Are we doing too much?: local excision before radical surgery in early rectal cancer

In early rectal cancer cases, the use of local excision is increasing. The general indication for local excision is based on the preoperative stage, but there is often a discrepancy between pre and postoperative stages. We sought to determine the indications for local excision in T1 rectal adenocarcinoma patients by comparing the preoperative clinical and postoperative pathological stages. A second aim was to compare the oncologic outcomes between local excision and radical resection.

Between 2004 and 2014, 152 T1 rectal adenocarcinoma patients were enrolled. We divided the subjects into two groups, local excision and radical resection, depending on the modality of treatment the patients initially received. The group of patients who underwent radical resection was subsequently subdivided into "excisable" and "non-excisable" groups based on the postoperative pathology.

Of 152 patients, 28 patients (18.4%) underwent local excision, while 124 patients (81.6%) underwent radical resection. Of 124 patients, in clinically suspected T2 or less and N0 (93) cases, 50 patients (53.8%) needed treatment beyond local excision, and local excision was sufficient for 43 patients (46.2%). The 3-year overall survival (p = 0.393) and 3-year disease-free survival (p = 0.076) between the local excision and radical resection groups showed no significant difference.

The clinical T stage was overestimated in more than half of the cases. Therefore, if cT1/2 tumors with cN0 are suspected preoperatively, local excision is initially recommended and will allow for determination of underlying pathology. The clinician can then decide whether to monitor or intervene with radical resection.