Background: Neoadjuvant chemoradiation therapy (CRT) is considered the preferred treatment option for distal rectal cancer due to increased local control, tumor downstaging and increased survival. However, due to this downstaging, the impact of final pathological features on recurrence has been questioned. Patients and Methods: 361 patients with distal rectal cancer were managed by neoadjuvant CRT including 5FU, Leucovorin and 5040 cGy. Patients with complete tumor response were not immediately operated on and were closely followed. Patients with incomplete tumor regression were managed by radical surgery. Recurrent disease was also categorized as curable and incurable when radical salvage treatment was feasible Results: Overall, 97 patients experienced any recurrence during follow-up. There was a significant association between any recurrent disease and pT status (0.04), pN status (<0.001), perineural and lymphovascular invasion (<0.001). Recurrent disease not amenable to radical salvage therapy was significantly associated with pN status and perineural/lymphovascular invasion (p<0.001). Incurable recurrence was significantly more frequent than curable recurrent disease (70% vs. 30%). Patients with recurrent disease amenable to radical salvage therapy had significantly improved 5-yr overall survival rates when compared to patients without possibility of radical salvage treatment (78% vs 49%; p=0.001). Conclusions:Pathologic T, N, and patterns of invasion are features that remain significantly associated with the risk of disease recurrence even after neoadjuvant chemoradiation therapy. Radical salvage therapy is possible only in one third of these patients and may significantly improve survival.