Synchronous Metastasis on Staging/Surveillance CT chest abdomen & Pelvis + CEA + MRI Liver /PET-CT Synchronous Metastasis on Staging/Surveillance CT chest abdomen & Pelvis + CEA + MRI Liver /PET-CT PHNT Video-Link SMDT Synchronous multiple peritoneal mets/extrahepatic nodal disease/unresectable lung mets (to be decided by lung MDT) Resectable liver only and/or lung mets/High volume liver mets/Liver and lung mets /High risk primary Potentially resectable liver and or lung mets Palliative chemotherapy Progression of metastasis and or unresectable Re-stage with CT chest abdomen & Pelvis (Consider MRI) Resectable Second line Chemo Good response and resectable Follow up in 4-6 weeks Histology discussion in SMDT PHNT patients FUP by HPB/Oncology Non-PHNT patients FUP by local oncology team SMDT No response - palliative treatment Consider SIRT/TACE Asymptomatic primary and liver mets Asymptomatic primary and liver mets LIVER followed by lung and bowel resection/ ★★ Synchronous resection LIVER followed by lung and bowel resection/ ★★ Synchronous resection Symptomatic primary and liver mets Re-stage (CT chest abdomen & Pelvis (Consider MRI) SMDT ★★ Only wedge or left lateral and major colonic resection/major Liver resection with Hartman's ✪ High-risk factors for recurrence and metastases: poorly differentiated histology, lymphatic/vascular invasion, bowel obstruction, <12 lymph nodes examined, perineural invasion, localized perforation, or close, indeterminate, or positive margins. See in clinic and consider for resection /CPET LIVER resection ★★ Synchronous resection LIVER resection ★★ Synchronous resection Bowel first/ ★★ Synchronous resection Liver and lung mets with or without symptomatic primary Neo-adjuvant chemotherapy Symptomatic primary with metastasis Stenting/resection

Metachronous Metastasis on Staging/Surveillance CT chest abdomen & Pelvis + CEA + MRI liver Metachronous Metastasis on Staging/Surveillance CT chest abdomen & Pelvis + CEA + MRI liver PHNT Video-Link SMDT Multiple peritoneal mets/extrahepatic nodal disease/lung mets- unresectable (to be decided by lung MDT) Resectable liver only mets (long interval from primary surgery and adjuvant chemotherapy) Resectable liver only mets (long interval from primary surgery and adjuvant chemotherapy) Potentially resectable liver and or lung mets/ Consider PET-CT Neo-adjuvant chemotherapy See in clinic and consider for resection /CPET Palliative chemotherapy Progression of metastasis Restage- CT chest, abdomen & pelvis Second line Chemo Good response and resectable Follow up in 4-6 weeks Histology discussion in SMDT Follow up in 4-6 weeks Histology discussion in SMDT PHNT patients FUP by HPB/Oncology Non-PHNT patients FUP by local oncology team SMDT No response - palliative treatment Consider SIRT/TACE LIVER resection LIVER resection Liver followed by lung resection SMDT ✪ High-risk factors for recurrence: poorly differentiated histology, lymphatic/vascular invasion, bowel obstruction, <12 lymph nodes examined, perineural invasion, localized perforation, or close, indeterminate, or positive margins. See in clinic and consider for resection /CPET Resectable liver and lung mets/ consider PET-CT ✪ High risk primary, Resectable high volume liver only mets – consider PET-CT Resectable See in clinic and consider for resection /CPET Restage- CT chest, abdomen & pelvis

Synchronous rectal cancer with metastasis on Staging CT chest abdomen & Pelvis+ CEA metastases + MRI Liver and pelvis + PET-CT PHNT Video-Link SMDT Synchronous multiple extrahepatic nodal abdominal /peritoneal metastasis/medically inoperable /unresectable lung mets (to be decided by lung MDT) Any T, Any N, and Resectable synchronous metastases Palliative chemotherapy Progression of metastasis and or unresectable Restage -CTTAP And MRI pelvis Resectable Second line Chemo Good response and resectable Follow up in 4-6 weeks Histology discussion in SMDT PHNT patients FUP by HPB/Oncology Non-PHNT patients FUP by local oncology team SMDT No response - palliative treatment Asymptomatic primary and liver mets Asymptomatic primary and liver mets LIVER followed by lung and bowel resection/ ★★ Synchronous resection LIVER followed by lung and bowel resection/ ★★ Synchronous resection Symptomatic primary and liver mets Re-stage CTTAP SMDT ★★ Only wedge or left lateral and major colonic /rectal resection/major Liver resection with Hartman's See in clinic and consider for resection /CPET LIVER resection ★★ Synchronous resection LIVER resection ★★ Synchronous resection Anterior/APR first/ ★★ Synchronous resection Liver and lung mets Neo-adjuvant chemotherapy +/- Pelvic RT (Oncologists decision) Any T, Any N, and potentially Resectable synchronous metastases-