failure rates of limited resection across tumor stage, and (3) evaluate the possibility of manag­ing low- lying T2 rectal adenocarcinomas with local excision and adjuvant combined modality therapy. Of the 59 patients with T1 adenocarci­noma managed with local excision alone, the 6­and 10-year local failure rates were 6.8% and 8%, the 10-year disease-free survival was 75%, and the overall survival at 5 and 10 years was 91% and 84% [48]. The authors report that results compare favorably to historical data queried from the NCDB, whose 5-year overall survival for T1 patients managed with APR was 94%. Interestingly, recurrences after local excision of T1 adenocarcinoma occurred as late as 8 years after local excision, corroborating ndings by other authors [49] that local and distant recur­rences can occur at long intervals and that pro­longed surveillance is advisable.

95.8), and the overall survival was 95% (95% CI

91.1–100). At the end of the study, 91% of patients who received neoadjuvant chemoradiotherapy had rectal preservation, with no substantial dete­rioration in rectal function as measured by the Fecal Incontinence Severity Index (FISI) [55, 56]. The main problem with this approach lies in the treatment toxicity; after 53 patients were recruited, the regimen was altered to 50.4Gy radiation by reducing the 9Gy boost to 5.4Gy, and capecitabine

of the rectal circumference, and without evidence of nodal metastasis. Transanal endoscopic sur­gery (TEM, TAMIS) may facilitate local excision of more proximal tumors. Tumors should be carefully resected en bloc and without fragmen­tation, and the specimens should be oriented with the surgical pathologist. Pathologic evidence of positive margins, lymphovascular invasion, poor differentiation, or invasion into the deeper layers of the submucosa (Sm3) or muscularis propria (T2) should prompt consideration of radical resection [57]. These recommendations are mir­rored by the European Association of Endoscopic Surgery (EAES), the European Society of Coloproctology (ESCP) [60], the practice param­eters of the American College of Colon and Rectal Surgeons (ASCRS) [61], and the Japanese Society for Cancer of the Colon and Rectum (JSCCR) [62]. It should be noted that the JSCCR only recommends local excision for rectal can­cers with limited submucosal invasion (malig­nant polyp, Sm1), as the national cancer registry in Japan reports approximately 10% incidence of nodal metastases in T1 rectal cancer. Thus, Japanese surgeons routinely perform a minimum D2 lymphadenectomy in the setting of cT1 dis­ease. Finally, adherence to the NCCN guidelines has been previously demonstrated to impart a survival benet inlocally advanced colon cancer patients [63]. One could extrapolate this nding to rectal cancer, and the authors prefer to err on the side of caution when managing these patients.

radical resection appears to offer a survival bene­t over salvage surgery at the time of recurrence [5-year DFS 94.1% for immediate radical resec­tion vs 55.5% for salvage at time of recurrence, p < 0.05] [64]. Salvage surgery at the time of recurrence often involves multivisceral resection and is associated with high rates of perioperative complications, and a signicant portion of patients will present with unsalvageable recurrence. At the University of Texas MD Anderson Cancer Center, among 46 patients with recurrence after initial treatment with TAE, 91% were candidates for sur­gical salvage and 87% elected to proceed. The R0 resection rate was 80%, and the required resec­tions were complex, requiring multivisceral resec­tion (33%), total pelvic exenteration (5%), or metasectomy (25%). The rate of sphincter preser­vation was 33%, perioperative morbidity was 50%, and 5-year OS was 63% [65]. In a similar fashion, Doornebosch etal. reviewed 18 patients who developed local recurrence after TEM exci­sion of pT1 rectal cancer. Two of these recur­rences were unsalvageable, and the remainder underwent TME without multivisceral resection for salvage. The 3-year OS reported in this series was 31% [66]. Current NCCN guidelines recom­mend immediate salvage surgery if high-risk his­topathological features are noted after local excision [57]. Clearly, waiting until the patient develops a recurrence is associated with a poorer prognosis. Newer data considering adjunctive chemoradiotherapy as salvage after local excision of high-risk pT1 tumors has some promise, with some studies reporting 5-year OS and DFS as 94% and 89%, respectively; however these patients still require very close follow-up and may remain at increased risk for disease recurrence. Locoregional recurrence at 5 years remains as high as 9% [67]. More studies are needed to deter­mine if this is an acceptable approach in LE with high-risk features.