How would you approach a young patient with metastatic rectal cancer and a painful local recurrence who underwent chemoRT to 50.4 Gy two years ago and declined surgery?  

The answer depends on the anatomy. I would re-irradiate to the GTV only with margin 39Gy in 26fx BID. With a 2 year interval, I would judge that this is not resistant disease and that should buy some more time, but obviously not definitive.  I would tell him the only curative option would be to...