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The indications and results of local excision of rectal lesions are currently under debate.Rectal lesions treated by transanal endoscopic microsurgery (TEM) wereprospectively analysed to identify risk factors for recurrence.Between 1993 and 2009, 107 patients were treated by TEM for an adenocarcinoma: 48 pT1, 43 pT2 and 16 pT3. The 5 year overall survival rate was100%, 87.6% and 58% for pT1, pT2 and pT3 respectively (P < 0.001). The 5 year disease-free survival rate was 93.8%, 80.1% and 42% for pT1, pT2 and pT3 respectively (P < 0.001). Recurrence among pT1 was 0% (0/27) in ‘low risk’ and 23.8% (5/21) in ‘high risk’ cancers (P < 0.05) Submucosal infiltration was a significant risk factor for recurrence: 0% sm1, 16.7% sm2 and 30% sm3. On univariate analysis pT stage, tumour grading and < 1 mm margin freedom were identified as positivepredictors. On multivariate analysis only < 1 mm margin freedom and a positive margin were risk factors.TEM is curative for ‘low risk’ early rectal malignancy. Preoperative assessment of the risk factors is crucial for optimal treatment.