Patients with low rectal cancer and inguinal involvement at presentation should obviously be treated with curative intent because inguinal lymph nodes are first echelon drainage from the low rectum and anal canal. Standard dose neoadjuvant chemoradiation and limited surgical excision of the involved...

For consideration: Tattoo the site of the primary with a 1.0cm margin before beginning neo-adjuvant chemotherapy. This should be followed by chemopotentiated IMRT to the rectal-anal tumor, including first and second station nodes in pelvic and and inguinal- fémoral sites.Then, using the ...

I agree with starting with chemo in cases of extensive LAD and would advocate for preop does of radiation followed by surgery. If after discussion with the surgeon I learned that these nodes could not be resected, I would use IMRT with SIB to 63-70Gy depending on OAR considerations.

The intent would be curative as inguinal nodes are regional spread and the plan would be preoperative chemo RT followed by surgery.