Pathological lymph node response after immunotherapy-based total neoadjuvant therapy supports local excision for organ preservation in locally advanced rectal cancer: a propensity-score weighted analysis
In brief
Immunotherapy neoadjuvant regimen lowers positive nodes to 13% in rectal cancer
In a propensity-score weighted analysis of 1,568 locally advanced rectal cancer patients, immunotherapy-based total neoadjuvant therapy reduced the rate of residual positive lymph nodes to 13.4%, compared with 34% after standard total neoadjuvant therapy and 44% after chemoradiotherapy. The finding suggests that local excision could be a safe organ-preserving option for near-complete responders, though longer-term outcomes remain unknown.
- Journal
- Clinical and translational radiation oncology (Q1)
- Published
- 24 July 2026
- Study design
- Prospective / inception cohort
- Evidence level
- Level 2, Moderate (CEBM 2b)
- Authors
- Shujuan Zhou, Maoguang Ma, Siyuan Chen, Ting Zou, Yaqi Wang, Lijun Shen, et al.
- PMID
- 42569463
- DOI
- 10.1016/j.ctro.2026.101244
Why clinicians should know about it
- Picked for Oncology and Radiation Oncology (paper of the day, 9 August 2026): iTNT improves nodal response, supports organ preservation
Abstract
BACKGROUND: The immunotherapy-based total neoadjuvant therapy (iTNT) has improved response rates in locally advanced rectal cancer (LARC); however, a majority of patients do not achieve clinical complete response (cCR) and still require total mesorectal excision. High rates of ypT0-1 and particularly ypN0 in non-cCR patients suggest organ preservation via local excision (LE). This study aims to assess the feasibility of LE in LARC by comparing pathological lymph node responses after three neoadjuvant regimens. METHODS: We included 1568 LARC patients with pathological outcomes after neoadjuvant therapy in three cohorts: 238 received fluorouracil-based chemoradiotherapy (CRT); 1256 received total neoadjuvant therapy (TNT); and 74 received iTNT from the prospective TORCH trial (NCT04518280). Baseline characteristics among three cohorts were balanced using the stabilized inverse probability of treatment weighting (IPTW) method. RESULTS: After IPTW adjustment, the overall rates of positive lymph nodes after neoadjuvant therapy (ypN+) were 44.1%, 34.0%, and 13.4% in the CRT, TNT, and iTNT cohorts, respectively. Notably, pathologic complete response of lymph nodes was achieved in both ypT0 and ypT1 tumors following iTNT. In contrast, the ypN+ rates for ypT0 and ypT1 tumors remained high at 16.8% and 26.4% with CRT and 11.2% and 19.2% with TNT. Univariate regression analysis identified that ypT2-4, positive ypMRF, and positive ypEMVI were associated with higher ypN+ risk, rather than baseline clinical characteristics. CONCLUSIONS: iTNT markedly improved lymph node regression in ypT0-1 tumors compared to CRT or TNT. LE, guided by tumor response but not by baseline clinical stages, may be considered for organ preservation in near-cCR patients with LARC following iTNT.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.