How would you sequence treatment (chemo and chemoRT) for a patient with a very symptomatic locally advanced rectal adenocarcinoma, MSS, with involved pelvic nodes and a mass abutting the sphincter, with no distant disease on CT but marked elevation in CEA above 300?

A pretreatment CEA level above 300 ng/mL is far beyond the typical range seen in stage II–III disease and warrants aggressive investigation. PET/CT should be strongly considered in this case to exclude occult distant disease, as it can change management in 8–11% of patients and is specifically recom...