Local excision for rectal cancer: an uncertain future

Adenocarcinoma of the rectum remains a significant public health challenge, with 39,000 new cases and 8,500 deaths predicted for 1998. Radical surgery, the current standard therapy, frequently necessitates the formation of a permanent colostomy and is associated with significant morbidity. For these reasons, alternatives to radical surgery have been sought. This review focuses on sphincter-sparing surgical modalities for distal rectal cancer. An extensive review of the literature on local excision alone, local excision plus postoperative radiation therapy (with or without chemotherapy), and local excision following preoperative chemoradiotherapy is presented. The design and interim results of the sole prospective multi-institution trial of local excision, Cancer and Leukemia Group B trial 8984, are also summarized. The literature on this subject, which is dominated by single-institution, retrospective reports, fails to support local excision as a superior or equal therapy to radical surgical excision for invasive distal rectal adenocarcinoma. The crucial question regarding the efficacy of radical surgical salvage for local recurrence following local excision also remains unanswered. We conclude that the role of local excision for invasive distal rectal adenocarcinoma remains undefined. If there is a future for this therapeutic modality, it will depend significantly on rigorous patient selection, provided that the efficacy of radical surgical salvage for local recurrence can be established.