Local excision versus total mesorectal excision following neoadjuvant chemoradiotherapy for rectal cancer: A systematic review and meta-analysis.

BACKGROUND

Total mesorectal excision (TME) with or without neoadjuvant chemoradiotherapy remains the gold standard treatment for rectal cancer. However, newer organ sparing methods, including Local Excision (LE) have been introduced in conjunction with neoadjuvant therapy to improve morbidity and functional outcomes while not impacting on oncological outcomes.

METHODS

A systematic review and meta-analysis was performed using the PRISMA guidelines. All studies comparing neoadjuvant chemoradiotherapy and local excision versus TME were included from 2000 to 2024. Primary endpoint included local recurrence rates. Secondary outcomes included distant recurrence, disease free survival (DFS), overall survival (OS), and morbidity. Subgroup analysis was performed on randomised control trials (RCT).

RESULTS

Sixteen studies (n = 2121; LE = 616, TME = 1505) were included. LE was associated with higher local recurrence (8.3 % vs 5.5 %; OR 1.82, 95 % CI 1.19-2.77, p = 0.006). However, in RCTs (n = 245), this difference was not significant (7.3 % vs 6.6 %; OR 1.10, 95 % CI 0.41-2.97, p = 0.84). No significant differences were observed in distant recurrence, DFS, or OS. LE was associated with significantly reduced morbidity (OR 0.30, 95 % CI 0.18-0.50, p < 0.0001).

CONCLUSION

Local recurrence was not statistically significant in the RCT subgroup analysis. Despite, higher local recurrence rates in the overall pooled analysis, no significant differences were observed for secondary outcomes. Neoadjuvant chemoradiotherapy and local excision appears oncologically safe, defined by DFS and OS, in select patient cohorts with a clinical complete or near-complete response to neoadjuvant therapy.