Patient has no active bleeding and obstruction problem.

Dear Sir, All rectal cancer at any stage has a very poor recovery as the metastasis is very profound due to the pelvic floor blood supply and lymphatic drainage of the same, But as Sir Osama Mohamed Zakaria states - I agree with that since the level of matastatic changes does make a lot of difference in the choice of surgical plan and management. Thanks

Dear Dr Ossama

Thanks for your comment, but metastatic work up of other sites such as liver , lung and para aorta was negative.

MRI for T staging.

Neoadjuvant radiochemotherapy. 

Restaging with MRI, including DWI.

Intersphincteric resection of the rectum with coloanal anastomosis or ELAPE and groin lymphadenectomy 

Dear Dr Tajudeen

Thanks for your replay, i want to know , do you prefer to start with surgery ? or you ask for any neoadjuvant?

Dear Dr Ionut

Thanks , do you consider involved groin nodes as a regional node N+ or metastasis M1 ?

Dear Dr.Mahmoodzadeh

As you touch to me, firstly we should identify the exactly site of the primary tumor according to the relation of the tumor with dented line.

Does it above or inferior to the marked line? I mean does it an anal canal tumor or rectal cancer? Although we know that adenocarcinomas most probably arise from rectal wall, in this case it could be determinative.

If its origin is anal canal therefore inguinal nodes are the regional lymph nodes and in this situation I prefer to complete the local staging with EUS/ DWI MRI and offering the patient to sperm saving and beginning the treatment with neoadjouant CRT(with widening the field of RT to the groin) and then APR with inguinal lymphadenectomy for involved site and SLNB for the opposite groin site.

BUT

If it comes from rectal wall ( which I think so)

Groin lymphadenopathy  can be considered as a metastasis and one of the most causes of inguinal involvements are blocking the usual routs of rectal lymph drainage, therefore if the patient does not have a history of previous pelvic surgery, groin involvement means the heavy burden of tumor in pelvis nodes (at least).

I recommend to take a CNB  to R/O other possible malignancies such as lymphoma(NHL) and review the abdominal ct and look for paraaortic LAP and adjust it with PETscan, if there is not any other site of hot point I consider to maintain the curative intention and after completion of local staging , sperm preserving and CRT , do the adequate surgery ( margin negative : VLAR/APR) with TME and lymphadenectpmy for involved site.

Here is the link of an article which presents the series of 18 patients with rectal adenocarcinoma and inguinal node(s) involvement.

http://www.ncbi.nlm.nih.gov/pubmed/8080070

sincerely yours

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4237326/

According to this article , the risk factors of inguinal lymph node metastasis for lower rectal cancer involving the anal canal are invasion of dentate line and lymphovascular invasion. Since poor prognosis of inguinal lymph node metastasis for rectal cancer is clear, I will suggest neoadjuvant chemoradiotherapy followed by TME surgery.  Although the available data from EORTC trial 22921, Dutch Colorectal PROCTOR/SCRIPT trials and phase III United Kingdom Chronicle trial showed that there is no benefits for postoperative chemotherapy in the patient who had neoadjuvant chemoradiotherapy before surgery, postoperative chemotherapy significantly improved overall survival in some subgroup patients. So postoperative chemotherapy is still maybe  an option for this young age  patient if his postoperative condition recovered well. 

According to NCCN guideline the anal canal is 3 - 5 cm long, from the anal verge to the anorectal ring (puborectalis muscle). Inguinal lymph nodes metastasis are stage as N2 for anal canal cancer.

The present tumor being 4 cm above the anal verge, has its origin in the glandular epithelium of the transitional zone (1-2 cm above the dentate line). Inguinal lymphnodes are not staged as regional for rectal cancer according to TNM 7th edition.

This is definitely not a standard case, and should be discussed in the tumor board.

If the CT of the thorax and abdomen reveal no metastasis, PET/CT may be considered. If there is no metastasis, I think that the inguinal lymph nodes should be regarded as N+.

LN mets out f regional basin. perhaps stands for M1. Approach as stage IV.

Groin LN is considered M1, so, this is a metastatic disease

Dear Dr Emad

Thanks for your comment. Do you have any evidence for your comment?

I suggest to use high-frequency ultrasound and perform a guided biopsy

Pelvic MR for local staging of tumour (accurate to determine level of T3 but less definitive for T1/2 disease) and lymph nodes pre-treatment planning. This is possible with surface coils although specific endo-coils are possibly superior. MR give superior contrast resolution in the pelvis for local staging but CT chest, abdomen and pelvis should be used to assess distant spread.