A 55-year-old patient presents with haematochezia. Colonoscopy shows a 2 cm polyp at 10 cm from the anal verge. Endoscopic mucosal resection (EMR) is performed and histology reveals a T1 rectal adenocarcinoma with submucosal invasion, grade 3 (poor differentiation), and lymphovascular invasion. What is the recommended additional treatment?
- A Radical surgery (anterior resection or TEM/TEMS reassessment) due to high-risk features ✓
- B Observation and repeat colonoscopy in 3 months
- C Adjuvant chemotherapy (FOLFOX) without further surgery
- D Transanal local excision to ensure clear margins only
Correct answer: A. Radical surgery (anterior resection or TEM/TEMS reassessment) due to high-risk features
Explanation
High-risk T1 rectal cancers after local excision or EMR require radical surgery due to significant lymph node metastasis risk (approximately 20–30% with all high-risk features). High-risk features per ESMO/BSG include: poor differentiation (grade 3), lymphovascular invasion, submucosal invasion level sm3 (deep third), budding, or positive/uncertain margins. This patient has grade 3 histology + lymphovascular invasion — these are absolute high-risk features mandating radical surgery (anterior resection) rather than observation.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.