What is your approach to TNT sequencing for locally advanced rectal primaries with low volume metastatic disease to liver?

This is a very common clinical scenario for which I'm not aware of a single correct answer.

I assume by "low volume" metastatic disease to the liver the question implies potentially curable through some combination of liver-directed therapies.

The only part of the sequencing about which I am fairly ...

With potentially resectable liver metastases initial systemic chemotherapy preferably FOLFOXIRI regimen with anti-EGFR monoclonal antibody (RAS wild-type) or bevacizumab to accomplish a deeper response (Shiozawa et al., PMID 39587053) followed by surgical evaluation should be considered first. Once ...

I have always felt that, for locally advanced rectal cancer with oligometastatic disease, the first priority is to "cure the pelvis". That is a necessary condition for durable survival with good quality of life.

I would favor short course RT ---> total neoadjuvant chemo ---> eval for rectal surgery...

Our institutional approach in patients with a good ECOG status and low volume liver mets is to treat systemically first and then with a reasonable response, proceed with pelvis-directed therapy pending the clinical stage of the pelvic disease. If the patient has distal rectal or node positive more p...

My practice has been systemic chemotherapy, and if there is a good response of the primary and liver, then I proceed with liver-directed therapy/resection. Then, based on the TN stage of the rectal tumor, I decide whether to proceed with surgery versus preop radiation ± chemo followed by surgery.