Worldwide earlier diagnosis and improvement in treatment modalities gained a huge amelioration of clinical results for locally advanced rectal cancer (i.e., T3, T4 and/or nodal positive clinical presentations) in the last three decades, but still there is urgency for further improvement; moreover, there are some controversies regarding the preferable clinical management. Radiotherapy currently plays a central role in primary treatment [1,2]. In the 1990s, at the beginning of the use of preoperative radiotherapy, its use gained a survival benefit with respect to the use of surgery alone . After the introduction of a high-level surgical technique, as the total mesorectal excision (i.e., en-bloc resection of the rectum with its mesorectum performed to the levator muscle in the avascular plane outside of the mesorectum)  survival improvement was not demonstrated in single randomized trials . Nevertheless, long-term results of the main randomized trials clarified that a preoperative approach should be preferred to the postoperative adjuvant .