Local excision: is it an adequate substitute for radical resection in T1/T2 patients?

Local excision (LE) was historically developed to palliate patients with rectal adenocarcinoma who either are medically unfit or have adamantly refused to undergo transabdominal standard resection (SR) procedures. Over the years, the tradeoffs between the oncologic benefit and adverse functional sequelae associated with SR procedures have been increasingly recognized. In parallel, there has been growing interest in considering LE as an alternative to SR in select patients with early-stage disease. However, concerns regarding its oncologic adequacy remain. These concerns relate to the adequacy of tumor resection, the removal of mesorectal disease, the accuracy of preoperative selection, and the use of adjunctive treatment modalities. Evolving strategies that aim at improving the oncologic outcomes of LE for stage I T1/T2 rectal cancers include adoption of transanal endoscopic microsurgery and the addition of non-surgical modalities. Current evidence surrounding these approaches is examined to provide a basis for an informed discussion with patients. Key factors to be considered in formulating the treatment plan for an individual patient with T1/T2 rectal cancer are summarized.