Abstract:Background and Aims Low rectal cancer is prone to lymph node metastasis due to its special anatomical location, which is a key determinant of postoperative recurrence and distant metastasis. The predictive accuracy of conventional imaging methods remains limited. Increasing evidence suggests that the inflammatory microenvironment and chemokines play important roles in tumor metastasis. This study aimed to investigate the predictive value of preoperative inflammatory burden index (IBI) and macrophage inflammatory protein 3α (MIP-3α) for lymph node metastasis in patients with low rectal cancer.Methods A total of 182 patients with low rectal cancer who underwent radical resection between January 2020 and January 2024 were retrospectively analyzed. Preoperative serum MIP-3α levels, C-reactive protein, neutrophils and lymphocytes were detected, and the IBI was calculated. Patients were divided into the lymph node metastasis-positive and -negative groups according to postoperative pathological findings. Univariate and multivariate Logistic regression analyses were performed to identify independent risk factors for LNM. Receiver operating characteristic (ROC) curves and Hosmer-Lemeshow calibration curves were used to evaluate predictive performance.Results LNM occurred in 70 patients (38.46%). Significant differences were observed between the lymph node metastasis-positive and -negative groups regarding tumor differentiation, tumor stage, vascular invasion, lymphatic invasion, preoperative neutrophil to lymphocyte ratio, IBI, and MIP-3α levels (all P<0.05). Multivariate analysis identified extramural vascular invasion (OR=4.870), lymphatic invasion (OR=5.387), IBI (OR=2.143), and MIP-3α (OR=1.539) as independent predictors of LNM (all P<0.05). The AUC values of IBI and MIP-3α were 0.782 and 0.767, respectively, while the combined model achieved an AUC of 0.821, which was significantly superior to either marker alone (P<0.05). The Hosmer-Lemeshow test demonstrated good calibration (P=0.721).Conclusion Preoperative IBI and MIP-3α are effective predictors of lymph node metastasis in low rectal cancer. Their combined application further improves predictive accuracy and may facilitate preoperative risk stratification and individualized treatment.