preoperative chemo is effective for down-staging of cancer as well as it makes procedure easy.  preoperative assessment  of tumor invasion to the layer of colon wall and lymph node extension is very important to determine prognosis of cancer case.

MRI-tumour is just above the dentate line,penetrated the muscularis mucosa but not breached,CRM is clear.

It is a very challenging situation, mainly because the lesion is just above the dentate line. Although 0,9 cm is the minimum acceptable margin for this tumor and theoretically suitable for a coloanal anastomosis, the patient must be prepared for a Miles procedure if technical problems during surgery are identified. Although neoadjuvant therapy is indicated, it seems to be a T1 tumor, prone to be completelly resected by surgery, without  preoperative down staging. Adjuvant therapy can be indicated if positive nodes are identified.

I think the best option would be to perform a complete rectum resection with a permanent colostomy

Thankyou all,Agree with you prof Luis as Miles APR with permanent colostomy has been the proccdure of choice ealier but the present trend seems preop chemo rad followed by Inter shincteric or colo anal anastamosis with covering Ileostomy.

If regression occurs after RT and CT watch and wait is also an option but only in a study protocol. The resection with a colo-anal anastomosis might lead to anal incontinence due to urge. A Miles procedure might be the end point even after colon-anal anastomosis.

Inter sphincter resection without neo adjuvant chemo radiation in this setting may not be evidence based. Since the patient has reservations for chemo radiation upfront options include Miles procedure vs neoadj chemo radiation followed by potential sphincter preserving proceedure

As the tumour invades only muscularis propria - neoadjuvant CRT + TEO is preferable

Dr Prasanna Kumar Reddy

Since this is cT1 N0, mod differentiated adenocarcinoma 1cm above dentate line, addition information on tumour size and persentage of circumference involvement may indicate the possibility of a Trans anal wide excision..

What is the location of the tumor? Anterior, posterior or lateral position is important because of the mesorectum thickness is different at this level.

MRI to see involvement of internal sphincter and intersphincteric plane

if isr contemplated preoperative CTRT advisable 

intersphincteric resection and handsewn coloanal nastomosis have recurrence rates comparable or less than aper 

Thanks for the evidence based discussion

What did you perform for the patient?

This techniques does not elude the possible relapse of the rectal tumor

I agree with Dr. Pravosudov and Dr. Reddy

The best option I think is to remove all the rectum and make a colo-anal anastomosis