The management of locally advanced rectal cancers, although has remarkably improved in the last years, still remains a challenge. The results of recent European randomised trias have marked a paradigm shift from the postoperative to preoperative CRT approach. However, this approach do not impact on the occurrence of distant metastases, disease-free survival and overall survival, underlining the need for a more intensified approach. Moreover, the data of retrospective analysis have evidenced that an other critical point is the selection of patients for whom a risk-adapted pre and postoperative treatment should be delivered, considering that locally advanced rectal tumours are a widely heterogeneous group of tumours. Therefore, a refinements of a multimodality therapy by an integrated approach of a highly skilled multidisciplinary team is needed for a further improvement of clinical management.