Multiple options for retreatment are available, which include whole-brain radiation therapy, stereotactic radiosurgery, surgery, chemotherapy, and supportive care. Size, number, timing, location, histology, performance status, and extracranial disease status all need to be carefully considered when choosing a treatment modality. There are no randomized trials examining the retreatment of brain metastases. Repeat whole-brain radiation has been examined in a single-institution experience, showing the potential for clinical responses in selected patients. Local control rates as high as 91% using stereotactic radiosurgery for relapses after whole-brain radiation are reported. Surgery can be indicated in progressive and/or hemorrhagic lesions causing mass effect. The role of chemotherapy in the recurrent setting is limited but some agents may have activity on the basis of experiences on a smaller scale. Supportive care continues to be an important option, especially in those with a poor prognosis. Follow-up for brain metastases patients is discussed, examining the modality, frequency of imaging, and imaging options in differentiating treatment effect from recurrence. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of the current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
*Mayo Clinic Arizona, Scottsdale
§§Barrow Neurological Institute, American Academy of Neurology, Phoenix, AZ
†Henry Ford Hospital, Detroit, MI
‡Medical College of Wisconsin, Milwaukee, WI
∥∥University of Wisconsin, Paul P. Carbone Comprehensive Cancer Center, American Society of Clinical Oncology, Madison, WI
§Alvin J. Siteman Cancer Center, St. Louis, MO
##Mallinckrodt Institute of Radiology, St Louis, MO
∥University of Colorado Denver, Aurora, CO
¶Mount Sinai School of Medicine, American Association of Neurological Surgeons/Congress of Neurological Surgeons, New York, NY
#Duke University Medical Center, Durham, NC
**Indiana University School of Medicine, Indianapolis, IN
††Blanchard Valley Regional Cancer Center, Findlay
¶¶Cleveland Clinic, Strongsville, OH
***Cleveland Clinic Foundation, Cleveland, OH
‡‡University of California-San Francisco, American Association of Neurological Surgeons/Congress of Neurological Surgeons, San Francisco, CA
The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.
This article is a revised version of the American College of Radiology Appropriateness Criteria Follow-Up and Retreatment of Brain Metastases, excerpts of which are reprinted here with permission. Practitioners are encouraged to refer to the complete version at www.acr.org/ac.
The authors declare no conflicts of interest.
Reprints: Samir H. Patel, MD, American College of Radiology, 1891 Preston White Drive, Reston, VA 20191. E-mail: email@example.com.