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Source created 2026-08-24 · updated 2026-08-24
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ASCRS Ch27 - Rectal Cancer Local Excision

Citation

Monson JRT, Hoedema R. Rectal Cancer: Local Excision. In: Steele SR, et al., eds. The ASCRS Textbook of Colon and Rectal Surgery, 4th ed. Springer; 2022. pp. 479–489 (book pagination; References end p. 489).

Scope

Twenty-seventh chapter of the ASCRS 4th-edition textbook (fifth of Part III, Colorectal Cancer). Covers patient selection for local excision of early rectal cancer; predicting lymph node metastasis risk (depth of invasion, lymphovascular invasion, differentiation, tumor budding — including the ITBCC 2016 consensus statements); the T2 local-excision question; local excision techniques (transanal excision, TEM, TAMIS) and their complications; oncologic results for T1 and T2 cancers; local excision combined with adjuvant or neoadjuvant therapy; quality of life; and salvage surgery after local excision failure.

Key content and reconciliation approach

This chapter substantially overlaps two existing pages — Local Excision of Rectal Neoplasms (technique detail, sourced from the Sabiston chapter plus ASCRS Ch05/Ch23) and Colorectal Polyps (malignant-polyp depth-of-invasion/lymph-node-risk data, sourced from ASCRS Ch23) — but adds substantial genuinely new content:

  • Local Excision of Rectal Neoplasms substantially enriched: new Complications section (urinary retention, bleeding, pelvic abscess, defect-closure debate — none previously covered); new Oncologic results section (T1 and T2, including the UK 21-center collaborative margin data and Junginger et al.'s long-term risk-stratified local recurrence/survival) — this resolves the page's own previously-flagged "no primary trial data comparing TEM/TAMIS to TME" open item; new Adjuvant and neoadjuvant therapy section (CALGB 8984, a 14-study meta-analysis, Cutting et al.'s systematic review, ACOSOG Z6041, the Lezoche RCT, GRECCAR 2, CARTS); new Quality of life and Salvage surgery sections. Technique detail (transanal excision/TEM/TAMIS positioning, closure) was already substantially covered — only the defect-closure evidence (a small RCT and a larger matched analysis, both showing no clear difference) is added as genuinely new.
  • Colorectal Polyps enriched with more granular nodal-metastasis risk data: Chang et al.'s 943-patient single-institution cohort (Table 27.1: lymph node metastasis rate by combination of lymphovascular invasion and differentiation, for both pT1 and pT2) and Hogan et al.'s independent- association analysis of LVI with locoregional vs. systemic recurrence, split by colon vs. rectal cancer (Table 27.2) — both genuinely new and more granular than the page's existing systematic- review-level odds ratios. The International Tumor Budding Consensus Conference (ITBCC) 2016 statements (Table 27.3) substantially formalize the page's existing brief tumor-budding mention with a definition, assessment method, and eleven GRADE-based consensus statements.
  • A new source page (sources/ASCRS Ch27 - Rectal Cancer Local Excision.md, this page) documents the citation and reconciliation approach.

Limitations

  • Textbook chapter, not primary literature — reproduced as described; several cited studies (Chang et al., Hogan et al., the ITBCC consensus, Junginger et al., CALGB 8984, ACOSOG Z6041, Lezoche's RCT, GRECCAR 2, CARTS) are not independently ingested from their own primary publications on this wiki, so figures given should be treated as textbook-secondary-source-level.
  • Flag — discrepant lymphovascular-invasion effect-size estimates, not reconciled: Chang et al. (943 patients, single institution) reports an odds ratio of 11.5 for LVI's association with lymph node metastasis; the existing Colorectal Polyps page (sourced from ASCRS Ch23, citing a 23-study/4510-patient systematic review and meta-analysis) reports OR 4.81 for the same risk factor. Both point the same direction (LVI is a strong, independent LNM risk factor) but differ substantially in magnitude — plausibly reflecting single-institution vs. pooled-meta-analysis effect-size differences, but not adjudicated here; reported side by side rather than merged.
  • Flag — similarly discrepant poor-differentiation effect-size estimates: this chapter's Bosch et al. citation (17-study meta-analysis) reports RR 4.9 (95% CI 3.3–6.9) for poor differentiation's association with lymph node metastasis; Colorectal Polyps's existing systematic review reports OR 5.60 for the same risk factor from a different (23-study) pooled analysis. Same pattern as above — same direction, different magnitude, not reconciled.

Relevance

Substantially expands Local Excision of Rectal Neoplasms (complications, oncologic results, adjuvant/neoadjuvant therapy, quality of life, salvage surgery — resolving that page's own previously-flagged open item) and Colorectal Polyps (more granular LVI/differentiation/tumor- budding nodal-risk data, formal ITBCC tumor-budding consensus). Flags two unresolved cross-source effect-size discrepancies (LVI and poor-differentiation odds/risk ratios) rather than silently merging them.