The Role of MRI in Non-Operative Management of Locally Advanced Rectal Cancer.

Advances in total neoadjuvant therapy have significantly increased complete response rates, and non-operative management of locally advanced rectal cancer has emerged as a viable alternative to traditional surgical resection for select patients achieving a complete clinical response after neoadjuvant therapy. There has been growing evidence in support of non-operative management, demonstrating promising survival outcomes and organ-preservation benefits. Appropriate patient selection at restaging and early detection of local tumor recurrence are key to positive oncological outcomes. High-resolution MRI, particularly when combined with diffusion-weighted imaging, can offer unmatched evaluation of treatment response, detection of residual disease, and identification of local recurrence. Standardized imaging protocols and emerging tools such as radiomics are further enhancing the precision of tumor assessment. This article provides a comprehensive synthesis of current evidence and reviews the critical role of MRI for the successful implementation of non-operative in clinical practice.