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## Complete Summary

#### GUIDELINE TITLE

Multiple brain metastases.

#### BIBLIOGRAPHIC SOURCE(S)

Videtic GM, Gaspar LE, Aref AM, Imperato JP, Marcus KJ, Rogers CL,
Simpson JR, Suh JH, Wolfson AH, McDermott MW, Rogers L, Expert Panel on
Radiation Oncology-Brain Metastases. Multiple brain metastases. \[online
publication\]. Reston (VA): American College of Radiology (ACR); 2006. 8
p. \[31 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Shaw EG, Gaspar LE, Gibbs FA,
Lewin AA, Wharam MD Jr, Larson D, Bloomer WD, Buckley JA, Loeffler JS,
Malcolm AW, Mendenhall WM, Schneider JF, Schupak KD, Simpson JR, Gutin
PH, Rogers L, Leibel S. Multiple brain metastases. American College of
Radiology. ACR Appropriateness Criteria. Radiology 2000
Jun;215(Suppl):1121-8.

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

### COMPLETE SUMMARY CONTENT

 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)

Multiple brain metastases

#### GUIDELINE CATEGORY

Treatment

#### CLINICAL SPECIALTY

Neurological Surgery\
Neurology\
Oncology\
Radiation Oncology\
Radiology

#### INTENDED USERS

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

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of treatment procedures for patients
with multiple brain metastases

#### TARGET POPULATION

Patients with multiple brain metastases

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Whole brain radiotherapy (WBRT)

2.  Radiosensitizer plus whole brain radiotherapy (WBRT)

3.  Stereotactic radiosurgery (SRS)

    -   SRS alone

    -   SRS plus WBRT

4.  Surgery

    -   Excise dominant lesion(s)

    -   Excise all lesions

    -   Surgery plus WBRT

#### MAJOR OUTCOMES CONSIDERED

-   Morbidity or mortality

-   Improved care

-   Median survival time

-   Local control rate

-   Improvement in neurologic symptoms

### 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 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 to reach 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 1-9, 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 percent agreement is considered a
consensus.

If consensus cannot be reached by the 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: 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. Untreated T3 N2
adenocarcinoma of lung. Bone and liver metastases also present.**

  ----------------------------------------------------------------------------
  **Treatment**         **Appropriateness   **Comments**
                        Rating**            
  --------------------- ------------------- ----------------------------------
  **Whole Brain                             
  Radiotherapy (WBRT)                       
  Alone**                                   

  2000 cGy/5 fractions  7                   Poor KPS and systemic disease
                                            favors shorter courses.

  3000 cGy/10 fractions 8                    

  3750 cGy/15 fractions 5                    

  4000 cGy/20 fractions 2                    

  5000 cGy/25 fractions 2                    

  **Radiosensitizer**                       

  Radiosensitizer +     2                    
  WBRT                                      

  **Stereotactic                            
  Radiosurgery (SRS)**                      

  SRS alone             2                    

  SRS + WBRT            2                    

  **Surgery Alone**                         

  Excise dominant       1                    
  lesion(s)                                 

  Excise all lesions    1                    

  ***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: 50-year-old man, 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.**

  ----------------------------------------------------------------------------
  **Treatment**         **Appropriateness   **Comments**
                        Rating**            
  --------------------- ------------------- ----------------------------------
  **Whole Brain                             
  Radiotherapy (WBRT)                       
  Alone**                                   

  2000 cGy/5 fractions  2                    

  3000 cGy/10 fractions 5                    

  3750 cGy/15 fractions 6                    

  4000 cGy/20 fractions 4                    

  5000 cGy/25 fractions 2                    

  **Radiosensitizer**                       

  Radiosensitizer +     2                    
  WBRT                                      

  **Stereotactic                            
  Radiosurgery (SRS)**                      

  SRS + WBRT            8                   Best for durable CNS control.

  SRS alone             5                    

  **Surgery Alone**                         

  Excise dominant       2                    
  lesion(s)                                 

  Excise all lesions    3                    

  ***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: 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.**

  ----------------------------------------------------------------------------
  **Treatment**         **Appropriateness   **Comments**
                        Rating**            
  --------------------- ------------------- ----------------------------------
  **Whole Brain                             
  Radiotherapy (WBRT)                       
  Alone**                                   

  2000 cGy/5 fractions  2                    

  3000 cGy/10 fractions 8                    

  3750 cGy/15 fractions 8                    

  4000 cGy/20 fractions 2                    

  5000 cGy/25 fractions 2                    

  **Radiosensitizer**                       

  Radiosensitizer +     2                    
  WBRT                                      

  **Stereotactic                            
  Radiosurgery (SRS)**                      

  SRS alone             2                    

  SRS + WBRT            2                   WBRT (upfront); SRS only for
                                            progressive or new lesions.

  **Surgery Alone**                         

  Excise dominant       2                    
  lesion(s)                                 

  Excise all lesions    1                    

  ***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: 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 s/p
right modified radical mastectomy and adjuvant chemotherapy for T2 N1
adenocarcinoma of breast. Newly diagnosed pulmonary nodules also
present.**

  ----------------------------------------------------------------------------
  **Treatment**         **Appropriateness   **Comments**
                        Rating**            
  --------------------- ------------------- ----------------------------------
  **Whole Brain                             
  Radiotherapy (WBRT)                       
  Alone**                                   

  2000 cGy/5 fractions  2                    

  3000 cGy/10 fractions 7                    

  3750 cGy/15 fractions 8                    

  4000 cGy/20 fractions 4                    

  5000 cGy/25 fractions 2                    

  **Radiosensitizer**                       

  Radiosensitizer +     2                    
  WBRT                                      

  **Stereotactic                            
  Radiosurgery (SRS)**                      

  SRS plus WBRT         8                   WBRT alone is reasonable as SRS
                                            does not impact survival.

  SRS alone             6                    

  **Surgery Alone**                         

  Excise dominant       2                    
  lesion(s)                                 

  Excise all lesions    3                    

  **Surgery + WBRT**    7                    

  ***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 5: 35-year-old woman with two newly diagnosed, asymptomatic,
surgically accessible, supratentorial brain metastases \<3 cm in size on
MRI. KPS 100. S/p wide local excision of Clark\'s level IV melanoma one
month ago. No other metastases.**

  ----------------------------------------------------------------------------
  **Treatment**         **Appropriateness   **Comments**
                        Rating**            
  --------------------- ------------------- ----------------------------------
  **Whole Brain                             
  Radiotherapy (WBRT)                       
  Alone**                                   

  2000 cGy/5 fractions  2                    

  3000 cGy/10 fractions 5                    

  3750 cGy/15 fractions 5                    

  4000 cGy/20 fractions 2                    

  5000 cGy/25 fractions 2                    

  **Radiosensitizer**                       

  Radiosensitizer +     2                    
  WBRT                                      

  **Stereotactic                            
  Radiosurgery (SRS)**                      

  SRS alone             7                    

  SRS + WBRT            8                    

  **Surgery Alone**                         

  Excise dominant       3                    
  lesion(s)                                 

  Excise all lesions    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.

**Summary of Literature Review**

**Background**

It is estimated that as many as 170,000 cancer patients per year will
develop brain metastases. Brain metastases represent the most common
neurologic manifestation of cancer, occurring in 15% of cancer patients,
particularly those with lung cancer, breast cancer, and melanoma, who
account for 39%, 17%, and 11%, respectively, of patients with brain
metastases. Clinical, imaging, and autopsy series have shown that about
half of brain metastases will be solitary and half will be multiple.
Renal cell and prostate cancer are more likely than average to manifest
a solitary metastasis, whereas melanoma is more prone to develop
multiple metastases. Among the patients with multiple lesions, 70% are
supratentorial, 26% are supratentorial and cerebellar, 3% are
cerebellar, and 1% are located in the brainstem. The most common
symptoms of brain metastases are headache, altered mental status, and
focal weakness, occurring in about one-third to one-half of patients.
The next most common symptoms include seizures and gait ataxia, which
are seen in about 10% to 20% of patients. Historically, whole brain
radiation therapy (WBRT) has been a standard of care in patients with
multiple brain metastases, although there are no randomized trials of
WBRT vs. supportive care showing a survival advantage for treatment.
Attempts to improve outcome in patients with multiple brain metastases
have included the use of different dose/fractionation schedules,
radiation sensitizers, and, more recently, surgery and stereotactic
radiosurgery (SRS).

**Prognostic Factors**

The median survival time of a patient with brain metastases following
WBRT is reproducibly in the 4 to 6 month range. Certain clinical
prognostic factors are associated with a better or worse outcome. For
instance, patients younger than 65 years of age whose Karnofsky
performance status (KPS) is ≥70, and who have a controlled primary
cancer without other systemic metastases have a median survival time of
7.1 months. Those with a KPS \<70, independent of other factors, have a
median survival time of 2.3 months, whereas all other patients have a
4.2 month median survival time. Imaging prognostic factors, such as the
number of metastases, presence of midline shift, and post-WBRT response,
can also influence outcome.

**Whole Brain Radiation Therapy with and without Radiation Sensitizers**

A variety of total doses and doses per fraction have been used in
prospective, randomized phase III clinical trials, primarily in patients
with multiple brain metastases. These regimens include 1000 cGy in 1
fraction (1000/1), 1200/2, 1800/3, 2000/5, 3000/10, 3600/6, 4000/20,
5000/20, and 5440/34 (160 cGy twice a day \[BID\]). While none of these
regimens has proven better than another in terms of survival or efficacy
(about half of patients have an improvement in their neurologic
symptoms), 3000 cGy in 10 fractions and 3750 cGy in 15 fractions
represent the most frequently used dose/fractionation schedules. In
selecting treatment regimens appropriate for individual patients,
clinicians should consider the Radiation Therapy Oncology Group
(RTOG^®^) recursive partitioning analysis (RPA) brain metastasis
classification, which supports short course treatment in poor risk
patients, (i.e., poor performance status, elderly, progressive systemic
disease.) In a recently published trial for patients with one to three
brain metastases carried out by the RTOG^®^, 3750 cGy in 15 fractions
WBRT (i.e., 250 cGy per fraction) was used as the standard treatment arm
based on concerns regarding late effects from series suggesting that 300
cGy fractions given after resection of a solitary brain metastasis was
associated with a greater likelihood of late effects to the normal
brain. Another study of patients with small-cell-lung cancer found that
prophylactic cranial irradiation with 250 cGy fractions (10 fractions)
was not associated with late effects.

Even though it is common for patients with multiple brain metastases to
have active primary and other systemic metastatic disease, progression
of brain disease is the cause of death in about half of these patients
(range, 26% to 70%). Various radiation sensitizers have been added to
WBRT without a demonstrated improvement in survival. Recent randomized
studies with efaproxiral and motexafin gadolinium have not demonstrated
survival benefits; however, subset analyses in each of these trials have
been provocative and suggested possible benefits for these drugs for
specific histologies (breast, non-small-cell lung), prompting ongoing
phase III studies. A randomized phase II study with temozolomide
suggested improved response rates and neurologic outcomes for patients
randomized to receive the drug. Overall, there is no strong evidence to
date to support the use of any radiation sensitizer in standard
practice.

**Surgery and Stereotactic Radiosurgery**

Surgery has traditionally not had a role to play in the management of
patients with multiple brain metastases, and its role in this setting
remains controversial. Retrospective studies have suggested a survival
benefit for surgery in this setting. Selection of patients clearly
influences outcomes. One study used the RTOG^®^ recursive partitioning
analysis (RPA) brain metastasis classification to analyze the results of
tumor resection and radiosurgery in the management of 52 patients with
multiple brain metastases and found that RPA class correlates best with
improved survival. Another study investigated the role of surgery in the
treatment of 138 patients with multiple brain metastases when performed
with radiation therapy. Median survival times were 8.7 months for
patients with single metastases and 9.2 months for those with multiple
metastases (no significant difference).

There are now three phase III trials addressing the role of stereotactic
radiosurgery (SRS) in the management of multiple brain metastases. One
study reported a small randomized trial in which 27 patients with two to
four brain metastases ≤25 mm in diameter received WBRT alone or with an
SRS boost. Local control at 1 year was 92% with SRS vs. 0% without SRS.
Median survival time was also better with SRS (11 months vs. 7.5
months). RTOG^®^ has published the results of its phase III trial in
which 333 patients were randomized to WBRT with or without SRS boost if
they had one to three brain metastases. The median survival with SRS was
6.5 months vs. 5.7 months, a nonsignificant difference. Subset analysis
suggested a survival advantage in the WBRT and SRS group for patients
with a single brain metastasis (median survival time 6.5 months vs. 4.9
months) but no survival advantage to SRS for multiple metastases.
Another study recently reported on a study of 132 patients to SRS plus
WBRT versus SRS alone for the treatment of brain metastases. Median
survival times were 7.5 months for the SRS alone arm and 8.0 months for
the SRS plus WBRT arm, a nonsignificant difference. Of interest
intracranial relapse occurred more frequently in those who did not
receive WBRT. These results suggest at a minimum the importance of WBRT
in patients with multiple metastases, and the role of selection in the
application of SRS for this class of patients. Given the absence of
survival impact with SRS, careful patient selection for this
intervention needs to be practiced by clinicians, use of the RTOG^®^ RPA
brain metastasis classification may prove useful in decision-making.

**Summary**

WBRT is an effective palliative treatment for patients with multiple
brain metastases. About half of these patients experience an improvement
in their neurologic symptoms. However, a majority of them do not achieve
local control and frequently succumb from progressive brain disease. Any
perceived benefits from surgery need verification in prospective,
randomized phase III clinical trials. The role of SRS for patients with
multiple metastases may be primarily a function of proper patient
selection but likely cannot replace the benefits of WBRT. Effective
radiation sensitizers are needed, because WBRT alone, even in doses of
50 to 54.4 Gy, has not been associated with an improved survival
outcome.

**Abbreviations**

-   CNS, central nervous system

-   KPS, Karnofsky Performance Status

-   MRI, magnetic resonance imaging

-   s/p, status post

-   SRS, stereotactic radiosurgery

-   TN, primary tumor, regional lymph node

-   WBRT, whole brain radiotherapy

#### 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 treatment procedures for patients with multiple
brain 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

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Videtic GM, Gaspar LE, Aref AM, Imperato JP, Marcus KJ, Rogers CL,
Simpson JR, Suh JH, Wolfson AH, McDermott MW, Rogers L, Expert Panel on
Radiation Oncology-Brain Metastases. Multiple brain metastases. \[online
publication\]. Reston (VA): American College of Radiology (ACR); 2006. 8
p. \[31 references\]

#### ADAPTATION

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

#### DATE RELEASED

1999 (revised 2006)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

The 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 Radiation
Oncology-Brain Metastases

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Gregory M. Videtic, MD; Laurie E. Gaspar, MD, MBA; Amr
M. Aref, MD; Joseph P. Imperato, MD; Karen J. Marcus, MD; C. Leland
Rogers, MD; Joseph R. Simpson, MD; John H. Suh, MD; Aaron H. Wolfson,
MD; Michael W. McDermott, MD; Lisa Rogers, DO

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Shaw EG, Gaspar LE, Gibbs FA,
Lewin AA, Wharam MD Jr, Larson D, Bloomer WD, Buckley JA, Loeffler JS,
Malcolm AW, Mendenhall WM, Schneider JF, Schupak KD, Simpson JR, Gutin
PH, Rogers L, Leibel S. Multiple brain metastases. American College of
Radiology. ACR Appropriateness Criteria. Radiology 2000
Jun;215(Suppl):1121-8.

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/ExpertPanelonRadiationOncologyBrainMetastasesWorkGroup/MultipleBrainMetastasesDoc2.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 January 30, 2001. The information
was verified by the guideline developer as of February 20, 2001. This
NGC summary was updated by ECRI Institute on May 16, 2007.

#### 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

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008