PURPOSE: The aim of this study was to evaluate the rate and pattern of recurrence of rectal cancer as well as analyze the risk factors affecting recurrence following resection with curative intent. METHODS: 460 patients underwent curative resection for adenocarcinoma of the rectum at our clinic from 1994 to 1998. Among these, 132 patients (29.1%) whose recurrence was confirmed by clinical and radiologic examination or reoperation were studied retrospectively. The risk factors that determined the recurrence patterns were analysed with univariate and multivariate analyses. RESULTS: The mean time to recurrence was 22.0 months. The locoregional recurrence rate was 5.7% (25/440). The systemic recurrence rate was 18.4% (81/440). 12 patients (2.7%) had two or more sites of recurrence at the time of diagnosis. The most common locoregional recurrence was a pelvic recurrence (2.3%; 10/440), followed by anastomosis (2.0%; 9/440) and presacral (0.9%; 4/440). The most common site of systemic recurrence was the liver (7.0%; 31/ 440), followed by the lung (5.9%; 26/440) and peritoneum (3.2%; 14/440). The mean time from recurrence to death was 16.0 months. Logistic regression analysis demonstrated that nodal metastasis (P=0.002), vascular invasion (P=0.027), elevated CEA level (P=0.011), and microscopic invasion to the lateral margin (P=0.008) were risk factors for postoperative recurrence. When the recurrence patterns were compared to stage, the systemic recurrence rate was 3.0% in stage I, 15.3% in stage II, and 28.9% in stage III. The locoregional recurrence rate was 3.0% in stage I, 6.0% in stage II, and 6.8% in stage III. CONCLUSION: Even though an excellent local control was obtained following curative resection of rectal cancer, the main cause of recurrence was a systemic failure in advanced rectal cancer. More effective systemic chemotherapy is required for the prevention of systemic recurrence.