TABLE 3.

Variant 3: Initial treatment of a 60-year-old female without significant past medical history, with uT3N0 rectal cancer, bilobar hepatic metastases (50% liver replacement), and bilateral pulmonary metastases. Rectal lesion causing pain and early symptoms of obstruction. KPS 80

Treatment	Rating*	Comments
Initial preoperative pelvic RT + concurrent 5-FU based chemotherapy	7
Initial systemic 5-FU-based chemotherapy (FOLFOX/FOLFIRI)	6	Consider anti-EGFR agents with FOLFOX/FOLFIRI in wild-type KRAS tumors
Initial palliative stent or loop colostomy to relieve obstruction	5
Initial systemic 5-FU-based chemotherapy (FOLFOX/FOLFIRI + bevacizumab)	4
Initial resection of rectal primary	3
Initial pelvic RT alone	2
Initial surgical debulking of metastatic disease	1
Initial liver directed therapies (transarterial embolization, radiation, RFA)	1
Best supportive care	1

^*Rating scale: 1–3, usually not appropriate; 4–6, may be appropriate; 7–9, usually appropriate.