Is radical surgery always necessary in early rectal cancer? A systematic review of randomised trials

Total mesorectal excision (TME) remains the standard of care for operable rectal cancer but is associated with significant long-term morbidity. Local excision (LE) following neoadjuvant therapy offers a potential organ-preserving alternative in selected patients. This systematic review evaluates oncological, functional, and safety outcomes from randomised trials comparing LE and TME in early rectal cancer.

A systematic review was conducted of randomised controlled trials comparing LE and TME in early-stage rectal adenocarcinoma. Trials were included if they enrolled predominantly cT2-T3N0 patients and compared either post-long course chemoradiotherapy (LCCRT) LE vs post-LCCRT TME, or neoadjuvant chemo(radiotherapy) + LE versus upfront TME. Primary outcomes were overall survival (OS) and disease-free survival (DFS); secondary outcomes included local/distant recurrence, functional outcomes, and health-related quality of life (HRQoL).

Four trials (GRECCAR-2, Lezoche, TAUTEM, TREC; n = 514) met inclusion. Pathological complete response after LE ranged 26-44%, with 10-35% requiring completion TME. Within scenario-specific pools, there was no significant difference between LE and TME for OS or DFS, local or distant recurrence. LE was associated with lower major complications and better patient-reported outcomes.

In selected patients who receive neoadjuvant therapy, local excision is associated with lower morbidity and favourable functional outcomes compared with TME. While scenario-specific estimates suggest comparable survival, heterogeneity in design and follow-up limits firm conclusions on oncologic equivalence. Within response-adapted pathways with predefined criteria for completion TME, local excision is a feasible organ-preserving option.