Rectal Cancer · Local Excision vs TME

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Stage/risk + sphincter/location
   T stage/pathologic risk? Sphincter involvement/location? (Nodal metastasis risk rises with depth of invasion: T1 ~10%, T2 ~26%, T3 ~51%.)
   • cT1, low-risk (well-differentiated, no lymphovascular/perineural invasion, <3 cm, <30% circumference, cN0) → Early low-risk → transanal local excision
   • High-risk T1 or cT2, cN0 → High-risk T1/T2 → TME
   • Locally advanced (cT3-4 or cN+) → Locally advanced → neoadjuvant then TME
   • Clinical complete response after neoadjuvant (cCR), selected → cCR → watch-and-wait
2. [End] Early low-risk → transanal local excision
   cT1 low-risk → transanal local excision (TEM/TAMIS, full-thickness); preserves anal/urinary-sexual function; pathologic upstaging (deep invasion/LVI+/margin+) → add TME.
3. [End] High-risk T1/T2 → TME
   High-risk T1 or cT2 cN0 → radical TME (total mesorectal excision); by sphincter involvement: low anterior resection (LAR, sphincter-preserving) vs abdominoperineal resection (APR, permanent stoma).
4. [End] Locally advanced → neoadjuvant then TME
   Locally advanced (cT3-4/cN+) → neoadjuvant chemoradiation (or total neoadjuvant therapy, TNT) then TME; downstaging, lower local recurrence.
5. [End] cCR → watch-and-wait
   Clinical complete response after neoadjuvant (cCR) with strict follow-up capability → watch-and-wait organ preservation; close surveillance, regrowth → salvage surgery.

Source guidelines & references

• Rectal cancer management (NCCN/ESMO; TEM local excision indications; TME standard)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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