Management and oncologic outcomes of rectal cancer patients with downstaged lateral pelvic lymph nodes in the era of total neoadjuvant therapy

Why clinicians should know about it

• Picked for Surgery (paper of the day, 30 September 2026): Downstaged lateral pelvic nodes after total neoadjuvant therapy in rectal

Abstract

BACKGROUND: Rectal cancer patients with positive lateral pelvic lymph nodes have traditionally been associated with poor prognosis. Although lateral pelvic lymph nodes often respond to neoadjuvant therapy, uncertainty remains regarding the management of patients whose initially positive lateral pelvic lymph nodes achieve complete radiographic regression in the era of total neoadjuvant therapy. This study aims to evaluate the oncologic outcomes and management of lateral pelvic lymph node-positive rectal cancer patients who completely respond to total neoadjuvant therapy. METHODS: Retrospective analysis of stage III rectal cancer patients completing total neoadjuvant therapy (2016-2025) at a high-volume center. Patients were stratified into 2 groups: the lateral pelvic lymph node-negative group (no suspicious lateral pelvic lymph nodes on baseline magnetic resonance imaging, remaining node negative on restaging magnetic resonance imaging) and the lateral pelvic lymph node-positive group (at least 1 lateral pelvic lymph node ≥7 mm short axis with malignant features on baseline magnetic resonance imaging, achieving complete nodal response on restaging magnetic resonance imaging). Patients with persistent lateral pelvic lymph node positivity or requiring lateral pelvic lymph node dissection were excluded. The primary outcome was disease-free survival; secondary outcomes included distant metastasis-free survival, overall survival, and local control. RESULTS: Of 325 patients, 68 (21%) were lateral pelvic lymph node positive and 257 (79%) were lateral pelvic lymph node negative. Lateral pelvic lymph node-positive patients had larger tumors (6 vs 5 cm; P = .003) and more lower rectal tumors (62% vs 39%; P = .004). In the surgery cohort (n = 226), 3-year disease-free survival (83% vs 80%), distant metastasis-free survival (87% vs 80%), local recurrence-free survival (91% vs 91%), and overall survival (97% vs 90%) did not differ between groups (P > .05). In the watch-and-wait cohort (n = 99), salvage surgery rates were identical (19% vs 19%; P = .99), and 3-year disease-free survival (81% vs 88%), distant metastasis-free survival (85% vs 89%), local regrowth-free survival (74% vs 70%), and overall survival (94% vs 98%) were comparable (P > .05). CONCLUSION: Lateral pelvic lymph node positivity at baseline is not associated with worse oncologic outcomes in rectal cancer patients whose lateral pelvic lymph nodes respond completely to total neoadjuvant therapy in both total mesorectal excision and watch-and-wait cohorts. Post-total neoadjuvant therapy nodal status, rather than baseline lateral pelvic lymph node involvement, may better guide management and organ preservation decisions.

Abstract as published, via PubMed.