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## Complete Summary

#### GUIDELINE TITLE

Suspected liver metastases.

#### BIBLIOGRAPHIC SOURCE(S)

Heiken JP, Bree RL, Foley WD, Gay SB, Glick SN, Huprich JE, Levine MS,
Ros PR, Rosen MP, Shuman WP, Greene FL, Expert Panel on Gastrointestinal
Imaging. Suspected liver metastases. \[online publication\]. Reston
(VA): American College of Radiology (ACR); 2005. 8 p. \[28 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Bree RL, Greene FL, Ralls PW,
Balfe DM, DiSantis DJ, Glick SN, Kidd R, Levine MS, Megibow AJ, Mezwa
DG, Saini S, Shuman WP, Laine LA, Lillemoe K. Suspected liver
metastases. American College of Radiology. ACR Appropriateness Criteria.
Radiology 2000 Jun;215(Suppl):213-24.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [May 23, 2007, Gadolinium-based Contrast
    Agents](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Gadolinium):
    The addition of a boxed warning and new warnings about the risk of
    nephrogenic systemic fibrosis (NSF) to the full prescribing
    information for all gadolinium-based contrast agents (GBCAs).

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Liver metastases

#### GUIDELINE CATEGORY

Diagnosis

#### CLINICAL SPECIALTY

Gastroenterology\
Internal Medicine\
Nuclear Medicine\
Oncology\
Radiology

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of initial radiologic examinations for
patients suspected of liver metastases

#### TARGET POPULATION

Patients with suspected liver metastases

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Computed tomography (CT)

    -   Abdominal CT without contrast

    -   Helical CT in portal venous phase (PVP)

    -   Helical in hepatic arterial phase (HAP) and PVP

    -   Helical without contrast followed by HAP and PVP

    -   Computed tomography arterial portography (CTAP) or computed
        tomography angiography (CTA)

2.  Magnetic resonance imaging (MRI)

    -   Abdominal spin-echo MRI then gradient-echo magnetic resonance
        imaging with extracellular contrast media (e.g., gadolinium
        chelates)

    -   Abdominal spin-echo MRI without contrast

    -   Abdominal MRI with reticulo-endothelial contrast (e.g.,
        iron-oxide)

3.  Ultrasound (US)

    -   Abdominal US

    -   Abdominal US with color Doppler

    -   Intraoperative/laparoscopic abdominal US

4.  Nuclear imaging

    -   Radionuclide liver scan with reticulo-endothelial agent

    -   Nuclear medicine (NUC), immunoscintigraphy

    -   Positron emission tomography (PET)

    -   Radionuclide liver scan with blood pool agent

    -   Somatostatin receptor imaging

5.  Hepatic angiography with or without CTAP or CTA

6.  Image-guided biopsy of liver

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic examinations in differential diagnosis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of peer-reviewed
medical journals, and the major applicable articles were identified and
collected.

#### NUMBER OF SOURCE DOCUMENTS

The total number of source documents identified as the result of the
literature search is not known.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed for reaching agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by the participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1 to 9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty (80) percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by this Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Suspected Liver Metastases**

**Variant 1: Initial Imaging test following detection of primary
tumor.**

  -----------------------------------------------------------------------------
  **Radiologic Exam      **Appropriateness   **Comments**
  Procedure**            Rating**            
  ---------------------- ------------------- ----------------------------------
  CT, abdomen, helical   8                    
  in PVP                                     

  CT, abdomen, helical   8                   HAP imaging is useful for patients
  in HAP and portal                          with a hypervascular primary tumor
  venous phase (PVP)                         such as (but not limited to) renal
                                             cell, pancreatic islet cell, and
                                             thyroid carcinoma; carcinoid and
                                             other neuroendocrine tumors; and
                                             melanoma.

  CT, abdomen, helical   6                   HAP imaging is useful for patients
  without contrast                           with a hypervascular primary tumor
  followed by HAP and                        such as (but not limited to) renal
  PVP                                        cell, pancreatic islet cell, and
                                             thyroid carcinoma; carcinoid and
                                             other neuroendocrine tumors; and
                                             melanoma.

  MRI, abdomen,          6                    
  spin-echo then                             
  gradient-echo with                         
  extracellular contrast                     
  e.g. gadolinium                            
  chelates                                   

  PET                    6                    

  MRI, abdomen, with     5                    
  reticulo-endothelial                       
  contrast e.g.,                             
  iron-oxide                                 

  CT, abdomen, without   4                    
  contrast                                   

  MRI, abdomen,          4                    
  spin-echo, without                         
  contrast                                   

  US, abdomen            4                    

  US, abdomen, with      4                    
  color Doppler                              

  NUC, liver scan with   4                    
  reticulo-endothelial                       
  agent                                      

  NUC,                   3                    
  Immunoscintigraphy                         

  CTAP or CTA            2                    

  NUC, liver scan with   2                    
  blood pool agent                           

  Somatostatin receptor  2                    
  imaging                                    

  INV, hepatic           2                    
  angiography with or                        
  without CTPA or CTA                        

  ***Appropriateness                         
  Criteria Scale*\                           
  1 2 3 4 5 6 7 8 9\                         
  1 = Least appropriate                      
  9 = Most appropriate**                     
  -----------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 2: Surveillance following treatment of primary tumor.**

  ---------------------------------------------------------------------------------
  **Radiologic Exam Procedure** **Appropriateness   **Comments**
                                Rating**            
  ----------------------------- ------------------- -------------------------------
  CT, abdomen, helical in PVP   8                    

  CT, abdomen, helical without  8                   HAP imaging is useful for
  contrast followed by HAP and                      patients with a hypervascular
  PVP                                               primary tumor such as (but not
                                                    limited to) renal cell,
                                                    pancreatic islet cell, and
                                                    thyroid carcinoma; carcinoid
                                                    and other neuroendocrine
                                                    tumors; and melanoma.

  CT, abdomen, helical in HAP   8                   HAP imaging is useful for
  and PVP                                           patients with a hypervascular
                                                    primary tumor such as (but not
                                                    limited to) renal cell,
                                                    pancreatic islet cell, and
                                                    thyroid carcinoma; carcinoid
                                                    and other neuroendocrine
                                                    tumors; and melanoma.

  MRI, abdomen, spin-echo then  6                    
  gradient-echo  with                               
  extracellular contrast e.g.,                      
  gadolinium chelates                               

  PET                           6                    

  MRI, abdomen, with            5                    
  reticulo-endothelial contrast                     
  e.g., iron-oxide                                  

  CT, abdomen, without contrast 4                    

  MRI, abdomen, spin-echo,      4                    
  without contrast                                  

  US, abdomen                   4                    

  US, abdomen, with color       4                    
  Doppler                                           

  NUC, liver scan with          4                    
  reticulo-endothelial agent                        

  NUC, Immunoscintigraphy       4                    

  Somatostatin receptor imaging 4                    

  CTAP or CTA                   2                    

  US, abdomen,                  2                    
  intraoperative/laparoscopic                       

  NUC, liver scan with blood    2                    
  pool agent                                        

  INV, hepatic angiography with 2                    
  or without CTAP or CTA                            

  ***Appropriateness Criteria                       
  Scale*\                                           
  1 2 3 4 5 6 7 8 9\                                
  1 = Least appropriate 9 =                         
  Most appropriate**                                
  ---------------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 3: Abnormal surveillance US, CT, or MRI in PVP: high suspicion
of malignancy.**

  ---------------------------------------------------------------------------------
  **Radiologic Exam Procedure** **Appropriateness   **Comments**
                                Rating**            
  ----------------------------- ------------------- -------------------------------
  INV, liver, image-guided      8                    
  biopsy                                            

  CT, abdomen, helical in HAP   8                   HAP imaging is useful for
  and PVP                                           patients with a hypervascular
                                                    primary tumor such as (but not
                                                    limited to) renal cell,
                                                    pancreatic islet cell, and
                                                    thyroid carcinoma; carcinoid
                                                    and other neuroendocrine
                                                    tumors; and melanoma.

  MRI, abdomen, spin-echo then  7                    
  gradient-echo with                                
  extracellular contrast e.g.,                      
  gadolinium chelates                               

  PET                           7                    

  MRI, abdomen, without         4                    
  contrast                                          

  MRI, abdomen, with            4                    
  reticulo-endothelial contrast                     
  e.g., iron-oxide                                  

  CT, abdomen, helical without  4                   HAP imaging is useful for
  contrast followed by HAP and                      patients with a hypervascular
  PVP                                               primary tumor such as (but not
                                                    limited to) renal cell,
                                                    pancreatic islet cell, and
                                                    thyroid carcinoma; carcinoid
                                                    and other neuroendocrine
                                                    tumors; and melanoma.

  US, abdomen                   4                    

  US, abdomen, with color       4                    
  Doppler                                           

  US, abdomen,                  4                    
  intraoperative/laparoscopic                       

  CTAP or CTA                   3                    

  NUC, liver scan with          3                    
  reticulo-endothelial agent                        

  NUC, liver scan with blood    3                    
  pool agent                                        

  Somatostatin receptor imaging 3                    

  NUC, Immunoscintigraphy       3                    

  INV, hepatic angiography with 3                    
  or without CTAP or CTA                            

  CT, abdomen, without contrast 2                    

  ***Appropriateness Criteria                       
  Scale*\                                           
  1 2 3 4 5 6 7 8 9\                                
  1 = Least appropriate 9 =                         
  Most appropriate**                                
  ---------------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 4: Abnormal surveillance US, CT, or MRI in PVP: high suspicion
of benignancy.**

  ---------------------------------------------------------------------------------
  **Radiologic Exam Procedure** **Appropriateness   **Comments**
                                Rating**            
  ----------------------------- ------------------- -------------------------------
  MRI, abdomen, spin-echo then  8                    
  gradient-echo with                                
  extracellular contrast e.g.,                      
  gadolinium chelates                               

  CT, abdomen, helical in HAP   7                    
  and PVP                                           

  MRI, abdomen, spin-echo,      5                    
  without contrast                                  

  CT, abdomen, helical without  5                    
  contrast followed by HAP and                      
  PVP                                               

  INV, liver, image-guided      4                    
  biopsy                                            

  MRI, abdomen, with            4                    
  reticulo-endothelial contrast                     
  e.g., iron-oxide                                  

  US, abdomen                   4                    

  US, abdomen, with color       4                    
  Doppler                                           

  NUC, liver scan with          4                    
  reticulo-endothelial agent                        

  NUC, liver scan with blood    4                   May be indicated with large
  pool agent                                        lesion with high suspicion of
                                                    hemangioma.

  CTAP or CTA                   3                    

  US, abdomen,                  3                    
  intraoperative/laparoscopic                       

  Somatostatin receptor imaging 3                    

  CT, abdomen, without contrast 2                    

  NUC, Immunoscintigraphy       2                    

  PET                           2                    

  INV, hepatic angiography with 2                    
  or without CTAP or CTA                            

  ***Appropriateness Criteria                       
  Scale*\                                           
  1 2 3 4 5 6 7 8 9\                                
  1 = Least appropriate 9 =                         
  Most appropriate**                                
  ---------------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

In the United States, metastatic disease is the most common cause of
malignancy in the liver and is 20 to 50 times more common than primary
liver cancer. The colon, stomach, pancreas, and breast are the most
common primary sites. The appearance of a new lesion in the liver in a
patient with a history of cancer strongly suggests hepatic metastasis.
On the other hand, most small (1-1.5 cm) liver lesions, even in patients
with known malignancy, are not malignant, especially if there are fewer
than five lesions. In most series, about one-third of patients who die
with a malignancy have liver involvement.

The liver is susceptible to metastatic disease primarily due to the
nature of the endothelial lining. The dual blood supply to the liver has
an effect on the vascularity of liver metastases, with those supplied by
the hepatic arterial system being more vascular than those supplied by
the portal venous system. Most gastrointestinal cancer is spread through
the portal venous system, whereas other tumors are spread through the
hepatic arterial system. Numerous imaging methods are available for
detecting intrahepatic metastatic disease before, during, and after
definitive therapy for the primary lesion. The usefulness of various
imaging modalities can vary significantly across institutions because of
local radiological expertise, availability of equipment or personnel,
and the wishes and biases of treating physicians and radiologists. This
review will attempt to identify the broad variety of available imaging
tests so that each can be rated by the consensus panel, realizing that
many published scientific studies do not compare all imaging modalities
at the current state of the art.

**Ultrasound**

Ultrasound (US) is the most available technique for liver imaging
worldwide, and in many countries is the major modality used to search
for liver metastases. In the United States, the relative availability of
computed tomography (CT) and magnetic resonance imaging (MRI) and
limited physician involvement in the performance of US, contribute to a
lesser role for US diagnosis. Many patients have liver masses detected
by US when suspicion of metastases is not high. In general, in the
United States pretreatment and post-treatment screening for metastases
is performed less often with US. Comparative studies demonstrate that US
has high specificity but lower sensitivity than other imaging
modalities. With US, metastases can be hypoechoic, hyperechoic, cystic,
or diffuse. Doppler may be useful, particularly in vascular lesions such
as neuroendocrine tumors, sarcomas and lymphomas. Metastases frequently
displace normal liver vessels.

**Intraoperative/Laparoscopic Ultrasound**

Intraoperative ultrasound (IOUS) is the most accurate imaging technique
for detecting liver metastases at the time of primary tumor resection or
resection of known metastases. It is complementary to surgical
inspection and palpation. Additionally, intraoperative US can be
important for localization of tumors for ablative techniques or to guide
intraoperative biopsy or surgical resection. Laparoscopic US (LUS) has
been developed as an alternative to open intraoperative US with
promising results. In one study of 55 patients with primary and
secondary liver neoplasms who underwent LUS as part of a tumor ablation
procedure, LUS demonstrated all 201 liver tumors shown by triphasic CT
and an additional 21 lesions not shown by CT.

**Computed Tomography**

CT is particularly suited for the evaluation of metastatic disease,
because the liver and potential extra-hepatic sites of tumor spread can
be evaluated during the same examination. Helical CT is the preferred
examination in the United States for surveillance for metastatic disease
after treatment of the primary neoplasm, with multidetector CT
representing the current state of the art. Because most hepatic
metastases are relatively hypovascular compared with normal liver
parenchyma, the lesions are hypoattenuating when imaged during the peak
of hepatic parenchymal enhancement (portal venous phase). In general,
therefore, imaging during the portal venous phase of hepatic enhancement
is adequate to detect most hepatic lesions in most patients.

Hypervascular lesions are less common, and tumors in this group include
metastases from renal cell carcinoma, carcinoid, islet cell carcinoma,
thyroid carcinoma, melanoma, and neuroendocrine tumors. In a large
series of patients, small (\<2 cm) hypervascular lesions were seen
better in the arterial phase than in the portal venous phase. With the
widespread use of multidetector row scanners, arterial phase scanning
can be routine. Although metastases from breast carcinoma are sometimes
hypervascular, one study showed that arterial phase imaging was not
necessary in this group. Hypervascular lesions may be isoattenuating to
liver during the portal venous phase of hepatic enhancement. With
helical CT, both arterial and portal venous phase imaging is recommended
for patients with hypervascular primary tumors. If helical CT is not
available, a noncontrast scan can also be useful.

CT arterial portography is no longer used extensively, as it is an
invasive angiographic technique that often yields confusing artifacts
that decreases accuracy. Newer arterial mapping techniques using MR and
CT angiography have largely replaced standard angiographic techniques
for preoperative staging.

When CT is used to characterize a liver lesion detected with US, the CT
examination should include arterial phase and porta venous phase
imaging. Many incidentally discovered liver lesions are hypervascular
and therefore may be demonstrated and/or characterized accurately only
if arterial phase imaging is included.

**Magnetic Resonance Imaging**

With MRI, most hepatic metastases, like most liver lesions, are
hypointense to normal liver on T1-weighted images and hyperintense to
liver on T2-weighted images. Some morphologic features have been shown
to be useful in distinguishing metastatic lesions from common benign
lesions such as hemangiomas and cysts. Findings in metastatic disease
include heterogenous signal intensity with an irregular or indistinct
outer margin, smooth or irregular central areas of high signal intensity
surrounded by a ring of low signal intensity, or a mass surrounded by a
ring of high signal intensity. On T2-weighted images, hemangiomas are
hyperintense compared with normal liver parenchyma and generally higher
in signal intensity than metastases. The typical early enhancement
pattern of hemangiomas after administration of gadolinium chelates is
eccentric, nodular peripheral enhancement. When present, this pattern,
which is similar to that seen with contrast enhanced CT, is highly
accurate in distinguishing hemangiomas from metastases.

Several studies have compared the accuracy of various MR techniques to
other standard imaging modalities. A large clinical trial in the
Radiology Diagnostic Oncology Group (RDOG) series compared MR to CT in
metastatic colorectal cancer to the liver. CT had a higher sensitivity
and similar specificity as compared to MR. Rapid imaging with breath
holding has been found to be more sensitive for hepatic masses than
conventional non-breath-hold spin-echo techniques.

There is continued debate about the value of MR contrast agents. One
study showed gadolinium chelate-enhanced 3D rapid gradient echo imaging
to be superior to unenhanced MR imaging for detecting focal hepatic
masses. Another study, however, demonstrated no statistically
significant difference between unenhanced and gadolinium-enhanced MR
imaging in differentiating patients with liver metastases from those
without metastases. Nevertheless, most experts in body MR imaging
consider gadolinium chelate enhancement to be an essential part of the
abdominal MR imaging examination of colorectal cancer patients being
evaluated for possible liver metastases. A report in 51 patients
suggests that MR with superparamagnetic iron oxide contrast (SPIO) may
be slightly superior to dual-phase CT for patients with colorectal
metastases.

**Nuclear Imaging**

Positron emission tomography (PET) has become more widely used in
detecting metastatic disease. A meta-analysis comparing US, CT, MRI, and
18F fluorodeoxyglucose (FDG) PET in patients with cancers of the
gastrointestinal tract concluded that FDG-PET is the most sensitive
imaging test for the diagnosis of hepatic metastases from colorectal
cancer. In addition, several studies have demonstrated that the addition
of FDG-PET to a conventional staging evaluation in colorectal cancer
patients with potentially resectable liver metastases results in a
change in management of 20%-32%, mainly due to detection of unknown
extrahepatic disease. PET also has been shown to be accurate in
distinguishing benign from malignant liver tumors. A limitation of
FDG-PET, however, is that it may fail to demonstrate small (\< 1 cm)
liver metastases. For staging and restaging patients with colorectal
liver metastases, integration of CT and FDG-PET data, either by fusion
or by integrated PET-CT imaging, enables better management guidance than
with either technique alone.

Traditional reticulo-endothelial imaging or blood pool imaging can be
useful for characterizing masses such as focal nodular hyperplasia or
hemangioma but are not typically used for detecting metastatic disease.
Newer agents such as isotope-tagged monoclonal antibodies directed
toward surface proteins expressed by colorectal liver metastases have
had some initial success in solving difficult clinical problems. Liver
metastases from endocrine active tumors from the pancreas or
gastrointestinal tract can be detected by somatostatin receptor
scintigraphy.

**Summary**

Many radiologic techniques are available for preoperative detection of
liver metastases and postoperative surveillance. Some of the less widely
used screening techniques can be useful when there is a need for
specific problem solving. Rapid technological and clinical advances in
equipment, contrast agents, and radioisotopes make direct comparison of
the various techniques difficult.  In addition, local custom and
equipment availability within communities or medical centers can be
expected to lead to a variety of indications and applications in
detecting of hepatic metastatic disease.

**Abbreviations**

-   CT, computed tomography

-   CTA, computed tomography angiography

-   CTAP, computed tomography arterial portography

-   HAP, hepatic arterial phase

-   INV, invasive

-   MRI, magnetic resonance imaging

-   NUC, nuclear medicine

-   PET, positron emission tomography

-   PVP, portal venous phase

-   US, ultrasound

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Selection of appropriate radiologic imaging procedures for evaluation of
patients suspected of liver metastases

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (ACR) Committee on Appropriateness
Criteria and its expert panels have developed criteria for determining
appropriate imaging examinations for diagnosis and treatment of
specified medical condition(s). These criteria are intended to guide
radiologists, radiation oncologists, and referring physicians in making
decisions regarding radiologic imaging and treatment. Generally, the
complexity and severity of a patient\'s clinical condition should
dictate the selection of appropriate imaging procedures or treatments.
Only those exams generally used for evaluation of the patient\'s
condition are ranked. Other imaging studies necessary to evaluate other
co-existent diseases or other medical consequences of this condition are
not considered in this document. The availability of equipment or
personnel may influence the selection of appropriate imaging procedures
or treatments. Imaging techniques classified as investigational by the
U.S. Food and Drug Administration (FDA) have not been considered in
developing these criteria; however, study of new equipment and
applications should be encouraged. The ultimate decision regarding the
appropriateness of any specific radiologic examination or treatment must
be made by the referring physician and radiologist in light of all the
circumstances presented in an individual examination.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Heiken JP, Bree RL, Foley WD, Gay SB, Glick SN, Huprich JE, Levine MS,
Ros PR, Rosen MP, Shuman WP, Greene FL, Expert Panel on Gastrointestinal
Imaging. Suspected liver metastases. \[online publication\]. Reston
(VA): American College of Radiology (ACR); 2005. 8 p. \[28 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1998 (revised 2005)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Gastrointestinal
Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Jay P. Heiken, MD; Robert L. Bree, MD, MHSA; W. Dennis
Foley, MD; Spencer B. Gay, MD; Seth N. Glick, MD; James E. Huprich, MD;
Marc S. Levine, MD; Pablo R. Ros, MD, MPH; Max Paul Rosen, MD, MPH;
William P. Shuman, MD; Frederick L. Greene, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Bree RL, Greene FL, Ralls PW,
Balfe DM, DiSantis DJ, Glick SN, Kidd R, Levine MS, Megibow AJ, Mezwa
DG, Saini S, Shuman WP, Laine LA, Lillemoe K. Suspected liver
metastases. American College of Radiology. ACR Appropriateness Criteria.
Radiology 2000 Jun;215(Suppl):213-24.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonGastrointestinalImaging/SuspectedLiverMetastasesDoc14.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on March 19, 2001. The information
was verified by the guideline developer on March 29, 2001. This NGC
summary was updated by ECRI on January 26, 2006. This summary was
updated by ECRI Institute on May 17, 2007 following the U.S. Food and
Drug Administration (FDA) advisory on Gadolinium-based contrast agents.
This summary was updated by ECRI Institute on June 20, 2007 following
the U.S. Food and Drug Administration (FDA) advisory on gadolinium-based
contrast agents.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

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Date Modified: 11/3/2008