Despite optimized surgery in combination with multi-modal therapeutic regimes local recurrences of rectal cancer are still a major challenge. Complete surgical resection is the only option offering potential cure. Multi-modal concepts will most likely further improve outcome. However, this notion is currently unproven. Surgical resection in palliative intent may be beneficial for selected patients, with external radiation being an alternative. The value of further therapeutic options in this situation, such as hyperthermia or isolated chemotherapeutic perfusion of the pelvis, needs to be evaluated in controlled studies. It is of major importance to avoid the occurrence of locally recurrent rectal cancer by an optimized therapy of primary rectal cancers.