A plea for local excision as the initial treatment strategy

Abstract

The widespread implementation of colorectal cancer screening has led to a substantial increase in the diagnosis of early-stage rectal cancer, necessitating treatment strategies that maximize organ preservation without compromising oncological outcomes. Although total mesorectal excision (TME) remains the standard of care, its considerable morbidity and long-term functional consequences contrast with the relatively low risk of lymph node metastasis in appropriately selected early rectal cancers. This review advocates a local excision first strategy as the preferred initial approach for early rectal cancer. Beyond its therapeutic role, local excision provides definitive histopathological staging, enabling individualized risk stratification and selective escalation to completion TME, adjuvant chemoradiotherapy, or close surveillance when indicated. Contemporary evidence demonstrates that this stepwise, risk-adapted approach achieves high rates of organ preservation while maintaining excellent oncological outcomes. Advances in local excision techniques, imaging, and pathological risk assessment have further strengthened this paradigm. Local excision should therefore be regarded not as an alternative to radical surgery, but as the cornerstone of modern management for early rectal cancer, reserving radical treatment for the minority of patients who truly require it.