Treatment of locally advanced low rectal cancer

Rectal cancer is a formidable disease with high recurrence and metastasis rates, particularly before total mesorectal excision (TME) was first described by Heald and Ryall in 1982. Through this ground-breaking operative procedure, rectal cancer has become a potentially curable condition. Traditional abdominoperineal resection has gradually been replaced with TME and coloanal anastomosis for resectable low rectal cancer. In addition, improved overall survival and decreased local recurrence rates have been achieved. For locally advanced (cT3/4, cN1/2) low rectal cancer (lower tumor margin < 6 cm above the anal verge), sphincter preservation is a major concern in cancer treatment. Randomized controlled trials have shown that neoadjuvant chemoradiation therapy (CRT) leads to a decrease in tumor size and enhances the likelihood of tumor resectability and sphincter preservation with low local recurrence rates. Therefore, neoadjuvant CRT followed by TME is the standard treatment guideline used worldwide for patients with low rectal cancer. However, one must understand the basic principles of TME to know why this procedure should be employed to treat locally advanced low rectal cancer. We therefore performed a minireview to explore how surgeons address this problem, how to help patients live longer, and how to reduce the occurrence of perioperative morbidities.