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

Abstract

Aim A total of 15-20% of patients with rectal cancer have liver metastases on presentation. The management of these patients is controversial. Heterogeneity in management strategies is considerable, with management often being dependent on local resources and available expertise. Method 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 15 statements reached consensus regarding the management of patients with advanced rectal cancer and oligometastatic liver disease. Routine use of liver MRI 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 onequarter of the panellists would consider simultaneous pelvic exenteration and liver resection. Conclusion This Delphi process highlights the diverse treatment of advanced rectal cancer with liver metastases and provides recommendations from an experienced international group regarding the multidisciplinary management approach.

Liver Transplantation Society of India Guidelines for the Management of Acute Liver Injury Secondary to Yellow Phosphorus–Containing Rodenticide Poisoning Using the Modified Delphi Technique of Consensus Development

“…The Delphi method of enquiry has been frequently used to develop guidelines and protocols in healthcare when high-quality evidence is lacking, especially in the case of rare or emerging clinical conditions. [12][13][14] The process involves a series of iterative questionnaires administered to a selected group of experts who may be geographically separated. The feedback from each round helps in modifying the statements and provides opportunities for experts to reassess and if necessary modify their own responses.…”

Staged or Simultaneous Surgery for Colon or Rectal Cancer with Synchronous Liver Metastases: Implications for Study Design and Clinical Endpoints

“…Simultaneous surgery for rectal cancer is controversial [ 37 , 38 , 39 , 40 ]. Some argue that it can be performed safely, even in combination with major liver surgery [ 40 ].…”

“…Furthermore, there have been reports arguing safety of liver-first strategy in locally advanced rectal cancer with synchronous liver metastases [ 10 ]. However, some reports even suggest liver surgery simultaneous with extensive pelvic surgery [ 37 , 38 ].…”

Contemporary Management of Locally Advanced and Recurrent Rectal Cancer: Views from the PelvEx Collaborative

“…Negative resection margins (R0) are the single most important prognostic factor in predicting long-term survival in patients undergoing pelvic exenteration [ 1 , 5 , 7 , 8 , 13 , 49 , 50 , 51 , 52 , 53 , 54 , 55 ]. The goal of exenterative surgery is to resect all involved organs/structures whilst balancing this radicality with an acceptable risk profile and postoperative quality of life.…”

“…For patients presenting with rectal cancer, 15–20% will have synchronous liver metastases [ 52 ]. The optimal management of these patients is subject to debate and often dependent on local resources and expertise [ 51 ]. Historically, surgical resection in patients with LARC or LRRC was confined to patients without metastatic disease.…”