Total mesorectal excision (TME) appears to be associated with a reduced local recurrence rate following surgery for rectal cancer. Of 20 patients with rectal cancer in whom TME was performed, adenocarcinoma was found in the distal mesorectum in four. Distal mesorectal spread often extended further than intramural spread. Patients with tumour in the distal mesorectum had a worse outcome at 4-year follow-up, a greater risk of local recurrence and an increased frequency of distant metastasis. Distal tumour spread is, therefore, a marker of poor prognosis in rectal cancer. This study provides further evidence that incomplete excision of the mesorectum contributes to local recurrence in a proportion of patients with rectal cancer, particularly in those with tumours in the middle and lower third of the rectum.