AIM: To validate the association between atypical endoscopic features and lymph node metastasis(LNM).METHODS: A total of 247 patients with rectal neuroendocrine tumors(NETs) were analyzed. Endoscopic images were reviewed independently by two endoscopists, each of whom classified tumors by sized and endoscopic features, such as shape, color, and surface change(kappa coefficient 0.76 for inter-observer agreement). All of patients underwent computed tomography scans of abdomen and pelvis for evaluation of LNM. Univariate and multivariate analyses were performed to identify the factors associated with LNM. Additionally, the association between endoscopic atypical features and immunohistochemical staining of tumors was analyzed.RESULTS: Of 247 patients, 156(63.2%) were male and 15(6.1%) were showed positive for LNM. On univariate analysis, tumor size(P < 0.001), shape(P < 0.001), color(P < 0.001) and surface changes(P < 0.001) were significantly associated with LNM. On multivariate analysis, tumor size(OR = 11.53, 95%CI: 2.51-52.93, P = 0.002) and atypical surface(OR = 27.44, 95%CI: 5.96-126.34, P < 0.001) changes were independent risk factors for LNM. The likelihood of atypical endoscopic features increased as tumor size increased. Atypical endoscopic features were associated with LNM in rectal NETs < 10 mm(P = 0.005) and 10-19 mm(P = 0.041) in diameter. Immunohistochemical staining showed that the rate of atypical endoscopic features was higher in non L-cell tumors.CONCLUSION: Atypical endoscopic features as well as tumor size are predictive factors of LNM in patients with rectal NETs. AIM: To validate the association between atypical endoscopic features and lymph node metastasis (LNM). METHODS: A total of 247 patients were with separately rectal neuroendocrine tumors (NETs) were analyzed. Endoscopic images were independently examined by two endoscopists, each of whom classified tumors by sized and endoscopic features, such as shape, color, and surface change (kappa coefficient 0.76 for inter-observer agreement). All of patients underwent computed tomography scans of abdomen and pelvis for evaluation of LNM. Univariate and multivariate analyzes were performed to identify the Factors associated with LNM. Additionally, the association between endogenous atypical features and immunohistochemical staining of tumors was analyzed. RESULTS: Of 247 patients, 156 (63.2%) were male and 15 (6.1%) were showed positive for LNM. On univariate analysis, (P <0.001) and surface changes (P <0.001) were significantly associated with LNM. On multivariate analysis , tumor size (OR = 11.53, 95% CI: 2.51-52.93, P = 0.002) and atypical surface (OR = 27.44, 95% CI: 5.96-126.34, P <0.001) of atypical endoscopic features increased associated with LNM in rectal NETs <10 mm (P = 0.005) and 10-19 mm (P = 0.041) in diameter. Immunohistochemical staining showed that the rate of atypical endoscopic features was higher in non L-cell tumors. CONCLUSION: Atypical endoscopic features as well as tumor size are predictive factors of LNM in patients with rectal NETs.