Skip to main content

Advertisement

SpringerLink
Log in

Recurrence After Transanal Excision of T1 Rectal Cancer: Should We Be Concerned?

  • Original Contribution
  • Published:
Diseases of the Colon & Rectum

PURPOSE

Transanal excision is an appealing treatment for low rectal cancers because of its low morbidity, mortality, and better functional results than transabdominal procedures. However, controversy exists about whether it compromises the potential for cure. Several, recent reports of high recurrence rates after local excision prompted us to review our results of transanal excision alone in patients with T1 rectal cancers.

METHODS

All patients with T1 low rectal cancer undergoing local excision alone between 1980 through 1998 were reviewed for local recurrence, distant metastasis, disease-free interval, results of salvage surgery, and overall and disease-free survival. Demographics, tumor size, distance from anal verge, and preoperative endoluminal ultrasound results also were recorded. Patients with poorly differentiated tumors, perineural or lymphovascular invasion, or with mucinous component were excluded.

RESULTS

Fifty-two patients underwent transanal excision during the study period. Five-year recurrence was estimated to be 29.38 percent (95 percent confidence interval, 15.39–43.48). For 52 patients, five-year, cancer-specific and overall survival rates were 89 and 75 percent respectively. Fourteen of 15 patients with recurrence underwent salvage treatment with 56.2 percent (95 percent confidence interval, 35.2–90) five-year survival rate. Gender, preoperative staging by endorectal ultrasound, distance from the anal verge, tumor size, location, and T1 status discovered after transanal excision of a villous adenoma did not influence local recurrence or tumor-specific survival.

CONCLUSIONS

Transanal excision for T1 rectal tumors with low-grade malignancy has a high rate of recurrence. Although overall cancer survival rates might be regarded as satisfactory, this high recurrence and low salvage rate raises the issue about the role of transanal excision alone for early rectal cancer and the possible need for adjuvant therapy or increased role of resective surgery.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1.
Figure 2.
Figure 3.

Similar content being viewed by others

REFERENCES

To the article

  1. WE Enker K Havenga T Polyak H Thaler M Cranor (1997) ArticleTitleAbdominoperineal resection via total mesorectal excision and autonomic nerve preservation for low rectal cancer World J Surg 21 715–20 Occurrence Handle10.1007/s002689900296 Occurrence Handle1:STN:280:ByiH383msFY%3D Occurrence Handle9276702

    Article  CAS  PubMed  Google Scholar 

  2. S Zaheer JH Pemberton R Farouk RR Dozois BG Wolff D Ilstrup (1998) ArticleTitleSurgical treatment of adenocarcinoma of the rectum Ann Surg 227 800–11 Occurrence Handle10.1097/00000658-199806000-00003 Occurrence Handle1:STN:280:DyaK1c3pvFKmtA%3D%3D Occurrence Handle9637543

    Article  CAS  PubMed  Google Scholar 

  3. DA Rothenberger WD Wong (1992) ArticleTitleAbdominoperineal resection for adenocarcinoma of the low rectum World J Surg 16 478–85 Occurrence Handle1:STN:280:By2B2s7ltlU%3D Occurrence Handle1589984

    CAS  PubMed  Google Scholar 

  4. A Cunsolo RB Bragaglia G Manara G Poggioli G Gozzetti (1990) ArticleTitleUrogenital dysfunction after abdominoperineal resection for carcinoma of the rectum Dis Colon Rectum 33 918–22 Occurrence Handle1:STN:280:By6D3s%2Fos1M%3D Occurrence Handle2226076

    CAS  PubMed  Google Scholar 

  5. I Balslev H Harling (1983) ArticleTitleSexual dysfunction following operation for carcinoma of the rectum Dis Colon Rectum 26 785–8 Occurrence Handle1:STN:280:BiuD2MjhtVM%3D Occurrence Handle6685615

    CAS  PubMed  Google Scholar 

  6. OR Biggers RW Beart DW Ilstrup (1986) ArticleTitleLocal excision of rectal cancer Dis Colon Rectum 29 374–7 Occurrence Handle1:STN:280:BimB3MbmsVM%3D Occurrence Handle3709314

    CAS  PubMed  Google Scholar 

  7. MG Varma SJ Rogers TR Schrock ML Welton (1999) ArticleTitleLocal excision of rectal carcinoma Arch Surg 134 863–8 Occurrence Handle10.1001/archsurg.134.8.863 Occurrence Handle1:STN:280:DyaK1MzntFCisg%3D%3D Occurrence Handle10443810

    Article  CAS  PubMed  Google Scholar 

  8. JW Milsom H Graffner (1990) ArticleTitleIntrarectal ultrasonography in rectal cancer staging and in evaluation of pelvic disease Ann Surg 212 602–6 Occurrence Handle1:STN:280:By6D2Mzjs10%3D Occurrence Handle2241316

    CAS  PubMed  Google Scholar 

  9. S Blair J Ellenhorn (2000) ArticleTitleTrans-anal excision for low rectal cancers is curative in early-stage disease with favourable histology Am Surg 66 817–20 Occurrence Handle1:STN:280:DC%2BD3cvktlGitg%3D%3D Occurrence Handle10993607

    CAS  PubMed  Google Scholar 

  10. B Mentges G Buess G Effinger K Manncke HD Becker (1997) ArticleTitleIndications and results of local treatment of rectal cancer Br J Surg 84 348–51 Occurrence Handle10.1046/j.1365-2168.1997.02556.x Occurrence Handle1:STN:280:ByiB3s3ht1A%3D Occurrence Handle9117305

    Article  CAS  PubMed  Google Scholar 

  11. DA Rothenberger (2000) ArticleTitleRole of local excision in the treatment of rectal cancer Semin Surg Oncol 19 367–75 Occurrence Handle1:STN:280:DC%2BD3MzitlCqug%3D%3D Occurrence Handle11241919

    CAS  PubMed  Google Scholar 

  12. S Sengupta JJ Tjandra (2001) ArticleTitleLocal excision of rectal cancer: what is the evidence? Dis Colon Rectum 44 1345–61 Occurrence Handle1:STN:280:DC%2BD3MrjsFWmsw%3D%3D Occurrence Handle11584215

    CAS  PubMed  Google Scholar 

  13. J Garcia-Aguilar A Mellgren P Sirivongs D Buie RD Madoff DA Rothenberger (2000) ArticleTitleLocal excision of rectal cancer without adjuvant therapy: a word of caution Ann Surg 231 345–51 Occurrence Handle10.1097/00000658-200003000-00007 Occurrence Handle1:STN:280:DC%2BD3c7nslWjuw%3D%3D Occurrence Handle10714627

    Article  CAS  PubMed  Google Scholar 

  14. MI Chorost NJ Petrelli M McKenna WG Kraybill MA Rodriguez-Bigas (2001) ArticleTitleLocal excision of rectal carcinoma Am Surg 67 774–9 Occurrence Handle1:STN:280:DC%2BD3Mvms1amsQ%3D%3D Occurrence Handle11510582

    CAS  PubMed  Google Scholar 

  15. A Mellgren P Sirivongs DA Rothenberger RD Madoff J Garcia-Aguilar (2000) ArticleTitleIs local excision adequate therapy for early rectal cancer? Dis Colon Rectum 43 1064–74 Occurrence Handle1:STN:280:DC%2BD3cvitVSgsA%3D%3D Occurrence Handle10950004

    CAS  PubMed  Google Scholar 

  16. A Chakravarti CC Compton PC Shellito et al. (1999) ArticleTitleLong-term follow-up of patients with rectal cancer managed by local excision with and without adjuvant irradiation Ann Surg 230 49–54 Occurrence Handle10.1097/00000658-199907000-00008 Occurrence Handle1:STN:280:DyaK1MzisFKhsQ%3D%3D Occurrence Handle10400036

    Article  CAS  PubMed  Google Scholar 

  17. DA Rothenberger WD Wong (1992) ArticleTitleAbdominoperineal resection for adenocarcinoma of the rectum World J Surg 16 478–85 Occurrence Handle1:STN:280:By2B2s7ltlU%3D Occurrence Handle1589984

    CAS  PubMed  Google Scholar 

  18. M Grigg FT McDermott EA Pihl ES Hughes (1984) ArticleTitleCurative local excision in the treatment of carcinoma of the rectum Dis Colon Rectum 27 81–3 Occurrence Handle1:STN:280:BiuC3s7ks1Y%3D Occurrence Handle6697834

    CAS  PubMed  Google Scholar 

  19. T Hager FP Gall P Hermanek (1983) ArticleTitleLocal excision of the cancer of the rectum Dis Colon Rectum 26 149–51 Occurrence Handle1:STN:280:BiyC3s%2FptFM%3D Occurrence Handle6825519

    CAS  PubMed  Google Scholar 

  20. FP Gall P Hermanek (1992) ArticleTitleUpdate of the German experience with local excision of rectal cancer Surg Oncol Clin N Am 1 99–109

    Google Scholar 

  21. CG Willett CC Compton PC Shellito JT Efird (1994) ArticleTitleSelection factors for local excision or abdominoperineal resection of early stage rectal cancer Cancer 73 2716–20

    Google Scholar 

  22. RH Taylor JH Hay SN Larsson (1998) ArticleTitleTransanal local excision of selected low rectal cancers Am J Surg 175 360–3 Occurrence Handle10.1016/S0002-9610(98)00038-5 Occurrence Handle1:STN:280:DyaK1c3mtV2jtg%3D%3D Occurrence Handle9600277

    Article  CAS  PubMed  Google Scholar 

  23. TM Heimann C Oh RM Steinhagen AJ Greenstein C Perez AH Aufses (1992) ArticleTitleSurgical treatment of tumors of the distal rectum with sphincter preservation Ann Surg 216 432–37 Occurrence Handle1:STN:280:ByyD3sjnsVE%3D Occurrence Handle1417192

    CAS  PubMed  Google Scholar 

  24. GC Zenni K Abraham FJ Harford DM Potocki C Herman PB Dobrin (1998) ArticleTitleCharacteristics of rectal carcinomas that predict the presence of lymph node metastases: implications for patient selection for local therapy J Surg Oncol 67 99–103 Occurrence Handle10.1002/(SICI)1096-9098(199802)67:2<99::AID-JSO5>3.0.CO;2-G Occurrence Handle1:STN:280:DyaK1c7ks1Wrtw%3D%3D Occurrence Handle9486780

    Article  CAS  PubMed  Google Scholar 

  25. JT Brodsky GK Richard AM Cohen BD Minsky (1992) ArticleTitleVariables related with the risk of lymph node metastasis in early rectal cancer Cancer 69 322–6 Occurrence Handle1:STN:280:By2D1Mnps1U%3D Occurrence Handle1728363

    CAS  PubMed  Google Scholar 

  26. PJ Sitzler F Seow-Choen YH Ho AP Leong (1997) ArticleTitleLymph node involvement and tumor depth in rectal cancers: an analysis of 805 patients Dis Colon Rectum 40 1472–6 Occurrence Handle1:STN:280:DyaK1c%2FmvFyktA%3D%3D Occurrence Handle9407987

    CAS  PubMed  Google Scholar 

  27. TJ Saclarides AK Bhattacharyya C Britton-Kuzel D Szeluga SG Economou (1994) ArticleTitlePredicting lymph node metastasis in rectal cancer Dis Colon Rectum 37 52–7 Occurrence Handle1:STN:280:ByuC3MnjvFQ%3D Occurrence Handle8287748

    CAS  PubMed  Google Scholar 

  28. R Kikuchi M Takano K Takagi et al. (1995) ArticleTitleManagement of early invasive colorectal cancer: risk of recurrence and clinical guidelines Dis Colon Rectum 38 1286–95 Occurrence Handle1:STN:280:BymC3c7lsF0%3D Occurrence Handle7497841

    CAS  PubMed  Google Scholar 

  29. R Nascimbeni LJ Burgart S Nivatvongs DR Larson (2002) ArticleTitleRisk of lymph node metastasis in T1 carcinoma of the colon and rectum Dis Colon Rectum 45 200–6 Occurrence Handle11852333

    PubMed  Google Scholar 

  30. M Sakuragi K Togashi F Konishi et al. (2003) ArticleTitlePredictive factors for lymph node metastasis in T1 stage colorectal carcinomas Dis Colon Rectum 46 1626–32 Occurrence Handle14668587

    PubMed  Google Scholar 

  31. NS Goldstein J Hart (1999) ArticleTitleHistologic features associated with lymph node metastasis in stage T1 and superficial T2 rectal adenocarcinomas in abdominoperineal resection specimens. Identifying a subset of patients for whom treatment with adjuvant therapy or completion abdominoperineal resection should be considered after local excision Am J Clin Pathol 111 51–8 Occurrence Handle1:STN:280:DyaK1M7htFyhtw%3D%3D Occurrence Handle9894454

    CAS  PubMed  Google Scholar 

  32. H Ueno H Mochizuki E Shinto Y Hashiguchi K Hase IC Talbot (2002) ArticleTitleHistologic indices in biopsy specimens for estimating the probability of extended local spread in patients with rectal carcinoma Cancer 94 2882–91 Occurrence Handle10.1002/cncr.10551 Occurrence Handle12115376

    Article  PubMed  Google Scholar 

  33. AG Heriot A Grundy D Kumar (1999) ArticleTitlePreoperative staging of rectal carcinoma Br J Surg 86 17–28 Occurrence Handle10.1046/j.1365-2168.1999.00996.x Occurrence Handle1:STN:280:DyaK1M7kvFKjsg%3D%3D Occurrence Handle10027354

    Article  CAS  PubMed  Google Scholar 

  34. HR Bailey WV Huval E Max KW Smith DR Butts LF Zamora (1992) ArticleTitleLocal excision of carcinoma of the rectum for cure Surgery 111 555–61 Occurrence Handle1:STN:280:By2B1crotlM%3D Occurrence Handle1598675

    CAS  PubMed  Google Scholar 

  35. DM Ota J Skibber TA Rich (1992) ArticleTitleMD Anderson Cancer Center experience with local excision and multimodality therapy for rectal cancer Surg Oncol Clin N Am 1 147–52

    Google Scholar 

  36. BD Minsky WE Enker AM Cohen G Lauwers (1994) ArticleTitleLocal excision and postoperative radiation therapy for rectal cancer Am J Clin Oncol 17 411–6 Occurrence Handle1:STN:280:ByuA2sbgtVQ%3D Occurrence Handle8092113

    CAS  PubMed  Google Scholar 

  37. L Fortunato NR Ahmad RS Yeung et al. (1995) ArticleTitleLong-term follow-up of local excision and radiation therapy for invasive cancer Dis Colon Rectum 38 1193–9 Occurrence Handle1:STN:280:BymD28%2Foslc%3D Occurrence Handle7587763

    CAS  PubMed  Google Scholar 

  38. R Bleday E Breen JM Jessup A Burgess SM Sentovich G Steele (1997) ArticleTitleProspective evaluation of local excision for small rectal cancers Dis Colon Rectum 40 388–92 Occurrence Handle1:STN:280:ByiB28%2Fls1E%3D Occurrence Handle9106685

    CAS  PubMed  Google Scholar 

  39. GD Steele JE Herdon R Bleday et al. (1999) ArticleTitleSphincter-sparing treatment for distal adenocarcinoma Ann Surg Oncol 6 433–41 Occurrence Handle10.1007/s10434-999-0433-5 Occurrence Handle10458680

    Article  PubMed  Google Scholar 

  40. BD Minsky (1995) ArticleTitleConservative treatment of rectal cancer with local excision and postoperative radiation therapy Eur J Cancer 31A 1343–6 Occurrence Handle10.1016/0959-8049(95)00157-E Occurrence Handle1:STN:280:BymD2cnjsFE%3D Occurrence Handle7577048

    Article  CAS  PubMed  Google Scholar 

  41. JP Lamont TM McCarty RD Digan R Jacobson P Tulanon WE Lichliter (2000) ArticleTitleShould locally excised T1 rectal cancer receive adjuvant chemoradiation? Am J Surg 180 402–6 Occurrence Handle1:STN:280:DC%2BD3M7lvVWrtA%3D%3D Occurrence Handle11182387

    CAS  PubMed  Google Scholar 

  42. PB Paty GM Nash P Baron et al. (2002) ArticleTitleLong term results of local excision for rectal cancer Ann Surg 236 522–30 Occurrence Handle10.1097/00000658-200210000-00015 Occurrence Handle12368681

    Article  PubMed  Google Scholar 

  43. PL Baron WE Enker MF Zakowski C Urmacher (1995) ArticleTitleImmediate vs. salvage resection after local treatment for early rectal cancer Dis Colon Rectum 38 177–81 Occurrence Handle1:STN:280:ByqC2Mvgs10%3D Occurrence Handle7851173

    CAS  PubMed  Google Scholar 

  44. JI Merlino MA Malangoni CM Smith RL Lange (2001) ArticleTitleProspective randomized trials affect the outcomes of intraabdominal infection Ann Surg 233 859–66 Occurrence Handle10.1097/00000658-200106000-00017 Occurrence Handle1:STN:280:DC%2BD3M3nslGkuw%3D%3D Occurrence Handle11371744

    Article  CAS  PubMed  Google Scholar 

To the Invited Commentary

  1. PB Paty GH Nash P Baron et al. (2002) ArticleTitleLong-term results of local excision for rectal cancer Ann Surg 236 522–30 Occurrence Handle10.1097/00000658-200210000-00015 Occurrence Handle12368681

    Article  PubMed  Google Scholar 

  2. A Mellgren P Sirivongs DA Rothenberger et al. (2000) ArticleTitleIs local excision adequate therapy for early rectal cancer? Dis Colon Rectum 43 1064–71 Occurrence Handle1:STN:280:DC%2BD3cvitVSgsA%3D%3D Occurrence Handle10950004

    CAS  PubMed  Google Scholar 

  3. A Chakravarti CC Compton PC Shellito et al. (1999) ArticleTitleLong-term follow-up of patients with rectal cancer managed by local excision with and without adjuvant irradiation Ann Surg 230 49–54 Occurrence Handle10.1097/00000658-199907000-00008 Occurrence Handle1:STN:280:DyaK1MzisFKhsQ%3D%3D Occurrence Handle10400036

    Article  CAS  PubMed  Google Scholar 

  4. BC Morson HJ Bussey S Samoorian (1977) ArticleTitlePolicy of local excision for early rectal cancer of the colorectum Gut 18 1045–50 Occurrence Handle1:STN:280:CSeC3cjovFM%3D Occurrence Handle606631

    CAS  PubMed  Google Scholar 

  5. T Hager FP Gall P Hermanek (1983) ArticleTitleLocal excision of cancer of the rectum Dis Colon Rectum 26 149–51 Occurrence Handle1:STN:280:BiyC3s%2FptFM%3D Occurrence Handle6825519

    CAS  PubMed  Google Scholar 

  6. M Grigg FT McDermott EA Pihl ES Hughes (1984) ArticleTitleCurative local excision in the treatment of carcinoma of the rectum Dis Colon Rectum 27 81–3 Occurrence Handle1:STN:280:BiuC3s7ks1Y%3D Occurrence Handle6697834

    CAS  PubMed  Google Scholar 

  7. RT Long RH Edwards (1989) ArticleTitleImplantation metastasis as a cause of local recurrence of colorectal carcinoma Am J Surg 157 194–201 Occurrence Handle10.1016/0002-9610(89)90527-8 Occurrence Handle1:STN:280:BiaC3s3ptlE%3D Occurrence Handle2916734

    Article  CAS  PubMed  Google Scholar 

  8. F Zinzindohoue C Penna R Parc (1997) ArticleTitleAdenocarcinoma arising on the site of a Gelpi rectractor after coloanal anastomosis for rectal cancer Br J Surg 84 362 Occurrence Handle10.1046/j.1365-2168.1997.02544.x Occurrence Handle1:STN:280:ByiB3s3ht1M%3D Occurrence Handle9117308

    Article  CAS  PubMed  Google Scholar 

  9. O Delattre S Olschwang DJ Law et al. (1989) ArticleTitleMultiple genetic alterations in distal and proximal colorectal cancer Lancet 2 353–6 Occurrence Handle10.1016/S0140-6736(89)90537-0 Occurrence Handle1:STN:280:BiaA2czjsVM%3D Occurrence Handle2569552

    Article  CAS  PubMed  Google Scholar 

  10. J Breivik RA Lothe GI Meling TO Rognum AL Borresen-Dale G Gaudernack (1997) ArticleTitleDifferent genetic pathways to proximal and distal colorectal cancer influenced by sex-related factors Int J Cancer 74 664–9 Occurrence Handle10.1002/(SICI)1097-0215(19971219)74:6<664::AID-IJC18>3.0.CO;2-5 Occurrence Handle1:STN:280:DyaK1c%2FotFOiuw%3D%3D Occurrence Handle9421366

    Article  CAS  PubMed  Google Scholar 

  11. R Nasciembeni LJ Burgart S Nivatvongs et al. (2002) ArticleTitleRisk of lymph node metastasis in T1 carcinoma of the colon and rectum Dis Colon Rectum 45 200–6 Occurrence Handle11852333

    PubMed  Google Scholar 

  12. S Okabe J Shia WD Wong et al. (2004) Lymph node metastasis in T1 adenocarcinoma of the colon and rectum Society for Surgery of Alimentary Tract Plenary Session; May 17, 2004 New Orleans

    Google Scholar 

  13. JT Brodsky GK Richard AM Cohen BD Minsky (1992) ArticleTitleVariables correlated with the risk of lymph node metastasis in early rectal cancer Cancer 69 322–6 Occurrence Handle1:STN:280:By2D1Mnps1U%3D Occurrence Handle1728363

    CAS  PubMed  Google Scholar 

  14. Y Adadchi K Yasuda K Kakisako K Sato N Shiraishi S Kitano (1999) ArticleTitleHistopathologic criteria for local excision of colorectal cancer: multivariate analysis Ann Surg Oncol 4 385–8 Occurrence Handle10.1007/s10434-999-0385-9

    Article  Google Scholar 

  15. D Blumberg PB Paty JG Guillem et al. (1999) ArticleTitleAll patients with small intramural rectal cancers are at risk for lymph node metastasis Dis Colon Rectum 42 881–5 Occurrence Handle1:STN:280:DyaK1Mzjslansw%3D%3D Occurrence Handle10411434

    CAS  PubMed  Google Scholar 

  16. G Steele JE Herndon R Bleday et al. (1999) ArticleTitleSphincter-sparing treatment for distal rectal adenocarcinoma Ann Surg Oncol 6 433–41 Occurrence Handle10.1007/s10434-999-0433-5 Occurrence Handle10458680

    Article  PubMed  Google Scholar 

  17. PL Baron WE Enker MF Zakowski C Umacher (1995) ArticleTitleImmediate vs. salvage resection after local treatment for early rectal cancer Dis Colon Rectum 38 177–81 Occurrence Handle1:STN:280:ByqC2Mvgs10%3D Occurrence Handle7851173

    CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio

    Khaled M. Madbouly M.D., Feza H. Remzi M.D., Bulent A. Erkek M.D., Anthony J. Senagore M.D., Christen M. Baeslach M.S., Victor W. Fazio M.B., M.S. & Ian C. Lavery M.B.B.S.

  2. Department of Biostatistics and Epidemiology, The Cleveland Clinic Foundation, Cleveland, Ohio

    Farah Khandwala M.S.

Authors
  1. Khaled M. Madbouly M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Feza H. Remzi M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Bulent A. Erkek M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Anthony J. Senagore M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Christen M. Baeslach M.S.
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Farah Khandwala M.S.
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Victor W. Fazio M.B., M.S.
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Ian C. Lavery M.B.B.S.
    View author publications

    You can also search for this author in PubMed Google Scholar

About this article

Cite this article

Madbouly, K., Remzi, F., Erkek, B. et al. Recurrence After Transanal Excision of T1 Rectal Cancer: Should We Be Concerned?. Dis Colon Rectum 48, 711–721 (2005). https://doi.org/10.1007/s10350-004-0666-0

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10350-004-0666-0

Key words

Search

Navigation