Staging and Restaging of Rectal Cancer with MRI: A Pictorial Review

MRI plays an integral role in the initial local staging of rectal cancer and assessment of treatment response, with the goal of treatment to minimize local recurrence. Standard treatment of rectal cancer includes surgical excision with the addition of neoadjuvant chemoradiation therapy for locally advanced disease. MRI is ideally suited for both surgical planning and risk stratification, allowing for accurate evaluation of tumor location and characteristics, T and N staging, and other MRI-specific features. The role of MRI in risk stratification continues to expand with the emergence of novel organ-sparing management options including active surveillance, minimally invasive surgery, and alternative neoadjuvant therapies. Thus, optimal MRI interpretation requires precise evaluation of the primary tumor and its relationship to surrounding structures with a familiarity of the concepts important in risk stratification and treatment management. Additionally, recognition of the imaging modality's current challenges and limitations can prevent interpretive errors and optimize its diagnostic utility. This pictorial review discusses key concepts of MRI in the initial staging of rectal cancer, assessment of treatment response, and active surveillance of disease, including a focus and discussion on current interpretive challenges and opportunities for advancement.