Stage 0 rectal cancer disease is associated with excellent long-term results irrespective of treatment strategy. Surgical resection may not lead to improved outcome in this situation and may be associated with high rates of temporary or definitive stoma construction and unnecessary morbidity and mortality rates.

European Registration of Cancer Care financed by European Society of Surgical Oncology, Champalimaud Foundation Lisbon, Bas Mulder Award granted by the Alpe d'Huzes Foundation and Dutch Cancer Society, and European Research Council Advanced Grant.

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Strict definition of the clinical and endoscopic findings of patients experiencing complete clinical response after neoadjuvant chemoradiation therapy may provide a useful tool for the understanding of outcomes of patients managed with no immediate surgery allowing standardization of classifications and comparison between the experiences of different institutions.

Extended chemoradiation therapy with additional chemotherapy cycles and 54 Gy of radiation may result in over 50% of sustained (>12 months) complete clinical response rates that may ultimately avoid radical rectal resection. Local failures occur more frequently during the initial 12 months of follow-up in up to 17% of cases, whereas late recurrences are less common but still possible, leading to 50% of patients who never required surgery. Strict follow-up may allow salvage therapy in the majority of these patients (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A113.).

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In rectal cancer patients with a cCR following neoadjuvant chemoradiotherapy, a Watch and Wait policy appears feasible and safe. Robust surveillance with early detection of regrowths allows a high rate of successful salvage surgery, without an increase in the risk of systemic disease, or adverse survival outcomes.

 As rectal cancer treatment becomes more precise, high-resolution imaging techniques have been established to identify important tumour characteristics that help guide management.  High-resolution magnetic resonance imaging scans are increasingly dictating treatment strategies by providing predictive and prognostic information related to the tumour, and are a standard part of the patient investigation pathway.  Surgical management depends on patient and tumour factors with an aim to optimise function and survival with the lowest risk of recurrence.  Multiple approaches are currently available for resection, including radical surgery involving excision of the rectum and associated mesentery and organsparing techniques involving local excision of the lesion or deferring surgery altogether.  The pathological assessment of the resected rectal cancer specimen provides a level of quality control ensuring that surgical principles have been adhered to and that the surgery was performed in an optimal oncological manner.  Multidisciplinary team presentation of imaging data, evidence-based oncological, surgical and functional recommendations, in addition to pathological assessment of surgical quality, is an essential part of formalised cancer care.