What is the clinical evidence from this study?

Study design: Observational. Population: Patients with mid or low rectal carcinoma undergoing transanal total mesorectal excision (TaTME) with curative intent (n=159). Intervention: Transanal total mesorectal excision (TaTME). Primary outcome: Local recurrence rate after TaTME.

What does this research mean for the field?

Transanal total mesorectal excision (TaTME) is associated with a 3-year local recurrence rate of 2.0% and a 5-year local recurrence rate of 4.0% in patients with mid or low rectal carcinoma, supporting upfront total mesorectal excision as a viable alternative to standard neoadjuvant chemoradiotherapy for selected patients. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.CHALLENGES_CONSENSUS.

What question did this study set out to answer?

This study aims to compare the oncologic outcomes of upfront surgery and neoadjuvant chemoradiotherapy in patients with stage II/III resectable rectal cancer.

February 28, 2026Open Access

Upfront surgery versus preoperative chemoradiotherapy: a comparative survival analysis for stage II/III resectable rectal cancer

Key Result

Transanal total mesorectal excision (TaTME) was associated with a 3-year local recurrence rate of 2.0% and a 5-year local recurrence rate of 4.0% in patients with mid or low rectal carcinoma.

Key Points

This study aims to compare the oncologic outcomes of upfront surgery and neoadjuvant chemoradiotherapy in patients with stage II/III resectable rectal cancer.
Analyzed using propensity score matching.
Compared long-term survival outcomes between upfront TME and nCRT followed by TME.
Evaluated primary and secondary endpoints related to survival outcomes over five years.
Upfront TME showed higher 5-year disease-free survival (63.3% vs. 43.9%).
Distant metastasis-free survival was significantly higher in the upfront TME group (88.1% vs. 70.3%).
No significant differences in survival outcomes after excluding patients with preoperative MRF involvement.
Kaplan-Meier survival analysis revealed no significant differences in any endpoints in the matched cohort.

Study Design

Type

Observational (n=159)

Multicenter

Yes

Structured PICO

Population

159 patients with histological proven distal or mid rectal carcinomas who had elective transanal total mesorectal excision (TaTME), mean age 66.9, 66.7% male, treated at two referral centers in The Netherlands.

Intervention

Transanal total mesorectal excision (TaTME)

Outcome

Locoregional recurrencehard clinical

Limitations

Observational design without randomized comparator group
Data from only two high volume tertiary referral centers limiting generalizability
Low number of local recurrence events preventing multivariate analysis
Learning curve and surgeon experience may influence outcomes
No direct comparison to other surgical techniques in this cohort

Abstract

Purpose: Current international guidelines recommend neoadjuvant chemoradiotherapy (nCRT) followed by total mesorectal excision (TME) for locally advanced rectal cancer (LARC). Although nCRT reduces the risk of local recurrence, it has not demonstrated a survival advantage and increases the likelihood of preoperative overtreatment. This study investigated whether upfront TME could be offered without compromising oncologic outcomes.Methods: From January 2015 to December 2020, patients with stage II/III LARC who underwent either upfront TME or nCRT followed by TME were analyzed using propensity score matching. Long-term survival outcomes were compared between the 2 groups. The primary endpoint was 5-year disease-free survival. Secondary endpoints included 5-year local recurrence-free survival, distant metastasis-free survival, and overall survival.Results: A total of 348 patients were included, of whom 138 (39.7%) underwent upfront TME. The upfront TME group showed significantly higher 5-year disease-free survival (63.3% vs. 43.9%) and distant metastasis-free survival (88.1% vs. 70.3%). However, after excluding patients with preoperative mesorectal fascia (MRF) involvement, no significant differences were observed in long-term oncologic outcomes. Following 1:1 propensity score matching, 47 patients from each group were compared. Kaplan-Meier survival analysis revealed no significant differences in any endpoints. Cox regression analysis of the matched cohort indicated that preoperative MRF involvement, positive extramural vascular invasion, and tumor deposits were not independent prognostic factors.Conclusion: Upfront TME may represent a viable treatment option for selected patients with LARC, particularly those without MRF involvement, providing comparable oncologic outcomes to the standard nCRT approach.

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