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 ...

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...

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...

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.