Multidisciplinary Tumor Board

The multidisciplinary tumor board has an increasing role in the multimodality management of rectal cancer.[1] This tumor board facilitates bringing together the expertise of different specialists, including the rectal cancer surgeon, medical onocologist, radiation oncologist, pathologist, radiologist, genetic counselor, and other surgical specialists (e.g., hepatobiliary surgeons). 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]

The National Accreditation Program for Rectal Cancer (NAPRC) considers it best practice for a multidisciplinary tumor board to discuss all rectal cancer cases prior to therapy, except in the highest-volume centers where that process 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.[3]

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 the size and location of the lymph nodes and the number of lymph nodes involved with cancer, the presence of any other synchronous disease Including metastases, and the anticipated circumferential resection margin. The recommendation for anal 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. In accounting for these disease specific characteristics, the tumor board also has the opportunity to present certain patient characteristics that may help to guide final care plans. For example, a multidisciplinary tumor board may meet to assess a young patient who desires to avoid radiation to maintain fertility.

The recommendation for curative (R0) 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.[4]

The management of patients with stage IV cancer is even further highly individualized, taking in account the local disease, distant disease, and again, patient characteristics. The multidisciplinary tumor board presentation is particularly valuable in this group. Assessing the resectability of distant metastases for potential cure while balancing the local disease is paramount. 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, which includes the use of so-called hemostatic radiotherapy. Surgery may be used to divert or resect the symptomatic primary lesion in the presence of stable distant metastases in an otherwise healthy patient.[4]