Cautious reappraisal of full thickness local excision in early-stage rectal cancer: When less is not more

The management of early-stage rectal cancer continues to evolve, with increasing emphasis on organ preservation and treatment personalisation. Full thickness local excision (LE) is commonly employed in cT1N0 cancer as a relatively low-morbidity method to risk stratify patients as having low-risk pT1 disease, high-risk pT1 disease or pT2+ disease depending on depth of invasion as well as other features such as lymphovascular invasion and tumour budding. This risk stratification as part of a 'two-stage' approach helps guide whether surveillance is safe or completion therapy is required. However, the morbidity of LE is frequently overlooked, including its impact on definitive completion therapy. In this article, we summarise the current role of LE in early rectal cancer and highlight concerns surrounding the morbidity and oncological risks of full thickness LE. We conclude with a proposed contemporary algorithm for managing early-stage rectal cancer that is patient-centred but optimises for oncological safety.