Defining endoscopic candidacy for intermediate size rectal neuroendocrine tumors

Endoscopic resection is standard for small, well-differentiated rectal neuroendocrine tumors, but management of intermediate lesions remains unsettled. In a large single-center cohort with propensity score matching, endoscopic treatment of grade 1 tumors measuring 1.0-1.5 cm achieved high negative-margin rates and no observed recurrences over a median 54-month follow-up, mirroring outcomes for lesions < 1 cm. Lymphovascular invasion was absent in the intermediate group, and endoscopic submucosal dissection was used more often than mucosal resection. These data support endoscopic resection as a feasible organ preserving option in carefully staged, well differentiated intermediate size tumors. Priorities now include prospective, multicenter validation; standardized pre-resection staging with high-resolution endoscopy and endoscopic ultrasound; refined risk stratification incorporating depth and lymphovascular invasion; pragmatic surveillance schedules; and assessment of patient-reported outcomes, function, and costs. Developing decision tools and targeted training to optimize endoscopic technique may further expand safe, individualized care, and health economic analyses.