Brain Tumors

Variant: 1 Adult. Primary brain tumor screening. Genetic risk factors.

Procedure	Appropriateness Category	Relative Radiation Level
MRI head without and with IV contrast	Usually Appropriate	O
MRI complete spine without and with IV contrast	May Be Appropriate	O
MRI head without IV contrast	May Be Appropriate	O
MR spectroscopy head without IV contrast	Usually Not Appropriate	O
MRI complete spine with IV contrast	Usually Not Appropriate	O
MRI complete spine without IV contrast	Usually Not Appropriate	O
MRI functional (fMRI) head without IV contrast	Usually Not Appropriate	O
MRI head perfusion with IV contrast	Usually Not Appropriate	O
MRI head perfusion without IV contrast	Usually Not Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
MRI head without IV contrast with DTI	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
DOTATATE PET/CT brain	Usually Not Appropriate	☢☢☢
DOTATATE PET/MRI brain	Usually Not Appropriate	☢☢☢
FDG-PET/CT brain	Usually Not Appropriate	☢☢☢
FDG-PET/MRI brain	Usually Not Appropriate	☢☢☢
Fluciclovine PET/MRI brain	Usually Not Appropriate	☢☢☢
Fluciclovine PET/CT brain	Usually Not Appropriate	☢☢☢☢

Variant: 2 Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.

Procedure	Appropriateness Category	Relative Radiation Level
MRI head without and with IV contrast	Usually Appropriate	O
MRI complete spine without and with IV contrast	May Be Appropriate	O
MRI head without IV contrast	May Be Appropriate	O
MR spectroscopy head without IV contrast	Usually Not Appropriate	O
MRI complete spine with IV contrast	Usually Not Appropriate	O
MRI complete spine without IV contrast	Usually Not Appropriate	O
MRI functional (fMRI) head without IV contrast	Usually Not Appropriate	O
MRI head perfusion with IV contrast	Usually Not Appropriate	O
MRI head perfusion without IV contrast	Usually Not Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
MRI head without IV contrast with DTI	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
DOTATATE PET/CT brain	Usually Not Appropriate	☢☢☢
DOTATATE PET/MRI brain	Usually Not Appropriate	☢☢☢
FDG-PET/CT brain	Usually Not Appropriate	☢☢☢
FDG-PET/MRI brain	Usually Not Appropriate	☢☢☢
Fluciclovine PET/MRI brain	Usually Not Appropriate	☢☢☢
Fluciclovine PET/CT brain	Usually Not Appropriate	☢☢☢☢

Variant: 3 Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.

Procedure	Appropriateness Category	Relative Radiation Level
MRI head perfusion with IV contrast	Usually Appropriate	O
MRI head without and with IV contrast	Usually Appropriate	O
MR spectroscopy head without IV contrast	May Be Appropriate	O
MRI complete spine without and with IV contrast	May Be Appropriate	O
MRI functional (fMRI) head without IV contrast	May Be Appropriate	O
MRI head perfusion without IV contrast	May Be Appropriate	O
MRI head without IV contrast	May Be Appropriate	O
MRI head without IV contrast with DTI	May Be Appropriate	O
Fluciclovine PET/MRI brain	May Be Appropriate	☢☢☢
Fluciclovine PET/CT brain	May Be Appropriate	☢☢☢☢
MRI complete spine with IV contrast	Usually Not Appropriate	O
MRI complete spine without IV contrast	Usually Not Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
DOTATATE PET/CT brain	Usually Not Appropriate	☢☢☢
DOTATATE PET/MRI brain	Usually Not Appropriate	☢☢☢
FDG-PET/CT brain	Usually Not Appropriate	☢☢☢
FDG-PET/MRI brain	Usually Not Appropriate	☢☢☢

Variant: 4 Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.

Procedure	Appropriateness Category	Relative Radiation Level
MRI head without and with IV contrast	Usually Appropriate	O
MRI complete spine without and with IV contrast	May Be Appropriate	O
MRI functional (fMRI) head without IV contrast	May Be Appropriate	O
MRI head without IV contrast	May Be Appropriate	O
DOTATATE PET/CT brain	May Be Appropriate	☢☢☢
DOTATATE PET/MRI brain	May Be Appropriate	☢☢☢
MR spectroscopy head without IV contrast	Usually Not Appropriate	O
MRI complete spine with IV contrast	Usually Not Appropriate	O
MRI complete spine without IV contrast	Usually Not Appropriate	O
MRI head perfusion with IV contrast	Usually Not Appropriate	O
MRI head perfusion without IV contrast	Usually Not Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
MRI head without IV contrast with DTI	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
FDG-PET/CT brain	Usually Not Appropriate	☢☢☢
FDG-PET/MRI brain	Usually Not Appropriate	☢☢☢
Fluciclovine PET/MRI brain	Usually Not Appropriate	☢☢☢
Fluciclovine PET/CT brain	Usually Not Appropriate	☢☢☢☢

Variant: 5 Adult. Known history of brain tumor. Posttreatment surveillance.

Procedure	Appropriateness Category	Relative Radiation Level
MRI head perfusion with IV contrast	Usually Appropriate	O
MRI head without and with IV contrast	Usually Appropriate	O
MRI complete spine without and with IV contrast	May Be Appropriate	O
MRI head perfusion without IV contrast	May Be Appropriate	O
MRI head without IV contrast	May Be Appropriate (Disagreement)	O
MR spectroscopy head without IV contrast	Usually Not Appropriate	O
MRI complete spine with IV contrast	Usually Not Appropriate	O
MRI complete spine without IV contrast	Usually Not Appropriate	O
MRI functional (fMRI) head without IV contrast	Usually Not Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
MRI head without IV contrast with DTI	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
DOTATATE PET/CT brain	Usually Not Appropriate	☢☢☢
DOTATATE PET/MRI brain	Usually Not Appropriate	☢☢☢
FDG-PET/CT brain	Usually Not Appropriate	☢☢☢
FDG-PET/MRI brain	Usually Not Appropriate	☢☢☢
Fluciclovine PET/MRI brain	Usually Not Appropriate	☢☢☢
Fluciclovine PET/CT brain	Usually Not Appropriate	☢☢☢☢

Variant: 6 Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI head perfusion with IV contrast	Usually Appropriate	O
MRI head perfusion without IV contrast	Usually Appropriate	O
MRI head without and with IV contrast	Usually Appropriate	O
MR spectroscopy head without IV contrast	May Be Appropriate	O
MRI head without IV contrast	May Be Appropriate	O
MRI head without IV contrast with DTI	May Be Appropriate	O
DOTATATE PET/CT brain	May Be Appropriate	☢☢☢
DOTATATE PET/MRI brain	May Be Appropriate	☢☢☢
FDG-PET/CT brain	May Be Appropriate	☢☢☢
FDG-PET/MRI brain	May Be Appropriate	☢☢☢
MRI complete spine with IV contrast	Usually Not Appropriate	O
MRI complete spine without and with IV contrast	Usually Not Appropriate	O
MRI complete spine without IV contrast	Usually Not Appropriate	O
MRI functional (fMRI) head without IV contrast	Usually Not Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
Fluciclovine PET/MRI brain	Usually Not Appropriate	☢☢☢
Fluciclovine PET/CT brain	Usually Not Appropriate	☢☢☢☢

Panel Members

Jana Ivanidze, MD, PhD^a; Robert Y. Shih, MD^b; Pallavi S. Utukuri, MD^c; Amna A. Ajam, MD, MBBS^d; Moises Auron, MD^e; Susan M. Chang, MD^f; Justin T. Jordan, MD, MPH^g; Aleks Kalnins, MD, MBA^h; Phillip H. Kuo, MD, PhDⁱ; Luke N. Ledbetter, MD^j; Jeffrey S. Pannell, MD^k; Jeffrey M. Pollock, MD^l; Jason Sheehan, MD, PhD^m; Bruno P. Soares, MDⁿ; Karl A. Soderlund, MD^o; Lily L. Wang, MBBS, MPH^p; Judah Burns, MD^q.

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Discussion of Procedures by Variant

Variant 1: Adult. Primary brain tumor screening. Genetic risk factors.

Variant 1: Adult. Primary brain tumor screening. Genetic risk factors.
A. CT head with IV contrast

Variant 1: Adult. Primary brain tumor screening. Genetic risk factors.
B. CT head without and with IV contrast

Variant 1: Adult. Primary brain tumor screening. Genetic risk factors.
C. CT head without IV contrast

Variant 1: Adult. Primary brain tumor screening. Genetic risk factors.
D. DOTATATE PET/CT brain

Variant 1: Adult. Primary brain tumor screening. Genetic risk factors.
E. DOTATATE PET/MRI brain

Variant 1: Adult. Primary brain tumor screening. Genetic risk factors.
F. FDG-PET/CT brain

Variant 1: Adult. Primary brain tumor screening. Genetic risk factors.
G. FDG-PET/MRI brain

Variant 1: Adult. Primary brain tumor screening. Genetic risk factors.
H. Fluciclovine PET/CT brain

Variant 1: Adult. Primary brain tumor screening. Genetic risk factors.
I. Fluciclovine PET/MRI brain

Variant 1: Adult. Primary brain tumor screening. Genetic risk factors.
J. MR spectroscopy head without IV contrast

Variant 1: Adult. Primary brain tumor screening. Genetic risk factors.
K. MRI complete spine with IV contrast

Variant 1: Adult. Primary brain tumor screening. Genetic risk factors.
L. MRI complete spine without and with IV contrast

Variant 1: Adult. Primary brain tumor screening. Genetic risk factors.
M. MRI complete spine without IV contrast

Variant 1: Adult. Primary brain tumor screening. Genetic risk factors.
N. MRI functional (fMRI) head without IV contrast

Variant 1: Adult. Primary brain tumor screening. Genetic risk factors.
O. MRI head perfusion with IV contrast

Variant 1: Adult. Primary brain tumor screening. Genetic risk factors.
P. MRI head perfusion without IV contrast

Variant 1: Adult. Primary brain tumor screening. Genetic risk factors.
Q. MRI head with IV contrast

Variant 1: Adult. Primary brain tumor screening. Genetic risk factors.
R. MRI head without and with IV contrast

Variant 1: Adult. Primary brain tumor screening. Genetic risk factors.
S. MRI head without IV contrast

Variant 1: Adult. Primary brain tumor screening. Genetic risk factors.
T. MRI head without IV contrast with DTI

Variant 2: Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.

Variant 2: Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.
A. CT head with IV contrast

Variant 2: Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.
B. CT head without and with IV contrast

Variant 2: Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.
C. CT head without IV contrast

Variant 2: Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.
D. DOTATATE PET/CT brain

Variant 2: Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.
E. DOTATATE PET/MRI brain

Variant 2: Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.
F. FDG-PET/CT brain

Variant 2: Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.
G. FDG-PET/MRI brain

Variant 2: Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.
H. Fluciclovine PET/CT brain

Variant 2: Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.
I. Fluciclovine PET/MRI brain

Variant 2: Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.
J. MR spectroscopy head without IV contrast

Variant 2: Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.
K. MRI complete spine with IV contrast

Variant 2: Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.
L. MRI complete spine without and with IV contrast

Variant 2: Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.
M. MRI complete spine without IV contrast

Variant 2: Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.
N. MRI functional (fMRI) head without IV contrast

Variant 2: Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.
O. MRI head perfusion with IV contrast

Variant 2: Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.
P. MRI head perfusion without IV contrast

Variant 2: Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.
Q. MRI head with IV contrast

Variant 2: Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.
R. MRI head without and with IV contrast

Variant 2: Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.
S. MRI head without IV contrast

Variant 2: Adult. Secondary or metastatic brain tumor screening. Extracranial malignancy.
T. MRI head without IV contrast with DTI

Variant 3: Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.

Variant 3: Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.
A. CT head with IV contrast

Variant 3: Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.
B. CT head without and with IV contrast

Variant 3: Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.
C. CT head without IV contrast

Variant 3: Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.
D. DOTATATE PET/CT brain

Variant 3: Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.
E. DOTATATE PET/MRI brain

Variant 3: Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.
F. FDG-PET/CT brain

Variant 3: Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.
G. FDG-PET/MRI brain

Variant 3: Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.
H. Fluciclovine PET/CT brain

Variant 3: Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.
I. Fluciclovine PET/MRI brain

Variant 3: Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.
J. MR spectroscopy head without IV contrast

Variant 3: Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.
K. MRI complete spine with IV contrast

Variant 3: Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.
L. MRI complete spine without and with IV contrast

Variant 3: Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.
M. MRI complete spine without IV contrast

Variant 3: Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.
N. MRI functional (fMRI) head without IV contrast

Variant 3: Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.
O. MRI head perfusion with IV contrast

Variant 3: Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.
P. MRI head perfusion without IV contrast

Variant 3: Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.
Q. MRI head with IV contrast

Variant 3: Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.
R. MRI head without and with IV contrast

Variant 3: Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.
S. MRI head without IV contrast

Variant 3: Adult. Suspected intra-axial brain tumor based on prior imaging. Pretreatment evaluation.
T. MRI head without IV contrast with DTI

Variant 4: Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.

Variant 4: Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.
A. CT head with IV contrast

Variant 4: Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.
B. CT head without and with IV contrast

Variant 4: Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.
C. CT head without IV contrast

Variant 4: Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.
D. DOTATATE PET/CT brain

Variant 4: Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.
E. DOTATATE PET/MRI brain

Variant 4: Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.
F. FDG-PET/CT brain

Variant 4: Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.
G. FDG-PET/MRI brain

Variant 4: Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.
H. Fluciclovine PET/CT brain

Variant 4: Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.
I. Fluciclovine PET/MRI brain

Variant 4: Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.
J. MR spectroscopy head without IV contrast

Variant 4: Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.
K. MRI complete spine with IV contrast

Variant 4: Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.
L. MRI complete spine without and with IV contrast

Variant 4: Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.
M. MRI complete spine without IV contrast

Variant 4: Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.
N. MRI functional (fMRI) head without IV contrast

Variant 4: Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.
O. MRI head perfusion with IV contrast

Variant 4: Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.
P. MRI head perfusion without IV contrast

Variant 4: Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.
Q. MRI head with IV contrast

Variant 4: Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.
R. MRI head without and with IV contrast

Variant 4: Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.
S. MRI head without IV contrast

Variant 4: Adult. Suspected extra-axial brain tumor on prior imaging. Pretreatment evaluation.
T. MRI head without IV contrast with DTI

Variant 5: Adult. Known history of brain tumor. Posttreatment surveillance.

Variant 5: Adult. Known history of brain tumor. Posttreatment surveillance.
A. CT head with IV contrast

Variant 5: Adult. Known history of brain tumor. Posttreatment surveillance.
B. CT head without and with IV contrast

Variant 5: Adult. Known history of brain tumor. Posttreatment surveillance.
C. CT head without IV contrast

Variant 5: Adult. Known history of brain tumor. Posttreatment surveillance.
D. DOTATATE PET/CT brain

Variant 5: Adult. Known history of brain tumor. Posttreatment surveillance.
E. DOTATATE PET/MRI brain

Variant 5: Adult. Known history of brain tumor. Posttreatment surveillance.
F. FDG-PET/CT brain

Variant 5: Adult. Known history of brain tumor. Posttreatment surveillance.
G. FDG-PET/MRI brain

Variant 5: Adult. Known history of brain tumor. Posttreatment surveillance.
H. Fluciclovine PET/CT brain

Variant 5: Adult. Known history of brain tumor. Posttreatment surveillance.
I. Fluciclovine PET/MRI brain

Variant 5: Adult. Known history of brain tumor. Posttreatment surveillance.
J. MR spectroscopy head without IV contrast

Variant 5: Adult. Known history of brain tumor. Posttreatment surveillance.
K. MRI complete spine with IV contrast

Variant 5: Adult. Known history of brain tumor. Posttreatment surveillance.
L. MRI complete spine without and with IV contrast

Variant 5: Adult. Known history of brain tumor. Posttreatment surveillance.
M. MRI complete spine without IV contrast

Variant 5: Adult. Known history of brain tumor. Posttreatment surveillance.
N. MRI functional (fMRI) head without IV contrast

Variant 5: Adult. Known history of brain tumor. Posttreatment surveillance.
O. MRI head perfusion with IV contrast

Variant 5: Adult. Known history of brain tumor. Posttreatment surveillance.
P. MRI head perfusion without IV contrast

Variant 5: Adult. Known history of brain tumor. Posttreatment surveillance.
Q. MRI head with IV contrast

Variant 5: Adult. Known history of brain tumor. Posttreatment surveillance.
R. MRI head without and with IV contrast

Variant 5: Adult. Known history of brain tumor. Posttreatment surveillance.
S. MRI head without IV contrast

Variant 5: Adult. Known history of brain tumor. Posttreatment surveillance.
T. MRI head without IV contrast with DTI

Variant 6: Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.

Variant 6: Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.
A. CT head with IV contrast

Variant 6: Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.
B. CT head without and with IV contrast

Variant 6: Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.
C. CT head without IV contrast

Variant 6: Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.
D. DOTATATE PET/CT brain

Variant 6: Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.
E. DOTATATE PET/MRI brain

Variant 6: Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.
F. FDG-PET/CT brain

Variant 6: Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.
G. FDG-PET/MRI brain

Variant 6: Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.
H. Fluciclovine PET/CT brain

Variant 6: Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.
I. Fluciclovine PET/MRI brain

Variant 6: Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.
J. MR spectroscopy head without IV contrast

Variant 6: Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.
K. MRI complete spine with IV contrast

Variant 6: Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.
L. MRI complete spine without and with IV contrast

Variant 6: Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.
M. MRI complete spine without IV contrast

Variant 6: Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.
N. MRI functional (fMRI) head without IV contrast

Variant 6: Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.
O. MRI head perfusion with IV contrast

Variant 6: Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.
P. MRI head perfusion without IV contrast

Variant 6: Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.
Q. MRI head with IV contrast

Variant 6: Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.
R. MRI head without and with IV contrast

Variant 6: Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.
S. MRI head without IV contrast

Variant 6: Adult. Known history of brain tumor. New or enlarging lesion on posttreatment surveillance. Next imaging study.
T. MRI head without IV contrast with DTI

Summary of Highlights

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Gender Equality and Inclusivity Clause

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

References

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Disclaimer

The 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 examinations 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 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.