How would you treat a patient with locally and distant recurrent rectal cancer who has previously received chemoradiation but now presents with pain and bleeding from the site of local recurrence?

Generally we like to see a 1 year interval between courses of radiation. We give 39Gy in 26 fx BID with a 3D conformal technique. The cumulative BED should be <100 or so. We use a 3 cm margin cranial an caudal on the GTV and include the presacral space. We give concurrent capecitabine.