When do you include the mesorectum for definitive cervical cancer patients getting concurrent chemoradiation followed by brachy?

I would also include it if there is direction invasion into the mesorectum or EMVI.

The incidence of mesorectal nodal metastasis (MRNM) in cervical cancer has not been well studied. Whether or not to include the mesorectum within the target volume is controversial.

The mesorectum is difficult to evaluate for nodal metastasis because MRNM are often too small to detect with imaging studies. In our previous study (Cordero-Gallardo et al., PMID 30640683) of MRNM in cervical cancer, MRNM was defined as LN greater than 0.5 cm for CT and MRI or PET scan SUV > 2.5. We found extensive pelvic LN metastasis, mesorectal fascia, or uterosacral ligament involvement to be high-risk factors for MRNM.

I would include mesorectum only in the presence of mesorectal nodes on imaging.