The initial evaluation of patients with rectal cancer and SCRLM includes determination of symptomatology, colonoscopy, staging, determination of resectability from an oncologic standpoint, and evaluation of the future liver remnant based on imaging before and after multimodality treatment, as well as assessment of fitness for surgery. In addition to imaging of the primary tumor with magnetic resonance imaging (MRI) and endorectal ultrasound [7], computed tomography (CT) is useful to evaluate distant disease. Contrast-enhanced MRI can detect or further characterize small hepatic lesions and is superior to CT in the setting of post-chemotherapy hepatic steatosis [8]. Fluorodeoxyglucose-positron emission tomography (FDG-PET) can detect extrahepatic disease that would preclude curative resection and change management in up to 24 % of cases [9, 10]. Two randomized prospective trials reported conflicting results regarding the utility of FDG-PET [11, 12]. Ruers et al. demonstrated that non-curative surgery was avoided in one of six patients as a result of PET findings [11] whereas Moulton et al. failed to confirm these results [12]. Additional studies have supported the use of FDG-PET in patients with rectal cancer and SCRLM [13–20]. Sensitivity of PET after chemotherapy is reduced due to decreased metabolic activity of residual tumor [21–24].

Liver biopsy can be helpful in select cases with equivocal imaging findings but should not be performed routinely due to the risk of tract seeding [25–28].

Following a diagnosis of rectal cancer with SCRLM, the treatment plan is formulated with the goal of prolonging survival and maximizing the prospects of a curative resection. Many studies combine both colon and rectal cancer and are compromised by selection bias; no prospective randomized data comparing treatment approaches exists to guide management decisions. Rectal cancer presents additional challenges compared to colon cancer with concerns for local recurrence, potential need for adjuvant or neoadjuvant radiation therapy, and complexity of pelvic surgery. The heterogeneity of scientific data pertaining to chemotherapy and radiation regimens, and the introduction of various drugs during the last two decades add to the challenges of data interpretation [29, 30].

Table 20.1 summarizes studies directly comparing the perioperative results of surgical approaches for colorectal cancer with SCRLM. Table 20.2 shows comparative oncologic outcomes of those studies. Table 20.3 presents outcomes of case series of the different surgical approaches.