Rectal cancer protocol (MRI)

Last revised by Andrew Murphy on 29 Aug 2023

MRI protocol for rectal cancer is a group of MRI sequences put together for imaging staging of primary tumors of the rectum and assessment of response following neoadjuvant therapy. Modified versions of the protocol may also be used for the assessment of local recurrence.

Note: This article is intended to outline some general principles of protocol design. The specifics will vary depending on MRI hardware and software, radiologist's and referrer's preference, institutional protocols, patient factors (e.g. allergy) and time constraints. 

Bowel preparation is not necessary for rectal MRI.

Studies are usually performed without rectal distension. Rectal distension leads to overestimation of the distance between the tumor and the anorectal junction, and errors in T staging 2

Antispasmodic agents (eg. Buscopan (hyoscine) or glucagon) are commonly prescribed for reducing bowel peristalsis and consequent motion artifacts 1.

A good protocol for this purpose involves at least:

  • overviews
    • sagittal T2
    • axial T2
  • small FOV T2 through tumor 
    • axial - perpendicular to the plane of the part of the rectum containing the tumor
    • coronal - parallel to the plane of the part of the rectum containing the tumor
    • if the tumor is long, or the part of the rectum bearing the tumor has an angulated course, multiple small field-of-view sequences may be necessary
  • optional
    • diffusion-weighted imaging

For restaging after chemoradiotherapy, a similar protocol may be deployed. Diffusion-weighted imaging has a greater role to play in this scenario. 

Contrast enhancement is generally considered unnecessary for primary staging and restaging following chemoradiotherapy, but may be deployed for staging of local recurrences, and for the staging of locally advanced rectal cancers where the relationships to other pelvis structures such as the internal iliac vessels and sacral bone involvement are important factors in determining the surgical approach.

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Cases and figures

  • Case 1: small field of view (FOV) axial T2 sequence
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  • Figure 1: rectal anatomy (illustrations)
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