Organ preservation in early-stage rectal cancer: a narrative review of biological rationale, treatment strategies, and future directions

Recent advances in rectal cancer treatment and evolving insights into tumour biology have expanded the opportunities for organ preservation in early-stage rectal cancer. Historically, these tumours were managed by rectal resection, but less invasive, step-up approaches are now increasingly being adopted. This narrative review summarizes current treatment strategies for early-stage rectal cancer (cT1b-T2N0). Organ preservation may start with local excision, followed by adjuvant (chemo)radiotherapy (CRTx), completion surgery, or active follow-up with salvage treatment in case of recurrence. Alternatively, management may begin with (C)RTx, followed by a response-based approach: a watch-and-wait strategy in case of clinical complete response, local excision or contact X-ray brachytherapy (CXB) in case of minimal residual intramural cancer, and completion surgery in case of poor response. The oncological and functional outcomes of these strategies are reviewed, aiming to support multidisciplinary discussion and shared decision-making in the management of early rectal cancer.