肛管癌2022.v2-NCCN（英文版）

NCCNClinicalPracticeGuidelinesinOncologyNCCNGuidelines®)AnalCarcinomarsionSeptemberVersion2.2022,09/02/2022©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.oolofMedicinetalandWashingtonPrintedbyMinTangon10/4/20226:42:49AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,oolofMedicinetalandWashingtonAnalCarcinomadex*AlB.Benson,III,MD/Chair†RobertH.LurieComprehensiveCancerCenterofNorthwesternUniversity*AlanP.Venook,MD/Vice-Chair†‡UCSFHelenDillerFamilyComprehensiveCancerCenteryofMichiganRogelCancerCenteryofMichiganRogelCancerCenterNiloferAzad,MD†TheSidneyKimmelComprehensiveCancerCenteratJohnsHopkinsYi-JenChen,MD,PhD§CityofHopeNationalMedicalCenterngramCancerCenterngramCancerCenterStaceyCohen,MD†FredHutchinsonCancerCenterHarryS.Cooper,MD≠FoxChaseCancerCenteryofWisconsinCarboneCanceryofWisconsinCarboneCancerCenterLindaFarkas,MD¶UTSouthwesternSimmonsComprehensiveCancerCenterIgnacioGarrido-Laguna,MD,PhD†HuntsmanCancerInstituteattheUniversityofUtahfettCancerfettCancerCenterAndrewGunn,MDфONealComprehensiveCancerCenteratUABJ.RandolphHecht,MD†UCLAJonssonComprehensiveCancerCenternterSarahHoffenteresPanelDisclosuresJoleenHubbard,MD†‡MayoClinicCancerCenternCancerCenteratBarnesnCancerCenteratBarnesJewishHospitalandWashingtonUniversitySchoolofMedicineWilliamJeck,MD≠DukeCancerInstitutenterSmilowCancerHospitalimberlyLnterSmilowCancerHospitalNatalieKirilcuk,MD¶StanfordCancerInstituteSmithaKrishnamurthi,MD†ÞCaseComprehensiveCancerCenter/UniversityHospitalsSeidmanCancerCenterandClevelandClinicTaussigCancerInstituteofColoradoCancerCenterJeffreyMeyerhardtofColoradoCancerCenterJeffreyMeyerhardt,MD,MPH†Dana-FarberBrighamandWomen’sCancerCenterEricD.Miller,MD,PhD§TheOhioStateUniversityComprehensiveCancerCenter-JamesCancerHospitalandSoloveResearchInstituteMaryF.Mulcahy,MD‡†RobertH.LurieComprehensiveCancerCenterofNorthwesternUniversityStevenNurkin,MD,MS¶RoswellParkComprehensiveCancerCenterTheUniversityofTexasMDAndersonCancerCenterTheUniversityofTexasMDAndersonCancerCenterAparnaParikh,MD†MassachusettsGeneralHospitalCancerCenterHitendraPatel,MD†UCSanDiegoMooresCancerCenternCancerCenteratBarnesrinanCancerCenteratBarnesElizabethRaskin,MD¶UCDavisComprehensiveCancerCenterLeonardSaltz,MD†‡ÞMemorialSloanKetteringCancerCenterCharlesSchneider,MD†AbramsonCancerCenterattheUniversityofPennsylvaniaTheUniversityofTennesseeHealthScienceTheUniversityofTennesseeHealthScienceCenterTheUniversityofTexasMDAndersonCancerTheUniversityofTexasMDAndersonCancerCenterConstantinosT.Sofocleous,MD,PhDфMemorialSloanKetteringCancerCenterElenaM.Stoffel,MD,MPH¤UniversityofMichiganRogelCancerCenterEdenStotsky-Himelfarb,BSN,RN†¶¥rCenteratJohnsrCenteratJohnsHopkinsChristopherG.Willett,MD§DukeCancerInstituteiPhDфDiagnostic/Interventionalradiology¤Gastroenterology‡Hematology/HematologyoncologyÞInternalmedicine†Medicaloncology≠Pathology¥Patientadvocate§Radiotherapy/Radiationoncology¶Surgery/Surgicaloncology*DiscussionSectionWritingCommitteeVersion2.2022,09/02/2022©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon10/4/20226:42:49AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.AnalCarcinomadexlievesthatthebestlievesthatthebestmanagementforanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.FindanNCCNMemberInstitution:/home/member-institutions.ofEvidenceanddationsotherwisedNCategoriesofEvidenceandConsensus.NCCNCategoriesofPreference:Allrecommendationsareconsideredappropriate.SeeNCCNCategoriesofPreference.oftheGuidelinesUpdateserANALntPerianalCancerANALeillanceANALyANALAtemicTherapyANALBherapyANALCorshipANALDTheNCCNGuidelinesareastatementofevidenceandconsensusoftheauthorsregardingtheirviewsofcurrentlyacceptedapproachestotreatmentAnyclinicianseekingtoapplyorconsulttheNCCNGuidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualstancestodetermineanypatientscareortreatmentTheNationalComprehensiveCancerNetworkNCCNmakesnorepresentationsorwarrantiesofanykindregardingtheircontentuseorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinanywayTheNCCNationalComprehensiveCancerNetworkAllrightsreservedTheNCCNGuidelinesandtheillustrationshereinmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.©2022.Version2.2022,09/02/2022©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon10/4/20226:42:49AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.AnalCarcinomadexANAL-C4of5•Table1DoseSpecificationofPrimaryandNodalPlanningTargetVolumespNodalPTVDoserevisedforTany,N+stagingntelymphnodes”(alsoappliestoANAL-2[T1,N0poorlydifferentiatedorT2-4,N0orAnyT,N+])daldalPlanningTargetVolumesfield.(alsoappliestoANAL-2)pRTpThefollowingrecommendationaddedchemoradiationwithpFootnoteremoved:AssignedcriteriapFootnoteremoved:Assignedcriteriaformajorandminorviolationswereconsideredaspartofthefeasibilitysecondaryendpoint.•SupportiveCare•SuperficiallyInvasiveSquamousCellCarcinoma(SISCCA)identities.identities.timeofbiopsy)with≤3-mmbasementmembraneinvasionandamaximalhorizontalspreadof≤7mm,localsurgicalresectionwithnegativemarginsmaybeadequatetreatment.eledabouttheeffectsofprematuremenopauseandconsiderationshouldbegiventoreferraleledabouttheeffectsofprematuremenopauseandconsiderationshouldbegiventoreferralfordiscussionofhormonereplacementstrategies.incidentallyinthesettingofabiopsyorexcisionofwhatisthoughttobeabenignlesionsuchasacondyloma,hemorrhoid,oranalskintag.counseledthatanirradiateduteruscounseledthatanirradiateduteruscannotcarryafetustoterm.dysfunctionpotentialforfuturelowtestosteronelevels,andinfertilitynegativemarginsincarefullyselectedpatientsfollowedbyanexperiencedproviderand/orteam,localexcisionalonewithastructuredsurveillanceplanmayrepresentadequatetreatment.risksandgiveninformationregardingspermrisksandgiveninformationregardingspermbankingoroocyte,egg,orovariantissuebanking,asappropriate,priortotreatment.pDiamond1modified:Localovariantissuebanking,asappropriate,priortotreatment.enessp5-FU225mg/m²IVover24hoursnessduringXRT(referenceaddedtoANAL-B2of2)pCapecitabine825mg/m²POtwicedaily5days/week+XRTx5weeks(referencesaddedtoANAL-B2of2)ANAL-C1of5•Footnote*added:NCCNrecommendationshavebeendevelopedtobeinclusiveofindividualsofallsexualandgenderidentitiestothegreatestextentpossible.Onthispage,thetermsmalesandfemalesrefertosexassignedatbirth.Version2.2022,09/02/2022©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESPrintedbyMinTangon10/4/20226:42:49AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.AnalCarcinomadexCLINICALPRESENTATIONAnalBiopsy:squamouscarcinomacarcinomabWORKUP•Digitalrectalexamination(DRE)•Inguinallymphnodeevaluation•Chest/abdominalCTc+•Chest/abdominalCTc+MRI•ConsiderPET/CTdorPET/MRI(ifavailable)•Anoscopy•HIVtesting(ifHIVstatusunknown)•Gynecologicexamforfemales,includingscreeningforcervicalcancer•Fertilityriskdiscussion/counselinginappropriatepatientsCLINICALPRIMARYTREATMENTgeeMetastaticwith5-FUorCapecitabinenfluorouracilwith5-FUorCapecitabinenfluorouracil(DCF)h(category2B)Mitomycin/5-FUh+RTiitomycinitomycincapecitabinehRTi5-FU/cisplatinh+RTi(category2B)Follow-upTherapyandSurveillancembrolizumabmbrolizumabh,kadiationhadiationhiyBaxelmbrolizumabh,kaThesuperiorborderofthefunctionalanalcanal,separatingitfromtherectum,hasbeendefinedasthepalpableupperborderoftheanalsphincterandpuborectalismusclesoftheanorectalring.Itisapproximately3to5cminlength,anditsinferiorborderstartsattheanalverge,thelowermostedgeofthesphinctermuscles,correspondingtotheintroitusoftheanalorifice.bFormelanomahistology,seetheNCCNGuidelinesforMelanoma:Cutaneous;foradenocarcinoma,seetheNCCNGuidelinesforRectalCancer.cCTshouldbewithIVandoralcontrast.PelvicMRIwithcontrast.Ifintravenousiodinatedcontrastmaterialiscontraindicatedduetosignificantcontrastallergyorrenalfailure,thenMRIexaminationoftheabdomenandpelviswithIVgadolinium-basedcontrastagent(GBCA)canbeobtainedinselectpatients(seeAmericanCollegeofRadiologycontrastmanual:/-/media/ACR/Files/Clinical-Resources/Contrast_Media.pdf).IntravenouscontrastisnotrequiredforthechestCT.dPET/CTscandoesnotreplaceadiagnosticCT.PET/CTperformedskullbasetomid-thigh.ePrinciplesofSurgery(ANAL-A).fPara-aorticnodesthatcanbeincludedinaradiationfield.gModificationstocancertreatmentshouldnotbemadesolelybasedonHIVstatus.SeeNCCNGuidelinesforCancerinPeoplewithHIV.hPrinciplesofSystemicTherapy(ANAL-B).iPrinciplesofRadiationTherapy(ANAL-C).jCarboplatin/paclitaxelistheonlyregimensupportedbyrandomizeddataandmaybepreferredover5-FU/cisplatinduetotoxicityprofiles.kNCCNGuidelinesfortheManagementofImmunotherapy-RelatedToxicities.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.ANAL-1Version2.2022,09/02/2022©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.screeningforcervicalFOLFOXhandconsiderNivolumabh,kforfemales,includingorRe-evaluateuspicioussphincteranomahistologyseethescreeningforcervicalFOLFOXhandconsiderNivolumabh,kforfemales,includingorRe-evaluateuspicioussphincteranomahistologyseetheNCCNGuidelinesforMelanomaCutaneousfor•erfertilityriskMetastaticLFCIShionh,imbrolizumabh,kAnalCarcinomadexCLINICALWORKUPCLINICALSTAGEPRIMARYTREATMENTgPRESENTATIONT1,N0WellorWellorAdequateObservepConsiderbiopsyornotinvolvemargins±5-FU/mitomycinhorFollow-upiunamphnodepConsiderbiopsyornotinvolvemargins±5-FU/mitomycinhorFollow-up•Chest/abdominalCTcT1,N0Poorly(ANAL-3)•Gynecologicexampaclitaxelh,j•Chest/abdominalCTcT1,N0Poorly(ANAL-3)•Gynecologicexampaclitaxelh,j adenocarcinoma,seetheNCCNGuidelinesforRectalCancer.fPara-aorticnodesthatcanbeincludedinaradiationfield.cCTshouldbewithIVandoralcontrast.PelvicMRIwithcontrast.IfintravenousgModificationstocancertreatmentshouldnotbemadesolelybasedonHIVstatus.iodinatedcontrastmaterialiscontraindicatedduetosignificantcontrastallergyNCCNGuidelinesforCancerinPeoplewithHIV.orrenalfailure,thenMRIexaminationoftheabdomenandpelviswithIVGBCAhPrinciplesofSystemicTherapy(ANAL-B).canbeobtainedinselectpatients(seeAmericanCollegeofRadiologycontrastiPrinciplesofRadiationTherapy(ANAL-C).manual:/-/media/ACR/Files/Clinical-Resources/Contrast_jCarboplatin/paclitaxelistheonlyregimensupportedbyrandomizeddataandmayMedia.pdf).IntravenouscontrastisnotrequiredforthechestCT.bepreferredover5-FU/cisplatinduetotoxicityprofiles.dPET/CTscandoesnotreplaceadiagnosticCT.PET/CTperformedskullbasetokNCCNGuidelinesfortheManagementofImmunotherapy-RelatedToxicities.mid-thigh.lTheperianalregionstartsattheanalvergeandincludestheperianalskinoveraePrinciplesofSurgery(ANAL-A).5-cmradiusfromthesquamousmucocutaneousjunction.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.ANAL-2Version2.2022,09/02/2022©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.•DREevery3–6mofor5y•Inguinalnodepalpationevery3–6mofor5y•Anoscopy•DREevery3–6mofor5y•Inguinalnodepalpationevery3–6mofor5y•Anoscopyevery6–12mox3yComplete•Chest/abdominal/remissionpelvicCTwithorchestoutcontrastominalMRIwithstannuallywkwithexam+DREPersistentdiseasemProgressivediseasemAnalCarcinomadexFOLLOW-UPSURVEILLANCEFOLLOW-UPSURVEILLANCEesectionAPRoLocalesectionAPRordiseasendiseaseninFUmitomycinhinFUmitomycinhycincapecitabinehCarboplatin/paclitaxelorUcisplatinhcategoryBRTModifiedDCFhcategory2B)TiTiifnopriorRTtoCarboplatin/paclitaxelh,jFOLFCIShFOLFCIShorUcisplatinhcategoryBNivolumabh,kmbrolizumabh,klowmBasedontheresultsoftheACT-IIstudy,itmaybeappropriatetofollowpatientswhohavenotachievedacompleteclinicalresponsewithpersistentanalcancerupto6monthsfollowingcompletionofradiationtherapyandlongasthereisnoevidenceofprogressivediseaseduringthisperiodoffollow-up.Persistentdiseasemaycontinuetoregressevenat26weeksfromthestartofePrinciplesofSurgery(ANAL-A).treatment.JamesRD,ePrinciplesofSurgery(ANAL-A).iplesofSystemicTherapyANALBiplesofRadiationTherapyANALCnPalliativeRTmaybeconsiderediniplesofSystemicTherapyANALBiplesofRadiationTherapyANALCjCarboplatin/paclitaxelistheonlyregimensupportedbyrandomizeddataandmaypreviouslyirradiatedjCarboplatin/paclitaxelistheonlyregimensupportedbyrandomizeddataandmaybepreferredover5-FU/cisplatinduetobepreferredover5-FU/cisplatinduetotoxicityprofiles.elinesfortheManagementofImmunotherapyRelatedelinesfortheManagementofImmunotherapyRelatedToxicitiesNote:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.ANAL-3Version2.2022,09/02/2022©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon10/4/20226:42:49AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.AnalCarcinomadexTREATMENTSURVEILLANCEpProgressivediseasemdiseasemPersistentdiseasemLocallyAPRo,r+groinLocallyAPRo,r+groinMetastaticdisMetastaticdiseasen5-FU/cisplatin5-FU/cisplatinh(category2B)ModifiedDCFhcategory2B)ssionorationandeasereevaluateqatCompletetervalsialexamsoralexams•Inguinalnodepalpationevery3–6mofor5y•Chest/abdominal/pelvicCTwithcontrastorchestCTwithoutcontrastandabdominal/pelvicMRIwithcontrastannuallyfor3ymbrolizumabh,keillanceANALlowhPrinciplesofSystemicTherapy(ANAL-B).jCarboplatin/paclitaxelistheonlyregimensupportedbyrandomizeddataandmaybepreferredover5-FU/cisplatinduetotoxicityprofiles.kNCCNGuidelinesfortheManagementofImmunotherapy-RelatedToxicities.mBasedontheresultsoftheACT-IIstudy,itmaybeappropriatetofollowpatientswhohavenotachievedacompleteclinicalresponsewithpersistentanalcancerupto6monthsfollowingcompletionofradiationtherapyandchemotherapyaslongasthereisnoevidenceofprogressivediseaseduringthisperiodoffollow-up.Persistentdiseasemaycontinuetoregressevenat26weeksfromthestartoftreatment.JamesRD,LancetOncol2013;14:516-524.nPalliativeRTmaybeconsideredinsymptomaticpatients.RecordsofpreviousRTshouldbecarefullyreviewedandconsideredpriortopotentialre-irradiationofpreviouslyirradiatedfields.PrinciplesofRadiationTherapy(ANAL-C).oConsidermuscleflapreconstruction.pPrinciplesofSurvivorship(ANAL-D).qUseimagingstudiesasperinitialworkup.rConsidertheuseofimmunotherapy(nivolumaborpembrolizumab)(category2B)beforeproceedingtoAPR.Institutionalexperiencehasdemonstratedsomepatientsreceiveagoodresponseandcanavoidsurgery.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.ANAL-4Version2.2022,09/02/2022©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon10/4/20226:42:49AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.AnalCarcinomadexPRINCIPLESOFSURGERY•SuperficiallyInvasiveSquamousCellCarcinoma(SISCCA)pSISCCAareanalcancersthataregenerallyfoundincidentallyinthesettingofabiopsyorexcisionofwhatisthoughttobeabenignlesionsuchasacondyloma,hemorrhoid,oranalskintag.pForsuchlesionsthatarenotedtohavehistologicallynegativemarginsincarefullyselectedpatientsfollowedbyanexperiencedproviderand/orteam,localexcisionalonewithastructuredsurveillanceplanmayrepresentadequatetreatment.•Perianal(AnalMargin)CancerpT1N0,moderatelytowell-differentiatedorselectT2N0squamouscellcarcinoma(SCC)oftheperianal(analmargin)regionmaybeadequatelytreatedbylocalexcisionwith1-cmmargins.◊Localsurgicalexcisionofselect,earlylesionsmaybeconsidered–Wherethetumorformsadiscretelesionarisingfromtheperianalskinthatisclearlyseparatefromtheanalcanal–Wherenegativemarginexcisioncanbeaccomplishedwithoutcompromiseoftheadjacentsphinctermuscles–WherethereisnoevidenceofregionalnodalinvolvementalRecurrencePersistencepAPRistheprimarytreatment.pGeneralprinciplesforAPRaresimilartothosefordistalrectalcancerandincludetheincorporationoftotalmesorectalexcision(TME).pAPRforanalcancermayrequirewiderlateralperianalmargins.pDuetothenecessaryexposureoftheperineumtoradiation,patientsarepronetopoorperinealwoundhealingandmaybenefitfromtheuseofreconstructivetissueflapsfortheperineumsuchastheverticalrectusorlocalmyocutaneousflaps.•InguinalRecurrencepPatientswhohavealreadyreceivedgroinradiationshouldundergoaninguinalnodedissection.pGroindissectioncanbedonewithorwithoutAPRdependingonwhetherdiseaseisisolatedtothegroinorisinconjunctionwithrecurrence/persistenceattheprimarysite.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.ANAL-AVersion2.2022,09/02/2022©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon10/4/20226:42:49AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.AnalCarcinomadexPRINCIPLESOFSYSTEMICTHERAPYercerentTherapyens•5-FU+mitomycin+RT•Capecitabine+mitomycin+RTommendedRegimens•5-FU+cisplatin+RTensarboplatinpaclitaxelecommendedRegimens•5-FU+cisplatin•FOLFCISLFOXModifiedDCFenslumab•PembrolizumabifneitherpreviouslyreceivedSystemicTherapyRegimensandDosing•5-FU+mitomycin+RT1,2pContinuousinfusion5-FU1000mg/m/dayIVdays1–4and29–32Mitomycin10mg/mIVbolusdays1and29Concurrentradiotherapy(ANAL-C)orpContinuousinfusion5-FU1000mg/m/dayIVdays1–4and29–32Mitomycin12mg/monday1(cappedat20mg)Concurrentradiotherapy(ANAL-C)•Capecitabine+mitomycin+RT3,4pCapecitabine825mg/mPOBID,Monday–Friday,oneachdaythatRTisgiven,throughoutthedurationofRT(typically28treatmentdays)Mitomycin10mg/mdays1and29Concurrentradiotherapy(ANAL-C)orpCapecitabine8