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NCCN Guidelines for Patients



Rectal Cancer, Version 1.2017


Metastatic disease

Metastases at diagnosis

Metastases at diagnosis

This section explains treatment options for

metastases found at diagnosis. These cancers are

stage IV. Options for rectal cancer that can be treated

with surgery are explained first. However, most

people with metastases can’t have surgery. If you

can’t have surgery, treatment options are explained

on page 60.

Guide 10

presents surgical options for liver or lung

metastases at diagnosis. Surgery is only an option if

all tumors can be fully removed. In other words, it’s

an option if a cure is possible.

Surgery is also only an option if your liver won’t

be too small afterward. To enlarge your liver, you

may receive portal vein embolization. Portal vein

embolization is the blocking of the blood vessel to the

liver tumor. This blockage causes the healthy part of

the liver to grow larger. This procedure will be done

before surgery.

The best treatment approach is unknown. Little

research has been done. Thus, five options are


Neoadjuvant treatment

All options start with neoadjuvant treatment. This

treatment is used to reduce the extent of the cancer.

Two to three months of treatment are advised.

Option 1

The first option starts with chemotherapy. FOLFIRI,

FOLFOX, or CAPEOX may be received. There are

pros and cons to starting with chemotherapy. Some

of these are:




You may receive early treatment of possible

cancer not yet found.



Knowing your response to chemotherapy early

can help with treatment planning.



If the cancer grows while taking chemotherapy,

you can avoid local treatment.




Fat may build up in your liver and your liver

may swell.



You may become unable to have surgery if the

cancer grows or shrinks too much.



Injury to small blood vessels may occur in your


Option 2

Option 2 starts with chemotherapy followed by

chemoradiation. Chemotherapy is described in

Option 1. For chemoradiation, radiation will be given

within your pelvis. It may decrease the chance of

cancer cells remaining in your pelvis after treatment.

Chemotherapy helps radiation to work better.

Infusional 5-FU or capecitabine is preferred. The side

effects of these regimens may be too much for you.

In this case, bolus 5-FU/LV may be received.