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Objective: To analyze the characteristics of recurrence and metastasis as well as survival outcomes in patients with No.253 lymph node metastasis from sigmoid colon or rectal cancer, and patients with M1 colorectal cancer who underwent radical resection of metastatic lesions in the same period. Methods: A retrospective cohort study was conducted. Inclusion criteria: (1) Preoperative clinical staging indicated non-metastatic colorectal cancer; (2) Patients underwent standard radical surgery with D3 lymphadenectomy; (3) Postoperative pathology confirmed sigmoid colon adenocarcinoma or rectal adenocarcinoma, with definite status of No.253 lymph node metastasis; (4) No concurrent or prior other malignant tumors; (5) Complete clinical and follow-up data. Exclusion criteria: Patients who received preoperative neoadjuvant chemoradiotherapy, or underwent emergency surgery due to complications such as intestinal obstruction or perforation. Clinical and pathological data of 41 patients with sigmoid colon and rectal cancer who received radical resection with pathologically verified No.253 lymph node metastasis postoperatively between February 2016 and February 2018 were retrieved from the colorectal cancer database of the Department of General Surgery, Nanfang Hospital, Southern Medical University (No.253-positive group). Additionally, 71 patients with stage M1 colorectal cancer who had distant metastasis underwent radical resection of both primary and metastatic lesions and achieved postoperative no evidence of disease were enrolled as the stage M1 group. A 1∶1 propensity score matching (PSM) was performed between the No.253-positive group and the stage M1 group based on gender, age, tumor location, tumor diameter, pT stage, preoperative carcinoembryonic antigen level and postoperative adjuvant therapy. After PSM, 25 patients were included in each group. The 5-year disease-free survival (DFS) rate, 5-year overall survival (OS) rate, and characteristics of recurrence and metastasis were compared between the two groups. Results: After propensity score matching (PSM), there were no statistically significant differences in baseline characteristics between the No.253-positive group and the stage M1 group (all P>0.05, SMD<0.2). The overall 5-year DFS rate was 24.0% in the No.253-positive group versus 8.0% in the stage M1 group, with no significant difference (P=0.094). The overall 5-year OS rate was 32.0% and 16.0% for the two groups, respectively, and the difference was also not statistically significant (P=0.108). Stratified analysis by tumor location revealed no significant between-group differences in 5-year DFS and OS among patients with lower rectal cancer and upper rectal cancer (all P>0.05). For patients with sigmoid colon cancer, the No.253-positive group had a higher 5-year DFS rate than the stage M1 group (P=0.017), while no significant difference was observed in 5-year OS (P=0.581). Following PSM, recurrence or metastasis occurred in 76.0% (19/25) of patients in the No.253-positive group and 96.0% (24/25) in the stage M1 group. There were no significant differences in the patterns and anatomical distribution of recurrence and metastasis between the two groups (all P>0.05). However, the rate of multiple-site recurrence or metastasis was markedly higher in the stage M1 group (50.0%) than in the No.253-positive group (10.5%), and the difference reached statistical significance (P=0.009). The median time to recurrence or metastasis was 19 (2-58) months in the No.253-positive group and 17 (2-64) months in the stage M1 group, without a significant difference (U=215.5, P=0.767). Conclusions: Patients with No.253-positive sigmoid colon or rectal cancer showed overall survival outcomes similar to those of patients with synchronous M1 colorectal cancer who underwent curative-intent resection of metastatic lesions, but their recurrence and metastasis were relatively more limited in extent. No.253 lymph node metastasis may represent a high-risk state in the transition from regional lymphatic progression to systemic dissemination in sigmoid colon and rectal cancer, and its clinical significance may differ according to tumor location.