Current Recommendations

On the basis of what has been presented before, curative LE should be considered in very select cases. In Table 2 the selection criteria for LE of rectal cancer are summarised [10].

In patients undergoing excision of a malignant polyp level 1, 2 or 3 according to Haggitt's classification [27], with a disease-free margin of a least 2 mm, the risk of local recurrence is probably less than 1%,

Table 2. Selection criteria for rectal cancers suitable for local treatment (Modified with permission from [10])

• Accessible

• Amenable to complete excision

• Haggitt levels 1, 2 or 3 in pedunculate polyps (clear margin > 2 mm)

• Haggitt level 4 (pedunculate or sessile T1 cancer) with sm1 invasion

• Haggitt level 4 (pedunculate or sessile T1 cancer) with sm2 invasion well or moderately differentiated no lymphovascular invasion even if lymphovascular infiltration or low-grade differentiation have been detected. In these cases a major surgical procedure is not justified. For T1 cancers, Haggitt's level 4, the risk of residual cancer or lymph node metastasis depends on the level of sub-mucosal infiltration. In T1sm1 with favourable histology the risk does not exceed 1-2%, a figure equivalent to perioperative mortality after anterior resection in low-risk patients. In these cases LE can be considered an adequate procedure. For T1sm2 with favourable histology the risk of residual cancer or nodal invasion grows to 2-10%, so if the patient has a low operative risk an anterior rectal resection would probably be the best choice, leaving LE for patients in a poor general condition or with moderate-high operative risk. In cases of T1sm2 with unfavourable histology, anterior rectal resection should be considered, or alternatively an adjuvant therapy if LE has already been carried out.

LE is not indicated in T1sm3. In T2 where the patient's general condition does not allow a radical resection, neoadjuvant radiotherapy followed by LE

Fig. 4. Flow-chart on decision making after local excision can be considered, together with other adjuvant therapies [10].

Finally, LE can be offered to patients not eligible for major surgery or who refuse to undergo a major operation. In these cases a multimodal approach with neoadjuvant or adjuvant radiochemotherapy is usually adopted [28] (Fig. 4).

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