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The frequency of abdomino-perineal resections of locally advanced and unresectable tumours is increasing worldwide. Long-term results of the management of locally advanced rectal cancer are therefore of major interest. This review focuses on the management of large recurrences of rectal cancer. Among patients with large recurrences (with or without distant metastases), no standard approach exists to identify those at risk of a rapid systemic progression. The first line approach is based on multimodal, aggressive and potentially curative approaches. If the disease is controlled, adjuvant therapy should be considered in a multidisciplinary discussion. The role of radiotherapy for a local control is still unclear. A neo-adjuvant chemoradiotherapy could be considered in a selected group of patients. There is no standard second line approach. Recently, advances in 0b46394aab