Management strategies for patients with advanced rectal cancer and liver metastases using modified Delphi methodology: results from the PelvEx collaborative

BACKGROUND: A total of 15-20% of patients with rectal cancer patients have liver metastases on presentation. The management of these patients is controversial. Heterogeneity in management strategies is considerable, and often dependent on local resources and available expertise. METHODS: members of the PelvEx Collaborative were invited to participate in the generation of a consensus statement on the optimal management of patients with advanced rectal cancer with liver involvement. Fifteen statements were created for topical discussion on diagnostic and management issues. Panellists were asked to vote on statements and anonymous feedback was given. A collaborative meeting was used to discuss any nuances and clarify any obscurity. Consensus was considered when >85% agreement on a statement was achieved. RESULTS: a total of 135 participants were involved in the final round of the Delphi questionnaire. Nine of the fifteen statements reached consensus regarding the management of patients with advanced rectal cancer and oligometastatic liver disease. Routine use of MRI Liver was not recommended for patients with locally advanced rectal cancer, unless there was concern for metastatic disease on initial Computed Tomography staging scan. Induction chemotherapy was advocated as first-line treatment in those with synchronous liver metastases in locally advanced rectal cancer. In the presence of symptomatic primary disease, a diverting stoma may be required to facilitate induction chemotherapy. Overall, only one-quarter of the panelists would consider simultaneous pelvic exenteration and liver resection. CONCLUSION: this Delphi highlights the diverse treatment of advanced rectal cancer with liver metastases and provides recommendations from an experienced international group regarding the multidisciplinary management approach.