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1 B y J a m e s Y e h 1

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5 CUA CUA CUA 5

6 2007 CUA CUA CUA

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8 clinical guidelines consensus based guideline evidence-based medicine EBM evidence based guideline World Health Organization WHO [1,2] [3] clinical practice guidelines 1994 [4]

9 2005 [3], (evidence based guideline development) 1 [5] 9

10 [6-8],

11 World Health Organization. Guidelines for WHO guidelines. EIP/GPE/EQC/2003. World Health Organization. Geneva, Switzerland, Burgers JS, Grol R, Klazinga NS, et al. Towards evidence based clinical practice: an international survey of 18 clinical guideline programs. Inter J Qua Health Care, 15:31-45, ,. :, McConnell JD, Barry MJ, Bruskewitz RC, et al. Benign prostatic hyperplasia: diagnosis and treatment. In: Clinical Practice Guideline. Rockville MD: Agency for Health Care Policy and Research, Guideline. :, Sackett DL, Rosenberg WMC, Muir Gray JA, et al. Evidence based medicine: what it is and what it isn t. BMJ, 1996:12: Atkins D, Eccles M, Flottorp S, et al. The GRADE Working Group. Systems for grading the quality of evidence 11

12 and the strength of recommendations I: critical appraisal of existing approaches. BMC Health Services Res. 2004: 4: Atkins D, Briss PA, Eccles M, et al. The GRADE Working Group. Systems for grading the quality of evidence and the strength of recommendations II: pilot study of a new system. BMC Health Services Res, 2005: 5:

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15 [ ] incidental renal cell carcinomas B CT paraneoplastic syndromes localized renal cell carcinoma 2002 AJCC TNM T 1 -T 2 N 0 M 0 locally advanced renal cell carcinoma 2002 AJCC metastatic renal cell carcinoma 2002 AJCC T 4 N 0 M 0 nephron-sparing surgery NSS minimally invasive treatment NSS 15

16 [1] [2] [3] [4] -1-1 A a b Meta B a b a b C D 80%~90% 2%~3% [1] 1988~ [5,6] 50~70 4% [1 7 8] 10%~20% [8] 16

17 7cm 2%~4% [8] 1981 Mostofi WHO1997 [9] 60%~85% 7%~14% 4%~10% 1%~2% 2 [10,11] 2004 WHO Bellini Xp WHO 1982 Fuhrman [13] 1997 WHO Fuhrman [9] 2002 AJCC TNM clinical stage grouping ctnm -2-3 [14] 2002 AJCC N N 0 N 1 2 N N AJCC TNM T T X T 0 T 1 7cm T 1a 4cm T 1b 4cm 7cm 17

18 T 2 T 3 7cm T 3a T 3b ( ) T 3c T 4 N N x N 0 N 1 N 2 M M X M 0 M AJCC T 1 N 0 M 0 T 2 N 0 M 0 T 1 N 1 M 0 T 2 N 1 M 0 T 3 N 1 M 0 T 3a N 0 M 0 T 3a N 1 M 0 T 3b N 0 M 0 T 3b N 1 M 0 T 3c N 0 M 0 T 3c N 1 M 0 18

19 T 4 N 0 M 0 T 4 N 1 M 0 T N 2 M 0 T N M 1 15% [1,11] %~48.9% [15 16] 33% 50% [8] 10%~40% [17] 30% B X CT CT X IVU CT CT X CT MRI MRI CT CT MRI positron emission tomography PET PET-CT 19

20 1~3 ctnm ctnm pathological stage grouping ptnm ptnm ctnm ptnm [18-20], 8cm CT [21-23] [24] [25] 2% [26] 1%~2% [27-29] (nephron sparing surgery NSS) NSS [30-33] NSS 0.5~1.0cm [34-36] [36-38] [39,40] NSS 0~10% 4cm 0~3% [41] NSS 1%~2% [41] NSS [1 8] NSS [1 8] NSS 20

21 NSS T 1a 4cm NSS [42] [43 44] T 3 radio-frequency ablation RFA high-intensity focused ultrasound HIFU cryoablation ~ 4cm [45 46] ~ pt 1a 5 90% pt 1b ~pt 2 1~2 20%~30% [47 48] gemcitabine [2] TNM [49] T 3b N 0 M 0 21

22 CT MRI 9% Mayo Clinic [50] 0 2cm 2cm 3 IFN-α IL [51] T 3 5 IFN-α ( )IL-2 [52-54] -4 [55] [56] 2%~11% LAK TIL IFN-γ IFN-α IL-2 15% IFN-α IFN-α 9MIU im H 3 / 12 3MIU 1 3MIU 2 6MIU 3 9MIU /L 9MIU 6MIU 3MIU IL-2 IL-2 6.0~ IU/ kg( ) 8h 15min ~ IL-2 4% 22

23 IL IU/kg H 5d/W 1 IL IU/kg H 5d /W MIU/d H 5d/W 8 IL-2 IFN-α ( )IL-2 [3] (vascular endothelial growth factor, VEGF) 10%~40% 80% [57-58] VEGF IFN-α ( )IL-2 [3] RECIST [59] [60-62] -4-4 > 70 mm/h 2 70 mm/h 0 23

24 > 280 U/L U/L 0 < 6 000/µL /µL 0 < 100g/L 1 100g/L ~3 >4 VHL BHD( Birt-Hogg-Dube) / VHL VHL VHL VHL 3cm 3cm NSS 4~6 [1,2] NSS 4~6 CT, [2] 24

25 X X CT NSS T 3 ~T 4 CT T 1 ~T 2 3~6 3 T 3 ~T VHL 6 CT 1 MRI 25

26 26

27 :, Michisch G, Carballido J, Hellsten S, et al. Guidelines on renal cell cancer. Eur Urol, 2001,40: ~1992. :, ~ :, Linehan WM, Walther MM, Zbar B. The genetic basis of cancer of the kidney. J Urol,2003,170: Walsh PC, Retik AB, Vaugh ED, et al. Campbell s Urology. 8th ed. Philadelphia, PA: WB Saunders Company, Störkel S, Eble JN, Adlakha K, et al. Classification of renal cell carcinoma. Cancer,1997,80: Delahunt B, Eble JN. Papillary renal cell carcinoma: a clinicopathologic and immunohistochemical study of 105 tumors. Mod Pathol,1997,10: Delahunt B, Eble JN, McCredie MR, et al. Morphologic typing of papillary renal cell carcinoma: comparison of growth kinetics and patient survival in 66 cases. Hum Pathol,2001,32: Ebele JN, Sauter G, Epstein JI, et al. Pathology and Genetics of Tumours of the Urinary System and Male Genital Organs. Lyon: IARC, 2004, Fuhrman SA, Lasky LC, Limas C. Prognostic significance of morphologic paramaeters in renal cell carcinoma. Am J Surg Pathol,1982,6: AJCC Cancer Staging Manual. Sixth ed. New York:Springer Verlag, ,,. ( 44 ).,2000,2: ,, ,2003,6:

28 17. Palapattu GS, Kristo B, Rajfer J. Paraneoplastic syndromes in urologic malignancy: the many faces of renal cell carcinoma. Rev Urol,2002,4: Godley PA, Stinchcombe TE. Renal cell carcinoma. Curr Opin Oncol,1999,11: ,2000,3: ,2001,23: Paul R, Mordhorst J, Busch R, Leyh H, Hartung R. Adrenal sparing surgery during radical nephrectomy in patients with renal cell cancer: a new algorithm. J Urol,2001,166: ,2002,23: ?,1998,19: Swanson DA, Borges PM. complications of transabdominal radical nephrectomy for renal cell carcinoma. J Urol,1983,129: Wunderlich H, Schlichter A, Reichelt O, et al. Renal indications for adrenalectomy in renal cell carcinoma. Eur Urol,1999,35: Sugao H, Matsuda M, Nakano E, et al. Comparison of lumbar flank approach and transperitoneal approach for radical nephrectomy. Urol Int,1991,46: Novick AC, Streem S, Montie JE, et al. Conservative surgery for renal cell carcinoma: a single-center experience with 100 patients. J Urol, 1989,141: Sandock DS, Seftel AD, Resnick MI. A new protocol for the followup of renal cell carcinoma based on pathological stage. J Urol,1995,154: Levy DA, Slaton JW, Swanson DA, et al. Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol, 1998,159: Van Poppel H, Bamelis B, Oyen R, et al. Partial nephrectomy for renal cell carcinoma can achieve long-term tumor control. J Urol,1998,160: Novick AC. Nephron-sparing surgery for renal cell carcinoma. Br J Urol,1998,82: Uzzo RG, Novick AC. Nephron sparing surgery for renal tumors: indications, techniques and outcomes. J Urol,2001,166: Fergany AF, Hafez KS, Novick AC. Long term results of nephron sparing surgery for localized renal cell carcinoma: 10 year follow-up. J Urol,2000,163: Sutherland SE, Resnick MI, Maclennan GT, et al. Does the size of the surgical margin in 28

29 partial nephrectomy for renal cell cancer really matter? J Urol,2002,167: ,..,2002,23: ,,,..,2003,2: Marshall FF, Taxy JB, Fishman ED, et al. The feasibility of surgical enucleation for renal cell carcinoma. J Urol,1986,135: Novick AC, Zincke H, Neves RJ, et al. Surgical enucleation for renal cell carcinoma. J Urol,1986,135: Dechet CB, Sebo T, Farrow G, et al. Prospective analysis of intraoperative frozen needle biopsy of solid renal masses in adults. J Urol,1999,162: Duvdevani M, Laufer M, Kastin A, et al. Is frozen section analysis in nephron sparing surgery necessary? A clinicopathological study of 301 cases. J Urol,2005,173: Uzzo RG, Novik AC. Nephron sparing surgery for renal tumors: indications, techniques and outcomes. J Urol, 2001,166: Humke U, Siemer S, Uder M, et al. Long-term outcome of conservative surgery for kidney cancer: survival, blood pressure, and renal function. Ann Urol (Paris),2002,36: Saranchuk JK, Savage SJ. Laparoscopic radical nephrectomy: current status. BJU Int,2005,2: Desai MM, Gill IS. Laparoscopic partial nephrectomy for tumour: current status at the Cleveland Clinic. BJU Int,2005,2: Gill IS, Novick AC, Schweizer D, et al. Laparoscopic renal cryoablation in 32 patients. Urology,2000,56: Ankem MK, Nakada SY. Needle-ablative nephron-sparing surgery. BJU Int,2005,2: Rabinovitch RA, Zelefsky MJ, Gaynor JJ, et al. Patterns of failure following surgical resection of renal cell carcinoma: Implications for adjuvant local and systemic therapy. J Clin Oncol,1994,12: Sandock DS, Seftel AD, Resnick MI. A new protocol for the follow-up of renal cell carcinoma based on pathological stage. J Urol,1995,154: Hatcher PA, Anderson EE, Paulson DF, et al. Surgical management and prognosis of renal 29

30 cell carcinoma invading the vena cava. J Urol,1991,145: Blute ML, Leibovich BC, Lochse CM, et al. The Mayo Clinic experience with surgical management, complications and outcome for patients with renal cell carcinoma and venous tumour thrombus. BJU Int,2004,94: Jocham D, Richter A, Hoffmann L, et al. Adjuvant autologous renal tumour cell vaccine and risk of tumour progression in patients with renal-cell carcinoma after radical nephrectomy: phase III, randomised controlled trial. Lancet,2004,363: Mickisch GH, Garin A, van Poppel H, et al. Radical nephrectomy plus interferon-alfa-based immunotherapy compared with interferon alfa alone in metastatic renal-cell carcinoma: a randomised trial. Lancet,2001,358: Flanigan RC, Salmon SE, Blumenstein BA, et al. Nephrectomy followed by interferon alfa-2b compared with interferon alfa-2b alone for metastatic renal-cell cancer. N Engl J Med,2001,345: Flanigan RC, Mickisch G, Sylvester R, et al. Cytoreductive nephrectomy in patients with metastatic renal cancer. A combined analysis. J Urol,2004,171: Haninen LE, Kirchner H, Atzpodien J. Interleukin-2 based home therapy of metastatic renal cell carcinoma: risks and benefits in 215 consecutive single institution patients. J Urol,1996,155: Kavolius JP, Mastorakos DP, Pavlovich C, et al. Resection of metastatic renal cell carcinoma. J Clin Oncol,1998,16: Eisen T, Bukowski RM., Staehler M, et al. Randomized phase III trial of sorafenib in advanced renal cell carcinoma (RCC): Impact of crossover on survival. ASCO Motzer RJ, Hutso n TE., Tomczak P, et al. Phase III randomized trial of sunitinib malate (SU11248) versus interferon-alfa (IFN-α) as first-line systemic therapy for patients with metastatic renal cell carcinoma (mrcc).asco Therasse P, Arbuck SG, Eisenhauer EA, et al. New guidelines to evaluate the response to treatment in solid tumors. JNCI,2000,92: Moch H, Gasser T, Amin MB, et al. Prognostic utility of the recently recommended histologic classification and revised TNM staging system of renal cell carcinoma : a Swiss experience with 588 tumors. Cancer,2000,89:

31 61. Amin MB, Tamboli P, Javidan J, et al. Prognostic impact of histologic subtyping of adult renal epithelial neoplasms: an experience of 405 cases. Am J Surg Pathol,2002,26: Motzer RJ, Bacik J, Mariani T, et al. Treatment outcome and survival associated with metastatic renal cell carcinoma of non clear-cell histology. J Clin Oncol,2002,20:

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34 [1-9] [10] % 9% [11] / / /10 [12] / / / ~79 70% % 40~59 2.2% 1/45 60~ % 1/7 [12] ~11 [13-14] 6~7 [15] 9% [11] [16-18] E D [18] 34

35 [19] [18 20] 1. Crawford ED. Epidemiology of prostate cancer. Urology, 2003, 62 (6 Suppl 1): Quinn M, Babb P. Patterns and trends in prostate cancer incidence, survival, revalence, and mortality. Part I: international comparisons. BJU Int, 2002, 90: Gronberg H. Prostate cancer epidemiology. Lancet, 2003, 361: ,.., ,2005 2: , ,, ,24 : Gu FL, Xia TL, Kong XT. Preliminary study of the frequency of benign prostatic hyperplasia and prostatic cancer in China. Urology, 1994,44 : , , Jemal A, Tiwari R, Murray T, et al. Cancer statistics, CA Cancer J Clin, 2004, 54: Bray F, Sankila R, Ferlay J, Parkin DM. Estimates of cancer incidence and mortality in Europe in 1995.Eur J Cancer, 2002, 38: Geenle RT, Hill-Harmon MB, Murray T, Thur M. Cancer statistics, 2001, 51: Haas GP, Sakr WA. Epidemiology of prostate cancer. CA Cancer J Clin, 1997, 47: Steinberg GD, Carter BS, Beaty TH, et al. Family history and the risk of prostate cancer. Prostate, 1990, 17: Gronberg H, Damber L, Damber JE. Familial prostate cancer in Sweden. A nationwide register cohort study. Cancer, 1996, 77: Bratt O. Hereditary prostate cancer: clinical aspects. J Urol, 2002, 168: Meyer F, Bairati I, Shadmani R, et al. Dietary fat and prostate cancer survival. Cancer Causes Control, 1999, 10: Denis L, Morton MS, Griffiths K. Diet and its preventive role in prostatic disease. Eur Urol,1999, 35:

36 19. Jian L, Xie LP, Lee AH,et al. Protective effect of green tea against prostate cancer: a case-control study in southeast China. Int J Cancer, 2004,108: Schulman CC, Zlotta AR, Dennis L, et al. Prevention of prostate cancer. Scand J Urol Nephrol, 2000, 205(Suppl):50-61 PSA PSA [1] 1 digital rectal examination DRE DRE [2-3] DRE PSA PSA DRE 2 prostate-specific antigen PSA PSA DRE TRUS transrectal ultrasonography 1 PSA AUA ASCO 50 DRE PSA 45 [4-6] [7] 50 PSA DRE 45 DRE PSA 36

37 PSA PSA 2 PSA PSA tpsa 4.0ng/ml PSA tpsa 4~10ng/ml 25% PSA 4~10ng/ml 15.9% [8] PSA BPH tpsa ng/ml ng/ml ng/ml ng/ml ng/ml [9] PSA 3 PSA (free PSA fpsa) fpsa tpsa fpsa tpsa tpsa 4~10ng/ml fpsa tpsa fpsa/tpsa % fpsa/tpsa % fpsa/tpsa 0.16 ( ) [10-18] 4 PSA (PSA density PSAD) PSA PSAD 0.15 PSAD PSA PSAD [19-22] PSAD 5 PSA (PSA velocity PSAV) PSA PSAV 0.75ng/ml/ PSAV 0.75ng/ml/ [23-24] PSAV PSA 2 3 PSA PSAV [(PSA2-PSA1) + (PSA3- PSA2)]/2 3 transrectal ultrasonography, TRUS TRUS 37

38 [25] TRUS BPH PIN TRUS 4 1 MRI B [26-29] 2 1) PSA 2) B MRI PSA 3) PSA 10ng/ml f/t PSA PSAD 4) PSA 4~10ng/ml f/t PSA PSAD PSA4~10ng/ml f/t PSA PSAD [30-31] 4 1) 4) [32-34] 1) PIN 2) PSA 10ng/ml f/t PSA PSAD 3) PSA 4~10ng/ml f/t PSA PSAD 4) PSA 4~10ng/ml f/t PSA PSAD 3 PSA PSA 2 10ng/ml PSAV 0.75/ml/ 5) 2 1~3 6) 2 1) 4) 2 7) 2 38

39 5 1 CT CT (MRI) CT [35] CT MRI 2 MRI/MRS MRI MRI [36] (magnetic resonance spectroscopy, MRS) MRI [36] TRUS CT MRI 3 ECT ECT X 3 ~6 [37] [38] PSA 20 GS 7 6 Gleason [39] Gleason 1~5 Gleason Gleason Gleason 1 Gleason 2 39

40 Gleason 3 Gleason 4 Gleason 5 1. Catalona WJ, Richie JP, Ahmann FR, et al. Comparison of digital rectal examination and serum prostate specific antigen (PSA) in the early detection of prostate cancer: results of a multicentre clinical trial of 6,630 men. J Urol, 1994,151: Carvalhal GF, Smith DS, Mager DE, et al. Digital rectal examination for detecting prostate cancer at prostate specific antigen levels of 4 ng/ml or less. J Urol, 1999, 161: Eastham JA, May R, Robertson JL,et al. Development of a monogram that predicts the probability of a positive prostate biopsy in men with an abnormal digital rectal examination and a prostate-specific antigen between 0 and 4 ng/ml. Urology, 1999, 54: Mettlin C, Jones G, Averette H, et al. Defining and updating the American Cancer Society guidelines for the cancer-related checkup: Prostate and endometrial cancers. Cancer,1993, 43:42 5.American Urological Association: Early detection of prostate cancer and the use of transrectal ultrasound. A. U. A. policy statement book, 1992, 4:20 6.The National Comprehensive Cancer Network (NCCN) Practice Guidelines in Oncology v , Prostate Cancer, ,. PSA , 201 9,. PSA., 2002, 23:

41 10.,,,. F/T.,2002,17: ,. T-PSA F/T., 2002,17: ,,,.PSA F/TPSA PSAD., 2003,24 : ,,,. PSA., 2003,24 :287 14,.., 2002, 23: ,. PSA PSA., 2002, 23: Catalona WJ, Smith DS, Wolfert RL, et al. Evaluation of percentage of free serum prostate specific antigen to improve specificity of prostate cancer screening. JAMA, 1995, 274: Catalona WJ, Smith DS, Ornstein DK. Prostate cancer detection in men with serum PSA concentration of 2.6 to 4.0 ng/ml and benign prostate examination: enhancement of specificity with free PSA measurements. JAMA, 1997, 277: Partin AW, et al. Contemporary update of prostate cancer staging nomograms (Partin tables) for the new Millenium. Urology, 2001, 58: Benson MC, Whang IS, Olsson CA,et al. Use of prostate specific antigen density to enhance predictive value of intermediate levels of serum prostate specific antigen. J Urol, 1992, 147: Brawer MK, Aramburu EA, Chen GL,et al. The inability of prostate specific antigen index to enhance the predictive value of prostate specific antigen in the diagnosis of prostatic carcinoma. J Urol,1993, 150: Catalona WJ, Richie JP, dekernion JB, et al. Comparison of prostate specific antigen Concentration versus prostate specific antigen density in the early detection of prostate cancer: receiver operating characteristic curves. J Urol,1994, 152 (6 Pt 1):

42 22.,,,. PSA., 2000, 21(10): Carter HB, Pearson JD, Metter EJ, et al. Prostate specific antigen variability in men without prostate cancer: The effect of sampling interval and number of repeat measurements on prostate specific antigen velocity. Urology, 1995, 45: Smith DS, Catalona WJ. Rate of change in serum prostate specific antigen levels as a method for prostate cancer detection. J Urol, 1994, 152: Brawer MK, Chetner NP. Ultrasonography of the prostate and biopsy. Campbell's Urology. 7th ed. W. B. Saunders, Aus G, Ahlgren G, Bergdahl S,et al. Infection after transrectal core biopsies of the prostate -risk factors and antibiotic prophylaxis. Br J Urol, 1996, 77: Collins GN, Lloyd SN, Hehir M,et al. Multiple transrectal ultrasound-guided biopsies -true morbidity and patient acceptance. Br J Urol, 1993, 71: ,,,..,2004 2: ,,,. MRI.,2000,16: Singh H, Canto EI, Shariat SF, et al. Improved detection of clinically significant, curable prostate cancer with systematic 12-core biopsy. J Urol, 2004,171(3): Fink KG, Hutarew G, Pytel A, et al. One 10-core prostate biopsy is superior to two sets of sextant prostate biopsies. BJU Int, 2003, 92(4): Applewhite JC, Matlaga BR, McCullough DL. Results of the 5 region prostate biopsy method: the repeat biopsy population. J Urol, 2002, 168: Roehrborn CG, Pickers GJ, Sanders JS. Diagnostic yield of repeated transrectal ultrasound-guided biopsies stratified by specific histopathologic diagnosis and prostate specific antigen levels. Urology, 1996, 47: Djavan B, Ravery V, Zlotta A,et al. Prospective evaluation of prostate cancer detected on biopsies 1,2,3 and 4, when should we stop? J Urol, 2001, 166: Walsh JW, Amendola MA, Konerding KF,et al. Computed tomographic detection of pelvic 42

43 and inguinal lymph node metastases from primary and recurrent pelvic malignant disease. Radiology,1980, 137: ,,,. MRI., 2001, 17: Platt JF, Bree RL, Schwab RE. The Accuracy of CT in the staging of carcinoma of the prostate. AJR, 1987, 149: ,,.., 1994, 14: Gleason DF. Veterans administration cooperative urological research group. Histological grading and clinical staging of prostatic carcinoma. In Tannenbaum Med: Urological Pathology: The Prostate. Philadelphia, Lea & Febiger, 1977, DRE PSA CT MRI 2002 AJCC TNM T DRE MRI PSA [1-7] N N T 2 PSA<20ng/ml Gleason <6 10% M MRI X Gleason 7 PSA 20ng/ml [8-11] TNM AJCC 2002 [12] T pt * T x pt 2 * T 0 pt 2a 1/2 T 1 pt 2b 1/2 43

44 T 1a < 5% pt 2c T 1b > 5% pt 3 T 1c PSA pt 3a T 2 pt 3b T 2a 1/2 1/2 pt 4 T 2b 1/2 1/2-1 T 2c T 3 ** T 3a T 3b T 4 N *** N x PN x N 0 pn 0 N 1 pn 1 M **** M x M 0 M 1 M 1a M 1b M 1c * 44

45 T 1c ** T 2 T 3 *** 0.2cm pn 1 mi **** 1 T 1a N 0 M 0 G 1 T 1a N 0 M 0 G 2,3-4 T 1b N 0 M 0 G T 1c N 0 M 0 G T 1 N 0 M 0 G T 2 N 0 M 0 G T 3 N 0 M 0 G T 4 N 0 M 0 G T N 1 M 0 G T N M 1 G G X G 1 Gleason 2~4 G 2 Gleason 5~6 G 3-4 Gleason 7~10 PSA Gleason -1 [13] -1 PSA ng/ml

46 Gleason T 2a T 2b T 2c 1. Spigelman SS, McNeal JE, Freiha FS, et al. Rectal examination in volume determination of carcinoma of the prostate: clinical and anatomical correlations. J Urol,1986, 136: Heenan SD. Magnetic resonance imaging in prostate cancer. Prostate Cancer Prostatic Dis, 2004, 7: Ravery V, Schimid HP, Toublanc M, et al. Is the percentage of cancer in biopsy cores predictive of extra capsular disease in T1-T2 prostate cancer? Cancer, 1996, 78: Partin AW, Carter HB, Chan DW, et al. Prostate specific antigen in the staging of localized prostate cancer: influence of tumor differentiation, tumor volume and benign hyperplasia. J Urol, 1990,143: Partin AW, Mangold LA, Lamm DM, et al. Contemporary update of the prostate cancer staging nomograms (Partin tables) for the new millennium. Urology, 2001, 58: Hammerer P, Huland H, Sparenberg A. Digital rectal examination, imaging, and systematic-sextant biopsy in identifying operable lymph node-negative prostatic carcinoma. Eur Urol, 1992, 22: Sebo TJ, Bock BJ, Cheville JC, et al. The percentage of cores positive for cancer in prostate needle biopsy specimens is strongly predictive of tumour stage and volume at radical prostatectomy. J Urol, 2000, 163: McGregor B, Tulloch AGS, Quinlan MF, et al. The role of bone scanning in the assessment of prostatic carcinoma. Br J Urol, 1978, 50: Chybowski FM, Keller JJ, Bergstrahl EJ, et al. Predicting radionuclide bone scan findings in patients with newly diagnosed, untreated prostate cancer: prostate specific antigen is superior to all other parameters. J Urol, 1991, 145: Kemp PM, Maguire GA, Bird NJ. Which patients with prostatic carcinoma require a staging bone scan? Br J Urol, 1997, 79:

47 11. Lee N, Fawaaz R, Olsson CA, et al. Which patients with newly diagnosed prostate cancer need a radionuclide bone scan? An analysis based on 631 patients. Int J Radiat Oncol Biol Phys, 2000, 48: Clinical Practice Guidelines in Oncology: Prostate Cancer. NCCN, Version Carroll PR. Nomograms are superior to staging and risk grouping systems for identifying high-risk patients: preoperative application in prostate cancer. Urol Oncol, 2003, 21(6): (watchful waiting) [1-7] PSA4 10ng/ml GS 6 T 2a T 1-3 N x N 0 M x M 0 3 PSA DRE DRE PSA 1 Chodak GW, Thisted RA, Gerber GS, et al. Results of conservative management of clinically localized prostate cancer. N Engl J Med, 1994, 330: Steinberg GD, Bales GT, Brendler CB. An analysis of watchful waiting for clinically localized prostate cancer. J Urol, 1998, 159: Brsso K, Friis S, Juel K, et al. Mortality of patients with clinically localized prostate cancer treated with observation for 10 years or longer: a population based study. J Urol, 1999, 161:

48 4 Johansson JE, Andren O, Andersson SO, et al. Natural history of early, localized prostate cancer. JAMA, 2004, 291: Bill-Axelson A, Holmberg L, Ruutu M, et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med, 2005, 352: Carter HB, Walsh PC, Landis P, et al. Expectant management of nonpalpable prostate cancer with curative intent: preliminary results. J Urol, 2002, 167: Choo R, Klotz L, Danjoux C, et al. Feasibility study: watchful waiting for localized low to intermediate grade prostate carcinoma with selective delayed intervention based on prostate specific antigen, histological and/or clinical progression. J Urol, 2002, 167: , [1-3] (1) T 1 -T 2c T 3 T 2c T 3 [4-5] (2) 10 [6] (3) (4) PSA Gleason PSA 20 Gleason 8 [7-9]

49 ,,, 1) 2) 2,, [10] [6] % [11-12] 1. Guidelines on prostate cancer. European Association of Urology, update March Walsh, PC. Surgery and the reduction of mortality from prostate cancer. New Engl J Med, 2002, 347(11):

50 3. Boccon-Gubid L, Bertaccini Albino AV,et al. Management of locally advanced prostate cancer: a European Consensus. Int J Clin Pract,2003, 57: Van Poppel H, Goethuys H,Callewaert P,et al.radical prostatectomy can provide a cure for well selected clinical stage T3 prostate cancer. Eur Urol, 2000, 38: Huland H.Treatment of localized disease:treatment of clinically localized prostate cancer(t1/t2).in:proceedings of the First International Consultation on Prostate Cancer, Scientific Communication International Ltd.Jersey. Channel Islands,1997, Konety BR, Eastham JA, Reuter VE, et al. Feasibility of radical prostatectomy after neoadjuvant chemohormonal therapy for patients with high risk or locally advanced prostate cancer: results of a phase I/II study. J Urol, 2004, 171(2 Pt 1): Ou YC, Chen JT, Cheng CL, Radical prostatectomy for prostate cancer patients with prostate-specific antigen >20 ng/ml. Jpn J Clin Oncol, 2003, 33(11): Eastham JA. Multimodal treatment strategies combining neoadjuvant hormonal therapy and/or chemotherapy with radical prostatectomy in high-risk localized prostate cancer. Expert Opin Investig Drugs, 2004, 13(1): Brown JA, Garlitz C, Gomella LG, et al. Perioperative morbidity of laparoscopic radical prostatectomy compared with open radical retropubic prostatectomy. Urol Oncol (United States), 2004, 22(2): Srongi M. Urinary continence and pathological outcome after bladder neck preservation during radical retropubic prostatectomy : randomized prospective trial. J Urol, 2001, 164 : Steiner MS,Morton RA,Walsh PC,et al. Impact of anatomical radical prostatectomy on urinary continence. J Urol, 1991, 145: EBRT 1 T 1-2 N 0 M 0 10 T 3-4 N 0 M 0 50

51 3D-CRT IMRT TNM Gleason PSA [1-5] 2 [1,7-12] (1) MRI CT (2) <55Gy 55 60Gy 60 65Gy 60 70Gy >70Gy [6] (3) L 5 S 1 1 2cm Gy 45Gy Gy 65 80Gy [6] 3 3D-CRT IMRT (1) 3D-CRT IMRT 3D-CRT CT IMRT Gy [13] 51

52 (2) CT CT 3D (3) DVH T 1a 64 66Gy T 1b T Gy T Gy T Gy 70 72Gy T Gy T 1a T cm 50Gy 4 (1) T 1-2 N 0 M 0 T 1 T 2a Gleason 6 PSA 10ng/ml [14] T 2b Gleason =7 PSA 10 20ng/ml [15] Gleason 7 PSA 20ng/ml [16] (2) T 3-4 N 0 M 0 T 1-4 N 1 M 0 pt 3 N 0 M 0 [17-20] 90% 100% (3) 5 52

53 1 1 [21,22] :, :, :, The American Urological Association Prostate Cancer Clinical Guidelines Panel Report on the Management of Clinically Localized Prostate Cancer R.Hofmann, A Heidenreich, J.W. Moul, et al. Prostate cancer diagnosis and surgical treatment. Springer, Hanks GE, Dimamond JJ, Krall JM, et al. A ten year followup of 682 patients treated for prostate cancer with radiation therapy in the United States. Int J Radiat Oncol Biol Phys,1987, 13: Walsh PC. Campbell s Urology. 8th ed. W.B. Saunders, Vol 4, E.David. Prostate Cancer Annual Update 2005 CCO, 2005,. 9. G. Aus, C.C. Abbou, M. Bolla. EAU Guidelines On Prostate Cancer, D. Andrew Loblaw, David S. Mendelson, James A. Talcott, et al. American Society of Clinical Oncology Recommendations for the Initial Hormonal Management of Androgen-Sensitive Metastatic, Recurrent, or Progressive Prostate Cancer. Journal of Clinical Oncology, 2004, 15: Peter T. Scardino, Mitchell Anscher, Alan Pollack. Prostate Cancer. NCCN Clinical Practice Guidelines in Oncology v Richard G, Rober P, Claus G, et al. AUA: the management of clinically localized prostate cancer Zelefsky MJ, Fuks Z, Hunt M, et al. High dose intensity modulated radiation therapy for prostate cancer: early toxicity and biochemical outcome in 772 patients. Int J Radiat Oncol 53

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62 print Huggins Hodges LHRH-A 1 [1] (1) N 1 M 1 (2) (3) (4) (5) (6) (7) 2 (castration) 62

63 (1) (2) LHRH-a leuprorelin goserelin triptorelin LHRH-a 1 3~4 [2] 10 [3] LHRH-a LHRH-a 2, 2 flare-up [4] LHRH-a (3) LHRH Leydig [5] 1mg/d 3mg/d 5mg/d 1mg/d 1mg/d mg/d [6] 3 maximal androgen blockade, MAB (1) (2) (bicalutamide) (flutamide) (3) MAB 3~ % [7] MAB PSA [8] MAB 63

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