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To analyzepreoperative endosonographic maximum tumor thickness (uMTT) of uT3 rectal cancers and its influence on oncological outcome.One hundred and ninety-five patients with uT3 rectal cancer (≤ 15 cm from anal verge) were evaluated by endorectal ultrasound in our Unit from 1996-2008 and classified as uT3a (uMTT ≤ 19 mm) or uT3b (uMTT > 19). Demographic, ultrasound, surgical and pathological data were collected. Local recurrence (LR), overall recurrence (OR) and overall survival (OS) rates were analyzed. Patients' oncologic outcome was analyzed according to uMTT and treatment strategy (surgery alone or neoadjuvant therapy plus surgery).Median follow-up was 53 (range 11-149) months. Postoperative mortality was 3.1%. Overall 5-year actuarial LR, TR and OS rate were 8.2%, 31.7% and 77.0% respectively. Regarding uT3a patients, no difference was found with or withoutpreoperative chemo-radiotherapy (LR: 5.4% vs 11.1, P = 0.2; OR 26.6% vs 24.6%, P = 0.6; OS 86.1% vs 86.6%, P = 0.7). On the contrary, uT3b patients had a worse oncological outcome when treated with direct surgery, compared to uT3b patients treated withpreoperative chemo-radiotherapy (LR:24.2% vs 6%, P = 0.05; OR:51.9% vs 21.1%, P = 0.005; OS:67.1% vs 89.7%, P = 0.018).MTT can classify uT3 rectal cancer in early and advanced withprognostic implications. From these oncological results early uT3 rectal cancer can be treated directly without neoadjuvant therapy.