Challenges in rectal cancer MRI: from image acquisition to interpretation

Precise and accurate staging of rectal cancer is critical for formulating an appropriate treatment plan, including determining the necessity for neoadjuvant therapy and establishing an adequate surgical approach. MRI is the gold standard for locoregional tumor staging, also playing a central role for patients selected for watchful waiting surveillance after total neoadjuvant therapy. Nevertheless, challenges exist from acquisition to interpretation of rectal MRI examinations and, despite societal guidelines, practices vary across institutions. In this paper, we review the optimal technique for acquisition of diagnostic quality rectal MRI and address its existing challenges and unmet needs, encompassing both acquisition and image interpretation.