Adenocarcinoma of the anal canal is an uncommon malignancy, making it challenging to perform randomized controlled clinical trials to define best practices in care. For patients with localized disease, there remains a lack of consensus regarding the optimal management, with some physicians advocating for trimodality therapy (similar to the locally advanced rectal adenocarcinoma paradigm) and others advocating for definitive radiation therapy with concurrent chemotherapy (similar to the management of anal squamous cell carcinoma). The objective of this clinical review is to describe the management and outcomes of patients with anal adenocarcinoma to help inform treatment recommendations.