Depthofinvasionandnodalstatusmustbeevaluatedforthepotential utilizationofneoadjuvantchemoradiotherapy.Theauthorsuggeststhat endorectalultrasound(EUS)and/ordedicatedhigh-resolutionrectal magneticresonanceimaging(MRI)shouldbeperformedonallmidand distaltumorsandselectuppertumors.Thereareadvantagesand disadvantagestobothmodalitiesandthereforecanbeconsidered complementarytoeachother.EUS,however,isnotwellsuitedforhigh tumorsand/orbulkytumors(T4).Inaddition,stenotictumorsposea technicalproblem,becausetheultrasoundprobemaynotbeableto traversethelesionforaccuratestaging.However,T3lesionsarewell distinguishablefromT4lesionswiththeaidofMRI.Theaccurate diagnosisofT3fromT2lesionsisimportant,becauseT3lesionsofthe midandlowrectumshouldreceiveneoadjuvantchemoradiationinmost instances.Intheauthors’experience,ultrasoundmaybebetterwhen lookinganteriorly(invasionintoprostate/bladderorvagina)andMRIis betterforevaluatingthecircumferentialmargin.Intermsoflymphnode status,MRIistherecommendedmodalityfordiagnosisofnodaldisease, despiteanoveralllowsensitivityandspecificity(66%and76%, respectively).Ingeneral,atourinstitution,allpatientswithT3–T4 and/orN+mid-to-lowrectaladenocarcinomaswillreceiveneoadjuvant long-coursechemoradiotherapyfollowedbyradicalexcision8–12weeks aftercompletion.