This is the current release of the guideline.

This guideline updates a previous version: Pollack A, Hayes S, Roach M III, Merrick G, Anscher MS, Beyer DC, Lawton CA, Lee WR, Michalski JM, Rosenthal SA, Vijayakumar S, Carroll PR, Higano CS, Expert Panel on Radiation Oncology-Prostate. Postradical prostatectomy irradiation in prostate cancer. [online publication]. Reston (VA): American College of Radiology (ACR); 2006. 18 p. [116 references]

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

Prostate cancer

To evaluate the appropriateness of radiation therapy procedures for prostate cancer patients after radical prostatectomy

Prostate cancer patients after radical prostatectomy

Literature Search Procedure

The Medline literature search is based on keywords provided by the topic author. The two general classes of keywords are those related to the condition (e.g., ankle pain, fever) and those that describe the diagnostic or therapeutic intervention of interest (e.g., mammography, MRI).

The search terms and parameters are manipulated to produce the most relevant, current evidence to address the American College of Radiology Appropriateness Criteria (ACR AC) topic being reviewed or developed. Combining the clinical conditions and diagnostic modalities or therapeutic procedures narrows the search to be relevant to the topic. Exploding the term "diagnostic imaging" captures relevant results for diagnostic topics.

The following criteria/limits are used in the searches.

1. Articles that have abstracts available and are concerned with humans.
2. Restrict the search to the year prior to the last topic update or in some cases the author of the topic may specify which year range to use in the search. For new topics, the year range is restricted to the last 5 years unless the topic author provides other instructions.
3. May restrict the search to Adults only or Pediatrics only.
4. Articles consisting of only summaries or case reports are often excluded from final results.

The search strategy may be revised to improve the output as needed.

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

Strength of Evidence Key

Category 1 - The conclusions of the study are valid and strongly supported by study design, analysis and results.

Category 2 - The conclusions of the study are likely valid, but study design does not permit certainty.

Category 3 - The conclusions of the study may be valid but the evidence supporting the conclusions is inconclusive or equivocal.

Category 4 - The conclusions of the study may not be valid because the evidence may not be reliable given the study design or analysis.

The topic author drafts or revises the narrative text summarizing the evidence found in the literature. American College of Radiology (ACR) staff draft an evidence table based on the analysis of the selected literature. These tables rate the strength of the evidence for all articles included in the narrative text.

The expert panel reviews the narrative text, evidence table, and the supporting literature for each of the topic-variant combinations and assigns an appropriateness rating for each procedure listed in the table. Each individual panel member forms his/her own opinion based on his/her interpretation of the available evidence.

More information about the evidence table development process can be found in the American College of Radiology (ACR) Appropriateness Criteria® Evidence Table Development document (see "Availability of Companion Documents" field).

Modified Delphi Technique

The appropriateness ratings for each of the procedures included in the Appropriateness Criteria topics are determined using a modified Delphi methodology. A series of surveys are conducted to elicit each panelist's expert interpretation of the evidence, based on the available data, regarding the appropriateness of an imaging or therapeutic procedure for a specific clinical scenario. American College of Radiology (ACR) staff distributes surveys to the panelists along with the evidence table and narrative. Each panelist interprets the available evidence and rates each procedure. The surveys are completed by panelists without consulting other panelists. The ratings are a scale between 1 and 9, which is further divided into three categories: 1, 2, or 3 is defined as "usually not appropriate"; 4, 5, or 6 is defined as "may be appropriate"; and 7, 8, or 9 is defined as "usually appropriate." Each panel member assigns one rating for each procedure per survey round. The surveys are collected and the results are tabulated, de-identified and redistributed after each round. A maximum of three rounds are conducted. The modified Delphi technique enables each panelist to express individual interpretations of the evidence and his or her expert opinion without excessive bias from fellow panelists in a simple, standardized and economical process.

Consensus among the panel members must be achieved to determine the final rating for each procedure. Consensus is defined as eighty percent (80%) agreement within a rating category. The final rating is determined by the median of all the ratings once consensus has been reached. Up to three rating rounds are conducted to achieve consensus.

If consensus is not reached, the panel is convened by conference call. The strengths and weaknesses of each imaging procedure that has not reached consensus are discussed and a final rating is proposed. If the panelists on the call agree, the rating is accepted as the panel's consensus. The document is circulated to all the panelists to make the final determination. If consensus cannot be reached on the call or when the document is circulated, "No consensus" appears in the rating column and the reasons for this decision are added to the comment sections.

Not applicable

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

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

ACR Appropriateness Criteria®

Clinical Condition: Postradical Prostatectomy Irradiation in Prostate Cancer

Variant 1: 65-year-old man, stage T2A, Gleason score 6, adenocarcinoma. PSA 14.5 ng/mL. Negative diagnostic workup. Treated with nerve-sparing radical prostatectomy. Right seminal vesicle involved by tumor, but surgical margins of prostatectomy specimen negative. Negative lymph nodes. Postprostatectomy PSA nondetectable.

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

Variant 2: 58-year-old man, stage T1C, Gleason score 7, adenocarcinoma. PSA 10.5 ng/mL. Negative metastatic workup. Treated with nerve-sparing radical prostatectomy. Negative lymph nodes. Positive margins at prostate apex. Postprostatectomy PSA nondetectable.

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

Variant 3: 58-year-old man, stage T1C, Gleason score 7, adenocarcinoma. PSA 10.5 ng/mL. Negative metastatic workup. Treated with nerve-sparing radical prostatectomy. Negative lymph nodes. Positive margins at prostate apex. Postprostatectomy PSA detectable at 0.3 ng/mL.

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

Variant 4: 67-year-old man, stage T1C, Gleason score 8, adenocarcinoma. PSA 8.0 ng/mL. Negative metastatic workup. Nerve-sparing radical prostatectomy performed. Margins negative. No seminal vesicle extension. Postoperative PSA nonmeasurable. Six months later PSA rose to 9.0 ng/mL. Extent of disease workup, including pelvic MRI, negative.

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

Variant 5: 64-year-old man, stage T2A, Gleason score 7, adenocarcinoma. PSA 10.5 ng/mL. Negative metastatic workup. Treated with nerve-sparing radical prostatectomy. Prostatectomy margins negative. No seminal vesicle extension. One positive obturator lymph node. Postprostatectomy PSA nondetectable.

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

Summary of Literature Review

Radical prostatectomy (RP) and radiation therapy (RT) are the primary treatment options for organ-confined prostate cancer (T1-2, stages I or II). Eventually, about 50% to 70% of postprostatectomy patients with high-risk pathologic features, such as a positive margin, extracapsular extension (ECE), or seminal vesicle involvement (SVI) will develop biochemical failure. Thus, RT may play a role either immediately following prostatectomy (based on various known high-risk pathologic features) or at the time of biochemical failure.

There are three main situations in which RT is given after RP: 1) adjuvant radiotherapy (ART) for men with an undetectable or barely detectable prostate-specific antigen (PSA) (<0.2 ng/mL) who have high risk pathologic features; 2) salvage radiotherapy (SRT) for men who have an undetectable or barely detectable PSA (<0.2 ng/mL) immediately postoperatively, but whose PSA rises at some later date -- a delayed rise in PSA (DR-PSA); and 3) SRT for men whose PSA remains at 0.2 ng/mL or above postoperatively -- a persistently detectable PSA (PD-PSA).

The purpose of distinguishing between ART and SRT is rooted in the observation that there are significant differences between the two groups in prognosis after RT, in dose of RT administered, and in prognostic factors. The further subdivision of salvage patients into two groups, those with a DR-PSA and those with a PD-PSA, is useful because their outcomes after RT appear to be different, with a worse prognosis for those having a PD-PSA. In general, the earlier the rise in PSA after RP, the worse the outcome because of a higher risk of metastatic disease; the PD-PSA group represents the extreme of patients being considered for SRT in this respect.

Adjuvant Radiotherapy

The rationale for administering ART after RP is predicated on the assumption that microscopic local disease remains. Local therapy would reduce recurrence in the prostate bed and prevent the residual nidus from disseminating distantly. The decision to administer ART is based on the presence of high-risk pathologic findings in the prostatectomy specimen. The primary high-risk features are ECE, positive margins (prostate cancer at the margin of resection), SVI, and lymph node involvement (LNI). The frequencies of occurrence are approximately 40% for ECE, 25% for margin positivity, 10% for SVI, and 5% for LNI. Another indication for ART is the presence of residual normal prostate at the inked specimen margin (a cut-through of the prostate), even without conclusive evidence that tumor remains and with an undetectable PSA. The assumption is that a cut-through of the prostate is representative of inadequate surgery and that microscopic disease could be left behind.

The prevalence of persistent local disease following RP is significant and generally under-recognized. Residual disease has been documented in approximately 50% of prostatectomy cases at autopsy and in biopsy specimens of the prostatic fossa and urethrovesical anastomosis. Long-term follow-up has revealed that the risk of biochemical failure following prostatectomy is substantial. Various surgical series have reported that this risk continues to be present between 5 and 10 years post prostatectomy, with an average relative risk of about 2% to 3% per year without reaching a plateau. Late biochemical failures are not insignificant, eventually leading to the development of painful bony metastases in 50% of patients in 7 to 8 years. ART has the potential to reduce failure and ultimately improve quality of life. Patients with a life expectancy of greater than 10 years should benefit from ART.

A powerful predictor of biochemical and local failure after prostatectomy is margin positivity. It is estimated that approximately 40% of men with a positive surgical margin will experience a rise in PSA to detectable levels within 5 to 10 years. Other pathologic features that predict for biochemical failure include extraprostatic extension, Gleason score ≥7, and SVI. The balance of data from available series indicates that margin status is an important determinant of outcome, along with Gleason score and PSA. The extent of margin positivity is another factor shown to influence biochemical failure that has only been examined in retrospective series. ART may have less effect in the case of a small focal positive margin in the absence of other unfavorable pathologic features. In this setting, other factors, such as the degree of extraprostatic extension and/or Gleason score ≥7 disease, appears to contribute to a greater risk of biochemical failure and provide a stronger rationale for ART. Similarly, a focal area of ECE alone is associated with a lower risk of biochemical progression, as compared to more extensive ECE; but, the risk will be higher when the ECE is accompanied by Gleason score ≥7 disease.

In the setting of negative margins and a rising PSA, a complete biochemical response to SRT is still achieved in the majority of cases, suggesting local disease persistence in the prostatic fossa. A rising PSA after a negative margin has been associated with a worse prognosis in some prostatectomy series; however, one must consider that not every micron of tissue in the prostatectomy specimen is pathologically assessed. The RT response data suggest that tumor cells were left behind (a focal positive margin) but were not identified on pathologic evaluation. The risk of local disease persistence when there is obvious ECE in addition to Gleason ≥7 disease, even with negative margins, is likely high enough that ART should be considered.

Adjuvant Radiotherapy Outcome

Many retrospective studies have examined the role of ART. More recently, three prospective randomized trials comparing prostatectomy alone to prostatectomy plus ART have been described. All three have shown an improvement in biochemical control of about 20% with ART, with one trial demonstrating an improvement in both metastasis-free and overall survival. The European Organisation for Research and Treatment of Cancer (EORTC) 22911 study included 972 patients with pT2-3 prostate cancer with at least one high-risk feature (ECE, positive margins, or SVI). Freedom from biochemical failure (FFBF) at 5 years was 53% in the RP alone group versus (vs) 74% in the RP + RT (60 Gy) group.

A similar study was conducted by the Southwest Oncology Group (SWOG) and presented at the 2005 meetings of the American Urological Association and American Society of Therapeutic Radiology and Oncology. There were 473 patients with pathologically determined ECE, positive margins, and/or SVI randomized to RT (60-64 Gy) vs observation. Freedom from biochemical failure was significantly improved by the addition of radiation from 38% to 61% at 5 years and from 23% to 47% at 10 years. This benefit was shared by each of the three pathologic risk groups. ART also prevented the need for androgen deprivation therapy (ADT) in some patients and delayed its use significantly (by 2.5 years) in others. Perhaps most convincingly, this study is now demonstrating an improvement in metastasis-free and overall survival. With a median follow up of 12.7 years, out of 425 evaluable patients, metastasis have developed in 114 of 211 patients on the observation arm versus 93 of 214 patients who received early adjuvant therapy (P=0.016). In addition, there have been 110 deaths on the observation arm versus 88 deaths in the irradiated patients (P=0.023). Although ART initially resulted in some adverse impact on quality of life, this difference disappeared by two years post-treatment, and the irradiated patients actually fared better beyond 3 years post radiotherapy.

A third study (ARO 96-02) randomized 388 men with pT3 disease after prostatectomy and an undetectable postoperative PSA to either RT (60 Gy) or observation. The 5-year FFBF rate was 54% in the RP alone group vs 72% in the RP plus RT group (P=.0015). ART was very well tolerated, with the rate of grade 3-4 late adverse events being 0.3%.

Salvage Radiotherapy

Radiotherapy is given for salvage after RP in three settings: 1) for a delayed rise in PSA after the PSA has dropped to undetectable immediately post-prostatectomy, 2) for a persistently detectable PSA after surgery, and 3) for treatment of a palpable recurrence within the prostatic fossa. This division may be important because the initial considerations in evaluation may be different, and there are reports of a distinction in prognosis. However, many retrospective series were based on small patient numbers and did not separate these patients, making conclusions difficult.

The time to a rising PSA after prostatectomy, the prostatectomy Gleason score, and the PSA doubling time are independent predictors of distant metastasis and mortality. When the time to biochemical failure (BF) is <3 years (the PD-PSA patients would be included in this group), Gleason score is ≥8, and PSA doubling time (PSADT) is <9 months, the risk of death due to prostate cancer at 5 years is ≥19%. This risk increases to ≥74% at 10 years. PSADT has taken on much more importance over the last 5 years. If the above parameters included a postoperative PSADT of <3 months, nearly 50% will die within 5 years. Even the PSA kinetics prior to prostatectomy may be an independent determinant of mortality. A rapidly rising PSA prior to RP or prior to RT connotes a poor prognosis, suggestive of occult metastatic disease even if the metastatic workup is negative. Although the ability to predict progression after SRT has improved, clinical experts are a long way from making conclusive judgments on whether SRT would benefit most men. There is a need to optimize treatment selection with the goal of prolonging survival without unnecessary toxicity, particularly in the setting rapid PSA kinetics.

Factors indicating that post-prostatectomy RT for a PD-PSA might be beneficial include extensive extraprostatic extension (particularly in those with high-grade disease) or positive margins. Other indicators that there may be disease in the prostatic fossa are SVI, a cut-through of the prostate (a partial prostatectomy when there is palpable, biopsy or imaging evidence of prostate remaining), or incomplete removal of the seminal vesicles in the setting of T3 disease (especially with ECE at the base or with SVI). In the absence of these features and with a PSA that is rising quickly (doubling time <6 months), the probability of distant metastasis is high, and SRT is discouraged.

The results of SRT have been relatively poor, with 5-year FFBF rates in most series ranging from 10% to 66%. The following factors have been correlated with worse FFBF rates: Gleason score >7, SVI, high pre-RT PSA (>1 to >2.5 ng/mL), short PSA doubling time, negative prostatectomy margins, treatment for a PD-PSA (vs. a DR-PSA), a palpable prostatic fossa mass, and RT dose <65 Gy.

Salvage Radiotherapy Outcome

In general, when the PSA remains detectable after RP, the risk of distant metastasis is greater than when the PSA goes to undetectable and then rises later. Thus, outcomes of SRT in most series have been worse for patients with a PD-PSA compared with a DR-PSA. However, some series have not found a significant difference in FFBF rates between the two groups. While distinguishing between the groups seems to be the most objective way of evaluating the utility of SRT, most of the studies reporting SRT outcomes do not separately analyze the DR-PSA and the PD-PSA patients. In addition, all of these studies are retrospective, and most include small numbers of patients.

As described above, the PSADT time is an important predictor of SRT outcome. The shorter it is, the greater the risk of death due to prostate cancer. A doubling time of ≤10 months in the setting of a DR-PSA or a PD-PSA, indicates a higher likelihood of occult metastatic disease, thus rendering postoperative RT much less effective. Another study showed a PSADT of ≥5 months predicted a response to SRT (a response was defined as a PSA nadir of ≤0.1 ng/mL). One caveat concerning the PSADT as a reliable predictor of distant metastasis is that when the PSA is below 1 ng/mL the estimates may be inaccurate. In reports of postoperative radiotherapy, few have identified PSADT as a predictor of FFBF. In a preliminary recursive partitioning analysis of about 1200 men in a pooled multi-institutional database, PSADT was not independently related to outcome, while pre-RT PSA, Gleason score, and margin status were. Standards are needed for when the PSADT calculation begins (from the PSA just prior to when an accelerated rise occurs or from the time of the first detectable PSA) and the minimum number of PSA values required to accurately calculate a PSADT.

The pre-RT PSA has been found to be the most consistent predictor of FFBF in both univariate and multivariate analyses of SRT. While a clear pre-RT PSA cutpoint has not yet been defined, evidence suggests that lower pre-RT PSAs are associated with higher FFBF rates. The best results have been seen when the pre-RT PSA is ≤1 ng/mL. A significant decline in FFBF is seen when the pre-RT PSA increases from ≤1 ng/mL to 2, and then to >2 ng/mL.

Other important prognostic factors include the Gleason score, margin status, and seminal vesicle invasion. Gleason scores of ≤7 predict for a better prognosis compared with scores of 8 to 10. A positive margin often indicates residual disease in the prostate bed, for which SRT is effective, and FFBF rates are higher when this is the case. Seminal vesicle invasion has been found to be a determinant of outcome in multivariate analysis in many series as well, with worse FFBF rates when the seminal vesicles were involved, due to these patients being at a higher risk of developing subsequent metastatic failure.

Androgen Deprivation Therapy

The use of concurrent ADT with ART and SRT could impact the course of the disease hypothetically by three principal mechanisms: 1) better disease eradication locally (recurrence in a hypoxic scar may be radioresistant), 2) improved disease control distantly (cells in microscopic metastatic deposits might retain sensitivity to ADT), and 3) the combination of ADT and RT may alter the PSA kinetics in patients who eventually relapse. The mechanism of the effect on the kinetics of BF and the delayed appearance of distant metastasis is unknown. However, any improvement upon the current results of ART and SRT is potentially worthwhile. In some reports ADT had positive results in patients at high risk of experiencing a rising PSA after SRT (e.g., a pre-RT PSA >1 ng/mL). Randomized trials are needed and are in progress.

Adjuvant versus Salvage Radiotherapy

The optimal timing of ART vs. SRT, for patients with high-risk pathologic features remains controversial. Some have supported watchful waiting before administering SRT. This rationale is based on three points. First, half of men will be treated unnecessarily. Second, salvage rates are fairly good when the pre-RT PSA is low (≤1.0 ng/mL). Third, the progression to distant metastasis after biochemical failure may be long. It is beyond the scope of this article to compare ART to SRT in depth; however, it should be noted that the addition of SRT to patients who were originally in the observation arm of the SWOG randomized trial still resulted in a higher rate of metastatic failure in these patients compared to early adjuvant therapy. Without a randomized trial to eliminate selection bias, it is impossible to ascribe an advantage to one strategy over the other based on FFBF outcomes. At least ART has a proven benefit in randomized, prospective studies, supporting first principles that RT treatment should be used if the risk of local failure is >20% and the side effect profile is reasonable. Local persistence leads to distant metastasis in most malignancies, and there is evidence that this is the case for prostate cancer. In younger men with a long life expectancy, ART should be considered.

Irradiation in Patients with Positive Lymph Nodes

LNI portends a very poor prognosis, with a high rate of distant failure. Although there are emerging data indicating that RP or RT should be used along with ADT when LNI is identified, there is no well-established benefit from this approach as yet. ART might be of some value when there is evidence of an appreciable local-regional tumor burden, such as extensive positive margins. There are insufficient data on the subject of pelvic nodal irradiation to make any recommendations, even when LNI has been documented.

Summary

• A high percentage of radical prostatectomy patients with high-risk pathologic features (positive surgical margins, extraprostatic extension of cancer, seminal vesicle involvement) will experience a subsequent biochemical failure, with failure often due to progression of residual disease within the surgical bed.
• The addition of adjuvant radiation therapy directed at the prostate fossa to these patients has been shown in three prospective randomized trials to improve the biochemical freedom-from-failure rate among the irradiated patients and, in one trial, to provide an improvement in metastasis-free and overall survival.
• Salvage radiation therapy, in which patients with biochemically detectable disease undergo radiotherapy to the prostate bed, has also been shown to improve freedom from biochemical failure, although the impact on overall survival remains uncertain.
• The appropriate radiation dose to the prostate fossa in the adjuvant or salvage setting is 66-70.2 Gy. Higher doses may be appropriate if there is evidence of gross recurrence within the prostate bed.
• The addition of pelvic radiotherapy to prostate fossa radiation is generally discouraged, although it may be appropriate in certain clinical situations (absence of lymph node dissection, evidence of nodal involvement at prostatectomy or on imaging studies, etc.).
• The benefit of neoadjuvant/adjuvant androgen deprivation therapy is the subject of ongoing clinical trials, and its use is discouraged outside of the protocol setting.

Abbreviations

• CT, computed tomography
• 2D, 2-dimensional
• 3D, 3-dimensional
• IMRT, intensity-modulated radiation therapy
• MRI, magnetic resonance imaging
• PSA, prostate-specific antigen
• SWOG, Southwest Oncology Group

Algorithms were not developed from criteria guidelines.

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

Selection of appropriate radiation treatment procedures for prostate cancer patients after radical prostatectomy

Adverse effects of radiotherapy

The 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 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 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.

An implementation strategy was not provided.

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

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

Committee on Appropriateness Criteria, Expert Panel on Radiation Oncology–Prostate

Panel Members: Carl J. Rossi Jr, MD (Principal Author); Gregory Merrick, MD (Panel Chair); I-Chow Joe Hsu, MD (Panel Vice-Chair); May Abdel-Wahab, MD, PhD; V. Elayne Arterbery, MD; Jay P. Ciezki, MD; Steven J. Frank, MD; Noah M. Hahn, MD; Brian J. Moran, MD; Seth A. Rosenthal, MD

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Pollack A, Hayes S, Roach M III, Merrick G, Anscher MS, Beyer DC, Lawton CA, Lee WR, Michalski JM, Rosenthal SA, Vijayakumar S, Carroll PR, Higano CS, Expert Panel on Radiation Oncology-Prostate. Postradical prostatectomy irradiation in prostate cancer. [online publication]. Reston (VA): American College of Radiology (ACR); 2006. 18 p. [116 references]

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

Electronic copies: Available in Portable Document Format (PDF) from the American College of Radiology (ACR) Web site.

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

The following are available:

• ACR Appropriateness Criteria®. Overview. 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.
• ACR Appropriateness Criteria®. Literature search process. Reston (VA): American College of Radiology; 1 p. Electronic copies: Available in Portable Document Format (PDF) from the ACR Web site.
• ACR Appropriateness Criteria®. Evidence table development. Reston (VA): American College of Radiology; 4 p. Electronic copies: Available in Portable Document Format (PDF) from the ACR Web site.

None available

This NGC summary was completed by ECRI Institute on May 17, 2007. This NGC summary was updated by ECRI Institute on January 11, 2011.

Instructions for downloading, use, and reproduction of the American College of Radiology (ACR) Appropriateness Criteria® may be found on the ACR Web site .