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Objective: The optimal model of total dose and fraction size for locally recurrent nasopharyngeal carcinoma (NPC) with intensity-modulated radiotherapy (IMRT) remains unclear.We designed a randomised phase 2, clinical trial to investigate the efficacy of two different models, aimed at determining an optimal model.Methods: Between January 2003 and December 2007, 117 patients with locally recurrent,non-metastatic NPC were randomized to two different models of total dose and firaction size: group A, 60 Gy/27f (59 patients);and group B, 68 Gy/34f (58 patients).Both received five daily fractions per week.All patients received IMRT alone.Results: Median follow-up was 25.0 months.Five-year overall survival in group A was higher than that in group B at 44.2% vs 30.3% (P=0.06), and the local failure-free survival in group A was slightly lower than that in group B at 63.7% vs 71.0%, (P=0.41).Severe late complications were the main cause of death.The incidences of mucosal necrosis and massive haemorrhage in group B were significantly higher than those in group A, at 50.8% vs 28.8% (P=0.02) and 31.0% vs 18.6% (P=0.12), respectively.Tumour volume (P<0.01) and model of total dose and fraction size (P=0.03) were significant factors for mucosal necrosis and massive haemorrhage.Conclusion: Appropriately decreasing total dose and increasing fraction size can achieve local control similar to that achieved with a higher dose after IMRT;furthermore, it can improve overall survival by significantly reducing the incidence of severe late complications including mucosal necrosis and massive haemorrhage.