The Utility of T2-Weighted MRI Radiomics in the Prediction of Post-Exenteration Disease Recurrence: A Multi-Centre Externally Validated Study via the PelvEx Collaborative

<b>Introduction:</b> Recurrence after pelvic exenteration remains a significant concern in patients with locally advanced rectal cancer (LARC). Therefore, there is a need for improved non-invasive predictive tools to aid in patient selection. Radiomics, which extracts quantitative imaging features, may help identify patients at greater risk of recurrence. This study aimed to develop and validate a radiomics-based nomogram using pre-treatment MRI to predict postoperative recurrence risk in LARC. <b>Methods:</b> The largest multicenter retrospective radiomics analysis of 191 patients with pathologically confirmed LARC treated at fourteen centres (2016-2018) was performed. All patients received neoadjuvant chemoradiotherapy followed by curative-intent exenterative surgery. Manual tumour segmentation was performed on pre-treatment T2-weighted MRI. Feature selection employed LASSO regression with 5-fold cross-validation across 1000 bootstrap samples. The most frequently selected features were used to construct a logistic regression model via stepwise backward selection. Model performance was assessed using ROC analysis, calibration plots, decision curve analysis, and internal validation with 1000 bootstraps. A nomogram was generated to enable individualized recurrence risk estimation. <b>Results:</b> Postoperative recurrence occurred in 51% (<i>n</i> = 98) of cases. Five radiomic features reflecting tumour heterogeneity, morphology, and texture were included in the final model. In multivariable analysis, all selected features were significantly associated with recurrence, with odds ratios ranging from 0.63 to 1.64. The model achieved an optimism-adjusted AUC of 0.70, indicating fair discrimination. Calibration plots showed good agreement between predicted and observed recurrence probabilities. Decision curve analysis confirmed clinical utility across relevant thresholds. A clinically interpretable nomogram was developed based on the final model. <b>Conclusions:</b> A radiomics-based model using preoperative MRI can predict recurrence in LARC. The derived nomogram provides a practical tool for preoperative risk assessment. Prospective validation is necessary.