1. SMDT SMDT SMDT Synchronous Metastasis on Staging/Surveillance
CT chest abdomen & Pelvis + CEA + MRI Liver /PET-CT
Synchronous multiple peritoneal mets/extrahepatic nodal disease/unresectable lung mets (to be decided by lung MDT)
Video-Link
PHNT
Symptomatic primary with metastasis
SMDT
Stenting/resection
Palliative chemotherapy
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
Neo-adjuvant chemotherapy
Re-stage with CT chest abdomen & Pelvis (Consider MRI)
SMDT
Progression of metastasis and or unresectable
Resectable
Second line Chemo
Asymptomatic primary
and liver mets
Symptomatic primary and liver mets
Liver and lung mets with or without symptomatic primary
Re-stage (CT chest abdomen & Pelvis (Consider MRI)
See in clinic and consider for resection /CPET
SMDT
LIVER resection
★★Synchronous resection
Bowel first/ ★★Synchronous resection
LIVER followed by
lung and bowel resection/
★★Synchronous resection
Good response and resectable
No response - palliative treatment
Consider SIRT/TACE
Follow up in 4-6 weeks
Histology discussion in SMDT
PHNT patients
FUP by HPB/Oncology
Non-PHNT patients
FUP by local oncology team
★★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.

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

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