How do you decide on the timing of neoadjuvant chemoRT or short course radiation for a patient with mid-upper rectal cancer with resectable liver only metastases?

Upfront multiD discussion is really essential for a case like this as I do think we need to be selective of ideal candidates. If the group consensus is to proceed along a pathway involving “curative intent” local therapies, I do favor starting with systemic therapy to establish disease biology/phenotype. It is critical to discuss with the liver surgeon from the start to clarify 1) if the lesions are so small they may become clinically occult with systemic tx (in which case upfront local tx may be considered in ULTRA select cases), more importantly, 2) how many cycles of systemic tx she/he is comfortable with and which agents (i.e., VEGF?) to balance performance status/liver injury/fatty liver/perioperative risks, and 3) what is the plan for...

There are compelling long-term outcomes from Bisschop et al with the Dutch 'M1' study supporting a rationale of short course radiation therapy followed by systemic therapy and curative surgery.

This study followed all 50 patients in this multi-institutional phase II study; and found a median overall survival of 3.8 years, and 32% of patients still alive at a median follow-up of 8.1 years. These are excellent outcomes, and only 72% of the patients received complete metastectomies.

The key, as above, is a good multidisciplinary discussion as well as the ability of the team to deliver radiation therapy promptly and efficiently. This allows the patient to start radiation therapy within a few days of consultation, and then systemic therapy can st...

These are potentially curable cases and therefore it's important to cure the pelvis. The extent of the pelvic disease impacts how I would time the RT and surgery. If the disease in the pelvis comes close to or involves the mesorectal fascia, I would not recommend chemotherapy followed by short course RT (SCRT) followed by immediate surgery. In such a setting, I would favor a SCRT -- chemo -- surg sequence. If one were to go with a chemo -- SCRT -- surg sequence, I would recommend at least 4 weeks from the completion of RT to surgery, to allow time for response to RT.

This would also apply to any cT3 tumors in the distal 5 cm of the rectum.