Management of Early (T1 or T2) Rectal Cancer

Early stage rectal cancers (T1/T2) are being found more commonly due to increasing compliance with population screening guidelines. Patient selection is the most important element in advising local excision versus standard transabdominal resection with total mesorectal excision (TME). Determining the best strategy for an individual patient relies on accurate histologic assessment (a surrogate of biologic behavior), accurate clinical staging (endorectal ultrasound or MRI), and accurate assessment of patient procedural risk. It is important to review the histology for high-risk features associated with occult lymph node metastasis as this portends a higher local recurrence rate. Since the local recurrence rate following local excision for T2 rectal cancer is high, it has been our practice to offer these patients proctectomy with TME unless the patient has a poor performance status, is unwilling to proceed, or is part of a clinical trial. We limit transanal resection to well-selected patients with T1 lesions without high-risk histologic features (lymphovascular invasion, poor grade, or deep submucosal invasion). Factors such as patient procedural preference and comorbidities may influence this decision but it is on a case by case basis. Local excision can be accomplished with conventional transanal procedures; however, newer techniques such as transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS) may have less specimen fragmentation and improved R0 resection rates. Neoadjuvant chemoradiation may add further benefit for maximizing local control but is associated with local wound problems including bleeding and infection. Adherence to a strict surveillance program after local excision allows clinicians to salvage recurrence as early as possible. In a multidisciplinary fashion, the surgeon, pathologist, gastroenterologist, and patient need to make informed decisions about risk and benefit when determining the best individualized care for the patient.