What would you recommend for a patient with a new or locally recurrent anal cancer s/p chemoRT for anal cancer 15 years ago?

I would never irradiate a local recurrence of anal cancer for several reasons. The anal canal is a sensitive structure and the consequence of radiation injury is severe (ulceration, pain, bleeding). We could only give 39Gy in 26# BID or maybe 45Gy in 30#BID with two agent chemo. The cumulative dose should be below 100Gy. Obviously a lower dose than was given initially will not result in a better outcome. I tell patients that there is an effective treatment and it is effective, APR has a 50-70% 5...