Abstract
PURPOSE: To highlight the opportunities and pitfalls of organ-preservation strategies for rectal cancer and to define the clinical circumstances in which radical total mesorectal excision (TME) remains imperative, particularly when treatment is delivered outside referral centres. METHODS: Two illustrative patients initially managed in a tertiary hospital that is not a referral centre for rectal cancer and organ-preservation strategies are presented. Clinical records, imaging, histopathology, and follow-up were reviewed. Key management decisions were compared with current European Society for Medical Oncology (ESMO) and Italian Association of Medical Oncology (AIOM) guidelines, as well as recent evidence from systematic reviews. RESULTS: Case 1 involved a bulky (10 cm), circumferential cT3N + mucinous adenocarcinoma. Despite apparent local control after transanal excision, the patient developed sphincter-destructive recurrence requiring abdominoperineal resection; final pathology was ypT3N2b KRAS-mutant. Case 2 concerned an initially pT1 rectal adenocarcinoma in a 6-cm laterally spreading tumour, but surveillance was non-standardized; the patient re-presented with metastatic (liver) mucinous adenocarcinoma 4 years later, misdiagnosed as liver abscesses. In both patients, deviation from guideline criteria (tumour size, nodal status, unfavourable histology, or inadequate follow-up) led to undertreatment and delayed radical therapy. CONCLUSION: Organ preservation offers functional benefits but must be confined to rigorously selected low-risk lesions within prospective protocols and high-volume centres. Radical TME remains the gold standard when guideline criteria are not fully met or staging is ambiguous.