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NCCN Guidelines for Patients



Rectal Cancer, Version 1.2017


Metastatic disease

Metastases at recurrence

Metastases at recurrence

This section explains treatment options for rectal

cancer that returns in the liver or lungs. 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 65.

Guide 13

presents surgical options for liver or lung

metastases at recurrence. 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.

Surgery with chemotherapy is advised for

metastases. The best order of chemotherapy and

surgery is unknown. Thus, two options are given.

Option 1

Option 1 starts with primary treatment. It may consist

of metastasectomy. Local treatment to the liver

or lung may be added. Local treatment includes

ablation and SBRT. Local treatment without surgery

is also an option. However, NCCN experts prefer

surgery over local treatment.

Results of primary treatment should be assessed

with CT with contrast. Scans of your chest, abdomen,

Guide 13. Surgical options

Option 1

Primary treatment

Adjuvant treatment

• Metastasectomy ± local treatment

• Local treatment


• No prior chemotherapy


◦◦ Capecitabine or 5-FU/LV


• Prior chemotherapy

◦◦ Observation

◦◦ Chemotherapy ± targeted therapy in Part 6

Option 2

Neoadjuvant treatment

Primary treatment

Adjuvant treatment


• FLOX or capecitabine

or 5-FU/LV


• Metastasectomy ±

local treatment

• Local treatment


• If neoadjuvant worked:

◦◦ Re-start neoadjuvant regimen


◦◦ Observation


• If neoadjuvant didn’t work:

◦◦ Chemotherapy ± targeted

therapy in Part 6

◦◦ Observation