MRI criteria can accurately identify patients with low rectal cancer at risk for lateral lymph node metastasis, impacting surgical strategies.

• In a study of 163 patients, 16.6% had pathological lateral lymph node metastasis (pllnm).
• Among 130 initially classified as llnm-negative, 3.8% were later found to have pllnm.
• The radiological criterion (short-axis diameter ≥6 mm) demonstrated high accuracy (90.2%) and specificity (91.9%), significantly informing treatment decisions.

This tool may help tailor surgical approaches, potentially reducing overtreatment for patients with low rectal cancer.