Local resection in rectal cancer: when, who and how?

Local resection (LR) in rectal cancer is indicated in stage T1N0M0 without unfavorable pathological factors, achieving oncologically satisfactory outcomes through transanal endoscopic surgery techniques. However, the initial step involves accurate staging and selection of these tumors through specific tests conducted in specialized colorectal units. For T2N0M0 tumors and T1 tumors with poor prognostic factors, the standard treatment is total mesorectal excision (TME), a procedure associated with high postoperative morbidity and mortality, functional impairments, and reduced quality of life. Therefore, new organ-preservation strategies are being explored as alternatives to TME. These include neoadjuvant therapy combined with LR, which has shown promising results, and neoadjuvant therapy followed by a "Watch and Wait" approach -where patients with complete clinical response are selected for strict surveillance- as an ideal future treatment, although there are still current challenges to be addressed.