Multidisciplinary Tumor Board

The multidisciplinary tumor board has an increasing role in the multimodality management of rectal cancer.[1] The tumor board facilitates bringing together the expertise of different specialists, including the rectal cancer surgeon, medical and radiation oncologists, pathologist, radiologist, genetic counselor, and other surgical specialists including hepatobiliary surgeons, and others. The value of the multidisciplinary tumor board is indicated by a change in management decisions in as many as 50% of rectal cancer cases.[2]

Through NAPRC it is considered a best practice to discuss all rectal cancer cases prior to therapy in a multidisciplinary tumor board, except in the highest-volume centers where that is simply not feasible. The NAPRC permits those programs who have 100 or more cases in a year, to give governance to the rectal cancer program director to develop a documented policy in which criteria are established for which patients are to be presented.

The recommendation for local excision depends on favorable histologic characteristics and superficial depth of invasion as assessed on imaging with the absence of obvious nodal involvement. The recommendation for neoadjuvant chemotherapy and radiotherapy depends on imaging assessment of T- and N-stage as well as anticipated circumferential resection margin. The recommendation for sphincter preserving resection depends on assessment of sphincter invasion and anorectal function. The recommendation for en bloc resection of adjacent organs depends on assessment of invasion of anterior pelvic organs as well as lateral and posterior pelvic anatomy. Lastly, the recommendation for curative resection depends on assessment of the resectability of distant metastases, if present. The management of distant metastases and the primary rectal cancer is certainly a multidisciplinary undertaking. If the distant metastasis is isolated, there is potential for curative resection of both the metastasis and primary lesion either at the same time or in staged surgeries.

The management of Stage IV patients is highly individualized, and tumor board presentation is particularly valuable in this group. If distant metastases are multiple and the primary lesion is asymptomatic, chemotherapy may be used to manage the distant metastases. However, the team must be mindful of the potential for complications related to unresected primary tumors. Symptoms from the primary can be treated using radiation or surgery. Radiation therapy is particularly useful for palliating bleeding from the primary tumor. Surgery may be used to divert or resect the symptomatic primary lesion in the presence of stable distant metastases in an otherwise fit patient.