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Session:: Super Session Nodal and Metastatic Disease Abstract Session

SS200 - Lymph Node Harvest and Prognosis in Stage II-III Rectal Cancer in the Era of Total Neoadjuvant Therapy

Sunday, May 10, 2026
8:53 AM - 9:01 AM ET

    Abstract Podium Presenter(s)

  • Janet Lee, MD

    Colon and Rectal Surgery Fellow
    University of Minnesota
    University of Minnesota
    Minneapolis, MN, United States

    All disclosed relationships have been reviewed and managed prior to the start of this activity. Any relevant relationships will be listed below. This individual has no financial relationships to disclose

    • Author(s)

  • Julia Frebault, MD (she/her/hers)

    General Surgery Research Resident
    University of Minnesota
    University of Minnesota
    Minneapolis, MN, United States

    Disclosure information not submitted.

  • SM

    Sarah Mott, MS

    Biostatistician
    University of Iowa Holden Comprehensive Cancer Center
    Iowa City, Iowa, United States

    Disclosure information not submitted.

  • CT

    Catherine Tran, MD

    Colon & Rectal Surgeon
    Colon & Rectal Surgery Associates
    Minneapolis, Minnesota, United States

    Disclosure information not submitted.

  • IH

    Imran Hassan, MD

    Attending Surgeon
    Mercy Medical Center
    Cedar Rapids, Iowa, United States

    Disclosure information not submitted.

  • Wolfgang Gaertner, MD, MSc, MBA

    Professor and Chief, Colon & Rectal Surgery
    University of Minnesota
    University of Minnesota
    Minneapolis, MN, United States

    All disclosed relationships have been reviewed and managed prior to the start of this activity. Any relevant relationships will be listed below. This individual has no relevant financial relationships.

  • PK

    Pridvi Kandagatla, MD

    Colorectal Surgeon
    Colon and Rectal Surgery Associates
    St. Paul, Minnesota, United States

    Disclosure information not submitted.

    • Senior Author(s)

  • Paolo Goffredo, MD (he/him/his)

    Assistant Professor
    University of Minnesota
    Minneapolis, MN, United States

    All disclosed relationships have been reviewed and managed prior to the start of this activity. Any relevant relationships will be listed below. This individual has no financial relationships to disclose

Purpose/Background: Current guidelines recommend the examination of a minimum of 12 lymph nodes (LN) following rectal cancer surgery. However, neoadjuvant treatment has been associated with a significant reduction of LN yield, questioning the significance of suboptimal LN harvest, especially in the era of total neoadjuvant therapy (TNT). The current study aimed to evaluate factors associated with inadequate LN harvest and its impact on overall survival (OS) in patients with stage II-III rectal adenocarcinoma.

Methods/Interventions

The National Cancer Database was queried for adults (≥18 years) with single primary stage II-III rectal adenocarcinoma who were diagnosed from 2006 to 2021 and underwent oncologic resection. Exclusion criteria included receipt of immunotherapy, history of transplantation, or missing follow-up data. Treatment groups were classified as surgery alone, neoadjuvant chemotherapy (neoChemo), neoadjuvant chemoradiotherapy with short-course radiation (nCRT+SC), nCRT with long-course radiation (nCRT+LC), TNT with SC (TNT+SC), and TNT with LC (TNT+LC). Neoadjuvant Rectal Score (NAR) was incorporated as a surrogate measure of treatment response, with NAR 8 indicating poor response to neoadjuvant therapy. Logistic regression identified factors associated with inadequate LN harvest, and Cox regression evaluated OS.

Results/Outcomes

Of 44,847 patients, 67% were < 65 years, 62% were male, and 80% resided in metropolitan areas. Most were treated at academic (34%) or integrated (60%) facilities, and 62% had clinical stage III disease. Inadequate LN harvest occurred in 23% of the overall cohort, including 11% with surgery alone, 12% with neoChemo, 10% with nCRT+SC, 25% with nCRT+LC, 11% with TNT+SC, and 23% with TNT+LC. On multivariable analysis, inadequate LN harvest was associated with treatment at community or integrated hospitals, publicly insured patients, those with lower income, clinical stage II disease, NAR < 8, and abdominoperineal resection (Table 1). Compared with surgery alone, patients who received TNT+LC had the highest odds of inadequate LN harvest (OR 3.94, 95% CI 3.38-4.60), followed by nCRT+LC (OR 3.46, 95% CI 3.02-3.97). In contrast, short-course regimens (nCRT+SC and TNT+SC) were associated with lower odds of inadequate LN harvest (OR 2.75, 95% CI 1.51-5.00; OR 2.33, 95% CI 1.55-3.49; and OR 2.14, respectively). NeoChemo was also associated with more than twofold increased odds of inadequate LN harvest, 95% CI 1.58-2.89). In the adjusted survival model, inadequate LN harvest was an independent predictor of higher mortality (HR 1.19, 95% CI 1.13-1.27). Use of neoadjuvant therapies and NAR < 8 were associated with better OS rates.

Conclusion/Discussion

In this national cohort of locally advanced rectal cancer, inadequate LN harvest occurred in nearly one-quarter of patients after neoadjuvant treatment, particularly following long-course radiation. Regardless of the biological and/or technical reasons, inadequate LN harvest was independently associated with worse OS, suggesting that LN evaluation continues to be an important prognostic factor in rectal cancer care.

Table 1. Multivariable analysis for odds of inadequate regional lymph node harvest ( <12).
Figure 1. Kaplan-Meier overall survival by lymph node examined