Table 9

Surgery: SIGN recommendations

Quality of evidences(SIGN)RecommendationStrength 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
DRadical (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
DMedical 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
DPreoperative bevacizumab must be interrupted 5–6 weeks before surgery.Strong for
BPatients with resectable disease can receive a perioperative treatment.41 42 Conditional for
DRadical (R0: negative margins) lung resection can be curative in selected cases.68 Strong for
  • *Panel opinion.

  • SIGN, Scottish Intercollegiate Guidelines Network.