Precision treatment and minimally invasive practice for locally advanced rectal cancer in the era of evidence‑based medicine

The management of locally advanced rectal cancer is undergoing a transition from standardization to precision medicine. As the cornerstone procedure for curative rectal cancer treatment, total mesorectal excision is no longer determined solely by anatomical staging in terms of timing, extent of resection, and technical approach. Instead, individualized decision‑making should integrate high‑quality imaging assessment, molecular classification, multidisciplinary discussion, and patients′ functional needs. In recent years, the wide-spread application of total neoadjuvant therapy has markedly changed the treatment sequence for middle and low locally advanced rectal cancer, improving tumor regression rates and the possibility of organ preservation. Immune checkpoint inhibitors have demonstrated breakthrough efficacy in deficient mismatch repair/microsatellite instability‑high rectal cancer, providing important evidence-based support for nonoperative manage-ment. Patients with proficient mismatch repair/microsatellite stable rectal cancer still constitute the majority in clinical practice, and individualized and precise treatment strategies are required to avoid undertreatment or overtreatment. Based on domestic and international guidelines, expert consensuses, and pivotal clinical studies, the authors elaborate on precise stratification of locally advanced rectal cancer, treatment strategies for patients with different expression of mismatch repair protein or microsatellite tumors, organ preservation, minimally invasive practice, and follow‑up management, with the aim of providing a reference for clinical practice.