Local recurrence of rectal cancer after combined radiation and adequate surgery is fortunately rare. It is difficult to manage and most patients have disseminated disease. The treatment possibilities were reviewed based upon a literature search and our own experience. In patients who have already had pre- or postoperative radiotherapy to a dose of about 50 Gy over five weeks or 25 Gy in one week, it is possible to re-irradiate those who develop recurrence up to at least 30 Gy externally over three weeks. In addition, intra-operative radiotherapy (IORT) or brachytherapy may be given. This strategy may give benefit but cure is not possible unless the recurrence is surgically resectable. There is, however, little information on secondary radiotherapy in these pre-irradiated patients.