What is your approach to cT3N0M0 mid rectal adenocarcinoma with clear circumferential resection margins on MRI?

This is an important issue in management of rectal cancers. It is best handled with an informed discussion and decision by the patients considering the pros and cons of initial surgery versus neoadjuvant therapy. The problem is, of course, inaccuracy of pretreatment staging, with the false negative rate for radiographic imaging of peri-rectal nodes of 20-30% both by ultrasound and MRI.

Given this, one has to inform the patient that there is a reasonable chance of positive nodes with initial surgery. In that case, with pathologic stage III disease, they will need postop chemo-radiation. The post operative approach is associated with more local complications including rectal stenosis and poor bowel function.

Many patients will prefer surgery ...

These reflect real-life management dilemmas. Upstaging after primary resection is something we have all had to deal with. A multidisciplinary approach is essential.