A 45-year-old man presents with painless rectal bleeding and a 2 cm sessile rectal lesion at 8 cm from the anal verge on flexible sigmoidoscopy. Histology confirms T1 rectal adenocarcinoma (submucosal invasion). MRI confirms no lymphovascular invasion, no perineural invasion, and lesion confined to the mucosa-submucosa on high-resolution MRI. The preferred management is:

• A Immediate anterior resection with total mesorectal excision (TME)
• B Preoperative long-course chemoradiotherapy followed by TME resection
• C Transanal endoscopic microsurgery (TEM) or endoscopic submucosal dissection (ESD) — local excision is oncologically adequate for low-risk T1 rectal cancer ✓
• D Active surveillance with 3-monthly endoscopy only

Explanation

Low-risk T1 rectal cancer (no lymphovascular invasion, no perineural invasion, well/moderately differentiated, invasion into superficial submucosa — Sm1/Sm2 rather than Sm3) carries a <5% risk of lymph node metastasis. Local excision by transanal endoscopic microsurgery (TEM), transanal minimally invasive surgery (TAMIS), or endoscopic submucosal dissection (ESD) achieves equivalent oncological outcomes to formal radical resection while preserving bowel function and avoiding the morbidity of TME surgery. High-risk T1 features (Sm3 invasion, LVI, PNI, budding) would require radical surgery. Surveillance alone without excision is inappropriate for a diagnosed adenocarcinoma.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.