Reducing TME burden with a risk-stratified approach in early rectal cancer

Patients with pT2 rectal cancer who underwent local excision and lacked histological risk factors appeared to have a low risk of lymph node metastases (LNM). This finding suggests that a risk-stratified approach, selecting patients based on these histological features, may be a viable strategy to reduce the number of completed total mesorectal excision (TME) procedures.

“In the Netherlands, we see about 3,000 new patients with rectal cancer each year. About 30% of them have cT1-2N0 stage cancer and are eligible for diagnostic local excision,” said Dr Sander Albers (Amsterdam University Medical Centre, the Netherlands) [1]. However, the role of local excision in pT2 cancer remains controversial due to a 20–30% risk of LNM. The current study aimed to better define LNM risk in pT2 rectal cancer following local excision to guide subsequent treatment decisions.

The multicentre, retrospective cohort study included 103 participants with locally excised pT2 rectal cancer who had not received neoadjuvant therapy. All participants underwent a standardised histopathological revision of the local excision specimens, and LNM status was determined by completion of TME or MRI follow-up exceeding 24 months. “The assessed histological risk factors included poor tumour differentiation and/or mucinous subtype, lymphovascular invasion, tumour budding and/or poorly differentiated clusters (grade 2 or 3), and perineural invasion,” explained Dr Albers.

Most participants underwent completion TME (74%), while the remainder opted for active surveillance (26%). The overall LNM rate was 18%. Among participants without histological risk factors (n=36), the LNM risk was only 5.6%. Furthermore, after a median follow-up of 53 months, no locoregional recurrences occurred in participants in the active surveillance group who lacked risk factors (n=10).

“The risk of LNM was low in patients with pT2 cancer who underwent local excision and had no histological risk factors,” concluded Dr Albers. “Since about 1/3 of the patients with pT2 rectal cancer fall into this low-risk category, a risk-stratified approach could substantially reduce the number of completion TME procedures performed.” Prospective validation is warranted before clinical implementation.

1. Albers SC, et al. Histological risk stratification for lymph node metastasis in PT2 rectal cancer after local excision: a multicentre international study (historic). LB14, Colorectal ESD: The better way? UEG Week, 4–7 October 2025, Berlin, Germany.

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Posted on 1 December 20251 December 2025