Radical versus local surgical treatment for rectum carcinoma. A variety of options?

Local excision has to be classified as either indeterminate or non curative from a surgical oncological point of view. It seems to be an acceptable procedure for well differentiated, exophytic/polypoid pT1 lesions of less than 3 cm in diameter, providing the resection margins are tumour-free. For all other lesions radical surgery is to be preferred, unless the patient is unfit for major surgery or refuses an eventual permanent colostomy. Complete local excision followed by radiation therapy may become a valuable alternative for well differentiated, small pT2 lesions, but results are too preliminary. If radical surgery is indicated, the distal clearance margin (to be measured in the fresh, unstretched specimen) may be reduced to 2 cm if taking more distal tissue would jeopardise the anal sphincter. The mesorectum should be completely cleared in patients with low- or mid-rectal cancer. A benefit of excision of the internal iliac nodes in rectal cancer below the peritoneal reflection has not been demonstrated. Low anterior resection is the operation of choice for carcinoma with its lower border above 8 cm from the anal verge. Complete, restorative rectum excision with colo-anal anastomosis (CAA) is the option for tumours with their lower border between 6 and 8 cm from the anal verge if an acceptable margin of distal clearance is obtained. Rectal cancer with its distal border below 6 cm usually requires abdominoperineal rectum excision, although restorative proctectomy with CAA may be a valuable alternative in selected patients with small, well or moderately differentiated tumours.