Does a fine line exist between regional and metastatic pelvic lymph nodes in rectal cancer—striking discordance between national guidelines and treatment recommendations by US radiation oncologists

Approximately 40,000 patients are diagnosed with rectal cancer in the United States annually (1). The standard of care for locally advanced Stage II (T3–T4, N0, M0) and Stage III (Tany, N+, M0) rectal cancer, based on the results of a randomized German rectal trial (2), is preoperative chemoradiation therapy, followed by total mesorectal excision (TME) and additional adjuvant chemotherapy—with the goal of achieving greater than 60% of 5-year disease-free survival. In contrast, patients with metastatic disease are treated less aggressively, with the goal of prolonging survival and decreasing disease-related symptoms, but rarely with a curative intent