clark level IV melanoma 1 month ago. No other metastases.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
20 Gy/5 fractions Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
30 Gy/10 fractions May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
37.5 Gy/15 fractions May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
40 Gy/20 fractions Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
SRS alone Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
SRS + WBRT Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Excise dominant lesion(s) Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Excise all lesions Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Radiosensitizer + WBRT Usually not appropriate TBD TBD 1 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
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.