MRI for assessing and predicting response to neoadjuvant treatment in rectal cancer

Guidelines recommend MRI as part of the staging work-up of patients with rectal cancer because it can identify high-risk groups requiring preoperative treatment. Phenomenal tumour responses have been observed with current chemoradiotherapy regimens-even complete regression in 25% of patients. For these patients, the options of organ-saving treatment as an alternative to surgery are now discussed, and critical for this approach is the availability of tools that can accurately measure response. The value of MRI in rectal cancer staging is established, but the role of MRI for the selection of patients for organ-saving treatment is debatable, because MRI is not able to accurately assess tumour response to preoperative chemoradiotherapy (owing to its reliance on morphological changes). Functional MRI is emerging in the field of oncology. It combines information on detailed anatomy with that of tumour biology, providing comprehensive information on tumour heterogeneity and its changes as a result of treatment. This Review provides knowledge on the strengths and weaknesses of MRI for response assessment after chemoradiotherapy in rectal cancer and on its ability to predict tumour response at the time of primary diagnosis. It elaborates on new functional magnetic resonance technology and discusses whether this and new postprocessing approaches have the potential to improve prediction and assessment of response.