Driven by the aim to avoid a permanent colostomy and also the morbidity and mortality of major radical surgery for rectal cancer, the proportion of patients with rectal cancer treated by local excision has increased the last ten years or so. In T1 carcinomas local excision is considered a curative option in selected tumors. However, the scientific base upon which this treatment regimen is built remains controversial. In this systematic review we try to elucidate current literature regarding local excision for T1 rectal carcinomas. Several questions are addressed. First, is there enough evidence to propagate LE as a curative option in selected (T1) rectal carcinomas? Second, if LE is justified, which technique should be the method of choice? Third, can we adequately identify, pre- and postoperatively, tumors suitable for LE? Finally, future perspectives are discussed.