修訂內容頁數原文修訂 / 新增第 1 頁第 7 頁第 7 頁第 12 頁第 13 頁第 14 頁前言.. Practice Guide-lines in Prostate Cancer V 版攝護腺癌治療指引 : 局部侵犯性腫瘤 T3~4 期攝護腺癌治療指引 : 2012 年

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1 中山醫學大學附設醫院攝護腺癌診療指引臨床指引參考台灣國家衛生研究院與美國 NCCN 版本再依據中山醫學大學附設醫院泌尿道癌小組經驗作編修泌尿道癌醫療小組癌症委員會主任委員癌症委員會執行長癌症防治中心主任團隊負責人

2 修訂內容頁數原文修訂 / 新增第 1 頁第 7 頁第 7 頁第 12 頁第 13 頁第 14 頁前言.. Practice Guide-lines in Prostate Cancer V 版攝護腺癌治療指引 : 局部侵犯性腫瘤 T3~4 期攝護腺癌治療指引 : 2012 年預期餘命依據內政部的男性簡易生命表為 76.4 歲放射治療及化學治療處置 : Definitive radiotherapy : (1) 70~81 Gy, IMRT/IGRT preferred. Principles of chemotherapy.. Docetaxel + Prednisolone Docetaxel 3 mg/m2 d1,8,15,22,29 標題..另類療法前言..修訂為 Practice Guide-lines in Prostate Cancer V 版攝護腺癌治療指引 : 修訂為局部侵犯性腫瘤 T3~4 期或 N1 攝護腺癌治療指引 : 修訂為 2015 年預期餘命依據內政部的男性簡易生命表為 77.0 歲放射治療及化學治療處置 : 修訂為 Definitive radiotherapy : (1) 75~81 Gy, IMRT/IGRT preferred. Principles of chemotherapy..修訂為 Docetaxel + Prednisolone Docetaxel 30 mg/m2 d1,8,15,22,29 標題..修訂為其他療法

3 目錄一前言 P.1 二症狀診斷和檢查 P.2 三組織病理分類與分化 P.3 四分期 P.4 五攝護腺癌臨床指引 P.6 六根除性攝護腺切除手術治療後之輔助治療 P.10 七根除性攝護腺切除手術治療後復發之救援處置 P.12 八放射治療後復發之救援處置 P.14 九放射治療及化學治療處置 P.11 十其他療法 P.14 十一安寧緩和照護原則 P.14 十二參考文獻 P.14

4 一前言本共識手冊內所提之各種診治意見, 為原則性之建議, 希望能為癌症患者及其家屬提供一個正確的指引 ; 但對臨床醫師之醫療行為無絕對之法律性約束力! 由於醫藥科技持續在進步, 每位患者的病情亦不盡相同 ; 醫師應就病人之病情做個別的考量, 病人和家屬亦應與醫師溝通討論, 以決定最適當之診治方式據行政院衛生署的統計, 前列腺癌的發生率與死亡率近年來均呈逐年增加之現象 ;2012 年死亡排名佔男性癌症的第 7 位本院登錄攝護腺惡性腫瘤 5 年個案數近為 240 例, 發病年齡在 65 歲以上明顯增加, 在 80 歲以上的組距佔最大族群隨著老年化人口的來臨, 攝護腺惡性腫瘤的篩檢顯得的格外重要隨著篩檢工具 ( 攝護腺特定抗原 PSA 檢測 ) 的準確率提高, 病患健康意識的提昇, 將來攝護腺癌的發生率必將持續增加, 也因此本院積極整合泌尿外科病理科腫瘤內科醫學影像部與放射腫瘤科以堅強的團隊, 提供攝護腺癌有效的預防與全方位的治療本院治療攝護腺 ( 前列腺 ) 惡性腫瘤具有相當優異成果, 於民國 90 年成為中部第一所完成攝護腺組織插種近接治療單位, 日前更引進先進且精準的光子刀 / 亞瑟刀放射定位治療儀器 ; 在微創 ( 局部 ) 治療部分, 也陸續引進海福刀 (HIFU) 及冷凍療法 (Cryotherapy) 本團隊目的是整合現有人力資源研究計劃臨床詴驗空間設備針對攝護腺癌做完善的的診斷及治療本攝護腺癌診斷及治療指引的建立, 除了依據已發表的實證醫學證據及專家意見外, 並參考國家衛生研究院攝護腺癌臨床指引美國 National Comprehensive Cancer Network (NCCN) 的 Practice Guide-lines in Prostate Cancer V 版及中山醫學大學附設醫院攝護腺癌治療經驗進行編修 1

5 二症狀診斷和檢查攝護腺癌在初期很少有症狀, 多半都是在腫瘤較大且壓迫到膀胱或尿道時, 才會出現像頻尿, 解尿困難, 排尿時有疼痛及燒灼的感覺, 甚至解血尿不過由於良性的攝護腺肥大也會有類似的症狀產生, 所以有時也很難以這些症狀來判斷是否罹患攝護腺癌攝護腺癌發生遠端轉移的時候, 最常轉移到骨骼, 此時多半會引起骨頭疼痛, 或壓迫神經引起神經痛的症狀, 嚴重的話, 還會有病理性骨折的情形要診斷攝護腺癌, 首先要詳細的詢問病史, 並要進行完整的身體檢查及評估, 這些檢查包括 : (1) 肛門指檢 : 直腸就在攝護腺的後側, 所以醫師可以用食指經肛門放入病人的直腸, 來觸診攝護腺, 這樣的檢查就稱為肛門指檢正常的攝護腺應該是柔軟有彈性的, 如同握拳時大姆指旁虎口的肌肉, 而攝護腺癌觸摸起來卻是如結節般的硬塊, 甚至硬如石頭但如果遇到攝護腺肥大攝護腺發炎攝護腺結石或做過經尿道攝護腺切除手術及切片的病人, 則肛門指檢就不易判讀 (2) 攝護腺特異抗原 (prostate specific antigen, 簡稱 PSA): 這是一種攝護腺產生的蛋白質, 其生理功能是使射精後的精液液化, 可能有助於精子游走和授孕攝護腺的上皮細胞與癌細胞都會分泌 PSA, 但癌細胞會分泌數倍以上的量血中 PSA 的正常值是小於 4.0 ng/ml, 若抽血檢驗 PSA 大於正常值, 就要懷疑有攝護腺癌的可能但由於攝護腺肥大攝護腺發炎肛門指檢導尿管的置放膀胱鏡的檢查經直腸超音波檢查及攝護腺的切片, 都會使 PSA 有不同程度的升高, 所以一旦發現病人有 PSA 升高的情形, 必頇先排除其他非攝護腺癌所引起的 PSA 升高因素, 才能下診斷 (3) 經直腸攝護腺超音波檢查 : 由於攝護腺是深埋在人體的一個小器官, 一般的 X 光只能看到外形的影子, 而肛門指診有時又會有人為因素的誤差, 因此就發展出經直腸超音波檢查, 可由距離攝護腺最近的位置直接掃描, 觀察攝護腺的變化當發現病灶時, 還可藉由超音波的引導, 將病變切片送檢查, 但切片正常, 並不一定代表就沒有癌症, 有可能是因為切片採樣時沒有取到病變細胞 (4) 電腻斷層及核磁共振攝影 : 為了確實了解病灶與鄰近器官的關係, 可以做電腻斷層及核磁共振攝影, 較清楚的評估骨盆腔內的淋巴結, 及其他器官是否有被癌細胞侵犯 (5) 其他 : 倘若懷疑有骨頭的轉移, 還要做骨骼掃描, 或是胸部 X 光檢查, 以觀察是否有肺部轉移 2

6 三組織病理分類與分化攝護腺癌的分類還可根據癌細胞分化程度來區隔, 稱格里森分級系統 * 格里森分級系統 (Gleason grading system): 此為攝護腺癌分級中最常使用的分級系統, 此系統是將腫瘤標本置於顯微鏡下, 依據細胞分化的成熟度將其分成 1~5 級, 分化最成熟的為 1 級, 分化最不成熟的則為 5 級 ; 而考慮攝護腺癌的多發性以及客觀評估預後, 此系統從攝護腺癌組織切片中, 取前二大面積者的級數相加而成格里森分數 (2~10) (Gleason score) 格里森分數在 7 以上的病人預後明顯比格里森分數在 6 以下的病人來得差 3

7 四臨床分期與病理分期臨床 T 期可依肛門指診及影像學檢查來評估腫瘤是否於攝護腺包膜內 (T1, T2) 或包膜外 (T3,T4) 分期目標 :(1) 評估預後 (2) 引導治療方向 (3) 不同治療方式的比較基準 TNM staging system 為採用 AJCC 2010 出版的第七版 TX T0 T1 T1a T1b T1c Primary tumor cannot be assessed No evidence of primary tumor PRIMARY TUMOR (T) Clinically inapparent tumor neither palpable nor visible by imaging Tumor incidental histologic finding in 5% or less of tissue resected Tumor incidental histologic finding in more than 5% of tissue resected Tumor identified by needle biopsy (e.g., because of elevated PSA) T2 Tumor confined within prostate* pt2 Organ confined T2a Tumor involves one-half of one lobe or less pt2a Unilateral, one-half of one side or less T2b Tumor involves more than one-half of one lobe but not both lobes pt2b Unilateral, involving more than one-half of side but not both sides T2c Tumor involves both lobes pt2c Bilateral disease T3 Tumor extends through the prostate capsule** pt3 Extraprostatic extension T3a Extracapsular extension (unilateral or bilateral) pt3a Extraprostatic extension or microscopic invasion of bladder neck*** T3b Tumor invades seminal vesicle(s) pt3b Seminal vesicle invasion T4 Tumor is fixed or invades adjacent structures other than seminal vesicles: such as external sphincter, rectum, bladder, levator muscles, and/or pelvic wall pt4 Invasion of rectum, levator muscles and/or pelvic wall 4

8 NX N0 N1 M0 M1 REGIONAL LYMPH NODES (N) Regional lymph nodes were Regional nodes not pnx not assessed sampled No regional lymph node No positive regional pn0 metastasis nodes Metastasis in regional lymph Metastases in regional pn1 node(s) node(s) DISTANT METASTASIS (M) No distant metastasis Distant metastasis M1a Non-regional lymph node(s) M1b Bone(s) M1c Other site(s) with or without bone disease Anatomic Stage.Prognostic Groups CLINICAL PATHOLOGIC Group T N M PSA Gleason T1a-c N0 M0 PSA < 10 Gleason 6 I T2a N0 M0 PSA < 10 Gleason 6 T1-2a N0 M0 PSA X Gleason X T1a-c N0 M0 PSA < 20 Gleason 7 T1a-c N0 M0 PSA 10 < 20 Gleason 6 IIA T2a N0 M0 PSA < 20 Gleason 7 T2b N0 M0 PSA < 20 Gleason 7 T2b N0 M0 PSA X Gleason X T2c N0 M0 Any PSA Any Gleason IIB T1-2 N0 M0 PSA 20 Any Gleason T1-2 N0 M0 Any PSA Gleason 8 III T3a-b N0 M0 Any PSA Any Gleason T4 N0 M0 Any PSA Any Gleason IV Any T N1 M0 Any PSA Any Gleason Any T Any N M1 Any PSA Any Gleason 5

9 五攝護腺癌臨床指引初步診斷臨床分期之檢查復發風險主要檢查肛門指診血清攝護腺特定抗原 (PSA) 預期餘命 5 年且無症狀暫不予檢查及治療直至症狀出現臨床局限性腫瘤非常低 / 低度復發風險 : T1-2a 期及 Gleason score 2-6 分及 PSA< 10 ng/ml 其中任何一項異常者, 應接受攝護腺切片檢查, 以確定診斷, 並判定 Gleason score 高風險病患或預期餘命 >5 年或有症狀 ± 胸部 X 光 ± 骨骼掃瞄 ± 骨盆腔電腻斷層或磁振造影中度復發風險 : T2b-2c 期或 Gleason score 7 分或 PSA >10-20 ng/ml 非常高 / 高度復發風險 : T3a 期或 Gleason score 8-10 分或 PSA >20 ng/ml 臨床侵犯性腫瘤 T3b-4 期腫大之淋巴結視需要可做細針抽吸細胞學 ( 或活體切片 ) 檢查或腹腔鏡淋巴結切除術轉移性腫瘤任何 T 期,N1 任何 T 期, 任何 N 期,M1 6

10 臨床期別 ( 復發風險 ) 預期餘命初步治療非常低 / 低度復發風險 <10 年積極監視 ( 暫不予治療, 定期 PSA 與 DRE 檢查 ) T1-2a 期及 Gleason score 6 分及 PSA<10 ng/ml 10 年積極監視 ( 暫不予治療, 定期 PSA 與 DRE 檢查, 視需要得重覆切片檢查 ) 或放射線治療 ± 組織插腫近接治療或根除性攝護腺切除手術 + 骨盆腔淋巴結 ( 切除 ) 擴清術臨床局限性腫瘤中度復發風險 T2b-2c 期或 Gleason score 7 分或 PSA10-20 g/ml <10 年 10 年積極監視 ( 暫不予治療, 定期 PSA 與 DRE 檢查, 視需要得重覆切片檢查 ) 或放射線治療 ±4-6 個月前置 / 伴隨 / 輔助性荷爾蒙治療 ± 組織插種近接治療根除性攝護腺切除手術 + 骨盆腔淋巴結 ( 切除 ) 擴清術或放射線治療 ±4-6 個月前置 / 伴隨 / 輔助性荷爾蒙治療 ± 組織插種近接治療非常高 / 高度復發風險 T3a 期或 Gleason score 8-10 分或 PSA>20 ng/ml 放射線治療 ± 2-3 年前置 / 伴隨 / 輔助性荷爾蒙治療或根除性攝護腺切除手術 + 骨盆腔淋巴結 ( 切除 ) 擴清術 ( 選擇性患者 ) 或荷爾蒙治療局部侵犯性腫瘤 T3b-4 期或 N1 放射線治療 ± 2-3 年前置 / 伴隨 / 輔助性荷爾蒙治療或根除性攝護腺切除手術 + 骨盆腔淋巴結 ( 切除 ) 擴清術 ( 選擇性患者 ) 或 ( 長期 ) 荷爾蒙治療轉移性腫瘤任何 T 期,N1,M0 任何 T 期, 任何 N 期,M1 ( 長期 ) 荷爾蒙治療或放射線治療 + 荷爾蒙治療 ( 長期 ) 荷爾蒙治療 + 緩解性放射治療年預期餘命依據內政部的男性簡易生命表為 77.0 歲

11 六根除性攝護腺切除手術治療後之輔助治療初步治療病理狀況輔助治療手術邊緣侵犯或包膜外侵犯或儲精囊侵犯追蹤觀察 ( 暫不予治療 ) 或放射治療根除性攝護腺切除手術 + 骨盆腔淋巴結切除術 PSA (<10ng/ml) PSA (>10 ng/ml) 追蹤觀察後續輔助治療淋巴結轉移荷爾蒙治療 ± 放射治療或追蹤觀察 ( 暫不予治療 ) 8

12 七根除性攝護腺切除手術治療後復發之救援處置復發情況救援檢查與評估初步救援治療無遠端轉移放射線治療 ± ( 前置 / 伴隨 / 輔助 ) 荷爾蒙治療或荷爾蒙治療或追蹤觀察 ( 暫不治療 ) PSA 可偵測 ( 0.04) 或連續兩次追蹤 PSA 上昇 ± 骨骼掃描 ± 骨盆電腻斷層或磁振造影檢查 ± 切片檢查 ±PSADT t log2/[log(psa2)- log(psa1)] 有遠端轉移 ± 緩解性放射線治療荷爾蒙治療或追蹤觀察 ( 暫不治療 ) 9

13 八放射治療後復發之救援處置復發情況救援檢查與評估初步救援治療切片陽性追蹤觀察或根除性攝護腺切除手術冷凍治療或視部位組織插種近接治療放射治療後核醫 PSA 升高 ( 最低值後上昇 2.0) 適合接受局部治療 * 初診斷臨床期別 T1-2, Nx 或 N0 * 預期餘命 >10 年 * 目前 PSA<10 ng/ml 骨骼掃描 ± 骨盆電腻斷層 ± 磁振造影檢查 ± 切片檢查無遠端轉移有遠端轉移切片陰性追蹤觀察或荷爾蒙治療或臨床詴驗治療荷爾蒙治療 ± 緩解性放射治療不適合接受局部治療追蹤觀察或荷爾蒙治療 10

14 擴散性疾病全身性治療全身性救援治療轉移性病灶及血清 PSA 升高未曾接受過荷爾蒙治療睪丸切除或單獨使用 LHRH 類似藥物 ± 7 天抗男性荷爾蒙藥物或合併男性荷爾蒙藥物去除治療 (Combined Androgen blockade,cab) 復發繼續服用荷爾蒙藥物治療或全身性化學治療或支持性療法 (Palliative R/T, BISPHOSPHONATE 類藥物 ) 或臨床詴驗用藥內臟或蝕骨性轉移且血清 PSA 偏低或快速進展的軟組織腫塊切片檢查無神經內分泌分化 ( 有或無小細胞特徵 ) 有神經內分泌分化 ( 有或無小細胞特徵 ) 與上述轉移性病灶治療相同化學治療或臨床詴驗用藥 11

15 九放射治療及化學治療處置 Principle of Sandwich Neoadjuvant androgen ablation + radiotherapy*+adjuvant androgen ablation Principles of radiation Selective adjuvant radiotherapy * : If margin positive /residual or LN positive,dose of 64~72Gy depended on the tumor position and the patient condition Definitive radiotherapy : (1) 75~81 Gy, IMRT/IGRT preferred. (2) high-dose-rate (HDR) interstitial brachytherapy Gy plus 45~55 Gy IMRT/IGRT could be considered for T1a~T2b Radiotherapy **: For primary recurrence : 65~76 Gy, IMRT/IGRT preferred. For distant metastasis : 20~40 Gy. Radiotherapy# : palliative radiotherapy:20~40 Gy 12

16 Principles of chemotherapy Docetaxel + Prednisolone Docetaxel 75 mg/m2 d1 Prednisolone 10mg/day Q3w Berthold DR et al. Docetaxel plus prednisone or mitoxantrone plus prednisone for advanced prostate cancer: updated survival in the TAX 327 study. J Clin Oncol 2008; 26:242 (link to the article). Docetaxel + Prednisolone Docetaxel 30 mg/m2 d1,8,15,22,29 Prednisolone 10mg/day Q6w Tannock IF et al. Docetaxel plus prednisone or mitoxantrone plus prednisone for advanced prostate cancer. N Eng J Med 2004; 351:1502. Mitoxantrone + Prednisone Mitoxantrone 12 mg/m2 d1 Prednisolone 10mg/day Q3w Tannock IF et al. Docetaxel plus prednisone or mitoxantrone plus prednisone for advanced prostate cancer. N Eng J Med 2004; 351:

17 十其他療法 Cryosurgical ablation of the prostate(csap) and high-intensity focussed ultrasound(hifu) have emerged as alternative therapeutic options in patients with clinically localised PCa who are not suitable for RP. The following factors might be indications: low-or intermediate-risk PCa and prostate size<40ml at the time of therapy. 十一安寧緩和照護原則若預期疾病難以治癒時, 病人存活期小於 6 個月便適合安寧療護 (Pomeranz & Brustman, 2005;Waldrop & Rinfrette, 2009) 若藉由症狀檢驗數據及確切的腫瘤診斷, 證實臨床上該惡性腫瘤已經廣泛侵犯或進展快速 ; 功能分數 (Palliative Performance Scale) 低於 70%; 拒絕進一步腫瘤治癒性治療, 或者在治療之下仍持續惡化者, 即可轉介緩和醫療團隊 ( 彭等,2006) 十二參考文獻 1. 衛生服利部全國衛生統計資訊網 (Health and National Health Insurance Annual Statistics Information Service): 民國 104 年國人主要死因統計資料 2. 國家衛生研究院 ; 攝護腺癌臨床指引 3. US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research 1992, p NCCN Clinical Practice Guidelines in Oncology Prostate Cancer,Version H.J. De Koning, M.K. Liem, C.A. Baan, R. Boer, F.H. Schroder and F.E. Alexander, Prostate cancer mortality reduction by screening: power and time frame with complete enrolment in the European Randomized Screening for Prostate Cancer (ERSPC) trial, Int J Cancer 98 (2002), pp

18 6. H.-P. Schmid, W. Riesen and L. Prikler, Update on screening for prostate cancer with prostate specific antigen, Crit Rev Oncol Hematol 50 (2004), pp G. Aus, C. Becker, S. Franzén, H. Lilja, P. Lodding and J. Hugosson, Cumulative prostate cancer risk assessment with the aid of the free-to-total prostate specific antigen ratio, Eur Urol 45 (2004), pp I.M. Thompson, D.K. Pauler and P.J. Goodman et al., Prevalence of prostate cancer among men with a prostatespecific antigen level 4.0 ng per milliliter, N Engl J Med 350 (2004), pp detection in men aged <50 years, BJU Int 99 (2007), pp G.W. Chodak, R.A. Thisted, G.S. Gerber, J.E. Johansson, J. Adolfsson, G.W. Jones, G.D. Chisholm, B. Moskovitz, P.M. Livne and J. Warner, Results of conservative management of clinically localized prostate cancer, N Engl J Med 330 (1994), pp P.C. Albertsen, J.A. Hanley, D.F. Gleason and M.J. Barry, Competing risk analysis of men aged 55 to 74 years at diagnosis managed conservatively for clinically localized prostate cancer, JAMA 280 (1998), pp Full Text via CrossRef View Record in Scopus Cited By in Scopus (394) 11. L. Klotz, Active surveillance for prostate cancer: for whom?, J Clin Oncol 23 (2005), pp Full Text via CrossRef View Record in Scopus Cited By in Scopus (129) 12. L. Zhang, A. Loblaw and L. Klotz, Modeling prostate specific antigen kinetics in patients on active surveillance, J Urol 176 (2006), pp A. Bill-Axelson, L. Holmberg and M. Ruutu et al., Scandinavian Prostate Cancer Group study no. 4: radical prostatectomy versus watchful waiting in early prostate cancer, N Eng J Med 352 (2005), pp A. Heidenreich, C.H. Ohlmann and S. Polyakov, Anatomical extent of pelvic lymphadenectomy in patients undergoing radical prostatectomy, Eur Urol 52 (2007), pp S. Joniau, C.-Y. Hsu and E. Lerut et al., A pretreatment table for the prediction of final histopathology after radical prostatectomy in clinical unilateral T3a prostate cancer, Eur Urol 51 (2007), pp J.F. Ward, J.M. Slezak, M.L. Blute, E.J. Bergstralh and H. Zincke, Radical prostatectomy for clinically advanced (ct3) prostate cancer since the advent of prostate-specific antigen testing: 15-year outcome, BJU Int 95 (2005), pp Kumar S, Shelley M, Harrison C, Coles B, Wilt TJ, Mason MD. Neo-adjuvant and adjuvant hormone therapy for 15

19 localised and locally advanced prostate cancer. Cochrane Database Syst Rev 2006;CD D.G. McLeod, P. Iversen, W.A. See, T. Morris, J. Armstrong, M.P. Wirth and Casodex Early Prostate Cancer Trialists Group, Bicalutamide 150 mg plus standard care vs standard care alone for early prostate cancer, BJU Int 97 (2006), pp E.M. Messing, J. Manola and J. Yao et al., Eastern Cooperative Oncology Group study EST 3886: immediate versus deferred androgen deprivation treatment in patients with node-positive prostate cancer after radical prostatectomy and pelvic lymphadenectomy, Lancet Oncol 7 (2006), pp P. Kupelian, D. Kuban and H. Thames et al., Improved biochemical relapse-free survival with increased external radiation doses in patients with localized prostate cancer: the combined experience of nine institutions in patients treated in 1994 and 1995, Int J Radiat Oncol Biol Phys 61 (2005), pp A. Pollack, G.K. Zagars and L.G. Smith et al., Preliminary results of a randomized radiotherapy dose-escalation study comparing 70 Gy with 78 Gy for prostate cancer, J Clin Oncol 18 (2000), pp View Record in Scopus Cited By in Scopus (315) 22. M. Bolla, L. Collette and L. Blank et al., Long-term results with immediate androgen suppression and external irradiation in patients with locally advanced prostate cancer (an EORTC study): a phase III randomised trial, Lancet 360 (2002), pp M. Bolla, D. Gonzalez and P. Warde et al., Improved survival in patients with locally advanced prostate cancer treated with radiotherapy and goserelin, N Engl J Med 337 (1997), pp D. Ash, A. Flynn, J. Batterman, T. de Reijke, P. Lavagnini, L. Blank and ESTRA/EAU Urological Brachytherapy Group, EORTC Radiotherapy Group, ESTRO/EAU/EORTC recommendations on permanent seed implantation for localized prostate cancer, Radiother Oncol 57 (2000), pp S. Machtens, R. Baumann and J. Hagemann et al., Long-term results of interstitial brachytherapy (LDR-brachytherapy) in the treatment of patients with prostate cancer, World J Urol 24 (2006), pp D. Bottke and T. Wiegel, Adjuvant radiotherapy after radical prostatectomy: indications, results and outcome, Urol Int 78 (2007), pp Full Text via CrossRef View Record in Scopus Cited By in Scopus (9) 27. G. Aus, Current status of HIFU and cryotherapy in prostate cancer a review, Eur Urol 50 (2006), pp

20 28. J. Seidenfeld, D.J. Samson and V. Hasselblad et al., Single-therapy androgen suppression in men with advanced prostate cancer: a systematic review and meta-analysis, Ann Intern Med 132 (2000), pp D.J. Samson, J. Seidenfeld and B. Schmitt et al., Systematic review and meta-analysis of monotherapy compared with combined androgen blockade for patients with advanced prostate carcinoma, Cancer 95 (2002), pp D.A. Loblaw, K.S. Virgo and R. Nam et al., Initial hormonal management of androgen-sensitive metastatic, recurrent, or progressive prostate cancer: 2006 update of an American Society of Clinical Oncology practice guideline, J Clin Oncol 25 (2007), pp M. Hussain, C.M. Tangen and C. Higano et al., Absolute prostate-specific antigen value after androgen deprivation is a strong independent predictor of survival in new metastatic prostate cancer data from Southwest Oncology Group Trial 9346 (INT-0162), J Clin Oncol 24 (2006), pp View Record in Scopus Cited By in Scopus (59) 32. J.W. Moul, H. Wu and L. Sun et al., Early versus delayed hormonal therapy for prostate specific antigen only recurrence of prostate cancer after radical prostatectomy, J Urol 171 (2004), pp M.S. Cookson, G. Aus and A.L. Burnett et al., Variation in the definition of biochemical recurrence in patients treated for localized prostate cancer: the American Urological Association Prostate Guidelines for localized prostate cancer update panel report and recommendations for a standard in the reporting of surgical outcomes, J Urol 177 (2007), pp M. Roach III, G. Hanks and H. Thames Jr. et al., Defining biochemical failure following radiotherapy with or without hormonal therapy in men with clinically localized prostate cancer: recommendations of the RTOG-ASTRO Phoenix Consensus Conference, Int J Radiat Oncol Biol Phys 65 (2006), pp G.J. Bubley, M. Carducci and W. Dahut et al., Eligibility and response guidelines for phase II clinical trials in androgen-independent prostate cancer: recommendations from the Prostate-Specific Antigen Working Group, J Clin Oncol 17 (1999), pp C.J. Ryan and E.J. Small, Role of secondary hormonal therapy in the management of recurrent disease, Urology 62 (Suppl 1) (2003), pp D.P. Petrylak, C.M. Tangen and M.H. Hussain et al., Docetaxel and estramustine compared with mitoxantrone and prednisone for advanced refractory prostate cancer, N Engl J Med 351 (2004), pp

21 38. I.F. Tannock, R. de Wit and W.R. Berry et al., TAX 327 Investigators. Docetaxel plus prednisone or mitoxantrone plus prednisone for advanced prostate cancer, N Engl J Med 351 (2004), pp F. Saad, D.M. Gleason and R. Murray et al., A randomized, placebo-controlled trial of zoledronic acid in patients with hormone-refractory metastatic prostate carcinoma, J Natl Cancer Inst 94 (2002), pp Berthold DR et al. Docetaxel plus prednisone or mitoxantrone plus prednisone for advanced prostate cancer: updated survival in the TAX 327 study. J Clin Oncol 2008; 26:242 (link to the article). 41. Tannock IF et al. Docetaxel plus prednisone or mitoxantrone plus prednisone for advanced prostate cancer. N Eng J Med 2004; 351: NCCN Clinical Practice Guidelines in Oncology Prostate Cancer,Version M Perera, N Krishnananthan, U Lindner and N Lawrentschuk. An update on focal therapy for prostate cancer. NATURE REVIEWS/UROLOGY. VOLUME 13 (2016); pp W.V.D Bos, Berrend G, Muller, H Ahmed et al. Focal Therapy in Prostate Cancer: International Multidisciplinary Consensus on Trial Design. EUROPEAN UROLOGY 65 (2014); pp A Marien, I Gill, O Ukimura. Target ablation Image-guided therapyinprostatecancer. Urologic Oncology: SeminarsandOriginalInvestigations 32(2014);

22 攝護腺癌 Stage IV 完治率定義 STAGE IV 荷爾蒙治療以 3 個月為基準若追蹤 serum PSA 下降算完治 STAGE IV 放射治療一個療程算完治接受安寧緩和算完治 19

,096 [1] ~4 45~ [2] 5. [3] 家庭醫學與基層醫療第八期 209

,096 [1] ~4 45~ [2] 5. [3] 家庭醫學與基層醫療第八期 209 家庭醫業前言概論 7 1 101 6 100 4 2, 5 5 9 28% 183.5 1,096 2.6% 6.4 [1] 嘉醫診所院長 prostate Ca 65~75 20 80 2.2233 85 4.2463 90 6.1 693 95 8. 3 957 98 208 家庭醫學與基層醫療第八期 8. 0 9 3 6 1 0 0 9. 4 1,096 [1] 1. 50 65 2.

修訂內容 頁數原文修訂 / 新增 第 1 頁第 7 頁第 7 頁第 12 頁第 13 頁第 14 頁 前言.. Practice Guide-lines in Prostate Cancer V 版 攝護腺癌治療指引 : 局部侵犯性腫瘤 T3~4 期 攝護腺癌治療指引 : 2012 年

修訂內容頁數原文修訂 / 新增第 1 頁第 7 頁第 7 頁第 12 頁第 13 頁第 14 頁前言.. Practice Guide-lines in Prostate Cancer V 版攝護腺癌治療指引 : 局部侵犯性腫瘤 T3~4 期攝護腺癌治療指引 : 2012 年