ence or absence of specific features predicts the risks for local recurrence, distant metastatic disease or both. This information thus determines the best of use of the many preoperative treatment strategies available. The initial preoperative assessment enables selection of patients for local therapies including non surgical and less radical therapy options when appropriate and identification of patients that require preoperative downsizing and downstaging in order to achieve the best results. Defining a robust preoperative strategy for patients with rectal cancer relies on consistent and reliable definitions of the risk factors by detailed imaging assessment that incorporates an understanding of surgical and oncological therapeutic limits.