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When the T stages were analyzed separately, EUS showed an accuracy of 76% for T1, 72% for T2, 91% for T3 and 67% for T4 stages. Overall, EUS misstaged T in 16% of cases, with 11% of overstaging and 5% of understaging [http://en.wikipedia.org/wiki/Thymidine_kinase Thymidine kinase] errors. The presence of a stricture lowered the accuracy rate of EUS for T stage from 93% to 56%; similarly the distance of RC from the anal verge affected the accuracy of EUS for T stage, which decreased from 92% for tumors located > 5 cm from the anal verge to 67% for cancer sites [http://www.selleckchem.com/products/Nutlin-3.html Nutlin3] data suggest that EUS should be used together with MRI for predicting CRM involvement in low anterior RC. N STAGING EUS allows the assessment of perirectal lymph nodes for metastatic infiltration: these are metastatic when they appear as roundish or oval, homogeneous echo-poor nodules with a short axis of at least 5 mm (Figure ?(Figure66)[5,7,9,10]. According to the number of metastatic lymph nodes, there are two different N (uN) echoendoscopic stages (Table ?(Table66). Figure 6 Perirectal metastatic lymph node: Ultrasonographic view. Endoscopic ultrasound with radial array transducer UM160 (5-20 [http://www.selleckchem.com/products/ABT-737.html ABT-737 datasheet] MHz). White arrow: Perirectal metastatic lymph node. Table 6 N staging at endoscopic ultrasound, according to the number of metastatic lymph nodes The incidence of malignant metastatic lymph nodes in patients with RC is strictly related to T stage and varies from 6%-11% for T1, 10%-35% for T2 and 26%-65% for T4 RC[3,5,7,8]. Determination of lymph nodes involvement during EUS is difficult and less precise, with a variable accuracy of 63%-85% (Table ?(Table44)[12-45]. Kauer et al[34] reported that EUS has an overall accuracy of 68% in diagnosing metastatic lymph nodes associated to RC, with a sensitivity of 52% and a specificity of 82%. A recent meta-analysis of 35 published studies evaluated the accuracy of EUS in diagnosing metastatic lymph nodes of patients with RC[7].