# The Role of Organ Sparing Approaches After Total Neoadjuvant Treatment in Rectal Cancer

## TL;DR

This paper reviews how non-surgical and local excision approaches can preserve organs in rectal cancer patients after total neoadjuvant therapy, balancing benefits and risks.

## Contribution

The paper highlights local excision as a safer alternative to surgery in confirming tumor response after neoadjuvant therapy.

## Key findings

- Watch-and-Wait strategies carry a 20–30% risk of local regrowth, impacting survival outcomes.
- Local excision improves oncologic safety by removing residual tumor cells and confirming complete response.
- Total neoadjuvant therapy increases complete response rates, enabling organ-preserving strategies.

## Abstract

Advances in Total Neoadjuvant Therapy (TNT) have increased complete responses in rectal cancer, raising interest in organ-preserving approaches. The Watch-and-Wait (W&W) strategy can avoid surgery but carries a relevant risk of local regrowth, which may worsen long-term outcomes. Local excision (LE) offers an alternative that allows for confirmation of true tumor disappearance and removal of any residual cancer cells, providing greater oncologic safety. This review summarizes current evidence on W&W and LE after TNT to help guide safe and tailored organ-preservation strategies.

Organ-preserving strategies have gained increasing relevance in the management of rectal cancer, driven by the improved ability of neoadjuvant therapies to induce major and complete tumor regression. The introduction of Total Neoadjuvant Therapy (TNT), delivered through induction and/or consolidation chemotherapy combined with radiotherapy, has substantially increased both pathological and clinical complete response rates. This progress has renewed interest in non-operative management—namely Watch-and-Wait (W&W)—and in local excision (LE) as potential alternatives to total mesorectal excision (TME). However, the W&W strategy raises important oncologic concerns, including a non-negligible rate of local regrowth—consistently reported at approximately 20–30%—which is associated with inferior distant metastasis-free survival and overall survival. These limitations underscore the inherent uncertainty in reliably defining a true clinical complete response. Within this context, LE may serve as a valuable diagnostic and therapeutic modality by confirming the pathological response, improving local control through removal of residual resistant tumor clones, and enabling more accurate stratification of patients suitable for organ preservation versus those requiring completion TME. Overall, while TNT has expanded the therapeutic opportunities for rectal preservation, LE appears to play a critical role in reducing the discordance between clinical and pathological assessment, thereby offering a more oncologically secure pathway toward organ preservation. This narrative review discusses the current role, benefits, and limitations of organ-preserving approaches after TNT in both locally advanced and early rectal cancer.