We report on the significance of staging investigations in the management of operable rectal cancer with short course preoperative radiation therapy and the outcome and toxicity of this treatment option in the TME era. 107 charts of patients with documented rectal carcinoma treated with preoperative short course radiotherapy (25 Gy in five fractions) between 2004 and 2010 at 2 major Canadian centers were reviewed. Emphasis was placed on the clinical vs. pathological staging based on imaging modality, survival and patterns of recurrence. Metastatic patients and those who did not receive surgical resection were excluded from the analysis. 79 patients were included. Staging was done by EUS 46(58%), MRI with or without endorectal coil 40(51%), CT scan alone 6 (8%). Preop staging revealed stage I (16%), stage II (51%), stage III (24%), and stage IV (0%). Pathologic staging revealed stage I (30%), stage II (38%), stage III (32%), and stage IV (0%). The stage changed in 35 (46%) of patients (14 (18%) upstaged all due to change in nodal staging , 21 (24%) downstaged , 13 (16%) due to change in T stage, 8 (10%) due to change in nodal stage. 11(79%) of the patients who were upstaged postop were initially staged with EUS. 19 (24%) of patients were thought to have nodal involvement preop and 54(68%) were found to have nodal involvement postop. All patients received TME resection (mesorectum complete or near complete in 53(67%) after completion of RT. 4(5%) of patients had positive radial margins all of whom had been staged with either EUS or MRI. 10 (13%) of patients experienced a postoperative complication. Recurrence developed in 8 (10%) patients, 4 (5%) locoregional only , 1 (1.2%)distant only , 3 (3.7%) both. The 3 year actuarial and relapse free survival rates were 88.7% and 88.2% respectively. Overall survival (actuarial) by stage were stage I (100%), stage II (95%), and stage III (58.5%). The survival probability for RFS by stage I (93.8%), stage II (93.8%), stage III (76.2%). Median follow-up time was 18 months (range 2-52 months). Patients staged with MRI staging were 4.2 times less likely to have a change in stage postop (p = 0.007). Pathological N stage most closely correlates with OS (p = 0.052) and RFS (p = 0.04). MRI and endorectal ultrasound are effective and essential imaging modalities for staging of rectal cancer patients. MRI imaging appears to be superior to EUS in the staging of rectal cancer when compared to pathological staging. We would recommend considering MRI imaging for patients undergoing preop short course radiotherapy. In addition, neoadjuvant short course RT is a tolerable treatment approach in terms of toxicity.