How would you approach a locally advanced anorectal melanoma with local progression after 4 cycles of nivolumab and ipilimumab who is not a surgical candidate?

For non-operative management of anorectal melanoma, I most commonly use radiotherapy with a regimen of 30 Gy in 5 fractions delivered every other day vs twice weekly (Ballo et al., PMID 11958890; Kelly et al., PMID 21446049).

The disease burden, in this case, sounds quite extensive in which case a...