Background: To assess the role of pelvic radiotherapy (RT) in the outcome of patients treated with chemotherapy (CT) with or without surgery in the management of metastatic rectal cancer. Methods: Between July 1996 and December 2002, 78 patients with rectal cancer metastatic at initial diagnosis were enrolled in this study. Patients had biopsy proven rectal adenocarcinoma, and complete initial diagnostic work-up confirmed metastatic disease (M1) in all patients. There were 3 patients with cT2 tumors, 73 with cT3, and 2 with cT4. According to the N-classification, there were 32 patients with cN0, 45 with cN1, and 1 patient with cN0 disease. Symptoms were rectal bleeding and/or pain in the majority of the patients. All patients received CT and/or RT with (n = 47 patients; 60%) or without (n = 31 patients; 40%) curative surgery (anterior resection in 81% of patients, and abdominoperineal amputation in 19%). CT consisted of 5-fluorouracil and leucovorin in the majority of patients. Pelvic RT was delivered using 6-18 MV high-energy photons following computer-tomography-based conformal planning. Median RT dose was 46 Gy at 2 Gy per fraction. Symptoms secondary to primary tumors were reassessed after pelvic RT. Results: Following pelvic RT, good clinical response was obtained with complete resolution of initial symptoms in 57 patients (73%), and partial resolution in 21 (27%). Median time to pelvic progression was 12 months (n = 7). Two-year overall survival and pelvic control rates were 43% (95% confidence interval [CI]: 31-56%) and 88% (95% CI: 77-98%), respectively. There was no difference in terms of pelvic progression between the patients treated with or without surgery (3[13%] of 47 vs. 4[6%] of 31, respectively; p = 0.43). The majority (n = 72) of the patients, as expected, died from their metastatic disease. No relevant late RT toxicity according to Common Terminology Criteria for Adverse Events, version 3.0 was observed. Conclusions: Pelvic RT combined with chemotherapy is efficient in symptomatic patients with rectal cancer, and should be considered in the management of metastatic rectal cancer in the light of increasingly efficient CT and/or emerging targeted therapies.