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Updated: Aug 10, 2026
Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer
Published on: February 12, 2022
Pathological lymph node response after immunotherapy-based total neoadjuvant therapy supports local excision for
Shujuan Zhou1,2,3,4, Maoguang Ma5, Siyuan Chen1,2,3,4
1Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China.
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.
