Table 9.

Surgery: SIGN recommendations

Quality of evidences(SIGN)	Recommendation	Strength of recommendation
D*	The timing and type of surgery in patients with unresected primary tumour and synchronous metastatic disease depends on performance status, extension of metastatic disease and symptoms from primary tumour. A multidisciplinary evaluation is recommended in the decision of the best strategy.	Strong for
D*	In patients with symptomatic rectal cancer and synchronous metastasis, polychemotherapy plus radiotherapy can be considered.	Conditional for
D	Radical (R0: negative margins) liver resection can be curative in selected cases.65	Strong for
D*	The number of liver metastasis is not related to a worse prognosis if the surgeon is an expert and the surgery is radical.	Conditional for
D*	Liver resection in borderline resectable disease must be considered after tumour shrinkage is achieved with chemotherapy.	Strong for
D	Medical treatment must be stopped when disease becomes resectable. The prosecution of chemotherapy could increase liver toxicity and surgery risks.66 A radiological complete response does not mean a pathological complete response; it could create difficulty for the surgeon in the individuation of metastasis.67	Strong for
D	Preoperative bevacizumab must be interrupted 5–6 weeks before surgery.	Strong for
B	Patients with resectable disease can receive a perioperative treatment.41 42	Conditional for
D	Radical (R0: negative margins) lung resection can be curative in selected cases.68	Strong for

*Panel opinion.

SIGN, Scottish Intercollegiate Guidelines Network.