Rectal Cancer - Local Excision

This deep dive focuses on the high-stakes risk-benefit analysis of Local Excision (LE) for rectal cancer, balancing the functional benefits of organ preservation against the critical risk of missing occult lymph node metastases. We trace the technical path from conventional surgery to the modern standard of TAMIS (Transanal Minimally Invasive Surgery), emphasizing that oncologic LE requires an en block, full thickness resection.The core discussion centers on the histological predictors that mandate completion surgery following LE. These powerful predictors include deep invasion (Kikuchi SM3 has up to 23% nodal risk), Poor Differentiation (PD), and critically, Lymphovascular Invasion (LVI), which carries an 11.5 odds ratio for nodal metastasis. We also review the standardized assessment of Tumor Budding (ITBCC 2016) as an independent prognostic marker.LE alone is deemed oncologically sound only for strictly selected low-risk T1 tumors (7% recurrence risk), but is substandard for T2 disease due to a high (30–40%) nodal risk. We analyze the emerging organ-preservation strategy of Neoadjuvant Therapy (NACT) followed by LE, noting trials show similar oncologic outcomes to TME for selected T2/T3 patients. However, patients must be aware that local recurrence after LE is a marker of aggressive biology, and subsequent salvage surgery carries a modest success rate (47% recurrence-free survival).

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