AIM: The purpose of this multicenter cohort study was to evaluate differentiated treatment of primary rectal cancer based on magnetic imaging (MRI) can reduce the number of incomplete resections and local recurrences and improve recurrence-free and overall survival. METHODS: February 2003 until January 2008, 296 patients with rectal cancer preoperative MRI using a lymph node specific contrast agent to predict circumferential resection margin (CRM), T- and N-stage. Based on expert of the MRI, patients were stratified in: (a) low risk for local (CRM>2mm and N0 status), (b) intermediate risk and (c) high risk CRM, N2 status or distal tumours). Mainly based on this MRI risk patients were treated with (a) surgery only (TME or local excision), (b) preoperative 5x5Gy+TME and (c) a long course of chemoradiation therapy by surgery after a 6-8week interval. RESULTS: Overall 228 patients treatment with curative intent: 49 with surgery only, 86 with 5x5Gy and and 93 with chemoradiation and surgery. The number of complete (margin>1mm) was 218 (95.6%). At a median follow-up of 41months the local recurrence rate, disease-free survival rate and overall survival 2.2%, 80% and 84.5%, respectively. CONCLUSION: With a differentiated multimodality treatment based on dedicated preoperative MR imaging, recurrence is no longer the main problem in rectal cancer treatment. The challenges are early diagnosis and treatment, reducing morbidity of preferably prevention of metastatic disease.