Jimenez Jimenez E, Romero-Zoghbi SE, López-Campos F, Couñago F. Letter to the Editor: Beyond ypN status: Lymph node regression grade refines risk stratification in rectal cancer. World J Gastroenterol 2026; 32(39): 120225 [DOI: 10.3748/wjg.v32.i39.120225]
Corresponding Author of This Article
Felipe Couñago, MD, PhD, Chief Physician, Department of Radiation Oncology, Genesis Care-San Francisco de Asís University Hospital, Calle de Joaquín Costa, 28, Madrid 28002, Spain. fcounago@gmail.com
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Oncology
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letter
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Jimenez Jimenez E, Romero-Zoghbi SE, López-Campos F, Couñago F. Letter to the Editor: Beyond ypN status: Lymph node regression grade refines risk stratification in rectal cancer. World J Gastroenterol 2026; 32(39): 120225 [DOI: 10.3748/wjg.v32.i39.120225]
World J Gastroenterol. Oct 21, 2026; 32(39): 120225 Published online Oct 21, 2026. doi: 10.3748/wjg.v32.i39.120225
Letter to the Editor: Beyond ypN status: Lymph node regression grade refines risk stratification in rectal cancer
Esther Jimenez Jimenez, Sigfredo E Romero-Zoghbi, Fernando López-Campos, Felipe Couñago
Esther Jimenez Jimenez, Department of Radiation Oncology, Hospital General Universitario de Ciudad Real, Ciudad Real 13005, Castille-La Mancha, Spain
Sigfredo E Romero-Zoghbi, Department of Radiation Oncology, GenesisCare Talavera de la Reina, Toledo 45600, Spain
Fernando López-Campos, Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
Felipe Couñago, Department of Radiation Oncology, GenesisCare San Francisco de Asís University Hospital, Madrid 28002, Spain
Co-first authors: Esther Jimenez Jimenez and Sigfredo E Romero-Zoghbi.
Author contributions: Jimenez Jimenez E and Romero-Zoghbi SE contributed equally to this article, they are the co-first authors of this manuscript; Jimenez Jimenez E and Couñago F designed the overall concept and outline of the manuscript; Romero-Zoghbi SE, López-Campos F, and Couñago F contributed to the intellectual discussion and design of the manuscript; Jimenez Jimenez E, Romero-Zoghbi SE, López-Campos F, and Couñago F contributed to the writing and editing of the manuscript, and review of literature; and all authors thoroughly reviewed and endorsed the final manuscript.
Conflict-of-interest statement: Couñago F reports grants, personal fees and non-financial support from Johnson & Johnson, grants, personal fees and non-financial support from Recordati, personal fees and non-financial support from AstraZeneca, personal fees and non-financial support from Roche Farma, personal fees and non-financial support from Astellas, personal fees from Ipsen, personal fees from Accord, personal fees and non-financial support from Bayer, outside the submitted work.
Corresponding author: Felipe Couñago, MD, PhD, Chief Physician, Department of Radiation Oncology, Genesis Care-San Francisco de Asís University Hospital, Calle de Joaquín Costa, 28, Madrid 28002, Spain. fcounago@gmail.com
Received: February 24, 2026 Revised: March 5, 2026 Accepted: April 13, 2026 Published online: October 21, 2026 Processing time: 195 Days and 1.9 Hours
Abstract
Risk stratification after neoadjuvant chemoradiotherapy for locally advanced rectal cancer remains suboptimal, largely due to the limited prognostic reliability of tumor regression grade (TRG) when lymph node status is not fully integrated. In the study by Shi et al published in this issue of the World Journal of Gastroenterology, lymph node regression grade (LRG) is proposed as a clinically relevant biomarker reflecting treatment response at the nodal level and a refined six-tier LRG system is validated. The internal coherence of the results is noteworthy: TRG retains prognostic value only in ypN0 patients, whereas LRG emerges as a key determinant of survival in patients with residual nodal disease, precisely where TRG loses relevance. The proposed LRG system also holds potential clinical value for refining postoperative risk stratification and guiding adjuvant chemotherapy decisions beyond conventional post-treatment pathological tumor-node-metastasis staging. Nonetheless, interpretation is tempered by histopathological challenges in distinguishing LRG0 from LRG1, the retrospective single-center design and limited sample size in higher LRG subgroups. Despite these constraints, the study represents a well-founded contribution that shifts prognostic focus from the primary tumor to lymph node biology, positioning LRG as a meaningful complement to TRG and tumor-node-metastasis staging.
Core Tip: Lymph node regression grade offers independent and clinically meaningful prognostic information after neoadjuvant chemoradiotherapy for rectal cancer that is not adequately captured by assessment of primary tumor regression alone. Evaluating nodal treatment response can enhance postoperative risk stratification beyond conventional pathological staging, particularly in patients with residual nodal disease, a subgroup in which therapeutic decision-making remains especially complex. Routine incorporation of lymph node response into standardized pathological reporting may support more precise, individualized adjuvant treatment strategies. However, harmonized histopathological criteria and robust prospective validation are required before widespread clinical implementation.
