KIDNEY CANCER

2. ﾍﾒｨｨﾐｾｺﾍﾒ｡ﾒﾃ犹ﾗ靉ｧｨﾒ｡｡ﾒﾃ｡ﾃﾐｨﾒﾂ｢ﾍｧﾁﾐ狹遘莉ｷﾕ襍ﾓ睛ｹ隗ﾍﾗ雹爼雹｡ﾒﾃ｡ﾃﾐｨﾒﾂ｢ﾍｧﾁﾐ狹遘莉ｷﾕ霆ﾍｴ, ｡ﾃﾐｴﾙ｡, ｵﾑｺ, ﾊﾁﾍｧ眷ﾐｵﾓ睛ｹ隗ﾍﾗ雹ｫﾖ隗ｾｺ莇鱠ﾁ霄靉ﾂｹﾑ｡莇鱆｡・ｼﾔﾇﾋｹﾑｧ, ｶﾘｧｹ鰌ｴﾕ, iris, epididymis, corpus cavernosum

3. ﾍﾒ｡ﾒﾃ犹ﾗ靉ｧｨﾒ｡ Paraneoplastic syndrome, ｻﾃﾐﾁﾒｳ 30% ｢ﾍｧｼﾙ鮟霽ﾂｨﾐﾁﾕﾍﾒ｡ﾒﾃ｢ﾍｧ Paraneoplastic

syndrome 莇鱆｡・anemia, erythrocytosis, thrombocytosis, hypertension, hypercalcemia, gynecomastia,

Cushing痴 syndrome, nephrotic syndrome, amyloidosis, polymyositis, dermatomyositis and hepatic

dysfunction without metastases (Stauffer痴 syndrome)

｡ﾃﾐｺﾇｹ｡ﾒﾃﾇﾔｹﾔｨｩﾑﾂ

1. Urinalysis ｨﾐｾｺ狠邏倏ﾗﾍｴ盒ｧ羯ｻﾑﾊﾊﾒﾇﾐﾁﾒ｡｡ﾇ靨 50% 盞鞴ﾁ鞨ｩｾﾒﾐ爲ﾒﾐｨｧ

2. Urine cytology ｼﾅｷﾕ鞴ｴ鬢靉ｹ｢鰓ｧｹ鯱ﾂ

3. Intravenous pyelogram (IVP) ﾊﾒﾁﾒﾃｶｺﾍ｡ｶﾖｧ｡鯱ｹｷﾕ靉ﾂﾙ霄ﾃﾔ猊ｳ莊莇・盞鞴ﾁ靆ﾒﾁﾒﾃｶｺﾍ｡｢ｹﾒｴ, ｵﾓ睛ｹ隗,

ﾅﾑ｡ﾉｳﾐﾀﾒﾂ羯｡鯱ｹ莇鬪ﾑｴ爲ｹ

4. Ultrasound ﾊﾒﾁﾒﾃｶ眥｡ﾃﾐﾋﾇ靨ｧｶﾘｧｹ鰌眷ﾐ｡鯱ｹ犹ﾗ鯱莇・/P>

5. CT scan 狃郢ﾇﾔｸﾕ｡ﾒﾃｷﾕ霖ﾕ sensitivity 眷ﾐ specificity ﾊﾙｧﾁﾒ｡, accuracy ｻﾃﾐﾁﾒｳ 90% 眷ﾐﾂﾑｧﾊﾒﾁﾒﾃｶｪ霽ﾂ

羯｡ﾒﾃｺﾍ｡ｶﾖｧﾃﾐﾂﾐ｢ﾍｧ篥､箒ﾂｴﾙ capsular extension, nodal metastases, renal vein invasion, bony and

hepatic metastases

6. Renal angiography ｹﾔﾂﾁ罨鱚ｹﾍｴﾕｵｫﾖ隗ﾂﾑｧ菽霖ﾕ CT scan 羯ｻﾑｨｨﾘｺﾑｹﾂﾑｧﾁﾕ｡ﾒﾃ罨鯱ﾂﾙ霄鰓ｧ｡靉ｹ｡ﾒﾃｼ靨ｵﾑｴ狎ﾗ靉

耆鯏ﾙ鮓ﾖｧｵﾓ睛ｹ隗｢ﾍｧ猝鮖倏ﾗﾍｴﾋﾃﾗﾍﾍﾒｨｨﾐｷﾓ renal artery embolization 狎ﾗ靉ﾅｴ｡ﾒﾃ猝ﾕﾂ倏ﾗﾍｴﾃﾐﾋﾇ靨ｧｼ靨ｵﾑｴ

7. MRI ﾁﾕ sensitivity 眷ﾐ specificity 犢靨犢ﾕﾂﾁ｡ﾑｺ CT scan ﾁﾕｻﾃﾐ篦ｪｹ・ﾋｹﾗﾍ｡ﾇ靨 CT scan ､ﾗﾍﾊﾒﾁﾒﾃｶﾊﾃ鰓ｧﾀﾒｾ

羯盪ﾇ sagittal 眷ﾐｴﾙ vascular anatomy 莇魘ﾕ｡ﾇ靨, 菽襍鯱ｧ罨・iodinated contrast ｫﾖ隗猴ﾁﾒﾐ癸霈ﾙ鮟霽ﾂｷﾕ鞦ｾ・莽簣ｴﾕｹ盞霖ﾕ｢鯱ｴ鯱ﾂ｡ﾇ靨 CT ､ﾗﾍﾃﾒ､ﾒ眄ｧ｡ﾇ靨, ﾍﾒｨｨﾐﾁﾕ motion artifact, ｴﾙ calcification 莇鱠ﾁ雍ﾕ

8. Biopsy ﾍﾒｨｨﾐ罨・fluoroscopic, ultrasound, ﾋﾃﾗﾍ CT-guided

ﾅﾑ｡ﾉｳﾐｷﾒｧｾﾂﾒｸﾔﾇﾔｷﾂﾒ

- ﾊﾓﾋﾃﾑｺ Renal cell carcinoma ﾍﾒｨｨﾐﾁﾕｪﾗ靉狹ﾕﾂ｡ﾍﾂ靨ｧﾍﾗ雹ﾍﾕ｡ﾋﾅﾒﾂｪﾗ靉爼雹 Renal adenocarcinoma,

clear cell carcinoma, hypernephroma 眷ﾐ Grawitz tumor ｵﾓ睛ｹ隗ｷﾕ鞨｡ﾔｴﾁﾑ｡ｨﾐﾍﾂﾙ霍ﾕ・cortex ｢ﾍｧ莊ｫﾖ隗爼ﾗ靉｡ﾑｹﾇ靨

爍ﾔｴﾁﾒｨﾒ｡ proximal convoluted tubule cell

- Grading 蘯隗莇魘ﾑｧｹﾕ・/P>

1. Well differentiated ｾｺｻﾃﾐﾁﾒｳ 45%

2. Moderately differentiated ｾｺｻﾃﾐﾁﾒｳ 36%

3. Poorly differentiated ｾｺｻﾃﾐﾁﾒｳ 18%

- ﾊﾓﾋﾃﾑｺﾁﾐ狹遘｢ﾍｧ renal pelvis ﾊ霽ｹ耆ｭ險ﾐ狃郢 transitional cell type

｡ﾒﾃ蘯隗ﾃﾐﾂﾐ｢ﾍｧ篥､ｵﾒﾁ TNM classification

T₁ £ 2.5 cm/ limited to kidney

T₂ > 2.5 cm/ limited to kidney

T₃ a) Perinephric invasion

b) Major veins invasion

T₄ Invades beyond Gerota痴 fascia

N₁ Metastasis in a single lymph node, £ 2 cm

N₂ Metastasis in a single lymph node, > 2 cm £ 5 cm

N₃ Metastasis in a multiple lymph node £ 5 cm., > 5 cm

Stage I T₁ N₀ M₀

Stage II T₂ N₀ M₀

Stage III T₁ N₁ M₀

T₂ N₁ M₀

T_3a N₀, N₁ M₀

T_3b N₀, N₁ M₀

Stage IV T₄ Any N M₀

Any T N₂, N₃ M₀

Any T Any N M₁

Staging Work-up

1. Blood tests : CBC, BUN, Creatinine, Liver function test

2. CT ﾋﾃﾗﾍ MRI ｢ﾍｧ abdomen

3. Chest x-rays

4. Bone scan ｶ鰓ｾｺ alkaline phosphatase ﾊﾙｧｼﾔｴｻ｡ｵﾔ

ﾋﾅﾑ｡｡ﾒﾃﾃﾑ｡ﾉﾒ

Renal cell carcinoma ｷﾑ鬧 primary 眷ﾐｵﾓ睛ｹ隗｢ﾍｧ篥､ｷﾕ陦ﾃﾐｨﾒﾂ莉ｨﾐﾁﾕ倏ﾗﾍｴﾁﾒ倏ﾕ鯆ｧﾁﾒ｡ｫﾖ隗狃郢

｢鯱､ﾇﾃﾃﾐﾇﾑｧ｢ﾍｧﾈﾑﾅﾂ眄ｷﾂ・ﾅﾑ｡ﾉｳﾐ｡ﾒﾃｴﾓ犹ﾔｹ｢ﾍｧ篥､ﾁﾕ｢鯱ｾﾖｧﾊﾑｧ爍ｵ 3 ｻﾃﾐ｡ﾒﾃ､ﾗﾍ

1. ﾍﾒｨﾁﾕ spontaneous regression 莇・盞靉ﾘｺﾑｵﾔ｡ﾒﾃｹﾑ鮖ｹ鯱ﾂ｡ﾇ靨 1%

2. ﾍﾒｨｨﾐﾁﾕ late recurrence 莇・ｺﾒｧ､ﾃﾑ鬧ｾｺ莇鮓ﾖｧ 30 ｻﾕﾋﾅﾑｧｨﾒ｡ｷﾓ nephrectomy 莉眷鯢

3. ｺﾒｧ､ﾃﾑ鬧眞鯢靨ｨﾐﾁﾕ｡ﾒﾃ｡ﾃﾐｨﾒﾂ｢ﾍｧ篥､莉ｷﾕ靉ﾗ雹眷鯢ｼﾙ鮟霽ﾂ｡酊ﾑｧﾁﾕｪﾕﾇﾔｵ莇鯆ﾒﾇｹﾒｹｾﾍﾊﾁ､ﾇﾃ

4. ｡ﾒﾃｼ靨ｵﾑｴ狃郢ﾇﾔｸﾕ犇ﾕﾂﾇｷﾕ靆ﾒﾁﾒﾃｶｷﾓ耆鮠ﾙ鮟霽ﾂｺﾒｧ､ｹﾋﾒﾂ｢ﾒｴｨﾒ｡篥､莇・ﾍﾑｵﾃﾒ｡ﾒﾃﾍﾂﾙ霤ﾍｴｷﾕ・5 ｻﾕ

ｻﾃﾐﾁﾒｳ 35-45%

｡ﾒﾃｼ靨ｵﾑｴ

1. ｡ﾒﾃﾃﾑ｡ﾉﾒﾋﾅﾑ｡｢ﾍｧ renal cancer ､ﾗﾍ Radical nephrectomy 箒ﾂｨﾐｵ鯱ｧｼﾙ｡ renal vein pedicle

｡靉ｹｷﾕ險ﾐｵﾑｴ莊狎ﾗ靉ｻ鯱ｧ｡ﾑｹ tumor embolization

2. Lymphadenectomy ﾊﾒﾁﾒﾃｶｴﾙ｡ﾒﾃ｡ﾃﾐｨﾒﾂ｢ﾍｧ篥､莉ﾂﾑｧｵ靉ﾁｹ鰌猴ﾅﾗﾍｧ盞靉ﾂ靨ｧ菘｡邨ﾒﾁｼﾅｵ靉

ﾍﾑｵﾃﾒ｡ﾒﾃﾍﾂﾙ霤ﾍｴｹﾑ鮖ﾂﾑｧ菽隱ﾑｴ爲ｹ箒ﾂｷﾑ霽莉眷鯢ﾈﾑﾅﾂ眄ｷﾂ・ﾑ｡ｨﾐｷﾓ Limited lymphadenectomy ﾃ霽ﾁ莉｡ﾑｺ

nephrectomy

3. ｡ﾒﾃｷﾓ Nephrectomy ﾂﾑｧﾊﾒﾁﾒﾃｶ罨鰲ｻ郢｡ﾒﾃﾃﾑ｡ﾉﾒ狎ﾗ靉ｺﾃﾃ犢ﾒﾍﾒ｡ﾒﾃｨﾒ｡ﾁﾐ狹遘眞鯢靨ｼﾙ鮟霽ﾂｨﾐﾁﾕ

篥､ﾍﾂﾙ鞳ｹﾃﾐﾂﾐｷﾕ陦ﾃﾐｨﾒﾂ莉ｷﾕ靉ﾗ雹眷鯢｡邨ﾒﾁ箒ﾂﾊﾒﾁﾒﾃｶﾅｴﾍﾒ｡ﾒﾃｻﾇｴ, ｻﾑﾊﾊﾒﾇﾐ狃郢倏ﾗﾍｴ, mass effect of tumor

4. ｡ﾒﾃｷﾓ Nephrectomy 羯ｼﾙ鮟霽ﾂ狎ﾗ靉ﾋﾇﾑｧｼﾅ spontaneous regression ｢ﾍｧ篥､ｷﾕ陦ﾃﾐｨﾒﾂ莉ｷﾕ靉ﾗ雹ｹﾑ鮖

菽鞨ﾋﾁﾒﾐﾊﾁ狎ﾃﾒﾐ簣｡ﾒﾊｷﾕ險ﾐ爍ﾔｴ spontaneous regression ｹﾑ鮖ｹ鯱ﾂ｡ﾇ靨 1% 盞靉ﾑｵﾃﾒ｡ﾒﾃｵﾒﾂｨﾒ｡｡ﾒﾃｷﾓ

Nephrectomy ｹﾑ鮖ｻﾃﾐﾁﾒｳ 6%

5. Bilateral renal cell carcinoma ｹﾑ鮖ｾｺ莇鮟ﾃﾐﾁﾒｳ 2-3% ﾃﾑ｡ﾉﾒ箒ﾂｷﾓ Conservative

Surgery ｢ﾍｧ莊ｴ鰓ｹｷﾕ霖ﾕﾁﾐ狹遘ｹ鯱ﾂ｡ﾇ靨

6. ｡ﾒﾃｷﾓ Renal transplantation 箒ﾂｷﾑ霽莉眷鯢ｨﾐ菽霍ﾓ狎ﾃﾒﾐｵ鯱ｧ罨・immosuppressive therapy

ｫﾖ隗ｨﾐｷﾓ耆鮹ﾐ狹遘爍ﾔｴ｢ﾖ鮖ﾁﾒ耆ﾁ・/P>

｡ﾒﾃﾃﾑ｡ﾉﾒｴ鯢ﾂﾃﾑｧﾊﾕ

ｺｷｺﾒｷ｢ﾍｧﾃﾑｧﾊﾕ羯 renal cell carcinoma ｹﾑ鮖狎ﾕﾂｧ狎ﾗ靉ｺﾃﾃ犢ﾒﾍﾒ｡ﾒﾃ犢靨ｹﾑ鮖 (palliative treatment)

ﾊﾓﾋﾃﾑｺｺｷｺﾒｷｷﾕ隱霽ﾂ猝ﾃﾔﾁ｡ﾑｺ｡ﾒﾃｼ靨ｵﾑｴﾋﾃﾗﾍ罨鯏ﾑｧﾊﾕﾃﾑ｡ﾉﾒｪｹﾔｴ犇ﾕﾂﾇ羯｡ﾒﾃﾃﾑ｡ﾉﾒ狎ﾗ靉ﾁﾘ隗ﾋﾇﾑｧ耆鰺ﾒﾂ｢ﾒｴｹﾑ鮖

ﾂﾑｧ菽鞨ｻ郢ｷﾕ霙ﾍﾁﾃﾑｺ｡ﾑｹ箒ﾂｷﾑ霽莉犹ﾗ靉ｧｨﾒ｡莊ﾍﾂﾙ鞳ｹｵﾓ睛ｹ隗ﾁﾕﾍﾇﾑﾂﾇﾐｷﾕ霍ｹｵ靉ﾃﾑｧﾊﾕ莇鱠ﾁ霖ﾒ｡ﾍﾂﾙ霰鯱ﾁﾃﾍｺ

爼雹｡ﾃﾐ狎ﾒﾐﾍﾒﾋﾒﾃ, ｵﾑｺ, ﾅﾓ萍・茲ﾊﾑｹﾋﾅﾑｧｨﾖｧﾊﾒﾁﾒﾃｶ耆鯏ﾑｧﾊﾕ莇鰲ｾﾕﾂｧ 45-50 Gy

｡ﾒﾃﾃﾑ｡ﾉﾒｴ鯢ﾂﾂﾒ爨ﾁﾕｺﾓｺﾑｴ

ｺｷｺﾒｷ｢ﾍｧﾂﾒ爨ﾁﾕｺﾓｺﾑｴ羯 renal cell carcinoma ､靉ｹ｢鰓ｧｹ鯱ﾂﾁﾕﾍﾑｵﾃﾒ｡ﾒﾃｵﾍｺﾊｹﾍｧ

ｵ靉ﾂﾒ狎ﾕﾂｧｻﾃﾐﾁﾒｳ 10-20% 眷ﾐ狃郢ｪ霽ｧﾊﾑ鮖・ｹﾍ｡ｨﾒ｡ｹﾕ鱠ｴ鮹ﾕ｡ﾒﾃｹﾓﾎﾍﾃ・ﾁｹﾋﾅﾒﾂｪｹﾔｴ爼雹 progestational

agent, androgens ﾁﾒ罨・盞靉ﾑｵﾃﾒ｡ﾒﾃｵﾍｺﾊｹﾍｧ｡酊ﾑｧｵ勒ﾍﾂﾙ鞦ﾅﾐ狃郢ｪ霽ｧﾊﾑ鮖・爼雹犇ﾕﾂﾇ｡ﾑｺﾂﾒ爨ﾁﾕｺﾓｺﾑｴ

Immunotherapy

ﾍﾑｵﾃﾒ｡ﾒﾃｵﾍｺﾊｹﾍｧｵ靉 immunotherapy ﾊﾙｧ｡ﾇ靨｡ﾒﾃ罨鯆ﾒ爨ﾁﾕｺﾓｺﾑｴ倏遑ｹ鯱ﾂ箒ﾂﾂﾒｷﾕ鞳ｪ鮹ﾕﾍﾂﾙ・3 ｡ﾅﾘ霖

ﾋﾅﾑ｡・､ﾗﾍ

1. IFN (Interferon) ﾍﾑｵﾃﾒ｡ﾒﾃｵﾍｺﾊｹﾍｧｵ靉ﾂﾒｻﾃﾐﾁﾒｳ 15-20%

2. Interlenkin -2 眷ﾐ lymphokine-activated killer (LAK) cells ﾍﾑｵﾃﾒ｡ﾒﾃｵﾍｺﾊｹﾍｧｻﾃﾐﾁﾒｳ 16-33%

3. Active specific immunotherapy with vaccines ｫﾖ隗狃郢 vaccine ｷﾕ霍ﾓｨﾒ｡ tumor cell ｢ﾍｧｼﾙ鮟霽ﾂ

､ｹｹﾑ鮖ﾍﾑｵﾃﾒ｡ﾒﾃｵﾍｺﾊｹﾍｧｻﾃﾐﾁﾒｳ 20-25%

ｼﾅ｡ﾒﾃﾃﾑ｡ﾉﾒ

ﾃﾐﾂﾐｷﾕ・1 眷ﾐ 2

ﾋﾅﾑｧｨﾒ｡ｷﾕ霍ﾓ Nephrectomy ﾍﾑｵﾃﾒ｡ﾒﾃﾍﾂﾙ霤ﾍｴｷﾕ・5 眷ﾐ 10 ｻﾕｻﾃﾐﾁﾒｳ 50-90% 眷ﾐ 20-65% ｵﾒﾁﾅﾓｴﾑｺ

ﾃﾐﾂﾐｷﾕ・3

ﾋﾅﾑｧｨﾒ｡｡ﾒﾃﾃﾑ｡ﾉﾒｴ鯢ﾂ Nephrectomy ﾍﾑｵﾃﾒ｡ﾒﾃﾍﾂﾙ霤ﾍｴｷﾕ・5 ｻﾕｻﾃﾐﾁﾒｳ 20-60%

ﾃﾐﾂﾐｷﾕ・4

ｾﾂﾒ｡ﾃｳ・ﾃ､羯ﾃﾐﾂﾐｹﾕ魴勒ﾁﾒ｡ﾍﾑｵﾃﾒ｡ﾒﾃﾍﾂﾙ霤ﾍｴｷﾕ・3 ｻﾕｻﾃﾐﾁﾒｳ 5% 眷ﾐﾂﾑｧ菽霖ﾕ｡ﾒﾃﾃﾑ｡ﾉﾒｷﾕ鞨ｻ郢

ﾁﾒｵﾃｰﾒｹﾊﾓﾋﾃﾑｺ篥､羯ﾃﾐﾂﾐｹﾕ・ﾍﾒｨｨﾐ罨鯏ﾑｧﾊﾕﾋﾃﾗﾍ immunotherapy 狎ﾗ靉ｺﾃﾃ犢ﾒﾍﾒ｡ﾒﾃ

ﾁﾐ狹遘｡ﾃﾐ狎ﾒﾐｻﾑﾊﾊﾒﾇﾐ (BLADDER CANCER)

ﾍﾘｺﾑｵﾔ｡ﾒﾃｳ・/A>

1. 羯ｻﾕ 1990 ｾｺｼﾙ鮟霽ﾂﾁﾐ狹遘｡ﾃﾐ狎ﾒﾐｻﾑﾊﾊﾒﾇﾐ羯ｻﾃﾐ犢ﾈ莵ﾂｷﾑ鬧ﾋﾁｴ 1,190 ﾃﾒﾂ

狃郢ｼﾙ鮟霽ﾂｪﾒﾂ 897 ﾃﾒﾂ, ｼﾙ鮟霽ﾂﾋｭﾔｧ 293 ﾃﾒﾂ¹

2. 羯ｻﾕ 1995 ｼﾙ鮟霽ﾂﾁﾐ狹遘｡ﾃﾐ狎ﾒﾐｻﾑﾊﾊﾒﾇﾐｷﾕ霖ﾒﾃﾑ｡ﾉﾒｷﾕ鞣ﾃｧｾﾂﾒｺﾒﾅｨﾘﾌﾒﾅｧ｡ﾃｳ・50 ﾃﾒﾂ

狃郢ｼﾙ鮟霽ﾂｪﾒﾂ 39 ﾃﾒﾂ, ｼﾙ鮟霽ﾂﾋｭﾔｧ 11 ﾃﾒﾂ²

3. ﾍﾒﾂﾘ箒ﾂ爻ﾅﾕ霙｢ﾍｧｼﾙ鮟霽ﾂﾍﾂﾙ霤ﾐﾋﾇ靨ｧ 50-70 ｻﾕ

ｻﾑｨｨﾑﾂ猝ﾕ霙ｧ

1. ｡ﾒﾃﾊﾙｺｺﾘﾋﾃﾕ・/P>

2. ﾊﾒﾃ爨ﾁﾕｻﾃﾐ狢ｷ b - naphthylamines ｫﾖ隗狃郢ｼﾅｨﾒ｡ﾍﾘｵﾊﾒﾋ｡ﾃﾃﾁｻﾃﾐ狢ｷ aniline dye

3. ｡ﾒﾃｵﾔｴ爼ﾗ鯱 schistosomiasis

4. ｼﾙ鮟霽ﾂｷﾕ霖ﾕ metabolic defect 羯 tryptophan metabolism

5. ﾂﾒ爨ﾁﾕｺﾓｺﾑｴ爼雹 Cyclophosphamide

ﾍﾒ｡ﾒﾃ眷ﾐﾍﾒ｡ﾒﾃ睫ｴｧ

1. ﾍﾒ｡ﾒﾃｹﾓｷﾕ霎ｺｺ靉ﾂ羯ﾁﾐ狹遘｡ﾃﾐ狎ﾒﾐｻﾑﾊﾊﾒﾇﾐ､ﾗﾍ

1.1 painless, microscopic or gross hematuria

1.2 urinary tract infection

1.3 irritative symptoms 莇鱆｡・urinary frequency, dysuria, urgency

2. ﾍﾒ｡ﾒﾃ犹ﾗ靉ｧｨﾒ｡ obstruction ﾋﾃﾗﾍﾍﾒ｡ﾒﾃｷﾕ鞨｡ﾔｴｨﾒ｡｡ﾒﾃ｡ﾃﾐｨﾒﾂ｢ﾍｧ篥､莉ｷﾕ靉ﾗ雹ｾｺ莇鱠ﾁ霄靉ﾂ

｡ﾃﾐｺﾇｹ｡ﾒﾃﾇﾔｹﾔｨｩﾑﾂ篥､

1. ｡ﾒﾃﾇﾔｹﾔｨｩﾑﾂｷﾕ鞦ｹ隱ﾑｴｵ鯱ｧﾍﾒﾈﾑﾂ cystoscopy 眷ﾐ transurethral biopsy ｢ﾍｧ｡鯱ｹｷﾕ鞨ﾋ郢ｨﾒ｡ scope

2. Urine cytology ﾍﾒｨｨﾐｪ霽ﾂ羯｡ﾒﾃﾇﾔｹﾔｨｩﾑﾂ盞鞴ﾁ靆ﾒﾁﾒﾃｶｺﾍ｡ｵﾓ睛ｹ隗｢ﾍｧ｡鯱ｹ莇鯱ﾂ靨ｧｪﾑｴ爲ｹ

ﾅﾑ｡ﾉｳﾐｷﾒｧｾﾂﾒｸﾔﾇﾔｷﾂﾒ

- 箒ﾂｷﾑ霽莉ｨﾐｾｺ transitional cell carcinoma 莇鮹ﾒ｡ｷﾕ靆ﾘｴｴﾑｧｵﾒﾃﾒｧ｢鰓ｧﾅ靨ｧｹﾕ・/P>

INCIDENCE

Transitional cell carcinoma 85%

Squamous cell carcinoma 10%

Adenocarcinoma 5%

Sarcoma < 1%

- Grade ｢ﾍｧ transitional cell carcinoma ﾂﾑｧ蘯隗ﾍﾍ｡狃郢 grade 1 (well differentiated), grade 2

(moderately well differentiated) 眷ﾐ grade 3 (poorly differentiated)

｡ﾒﾃ蘯隗ﾃﾐﾂﾐ｢ﾍｧ篥､ｵﾒﾁ TNM classification

T0: No evidence of primary tumor

Ta: Noninvasive papillary carcinoma

Tis: Carcinoma in situ ("flat tumor")

T1: Tumor invades subepithelial connective tissue

T2: Tumor invades superficial muscle (inner half)

T3: Tumor invades deep muscle or perivesical fat

T3a: Tumor invades deep muscle (outer half)

T3b: Tumor invades perivesical fat

i: microscopically

ii: macroscopically (extravesical mass)

T4: Tumor invades any of the following: prostate, uterus, vagina, pelvic

wall, or abdominal wall.

T4a: Tumor invades the prostate, uterus, or vagina

T4b: Tumor invades the pelvic wall or abdominal wall

N1: Metastasis in a single lymph node, 2.0 cm or less in greatest dimension

N2: Metastasis in a single lymph node, more than 2.0 cm but not more than 5.0 cm in greatest dimension; or multiple lymph nodes, none more than 5.0 cm in greatest dimension

N3: Metastasis in a lymph node more than 5.0 cm in greatest dimension

M1: Distant metastasis

--Stage 0a-- Ta, N0, M0

--Stage 0is-- Tis, N0, M0

--Stage I-- T1, N0, M0

--Stage II-- T2-T3a, N0, M0

--Stage III-- T3b-T4a, N0, M0

--Stage IV-- T4b, N0, M0

any T, N1-3, M0

any T, any N, M1

Staging Work-up

1. Blood test, chest x-rays

2. Cystoscopic examination 狃郢｡ﾒﾃｵﾃﾇｨｷﾕ靆ﾓ､ﾑｭﾁﾒ｡箒ﾂｵ鯱ｧｷﾓ deep biopsy 狎ﾗ靉ｴﾙﾇ靨ﾁﾕ

muscle invasion ﾋﾃﾗﾍ菽・眷ﾐｷﾓ random biopsy 狎ﾗ靉ｴﾙﾇ靨ﾁﾕ carcinoma in situ (CIS) ｷﾕ靉ﾗ雹ﾃ霽ﾁｴ鯢ﾂﾋﾃﾗﾍ菽・/P>

3. IVP ﾊﾒﾁﾒﾃｶ罨魘ﾙ｢ｹﾒｴ｢ﾍｧ｡鯱ｹ眷ﾐ ureter obstruction

4. CT scans ﾊﾒﾁﾒﾃｶ罨魘ﾙ｡ﾒﾃ｡ﾃﾐｨﾒﾂ莉ｷﾕ襍靉ﾁｹ鰌猴ﾅﾗﾍｧ, ｡ﾒﾃ｡ﾃﾐｨﾒﾂ莉ｷﾕ襍ﾑｺ盞鞴ﾁ靆ﾒﾁﾒﾃｶ

ｺﾍ｡ｶﾖｧ depth of invasion 莇鯱ﾂ靨ｧｪﾑｴ爲ｹ

5. MRI ﾊﾒﾁﾒﾃｶｺﾍ｡ bladder-wall invasion 莇魘ﾕ｡ﾇ靨 CT accuracy ｻﾃﾐﾁﾒｳ 85-94%

ﾋﾅﾑ｡｡ﾒﾃﾃﾑ｡ﾉﾒ

箒ﾂｷﾑ霽莉羯｡ﾒﾃﾃﾑ｡ﾉﾒ狹ﾒｨﾐ蘯隗｡ﾅﾘ霖｢ﾍｧ篥､狃郢ｴﾑｧｹﾕ鬢ﾗﾍ

1. Superficial disease ｫﾖ隗莇鱆｡・T_is, T_a, T₁ ｻﾃﾐﾁﾒｳ 75% ｢ﾍｧｼﾙ鮟霽ﾂｨﾑｴﾍﾂﾙ鞳ｹ｡ﾅﾘ霖ｹﾕ・ﾊ霽ｹ耆ｭ鞦ﾅ鯢

ｨﾐ猴郢 low grade 盞・50% ｢ﾍｧｼﾙ鮟霽ﾂｷﾕ鞴ｴ鯏ﾑｺ｡ﾒﾃﾃﾑ｡ﾉﾒﾁﾑ｡ｨﾐﾁﾕ｡ﾒﾃ｡ﾅﾑｺ｢ﾍｧ篥､｢ﾖ鮖ﾁﾒﾍﾕ｡ﾀﾒﾂ羯 6-12 犇ﾗﾍｹ眷ﾐｨﾐ狃郢 low grade 眷ﾐlow stage 猴ﾁﾗﾍｹ犇ﾔﾁｹﾍ｡ｨﾒ｡ grade 眷ﾐ stage 眷鯢 degree of multicentricity 眷ﾐ amount of CIS ﾂﾑｧ狃郢ｻﾑｨｨﾑﾂｷﾕ靆ﾓ､ﾑｭｷﾕ險ﾐｺﾍ｡ｶﾖｧﾅﾑ｡ﾉｳﾐ｡ﾒﾃｴﾓ犹ﾔｹ篥､爼雹羯｡ﾅﾘ霖 T_a ｶ鰓ﾁﾕ篥､狃郢 single focus ﾍﾑｵﾃﾒ｡ﾒﾃ｡ﾅﾑｺ｢ﾖ鮖ﾁﾒ耆ﾁ・= 30% 盞雜鰓篥､狃郢 multifocal ﾍﾑｵﾃﾒ｡ﾒﾃ｡ﾅﾑｺ｢ﾖ鮖ﾁﾒ耆ﾁ・= 65% ｶ鰓ｾｺ T_is ｨﾓｹﾇｹﾁﾒ｡ﾃ霽ﾁｴ鯢ﾂ recurrence rate ｡遞ﾐﾊﾙｧｶﾖｧ 85% 眷ﾐﾍﾑｵﾃﾒ｡ﾒﾃ｡ﾅﾑｺ｢ﾖ鮖ﾁﾒ耆ﾁ鞣ｴﾂﾅﾘ｡ﾅﾒﾁ爐鰓ｶﾖｧ｡ﾅ鰓ﾁ犹ﾗ鯱ｻﾃﾐﾁﾒｳ 30%

2. Invasive disease ､ﾗﾍ｡ﾒﾃｷﾕ霖ﾐ狹遘ﾅﾘ｡ﾅﾒﾁ爐鰓ｶﾖｧｪﾑ鮖｢ﾍｧ Detrusor muscle 眷ﾐﾁﾑ｡ｨﾐﾁﾕ subclinical

metastasis ﾃ霽ﾁｴ鯢ﾂ狎ﾃﾒﾐｻﾃﾐﾁﾒｳ 50% ｢ﾍｧ､ｹ茲鬘ﾅﾘ霖ｹﾕ鬨ﾐ猝ﾕﾂｪﾕﾇﾔｵ犹ﾗ靉ｧｨﾒ｡｡ﾒﾃ｡ﾃﾐｨﾒﾂ｢ﾍｧ篥､莉ｷﾕ・/P>

ｵﾓ睛ｹ隗ﾍﾗ雹

3. Metastatic disease ､ﾗﾍ｡ﾒﾃｷﾕ霖ﾐ狹遘ﾅﾘ｡ﾅﾒﾁ莉ﾂﾑｧﾍﾇﾑﾂﾇﾐﾍﾗ雹眷鯢ｨﾘｴｻﾃﾐﾊｧ､・ﾍｧ｡ﾒﾃﾃﾑ｡ﾉﾒｼﾙ鮟霽ﾂ

羯｡ﾅﾘ霖ｹﾕ鰲ｾﾕﾂｧｺﾃﾃ犢ﾒﾍﾒ｡ﾒﾃ犢靨ｹﾑ鮖

｡ﾒﾃﾃﾑ｡ﾉﾒﾊﾓﾋﾃﾑｺ篥､盞霰ﾐﾃﾐﾂﾐ

Superficial Disease

1. Focal T_is, T_a, T₁ ﾃﾑ｡ﾉﾒ箒ﾂ TURBT (Transurethral resection of bladder tumor ) 眷ﾐｵﾔｴｵﾒﾁｼﾅ｡ﾒﾃﾃﾑ｡ﾉﾒﾍﾂ靨ｧﾊﾁ勒猝ﾁﾍｴ鯢ﾂ cystoscopy

2. Multifocal T_is, T_a, T₁ ﾃﾑ｡ﾉﾒ箒ﾂ TURBT 眷ﾐ intravesicle therapy ｴ鯢ﾂ Mitomycin C ﾋﾃﾗﾍ

Doxorubicin ﾋﾃﾗﾍ BCG 箒ﾂｷﾑ霽莉篥､ｨﾐｵﾍｺﾊｹﾍｧｵ靉ﾂﾒｻﾃﾐﾁﾒｳ 35-70% 眷ﾐﾊﾒﾁﾒﾃｶ､ﾇｺ､ﾘﾁ篥､莇・/P>

狃郢ﾃﾐﾂﾐ猊ﾅﾒｹﾒｹ盞霆ﾃﾐﾁﾒｳ 50%ｨﾐﾁﾕ recurrence 盞靆ﾒﾁﾒﾃｶﾃﾑ｡ﾉﾒｫ鰌・莇魘鯢ﾂﾇﾔｸﾕ犇ﾔﾁ

Invasive Bladder Cancer

ﾇﾔｸﾕ｡ﾒﾃﾃﾑ｡ﾉﾒｼﾙ鮟霽ﾂ｡ﾅﾘ霖ｹﾕ鮹ﾕﾋﾅﾒﾂﾇﾔｸﾕ莇鱆｡・/P>

｡. Radical cystectomy

｢. Difinitive irradiation

､. Preoperative irradiation + radical cystectomy

ｧ. Radical cystectomy + postoperative irradiation

ｨ. Neoadjuvant chemotherapy + cystectomy

ｩ. Neoadjuvant chemotherapy + radiation

1. Radical cystoprostatectomy ､ﾗﾍ｡ﾒﾃﾃﾑ｡ﾉﾒﾁﾒｵﾃｰﾒｹ羯｡ﾅﾘ霖篥､ﾃﾐﾂﾐｹﾕ・ﾍﾑｵﾃﾒ｡ﾒﾃﾍﾂﾙ霤ﾍｴ

ｷﾕ・5 ｻﾕﾋﾅﾑｧ｡ﾒﾃｼ靨ｵﾑｴｻﾃﾐﾁﾒｳ 50%, ｻﾃﾐﾁﾒｳ 50% ｢ﾍｧｼﾙ鮟霽ﾂｨﾐ猝ﾕﾂｪﾕﾇﾔｵ犹ﾗ靉ｧｨﾒ｡ﾁﾕ｡ﾒﾃ｡ﾃﾐｨﾒﾂ｢ﾍｧ篥､莉

ﾂﾑｧﾍﾇﾑﾂﾇﾐﾍﾗ雹

2. Adjuvant radiation therapy ､ﾗﾍ｡ﾒﾃ罨鯏ﾑｧﾊﾕｪ霽ﾂ狃郢｡ﾒﾃﾃﾑ｡ﾉﾒ猝ﾃﾔﾁ｡ﾑｺ｡ﾒﾃｼ靨ｵﾑｴｫﾖ隗ﾁﾕ｡ﾒﾃ耆鯏ﾑｧﾊﾕ

｡靉ｹ｡ﾒﾃｼ靨ｵﾑｴ (preoperative radiation therapy) 眷ﾐ｡ﾒﾃ耆鯏ﾑｧﾊﾕﾋﾅﾑｧ｡ﾒﾃｼ靨ｵﾑｴ (postoperative radiation

therapy)

2.1 Preoperative radiation therapy ｡ﾒﾃ耆鯏ﾑｧﾊﾕ｡靉ｹ｡ﾒﾃｼ靨ｵﾑｴｨﾐﾊﾒﾁﾒﾃｶｷﾓ耆鬘鯱ｹﾁﾐ狹遘ﾂﾘｺﾅｧﾋﾃﾗﾍｷﾓ耆鯏ﾐﾂﾐ｢ﾍｧ篥､ﾅｴﾅｧ (downstage) ｡靉ｹｼ靨ｵﾑｴｫﾖ隗羯ｺﾒｧ､ﾃﾑ鬧ﾍﾒｨｨﾐﾁﾕ pathological complete response 莇鱆ｵ靉ﾂ靨ｧ菘｡邨ﾒﾁﾁﾕ｡ﾒﾃﾇﾔｨﾑﾂ(蘯ｺ randomized study) 3 ｡ﾒﾃﾇﾔｨﾑﾂｾｺ狎ﾕﾂｧ 1 ｡ﾒﾃﾈﾖ｡ﾉﾒ犢靨ｹﾑ鮖ｷﾕ靆ﾒﾁﾒﾃｶ睫ｴｧｶﾖｧ

ｻﾃﾐ篦ｪｹ・ﾍｧ｡ﾒﾃ耆鯏ﾑｧﾊﾕ蘯ｺ preoperative 狠ﾗ靉狃ﾃﾕﾂｺ犢ﾕﾂｺ｡ﾑｺ｡ﾒﾃｼ靨ｵﾑｴﾍﾂ靨ｧ犇ﾕﾂﾇ箒ﾂ菽鞳ﾋ鯏ﾑｧﾊﾕ

犢､ｹﾔ､｡ﾒﾃ耆鯏ﾑｧﾊﾕ｡靉ｹ｡ﾒﾃｼ靨ｵﾑｴｹﾕ鱆ｺ隗莇鰲ｻ郢 2 蘯ｺ､ﾗﾍ

2.1.1 耆鮟ﾃﾔﾁﾒｳﾃﾑｧﾊﾕｷﾑ鬧ﾋﾁｴ 2,000 cGy 蘯隗耆・5 ､ﾃﾑ鬧・ﾅﾐ 4,00 cGy 猊ﾅﾒｷﾕ鞳ｪ・/P>

ｷﾑ鬧ﾋﾁｴ羯 5-7 ﾇﾑｹ

2.1.2 耆鮟ﾃﾔﾁﾒｳﾃﾑｧﾊﾕｷﾑ鬧ﾋﾁｴ 4,500 cGy 蘯隗耆鬢ﾃﾑ鬧ﾅﾐ 180-200 cGy 罨鰲ﾇﾅﾒｷﾑ鬧ﾋﾁｴ

ｻﾃﾐﾁﾒｳ 4 ﾍﾒｷﾔｵﾂ・/P>

2.2 Postoperative radiation therapy 犹ﾗ靉ｧｨﾒ｡ｼﾙ鮟霽ﾂｷﾕ霖ﾕ篥､ﾍﾂﾙ鞳ｹﾃﾐﾂﾐ T₂ grade 3, T₃

ﾁﾕ簣｡ﾒﾊｷﾕ險ﾐﾁﾕ local recurrence ﾊﾙｧ箒ﾂｷﾕ霙ﾑｧ菽霖ﾕ distant metastasis 羯ｼﾙ鮟霽ﾂ｡ﾅﾘ霖ｹﾕ鬘ﾒﾃ耆鯏ﾑｧﾊﾕﾋﾅﾑｧ｡ﾒﾃｼ靨ｵﾑｴ

ｨﾖｧｹ靨ｨﾐﾁﾕｻﾃﾐ篦ｪｹ・盞鞳ｹｻﾑｨｨﾘｺﾑｹﾂﾑｧ菽霖ﾕ｡ﾒﾃﾈﾖ｡ﾉﾒ狃ﾃﾕﾂｺ犢ﾕﾂｺ蘯ｺ randomized ｾﾔﾊﾙｨｹ・ﾂ靨ｧ盪隱ﾑｴ

ﾊﾓﾋﾃﾑｺｼﾙ鮟霽ﾂ｡ﾅﾘ霖ｷﾕ霖ﾕﾃﾐﾂﾐ｢ﾍｧ篥､ｵ勒｡ﾇ靨 T₂ grade 2 簣｡ﾒﾊｷﾕ險ﾐﾋﾒﾂｨﾒ｡篥､ｴ鯢ﾂ｡ﾒﾃｼ靨ｵﾑｴ狎ﾕﾂｧﾍﾂ靨ｧ犇ﾕﾂﾇ

ﾊﾙｧﾍﾂﾙ鞦ﾅ鯢ｨﾖｧ菽險ﾓ狃郢ｵ鯱ｧ罨鬘ﾒﾃﾃﾑ｡ﾉﾒﾍﾂ靨ｧﾍﾗ雹ｪ霽ﾂ

3. Definitive radiation therapy 羯ｼﾙ鮟霽ﾂ｡ﾅﾘ霖 invasive disease ｹﾑ鮖｡ﾒﾃ罨鯏ﾑｧﾊﾕﾃﾑ｡ﾉﾒﾍﾂ靨ｧ犇ﾕﾂﾇ

ｼﾙ鮟霽ﾂ羯｡ﾅﾘ霖ｹﾕ鬨ﾐﾁﾕﾍﾑｵﾃﾒ｡ﾒﾃﾍﾂﾙ霤ﾍｴｷﾕ・5 ｻﾕｻﾃﾐﾁﾒｳ 30% 箒ﾂ｡ﾒﾃ罨鯏ﾑｧﾊﾕ蘯ｺ external beam 犹ﾗ靉ｧｨﾒ｡

ｼﾅ｡ﾒﾃﾃﾑ｡ﾉﾒﾂﾑｧ菽雍ﾕｹﾑ｡莇鮹ﾕ眄ｷﾂ・ﾒｧｷ靨ｹ耆鯏ﾑｧﾊﾕ蘯ｺ interstitial implantation ﾃ霽ﾁ｡ﾑｺ external beam

radiation ｫﾖ隗ｼﾅｷﾕ鞴ｴ鱚｡ﾅ鰲､ﾕﾂｧ｡ﾑｺ｡ﾒﾃｼ靨ｵﾑｴ盞陦鈕ﾁ鞨ｻ郢ｷﾕ雹ﾔﾂﾁﾁﾒ｡ｹﾑ｡狎ﾃﾒﾐﾇﾔｸﾕ｡ﾒﾃｷﾓ､靉ｹ｢鰓ｧﾂﾒ｡

4. Chemotherapy 犹ﾗ靉ｧｨﾒ｡｡ﾒﾃｵﾍｺﾊｹﾍｧ｢ﾍｧ篥､羯ﾃﾐﾂﾐｷﾕ霖ﾕ｡ﾒﾃ｡ﾃﾐｨﾒﾂ眷鯢 (metastatic

disease) ､靉ｹ｢鰓ｧﾊﾙｧｨﾖｧﾁﾕ｡ﾒﾃｹﾓﾁﾒ罨鬪霽ﾂ猝ﾃﾔﾁ狠ﾗ靉ﾃﾐﾂﾐ｢ﾍｧ篥､狃郢狎ﾕﾂｧ invasive diisease ｫﾖ隗ﾍﾒｨｨﾐﾁﾕ

subclinical metastasis 眷鯢｡鈕ｴ・/P>

4.1 Chemotherapy + Radical Cystoprostatectomy 箒ﾂﾁﾘ隗ﾋﾇﾑｧ耆・chemotherapy ｷﾓﾅﾒﾂ

subclinical disease ｡靉ｹ眷鯢ｨﾖｧｷﾓ cystectomy

4.2 Chemotherapy + Radiation therapy 箒ﾂ｡ﾒﾃ耆・chemotherapy ﾁﾘ隗ﾋﾇﾑｧ狎ﾗ靉猝ﾃﾔﾁｼﾅ｢ﾍｧ

｡ﾒﾃﾃﾑ｡ﾉﾒ耆魘ﾕ｢ﾖ鮖眷ﾐｼﾙ鮟霽ﾂ菽襍鯱ｧﾊﾙｭ猝ﾕﾂ bladder 眷ﾐ｡ﾒﾃｼ靨ｵﾑｴ (bladder preservation treatment)

ﾍﾂ靨ｧ菘｡邨ﾒﾁ｡ﾒﾃ罨・chemotherapy ｪ霽ﾂ猝ﾃﾔﾁ羯｡ﾒﾃﾃﾑ｡ﾉﾒ｡ﾓﾅﾑｧﾍﾂﾙ鞳ｹｪ霽ｧﾇﾔｨﾑﾂﾈﾖ｡ﾉﾒｼﾅ｡ﾒﾃﾃﾑ｡ﾉﾒ

ﾂﾑｧ菽靆ﾒﾁﾒﾃｶﾊﾃﾘｻ莇鯱ﾂ靨ｧ盪隱ﾑｴｹﾑ｡

Metastatic Disease

Chemotherapy 狃郢｡ﾒﾃﾃﾑ｡ﾉﾒﾋﾅﾑ｡羯ｼﾙ鮟霽ﾂ｡ﾅﾘ霖ｹﾕ・羯ｼﾙ鮟霽ﾂ｡ﾅﾘ霖ｹﾕ鮓鰓菽鞴ｴ鯏ﾑｺ chemotherapy

ｨﾐﾁﾕﾍﾑｵﾃﾒ｡ﾒﾃﾍﾂﾙ霤ﾍｴｷﾕ・2 ｻﾕｻﾃﾐﾁﾒｳｹ鯱ﾂ｡ﾇ靨 10% 盞鞳ｹ｡ﾅﾘ霖ｷﾕ鞴ｴ鯏ﾑｺ chemotherapy ｼﾙ鮟霽ﾂｺﾒｧ､ｹ

ﾊﾒﾁﾒﾃｶﾁﾕｪﾕﾇﾔｵﾂﾗｹﾂﾒﾇ箒ﾂｻﾃﾒﾈｨﾒ｡篥､莇鮹ﾒ｡｡ﾇ靨 4 ｻﾕ chemotherapy ｷﾕ鞳ﾋ・爼雹 M-VAC, CMV 眷ﾐ

CISCA regimen ｨﾐﾁﾕﾍﾑｵﾃﾒ｡ﾒﾃｵﾍｺﾊｹﾍｧ｢ﾍｧ篥､ｻﾃﾐﾁﾒｳ 50-70% 眷ﾐﾍﾑｵﾃﾒｷﾕ鞣ﾃ､ｵﾍｺﾊｹﾍｧﾍﾂ靨ｧ

ﾊﾁｺﾙﾃｳ・(complete response) ｻﾃﾐﾁﾒｳ 20-40%

CISCA: CYCLOPHOSPHAMIDE [CTX] 650 mg/m2 IV...D1

DOXORUBICIN [DOX] 50 mg/m2 IV...D1

CISPLATIN [CDDP] 100 mg/m2 IV...D2

CYCLE: 21-28 days

REFER: Sternberg JJ, et al: JAMA 1977; 238:2282-2287.

CMV: CISPLATIN [CDDP] 100 mg/m2 IV/4hr...D2

METHOTREXATE [MTX] 30 mg/m2 IV...D1,8

VINBLASTINE [VLB] 4 mg/m2 IV...D1,8

CYCLE: 21 days

REFER: Harker WG, et al: J CLIN ONCOL 1985; 3:1463-1470.

MVAC: METHOTREXATE [MTX] 30 mg/m2 per day IV...D1,15,22

VINBLASTINE [VLB] 3 mg/m2 per day IV...D2,15,22

DOXORUBICIN [DOX] 30 mg/m2 IV...D2

CISPLATIN [CDDP] 70 mg/m2 IV...D2

CYCLE: 28 days

REFER: Skeel RT: Handbook of Cancer Chemotherapy, 3rd Ed. Little, Brown & Co. 1991; 224-225.

ｪｹﾔｴ｢ﾍｧ｡ﾒﾃﾃﾑ｡ﾉﾒ

1. ｡ﾒﾃｼ靨ｵﾑｴ

｡. TURBT 猴ﾁﾒﾐﾊﾓﾋﾃﾑｺ localized superficial bladder cancer

｢. Radical Cystectomy ﾊﾓﾋﾃﾑｺ invasive disease ｫﾖ隗羯ｼﾙ鬪ﾒﾂ､ﾗﾍ cystoprostatectomy 眷ﾐ

羯ｼﾙ鰺ｭﾔｧｻﾃﾐ｡ﾍｺｴ鯢ﾂ anterior vaginectomy, anterior pelvic exenteration 眷ﾐ cystectomy

､. ｼﾅ｢鰓ｧ爨ﾕﾂｧｷﾕ靆ﾓ､ﾑｭｨﾒ｡ radical cystectomy ､ﾗﾍ impotence 眷ﾐｼﾅ｢鰓ｧ爨ﾕﾂｧｨﾒ｡｡ﾒﾃﾁﾕ ileal loop

ﾃﾑｧﾊﾕﾃﾑ｡ﾉﾒ

ｺｷｺﾒｷ｢ﾍｧﾃﾑｧﾊﾕﾃﾑ｡ﾉﾒ､ﾅ鰓ﾂ｡ﾑｺｺｷｺﾒｷ｢ﾍｧ｡ﾒﾃｼ靨ｵﾑｴ､ﾗﾍ罨鱚ｹ｡ﾃｳﾕｷﾕ霙ﾑｧ菽霖ﾕ｡ﾒﾃ｡ﾃﾐｨﾒﾂ

｢ﾍｧ篥､莉ｷﾕ靉ﾗ雹ﾊ霽ｹｼﾅ｢ﾍｧ｡ﾒﾃﾃﾑ｡ﾉﾒ狠ﾗ靉狃ﾃﾕﾂｺ犢ﾕﾂｺ｡ﾑｺ｡ﾒﾃｼ靨ｵﾑｴｹﾑ鮖ｷﾓ莇鯆ﾒ｡狎ﾃﾒﾐｼﾙ鮟霽ﾂｷﾕ鞴ｴ鯏ﾑｺ｡ﾒﾃ

ﾃﾑ｡ﾉﾒｴ鯢ﾂﾃﾑｧﾊﾕｨﾐﾍﾂﾙ鞳ｹ｡ﾅﾘ霖ｷﾕ鞳ｪ・clinical staging ﾊ霽ｹｼﾙ鮟霽ﾂｷﾕ鞴ｴ鯏ﾑｺ｡ﾒﾃｼ靨ｵﾑｴｨﾐﾍﾂﾙ鞳ｹ｡ﾅﾘ霖 pathological staging

｡. Definitive, high-dose radiation ﾍﾑｵﾃﾒ｡ﾒﾃ､ﾇｺ､ﾘﾁ篥､狠ﾗ靉犢ﾕﾂｺ｡ﾑｺ｡ﾒﾃｼ靨ｵﾑｴ羯盞霰ﾐﾃﾐﾂﾐ｢ﾍｧ篥､ｨﾐｵ勒｡ﾇ靨｡ﾒﾃｼ靨ｵﾑｴｻﾃﾐﾁﾒｳ 20% ｫﾖ隗ﾍﾒｨｨﾐ爍ﾔｴｨﾒ｡｡ﾒﾃ狃ﾃﾕﾂｺ犢ﾕﾂｺ clinical staging ｡ﾑｺ pathological staging ｡鈕ｴ・/P>

｢. 犢､ｹﾔ､｢ﾍｧ｡ﾒﾃ耆鯏ﾑｧﾊﾕﾊ霽ｹ耆ｭ險ﾐ罨・external beam, high energy photon

､. ｼﾅ｢鰓ｧ爨ﾕﾂｧｷﾕ靆ﾓ､ﾑｭｨﾒ｡ﾃﾑ｡ﾉﾒ莇鱆｡・radiation proctocystitis, bladder fibrosis 眷ﾐ contracture

3. ｡ﾒﾃ罨鯆ﾒ爨ﾁﾕｺﾓｺﾑｴ

｡. Superficial bladder cancer 箒ﾂ耆鰲ｻ郢 Intravesicle therapy ﾂﾒｷﾕ鞳ｪ鱠ｴ鱆｡・mitomycin C,

doxorubicin 眷ﾐ BCG (Bacillus Calmette Guerin) ｫﾖ隗 BCG 莇鯏ﾑｺ､ﾇﾒﾁｹﾔﾂﾁﾁﾒ｡｡ﾇ靨狎ﾃﾒﾐｷﾓ耆・complete

remission 莇鮓ﾖｧ 70% 眷ﾐﾅｴﾍﾑｵﾃﾒ｡ﾒﾃ｡ﾅﾑｺ｢ﾖ鮖ﾁﾒ耆ﾁ鞦ﾅﾐﾍﾑｵﾃﾒｷﾕ險ﾐ｡ﾅﾒﾂ狃郢 invasive disease 狠ﾗ靉ﾁﾕ

｡ﾒﾃ｡ﾅﾑｺ｢ﾖ鮖ﾁﾒ耆ﾁ陲ﾍｧ篥､ﾂﾒﾊﾒﾁﾒﾃｶ飜鞨｢鰓莉羯｡ﾃﾐ狎ﾒﾐｻﾑﾊﾊﾒﾇﾐｼ靨ｹﾊﾒﾂﾊﾇｹｻﾑﾊﾊﾒﾇﾐ眷ﾐｷﾔ鬧萇・/P>

ｻﾃﾐﾁﾒｳ 1-2 ｪﾑ霽簔ｧｨﾖｧｻﾅ靉ﾂﾂﾒﾍﾍ｡｡ﾃﾐｺﾇｹ｡ﾒﾃｹﾕ鬨ﾐｷﾓｷﾘ｡ﾍﾒｷﾔｵﾂ・ﾃﾐﾁﾒｳ 4-8 ﾍﾒｷﾔｵﾂ・ｶ鰓篥､ﾁﾕ

｡ﾒﾃｵﾍｺﾊｹﾍｧｵ靉ﾂﾒｷﾕ雍ﾕ｡遞ﾐｷﾓｵ靉ｨｹ｡ﾇ靨ｨﾐ､ﾃｺ 1-2 ｻﾕ

｢. Metastatic bladder cancer ﾊﾙｵﾃﾂﾒ爨ﾁﾕｺﾓｺﾑｴｷﾕ霆ﾃﾐ｡ﾍｺｴ鯢ﾂ Methotrexate, Vinblastine,

Doxorubicin 眷ﾐ Cisplatin (M-VAC) ﾁﾕﾍﾑｵﾃﾒ｡ﾒﾃｵﾍｺﾊｹﾍｧ｢ﾍｧ篥､ (response rate) ﾊﾙｧｶﾖｧ 67%

ﾂﾒ｡ﾅﾘ霖ﾍﾗ雹ｨﾐ耆鯱ﾑｵﾃﾒ｡ﾒﾃｵﾍｺﾊｹﾍｧ｢ﾍｧ篥､ｵ勒｡ﾇ靨ｹﾕ・/P>

ｼﾅ｡ﾒﾃﾃﾑ｡ﾉﾒ

ｼﾅ｡ﾒﾃﾃﾑ｡ﾉﾒｹﾑ鮖ｨﾐ｢ﾖ鮖ﾍﾂﾙ陦ﾑｺﾃﾐﾂﾐ｢ﾍｧ篥､ (stage) ｴﾑｧｵﾒﾃﾒｧ

Pathologic Stage

5-Year survival

0, CIS, 1

2

3A

3B

4

71-83%

83-88%

57-69%

29-40%

27-36%

ﾁﾐ狹遘ｵ靉ﾁﾅﾙ｡ﾋﾁﾒ｡ (Prostate Cancer)

ﾍﾘｺﾑｵﾔ｡ﾒﾃｳ・/A>

1. 羯ｻﾕ 1990 ｾｺｼﾙ鮟霽ﾂﾁﾐ狹遘ｵ靉ﾁﾅﾙ｡ﾋﾁﾒ｡羯ｻﾃﾐ犢ﾈ莵ﾂ 649 ﾃﾒﾂ¹

2. 羯ｻﾕ 1995 ｼﾙ鮟霽ﾂﾁﾐ狹遘ｵ靉ﾁﾅﾙ｡ﾋﾁﾒ｡ﾁﾒﾃﾑｺ｡ﾒﾃﾃﾑ｡ﾉﾒｷﾕ鞣ﾃｧｾﾂﾒｺﾒﾅｨﾘﾌﾒﾅｧ｡ﾃｳ・ﾁﾕｨﾓｹﾇｹ 34 ﾃﾒﾂ²

3. 羯ｻﾕ 1997 ｼﾙ鮟霽ﾂ莇鯏ﾑｺ｡ﾒﾃﾇﾔｹﾔｨｩﾑﾂ狃郢ﾁﾐ狹遘ｵ靉ﾁﾅﾙ｡ﾋﾁﾒ｡羯ｻﾃﾐ犢ﾈﾊﾋﾃﾑｰﾍ狠ﾃﾔ｡ﾒﾁﾕｨﾓｹﾇｹ

132,000 ﾃﾒﾂｫﾖ隗ﾁﾒ｡｡ﾇ靨ﾁﾐ狹遘ｻﾍｴ

4. ﾍﾒﾂﾘ｢ﾍｧｼﾙ鮟霽ﾂﾁﾑ｡ｨﾐ >50 ｻﾕ

ｻﾑｨｨﾑﾂ猝ﾕ霙ｧ

1. ﾍﾒｨｨﾐ爍ﾕ霙ﾇ犹ﾗ靉ｧ｡ﾑｺﾎﾍﾃ・ﾁｹ狎ﾈ

2. 菽霖ﾕ､ﾇﾒﾁ爍ﾕ霙ﾇ犹ﾗ靉ｧ｡ﾑｺ Benign prostatic hypertophy, prostatitis

ﾍﾒ｡ﾒﾃ眷ﾐﾍﾒ｡ﾒﾃ睫ｴｧ

1. 菽霖ﾕﾍﾒ｡ﾒﾃ盞襍ﾃﾇｨｾｺ莇鰾ｴﾂｺﾑｧ猩ﾔｭｨﾒ｡｡ﾒﾃ爲ﾒﾐ screening PSA, ｡ﾒﾃ PR ﾋﾃﾗﾍ莇鮠ﾅｾﾂﾒｸﾔ

ｨﾒ｡｡ﾒﾃｷﾓ TUR 羯 Benign prostatic hypertrophy

2. ﾍﾒ｡ﾒﾃ obstructive symptom 爼雹ｶ靨ﾂｻﾑﾊﾊﾒﾇﾐﾅﾓｺﾒ｡, ｵ鯱ｧ犲隗ｻﾑﾊﾊﾒﾇﾐｹﾒｹ

3. systemic presentation 爼雹ﾁﾕ茲・ｹ鰌ﾋｹﾑ｡ﾅｴ, ｫﾕｴ, ｻﾇｴ｡ﾃﾐｴﾙ｡

｡ﾃﾐｺﾇｹ｡ﾒﾃﾇﾔｹﾔｨｩﾑﾂ

1. Digital rectal examination 狃郢｡ﾒﾃｵﾃﾇｨｷﾕ靆ﾓ､ﾑｭ羯｡ﾒﾃﾇﾔｹﾔｨｩﾑﾂﾁﾐ狹遘ｵ靉ﾁﾅﾙ｡ﾋﾁﾒ｡箒ﾂ､ﾅﾓ莇・/P>

ｵ靉ﾁﾅﾙ｡ﾋﾁﾒ｡箏發遘ﾋﾃﾗﾍｼﾔﾇ菽鞨ﾃﾕﾂｺ

2. Transrectal ultrasound ﾊﾒﾁﾒﾃｶｪ霽ﾂ羯｡ﾒﾃﾇﾔｹﾔｨｩﾑﾂ羯｡ﾃｳﾕｷﾕ陦鯱ｹﾁﾐ狹遘ﾁﾕ｢ｹﾒｴ倏遑眷ﾐ菽靆ﾒﾁﾒﾃｶ

ｵﾃﾇｨｾｺｨﾒ｡｡ﾒﾃｵﾃﾇｨﾃ靨ｧ｡ﾒﾂ盞靉ﾂ靨ｧ菘｡邨ﾒﾁ Transrectal ultrasound ﾁﾕ false positive 眷ﾐ false negative

ｻﾃﾐﾁﾒｳ 40-60% 犹ﾗ靉ｧｨﾒ｡菽靆ﾒﾁﾒﾃｶ眥｡莇鬨ﾒ｡ prostatic hyperplasia 莇鯱ﾂ靨ｧ犇雹ｪﾑｴｵ鯱ｧ罨鯏霽ﾁ｡ﾑｺ

needle biospsy

3. Needle biopsy 狃郢ﾇﾔｸﾕｷﾓﾊﾓ､ﾑｭｷﾕ靆ﾘｴ狠ﾗ靉耆鱠ｴ鮠ﾅｾﾂﾒｸﾔ｢ﾍｧｵﾓ睛ｹ隗ｷﾕ靆ｧﾊﾑﾂｷﾓ莇鰺ﾅﾒﾂﾇﾔｸﾕ爼雹

transperineal needle biopsy, transrectal needle biopsy , ﾇﾔｸﾕ transrectal ultrasound guided needle biopsy 莇鯏ﾑｺ､ﾇﾒﾁｹﾔﾂﾁﾁﾒ｡ｷﾕ靆ﾘｴ

4. CT ﾋﾃﾗﾍ MRI of pelvis/abdomen MRI ｨﾐﾊﾒﾁﾒﾃｶ猴郢ｶﾖｧ｡ﾒﾃﾅﾘ｡ﾅﾒﾁ｢ﾍｧﾁﾐ狹遘ｵ靉ﾁﾅﾙ｡ﾋﾁﾒ｡

莇魘ﾕ｡ﾇ靨 CT

5. Prostatic acid phosphatase (PAP) ﾋﾒ莇鰾ｴﾂ｡ﾃﾐｺﾇｹ｡ﾒﾃ radioimmunoassay ｫﾖ隗ｨﾐﾋﾒｻﾃﾔﾁﾒｳ

acid phosphatase ｷﾕ霈ﾅﾔｵ箒ﾂｵ靉ﾁﾅﾙ｡ﾋﾁﾒ｡ｻﾃﾔﾁﾒｳ｢ﾍｧ PAP ｨﾐﾊﾑﾁｾﾑｹｸ・ﾑｺﾃﾐﾂﾐ｢ﾍｧ篥､

6. PSA (Prostatic specific antigen) 罨鬘ﾃﾐｺﾇｹ｡ﾒﾃｷﾒｧ Monoclonal antibody against prostate

tissue ｻﾃﾔﾁﾒｳ｢ﾍｧ PSA ﾊﾑﾁｾﾑｹｸ・ﾑｺﾃﾐﾂﾐ｢ﾍｧ篥､眷ﾐﾂﾑｧﾊﾒﾁﾒﾃｶ罨魴ﾔｴｵﾒﾁｼﾅ｡ﾒﾃﾃﾑ｡ﾉﾒ莇鰲ｻ郢ﾍﾂ靨ｧｴﾕ

盞靉ﾂ靨ｧ菘｡邨ﾒﾁ､靨 PSA ﾁﾒ｡｡ﾇ靨ｻ｡ｵﾔ｡醋ﾒﾁﾒﾃｶｾｺ莇鱚ｹ Benign prostatic hypertrophy

7. ｻﾃﾐ篦ｪｹ・ﾍｧ｡ﾒﾃ screening 狎ﾗ靉ﾋﾒﾁﾐ狹遘ｵ靉ﾁﾅﾙ｡ﾋﾁﾒ｡ｴ鯢ﾂ digital rectal examination PSA,

transrectal ultrasound ﾂﾑｧ菽鞦ｹ隱ﾑｴｹﾑ｡

ﾅﾑ｡ﾉｳﾐｷﾒｧｾﾂﾒｸﾔﾇﾔｷﾂﾒ

爍ﾗﾍｺｷﾑ鬧ﾋﾁｴ｢ﾍｧﾁﾐ狹遘ｵ靉ﾁﾅﾙ｡ﾋﾁﾒ｡ｨﾐﾁﾕﾅﾑ｡ﾉｳﾐｷﾒｧｾﾂﾒｸﾔ狃郢 adenocarcinoma 箒ﾂ蘯隗ｵﾒﾁ

degree of differentiation 眷ﾐｵﾒﾁ Gleason system of grading

1. Well differentiated ﾋﾃﾗﾍ Gleason grade 2-4

2. Moderately well differentiated ﾋﾃﾗﾍ Gleason grade 5-7

3. Poorly differentiated ﾋﾃﾗﾍ Gleason grade 7-10

｡ﾒﾃ蘯隗ﾃﾐﾂﾐ｢ﾍｧ篥､ｵﾒﾁ TNM Classification

T0: No evidence of primary tumor

T1: Clinically inapparent tumor not palpable or visible by imaging

T1a: Tumor incidental histologic finding in 5% or less of tissue resected

T1b: Tumor incidental histologic finding in more than 5% of tissue resected

T1c: Tumor identified by needle biopsy (e.g., performed because of elevated PSA)

T2: Tumor confined within prostate

T2a: Tumor involves half of a lobe or less

T2b: Tumor involves more than half of a lobe, but not both lobes

T2c: Tumor involves both lobes

T3: Tumor extends through the prostatic capsule

T3a: Unilateral extracapsular extension

T3b: Bilateral extracapsular extension

T3c: Tumor invades seminal vesicle(s)

T4: Tumor is fixed or invades adjacent structures other than seminal vesicles

T4a: Tumor invades any of: bladder neck, external sphincter, or rectum

T4b: Tumor invades levator muscles and/or is fixed to pelvic wall

N0: No regional lymph node metastasis

N1: Metastasis in a single lymph node, 2 cm or less in greatest dimension

N2: Metastasis in a single lymph node, more than 2 cm but not more than 5 cm in greatest dimension; or multiple lymph node metastases, none more than 5 cm in greatest dimension

N3: Metastasis in a lymph node more than 5 cm in greatest dimension

M0: No distant metastasis

M1: Distant metastasis

M1a: Nonregional lymph node(s)

M1b: Bone(s)

M1c: Other site(s)

-- Stage 0 -- T1a, N0, M0, G1

-- Stage I -- T1a, N0, M0, G2, 3-4

T1b-1c, N0, M0, any G

-- Stage II -- T2, N0, M0, any G

-- Stage III -- T3, N0, M0, any G

-- Stage IV -- T4, N0, M0, any G

any T, N1-3, M0, any G

any T, any N, M1, any G

The Jewett staging system

-- Stage A --

Stage A is clinically undetectable tumor confined to the prostate gland and is an incidental finding at prostatic surgery.

-- Stage B --

Stage B is tumor confined to the prostate gland.

-- Stage C --

Stage C is a tumor clinically localized to the periprostatic area but extending through the prostatic capsule; seminal vesicles may be involved.

-- Stage D --

Stage D is metastatic disease.

Staging Work-up

1. Transrectal ultrasound ﾊﾒﾁﾒﾃｶ罨魘ﾙ｢ｹﾒｴ｢ﾍｧ｡鯱ｹ extracapsular penetratron, seminle vesicle

invasion 莇魘ﾕ

2. CT / MRI

3. Lymph node staging ｴ鯢ﾂ laparoscopic lymph node biopsy ﾋﾃﾗﾍ pelvic lymphadenectomy

狃郢ﾇﾔｸﾕｷﾕ雜ﾙ｡ｵ鯱ｧｷﾕ靆ﾘｴ羯｡ﾒﾃ staging lymph node

4. Bone scan 狎ﾗ靉ｴﾙ｡ﾒﾃ｡ﾃﾐｨﾒﾂ｢ﾍｧ篥､莉ﾂﾑｧ｡ﾃﾐｴﾙ｡

5. Plain x-rays ｵﾃｧｺﾃﾔ猊ｳｵﾓ睛ｹ隗ｷﾕ霈ﾔｴｻ｡ｵﾔ羯 bone scan 狎ﾗ靉ｪ霽ﾂ眥｡ﾀﾒﾇﾐｷﾕ鞨｡ﾔｴｨﾒ｡｡ﾒﾃｷﾕ・/P>

ﾁﾐ狹遘｡ﾃﾐｨﾒﾂ莉ｷﾕ陦ﾃﾐｴﾙ｡ﾍﾍ｡ｨﾒ｡ﾀﾒﾇﾐﾍﾗ雹・/P>

6. Chest films

ﾋﾅﾑ｡｡ﾒﾃﾃﾑ｡ﾉﾒ
｡ﾒﾃﾃﾑ｡ﾉﾒﾊﾓﾋﾃﾑｺ篥､盞霰ﾐﾃﾐﾂﾐ

ﾃﾐﾂﾐｷﾕ・1 眷ﾐﾃﾐﾂﾐｷﾕ・2 (T₁ , N₀ , M₀ 眷ﾐ T₂ , N₀ , M₀)

1. ｵﾔｴｵﾒﾁ｡ﾒﾃｴﾓ犹ﾔｹ篥､箒ﾂﾂﾑｧ菽鞳ﾋ鬘ﾒﾃﾃﾑ｡ﾉﾒ爻ｾﾒﾐ箒ﾂｷﾑｹｷﾕ羯ｼﾙ鮟霽ﾂ｡ﾅﾘ霖ｷﾕ靉ﾒﾂﾘﾁﾒ｡眷鯢^,,

2. ﾃﾑｧﾊﾕﾃﾑ｡ﾉﾒｫﾖ隗｡ﾒﾃｨﾐ狹ﾔ霖ﾋﾅﾑｧｨﾒ｡｡ﾒﾃｷﾓ transurethral resection 眷鯢ﾍﾂ靨ｧｹ鯱ﾂ 4-6 ﾍﾒｷﾔｵﾂ・

狎ﾗ靉ﾅｴ urethral stricture ｪｹﾔｴ｢ﾍｧﾃﾑｧﾊﾕﾃﾑ｡ﾉﾒﾁﾕ 3 ﾇﾔｸﾕ､ﾗﾍ

2.1 External-beam radiation therapy ､ﾗﾍ｡ﾒﾃｩﾒﾂﾃﾑｧﾊﾕｨﾒ｡ﾀﾒﾂｹﾍ｡ｵﾑﾇｼﾙ鮟霽ﾂ

2.2 Interstitial Implantation of radioisotopes 箒ﾂ罨・Iodine-125 ﾋﾃﾗﾍ Palladium-103

箒ﾂｷﾓ蘯ｺ transperineal approach 罨・ultrasound or CT guidance ﾊﾓﾋﾃﾑｺﾇﾔｸﾕ｡ﾒﾃｹﾕ鰲ﾋﾁﾒﾐﾊﾁ｡ﾑｺｼﾙ鮟霽ﾂ

羯ﾃﾐﾂﾐ T₁ - T_2A ｼﾅ｡ﾒﾃﾃﾑ｡ﾉﾒ莇鰲ｷ靨犢ﾕﾂﾁ｡ﾑｺﾇﾔｸﾕﾍﾗ雹盞霖ﾕ｢鯱ｴﾕ､ﾗﾍ

｡. ﾊﾐｴﾇ｡ﾃﾇｴ狹酩ﾊﾒﾁﾒﾃｶｷﾓ莇鰾ｴﾂ菽襍鯱ｧﾃﾑｺｼﾙ鮟霽ﾂ萇鱚ｹ篥ｧｾﾂﾒｺﾒﾅ

｢. ｼﾅ｢鰓ｧ爨ﾕﾂｧｨﾒ｡｡ﾒﾃﾃﾑ｡ﾉﾒｹ鯱ﾂ｡ﾇ靨ﾇﾔｸﾕﾍﾗ雹箒ﾂｼﾙ鮟霽ﾂﾊﾒﾁﾒﾃｶﾁﾕ sexual potency ｻﾃﾐﾁﾒｳ

86-92% (狠ﾗ靉狃ﾃﾕﾂｺ犢ﾕﾂｺ｡ﾑｺ｡ﾒﾃｷﾓ radical prostatectomy ｼﾙ鮟霽ﾂﾁﾕ sexual potency ｻﾃﾐﾁﾒｳ 10-40% ﾋﾃﾗﾍ

external - beam radiotherapy ｻﾃﾐﾁﾒｳ 60%)

2.3 External-beam radiation therapy 箒ﾂ罨・computed tomography-based 3-D conformal

treatment planning 狎ﾗ靉ｷﾕ險ﾐﾅｴｻﾃﾔﾁﾒｳﾃﾑｧﾊﾕｷﾕ險ﾐ莉ﾊﾙ鞨ｹﾗ鯱狡ﾗ靉ｻ｡ｵﾔ耆鮖鯱ﾂｷﾕ靆ﾘｴ

3. Radical prostatectomy with lymphadenectomy (with or without nerve sparing technique 狎ﾗ靉ｷﾕ險ﾐ preserve sexual potency) ﾊﾓﾋﾃﾑｺｼﾙ鮟霽ﾂｷﾕ霖ﾕ capsular penetration, seminal vesicle or pelvic lymph node invasion, ﾃﾐｴﾑｺ prostatic-specific antigen ﾂﾑｧ菽霆｡ｵﾔﾋﾅﾑｧ 3 ﾍﾒｷﾔｵﾂ・ﾒ｡ﾒﾃｼ靨ｵﾑｴ､ﾇﾃｨﾐ莇鯏ﾑｺ postoperative radiotherapy ｫﾖ隗ｨﾐﾊﾒﾁﾒﾃｶﾅｴ local recurrence rate 莇・/P>

ﾃﾐﾂﾐｷﾕ・3 (T₃ , N₀ , M₀) 眷ﾐﾃﾐﾂﾐｷﾕ・4 ｷﾕ霙ﾑｧ菽霖ﾕ｡ﾒﾃ｡ﾃﾐｨﾒﾂ｢ﾍｧ篥､莉ｷﾕ靉ﾗ雹 (T₄ , N_0-3 , M₀ )

1. External-beam irradiation ｨﾐ狃郢｡ﾒﾃﾃﾑ｡ﾉﾒﾋﾅﾑ｡

2. Palliative surgery (transurethral resection) ｫﾖ隗ｨﾐﾊﾒﾁﾒﾃｶﾅｴ obstructive symptom 莇鰲ﾃ酩

盞陦邨鯱ｧ耆・radiation ｵﾒﾁﾋﾅﾑｧｨﾒ｡｡ﾒﾃｼ靨ｵﾑｴ4-6 ﾍﾒｷﾔｵﾂ・ﾅ鯢

3. Hormonal manipulation ｫﾖ隗ﾍﾒｨｨﾐ罨鰲ﾊﾃﾔﾁ｡ﾑｺ radiation 盞霈ﾅｷﾕ鞴ｴ鯆ﾑｧ菽鞦ｹ隱ﾑｴ莇鱆｡・/P>

a. orchiectomy

b. leuteinizing releasing hormone agonists

c. estrogens

4. Alternative forms of radiotherapy 莇鱆｡・ﾃﾑｧﾊﾕ篏ﾃｵﾍｹ (proton beam), ﾃﾑｧﾊﾕｹﾔﾇｵﾃﾍｹ (Neutron beam)

ﾃﾐﾂﾐｷﾕ・4 ｷﾕ霖ﾕ｡ﾒﾃ｡ﾃﾐｨﾒﾂ｢ﾍｧ篥､莉ｷﾕ靉ﾗ雹 (M₁)

1. Hormonal manipulation ｨﾐ狃郢｡ﾒﾃﾃﾑ｡ﾉﾒﾋﾅﾑ｡羯｡ﾃｳﾕｷﾕ霖ﾕ｡ﾒﾃ｡ﾃﾐｨﾒﾂ｢ﾍｧ篥､莉ﾂﾑｧｵﾓ睛ｹ隗ﾍﾗ雹

｡ﾒﾃｵﾍｺﾊｹﾍｧ｢ﾍｧ篥､ｨﾐ､靉ｹ｢鰓ｧﾊﾙｧ ~ 70-80% 盞霙ﾑｧ菽靆ﾒﾁﾒﾃｶｷﾓ耆鰺ﾒﾂ莇・/P>

a) Orchiectomy alone or with androgen blocker ｡ﾒﾃｷﾓ orchiectomy ﾃ霽ﾁ｡ﾑｺ｡ﾒﾃ耆鯏ﾑｺｻﾃﾐｷﾒｹ

ﾂﾒ nilutamide ｷﾓ耆鯱ﾒ｡ﾒﾃ｢ﾍｧ篥､ｴﾕ｢ﾖ鮖ﾁﾒ｡｡ﾇ靨｡ﾒﾃｷﾓ orchiectomy ﾍﾂ靨ｧ犇ﾕﾂﾇ盞靉ﾂ靨ｧ菘

｡邨ﾒﾁ菽霎ｺﾇ靨｡ﾒﾃ耆・androgen blocker ﾃ霽ﾁｴ鯢ﾂｨﾐ狎ﾔ霖ﾍﾑｵﾃﾒ｡ﾒﾃﾍﾂﾙ霤ﾍｴ｢ﾍｧｼﾙ鮟霽ﾂ

羯｡ﾒﾃﾈﾖ｡ﾉﾒ蘯ｺ meta-analysis.

b) LHRH agonists (Leuteinizing-releasing hormone agonist) 爼雹 leuprolide, goserelin

｡ﾒﾃ耆鯆ﾒ羯ﾃﾐﾂﾐ犇ﾗﾍｹ眦｡ﾍﾒｨｨﾐｷﾓ耆鯱ﾒ｡ﾒﾃ｢ﾍｧ篥､狃郢ﾁﾒ｡｢ﾖ鮖犹ﾗ靉ｧｨﾒ｡ﾁﾐ狹遘箏｢ﾖ鮖

､ﾇﾃｨﾐ耆・antiandrogen ､ﾇｺ､ﾙ鞴ｻｴ鯢ﾂ羯犇ﾗﾍｹ眦｡

c) LHRH agonist 眷ﾐ antiandrogen ﾋﾃﾗﾍｷﾕ鞨ﾃﾕﾂ｡ﾇ靨 maximum androgen blockage (MAB)

ｷﾓ耆鯱ﾑｵﾃﾒ｡ﾒﾃｵﾍｺﾊｹﾍｧ｢ﾍｧ篥､ｴﾕ｡ﾇ靨 LHRH agonist 狎ﾕﾂｧﾍﾂ靨ｧ犇ﾕﾂﾇ盞靉ﾂ靨ｧ菘｡邨ﾒﾁ

ﾂﾑｧ菽靆ﾒﾁﾒﾃｶｾﾔﾊﾙｨｹ・ｴ鯢靨ﾊﾒﾁﾒｶ狎ﾔ霖ﾍﾑｵﾃﾒ｡ﾒﾃﾍﾂﾙ霤ﾍｴ｢ﾍｧｼﾙ鮟霽ﾂ莇・/P>

d) Estrogens 莇鱆｡・DES (Diethyl stillbestol), chlorotrianisene, ethinyl estradiol, conjugated

estrogens U.P.P.

2. Palliative local treatment 莇鱆｡・/P>

a) Palliative radiotherapy

b) Palliative surgery (transurethral resection)

ｪｹﾔｴ｢ﾍｧ｡ﾒﾃﾃﾑ｡ﾉﾒ

1. ｡ﾒﾃｵﾔｴｵﾒﾁ｡ﾒﾃｴﾓ犹ﾔｹ｢ﾍｧ篥､箒ﾂ菽鞳ﾋ鬘ﾒﾃﾃﾑ｡ﾉﾒｷﾕ鞨ｩｾﾒﾐ爲ﾒﾐｨｧ犹ﾗ靉ｧｨﾒ｡箒ﾂｷﾑ霽莉眷鯢ｻﾃﾐﾁﾒｳ

､ﾃﾖ隗ﾋｹﾖ隗｢ﾍｧｼﾙ鮟霽ﾂﾁﾐ狹遘ｵ靉ﾁﾅﾙ｡ﾋﾁﾒ｡ﾁﾕﾍﾒﾂﾘﾁﾒ｡｡ﾇ靨 70 ｻﾕｫﾖ隗ｼﾙ鮟霽ﾂ｡ﾅﾘ霖ｹﾕ鯱ﾒｨｨﾐ猝ﾕﾂｪﾕﾇﾔｵｨﾒ｡篥､ﾍﾗ雹・

箒ﾂｷﾕ霙ﾑｧ菽霖ﾕﾍﾒ｡ﾒﾃｷﾕ霍ﾃﾁﾒｹｨﾒ｡ﾁﾐ狹遘ｵ靉ﾁﾅﾙ｡ﾋﾁﾒ｡ﾁﾕ｡ﾒﾃﾈﾖ｡ﾉﾒ｢ﾍｧ Veteran痴 Administration 羯ｼﾙ鮟霽ﾂﾁﾐ狹遘ｵ靉ﾁﾅﾙ｡ﾋﾁﾒ｡ stage C 眷ﾐ stage D ｨﾐ猝ﾕﾂｪﾕﾇﾔｵｨﾒ｡ﾊﾒ猴ｵﾘﾍﾗ雹ｷﾕ鞴ﾁ鞳ｪ霖ﾐ狹遘ｵ靉ﾁﾅﾙ｡ﾋﾁﾒ｡ 80 眷ﾐ 46% ｵﾒﾁﾅﾓｴﾑｺﾇﾔｸﾕｹﾕ鬨ﾖｧ猴ﾁﾒﾐﾊﾓﾋﾃﾑｺｼﾙ鮟霽ﾂ low grade tumor ﾃﾐﾂﾐｷﾕ・1 ﾋﾃﾗﾍ 2 ｷﾕ霖ﾕ篥､ﾍﾗ雹・ﾃ霽ﾁｴ鯢ﾂ

2. ｡ﾒﾃｼ靨ｵﾑｴ莇鱆｡・Radical prostatectomy ｫﾖ隗罨鰲ｻ郢｡ﾒﾃﾃﾑ｡ﾉﾒﾇﾔｸﾕﾋｹﾖ隗羯ｼﾙ鮟霽ﾂｷﾕ靉ﾒﾂﾘｹ鯱ﾂ｡ﾇ靨 70 ｻﾕ

眷ﾐﾍﾂﾙ鞳ｹﾃﾐﾂﾐｷﾕ・1 ﾋﾃﾗﾍ 2 眷ﾐﾁﾑ｡ｨﾐｷﾓﾃ霽ﾁ莉｡ﾑｺ pelvic lymphadenectomy ﾂ｡猊鮖羯｡ﾃｳﾕｷﾕ鞨ｻ郢 well-

differentiated small tumor ｼﾅ｢鰓ｧ爨ﾕﾂｧｷﾕ靆ﾒﾁﾒﾃｶｾｺ莇鬨ﾒ｡｡ﾒﾃｷﾓ prostatectomy 莇鱆｡・urinary incontinence,

urinary stricture, impotence 眷ﾐｼﾅ｢鰓ｧ爨ﾕﾂｧｨﾒ｡｡ﾒﾃｴﾁﾂﾒﾊﾅｺｨﾒ｡ national review ｢ﾍｧｼﾙ鮟霽ﾂ羯ｻﾃﾐ犢ﾈ

ﾊﾋﾃﾑｰﾍ狠ﾃﾔ｡ﾒｨﾓｹﾇｹ 10,600 ､ｹｾｺﾇ靨 30-day mortality 眷ﾐ cardiovascular morbidity = 2% 眷ﾐ 8%

ｵﾒﾁﾅﾓｴﾑｺｫﾖ隗 mortality 眷ﾐ morbidity ｨﾐﾊﾙｧ｢ﾖ鮖ｵﾒﾁﾍﾒﾂﾘ箒ﾂ爻ｾﾒﾐ狠ﾗ靉ｼﾙ鮟霽ﾂﾍﾒﾂﾘﾁﾒ｡｡ﾇ靨 75 ｻﾕｨﾒ｡ﾒﾃﾈﾖ｡ﾉﾒ

｢ﾍｧ Catalona UJ, Basler JU ｾｺﾇ靨｡ﾒﾃｷﾓ prostatectomy 蘯ｺ anatomic ﾋﾃﾗﾍ nerve-sparing technique ｾｺﾇ靨

ｻﾃﾐﾁﾒｳ 6% ｢ﾍｧｼﾙ鮟霽ﾂｵ鯱ｧ罨・pads 犹ﾗ靉ｧｨﾒ｡ﾇ靨ﾁﾕ urinary incontinence 眷ﾐｻﾃﾐﾁﾒｳ 40-65% ｢ﾍｧｼﾙ鮟霽ﾂﾂﾑｧ

ﾊﾒﾁﾒﾃｶﾁﾕ狎ﾈﾊﾑﾁｾﾑｹｸ・ｴ・盞靉ﾂ靨ｧ菘｡邨ﾒﾁｨﾒ｡ national survey of Medicare ﾊﾓﾃﾇｨｼﾙ鮟霽ﾂｷﾕ鞴ｴ鯏ﾑｺ｡ﾒﾃﾃﾑ｡ﾉﾒ箒ﾂ

prostatectomy 羯ｻﾕ 1988-1990 ｾｺﾇ靨ｻﾃﾐﾁﾒｳ 30% ｢ﾍｧｼﾙ鮟霽ﾂｨﾓ狃郢ｵ鯱ｧ罨・pads 犹ﾗ靉ｧｨﾒ｡ urinary

incontinence 30% 眷ﾐｻﾃﾐﾁﾒｳ 90% 菽霖ﾕ erections 狎ﾕﾂｧｾﾍｷﾕ險ﾐﾁﾕ狎ﾈﾊﾑﾁｾﾑｹｸ・ｴ鬢ﾇﾒﾁ盞｡ｵ靨ｧ

｢ﾍｧｼﾅ｢鰓ｧ爨ﾕﾂｧｨﾒ｡｡ﾒﾃﾈﾖ｡ﾉﾒ｢ﾍｧ Catalona UJ, Basler JU ｡ﾑｺ national survey of Medicare 犹ﾗ靉ｧｨﾒ｡

｡. ｼﾙ鮟霽ﾂ羯 Medicare survey ﾁﾕﾍﾒﾂﾘ爻ﾅﾕ霙ﾁﾒ｡｡ﾇ靨

｢. ､ﾇﾒﾁｪﾓｹﾒｭ｢ﾍｧﾈﾑﾅﾂ眄ｷﾂ・/P>

､. Selection factors and publication bias

ｧ. Different methods of collecting information

ﾁﾕ｡ﾒﾃﾃﾒﾂｧﾒｹｨﾒ｡ﾊｶﾒｺﾑｹﾍﾗ雹ｾｺﾇ靨ｶ鰓罨鱆ｺｺﾊﾍｺｶﾒﾁ爼雹犇ﾕﾂﾇ｡ﾑｺ Medicare survey, sexual potency 眷ﾐ urinary incontinence rate 菽鞦ｵ｡ｵ靨ｧｨﾒ｡ Medicare survey, Litwin MS 眷ﾐ､ｳﾐ莇鯤ﾖ｡ﾉﾒ､ﾘｳﾀﾒｾｪﾕﾇﾔｵ

｢ﾍｧｼﾙ鮟霽ﾂﾁﾐ狹遘ｵ靉ﾁﾅﾙ｡ﾋﾁﾒ｡ﾃﾐﾂﾐｷﾕ・1 眷ﾐ 2 ｵﾕｾﾔﾁｾ・ｹ JAMA 1995 ｫﾖ隗ｷﾓ狃郢蘯ｺ cross-sectional

survey ｾｺﾇ靨､ﾇﾒﾁ盞｡ｵ靨ｧ｢ﾍｧ sexual and urinary dysfunction ﾃﾐﾋﾇ靨ｧｼﾙ鮟霽ﾂｷﾕ鞴ｴ鯏ﾑｺ｡ﾒﾃﾃﾑ｡ﾉﾒ蘯ｺ

nerve-sparing prostatectomy 眷ﾐ standard prostatectomy 菽霖ﾕ､ﾇﾒﾁ盞｡ｵ靨ｧﾍﾂ靨ｧﾁﾕｹﾑﾂﾊﾓ､ﾑｭｷﾒｧﾊｶﾔｵﾔ

眷ﾐ莇鮠ﾅ罍ﾅ鰲､ﾕﾂｧ｡ﾑｺ Medicare survey

3. ﾃﾑｧﾊﾕﾃﾑ｡ﾉﾒ羯ﾊﾁﾑﾂ｡靉ｹｺｷｺﾒｷ｢ﾍｧﾃﾑｧﾊﾕ羯｡ﾒﾃﾃﾑ｡ﾉﾒﾁﾐ狹遘ｵ靉ﾁﾅﾙ｡ﾋﾁﾒ｡ﾁﾕｺｷｺﾒｷ羯ｼﾙ鮟霽ﾂｷﾕ・/P>

medically inoperable ﾋﾃﾗﾍ狠ﾗ靉ﾃﾐﾂﾐ｢ﾍｧ篥､ﾍﾂﾙ鞳ｹ late stage 眷鯢盞鞳ｹｻﾑｨｨﾘｺﾑｹ莇鮹ﾕ｡ﾒﾃｾﾔﾊﾙｨｹ・ﾅ鯢ﾇ靨

｡ﾒﾃﾃﾑ｡ﾉﾒｴ鯢ﾂﾃﾑｧﾊﾕﾁﾕｺｷｺﾒｷﾊﾓ､ﾑｭ眷ﾐ狃郢ｷﾒｧ倏ﾗﾍ｡ﾇﾔｸﾕﾋｹﾖ隗ﾊﾓﾋﾃﾑｺﾁﾐ狹遘ｵ靉ﾁﾅﾙ｡ﾋﾁﾒ｡羯ﾃﾐﾂﾐ狹ﾔ霖ｵ鮖

(ﾃﾐﾂﾐｷﾕ・1, 2) 箒ﾂｷﾕ霈ﾅ｡ﾒﾃﾃﾑ｡ﾉﾒ莇鮴ﾍ・｡ﾑｺ Radical prostatectomy ﾇﾔｸﾕ｡ﾒﾃﾃﾑ｡ﾉﾒｴ鯢ﾂﾃﾑｧﾊﾕ蘯隗狃郢

3 ﾇﾔｸﾕ､ﾗﾍ

3.1 External-beam radiation therapy ､ﾗﾍ｡ﾒﾃ耆鯏ﾑｧﾊﾕｨﾒ｡ﾀﾒﾂｹﾍ｡ﾃ靨ｧ｡ﾒﾂｻﾃﾔﾁﾒｳﾃﾑｧﾊﾕｻﾃﾐﾁﾒｳ

60-70 Gy 羯ﾃﾐﾂﾐ猊ﾅﾒ 6-7 ﾍﾒｷﾔｵﾂ・/P>

3.2 Radioactive implant ､ﾗﾍ｡ﾒﾃ飜鑽adioisotope 爼雹 Iodine-125, Palladium-103 ﾂﾑｧ爐鰓莉羯

prostate gland 狃郢 permanent implant ｫﾖ隗 radioisotopes 猴ﾅ靨ｹﾕ鬨ﾐ耆鯏ﾑｧﾊﾕｵ靉ｵ靉ﾁﾅﾙ｡ﾋﾁﾒ｡ｵﾅﾍｴ猊ﾅﾒ箒ﾂｷﾕ・ｨﾐﾅｴﾅｧ狠ﾗ靉猊ﾅﾒｼ靨ｹ莉眷ﾐ犹ﾗ靉ｧｨﾒ｡ｾﾅﾑｧｧﾒｹ｢ﾍｧ radioisotopes ｷﾕ鞳ｪ魴勒ﾁﾒ｡ｨﾖｧﾁﾕﾃﾑｧﾊﾕ眈靉ﾍ｡ﾁﾒｹﾍ｡ｼﾙ鮟霽ﾂｹ鯱ﾂﾁﾒ｡狃郢ﾇﾔｸﾕｷﾕ霍ﾓ莇鯡ﾐｴﾇ｡ﾃﾇｴ狹酩ｼﾙ鮟霽ﾂﾊﾒﾁﾒﾃｶ｡ﾅﾑｺｺ鰓ｹ莇鯊ﾒﾂ羯ﾇﾑｹ犇ﾕﾂﾇ

3.3 External-beam radiation therapy 箒ﾂ罨・computed tomography-based 3-D conformal

treatment planning ､ﾗﾍ｡ﾒﾃ罨・treatment planning computer ﾁﾒｪ霽ﾂﾇﾒｧ眈ｹ｡ﾒﾃﾃﾑ｡ﾉﾒ狎ﾗ靉耆・dose volume conform to target volume 箒ﾂ罨鬘ﾒﾃﾊﾃ鰓ｧﾀﾒｾ target volum 眷ﾐﾍﾇﾑﾂﾇﾐﾍﾗ雹・狃郢蘯ｺ 3 ﾁﾔｵﾔ眷ﾐ

｡ﾒﾃﾇﾒｧ beam ｢ﾍｧﾃﾑｧﾊﾕ羯盪ﾇ羔｡鈕ｴ・/P>

Complication 莇鱆｡・/P>

a) acute complication 莇鱆｡・acute cystitis, proctitis, enteritis ﾊ霽ｹ耆ｭ鞦ﾅ鯢ｨﾐﾁﾕﾍﾒ｡ﾒﾃ

菽霖ﾒ｡眷ﾐ revesible 耆鬘ﾒﾃﾃﾑ｡ﾉﾒｵﾒﾁﾍﾒ｡ﾒﾃｷﾕ霎ｺ犢靨ｹﾑ鮖

b) chronic complication ｾｺ radiation cystitis, proctitis < 10% 眷ﾐ impotence

ｻﾃﾐﾁﾒｳ 30% ｫﾖ隗｢ﾖ鮖｡ﾑｺﾍﾒﾂﾘ｢ﾍｧｼﾙ鮟霽ﾂ眷ﾐ vascular risk factors

4. Hormonal therapy 罨鰲ｻ郢｡ﾒﾃﾃﾑ｡ﾉﾒﾋﾅﾑ｡ﾊﾓﾋﾃﾑｺ｡ﾃｳﾕｷﾕ霖ﾕ｡ﾒﾃ｡ﾃﾐｨﾒﾂ｢ﾍｧ篥､莉ﾂﾑｧｵﾓ睛ｹ隗ﾍﾗ雹

Hormonal manipulation 羯ﾃﾐﾂﾐ狹ﾔ霖ｵ鮖莇鬨ﾒ｡｡ﾒﾃﾊﾑｧ爍ｵ｢ﾍｧ Huggins 眷ﾐ Hodgs ｾｺﾇ靨｡ﾒﾃｷﾓ orchiectomy

ﾋﾃﾗﾍ｡ﾒﾃ耆・female hormons ﾊﾒﾁﾒﾃｶｷﾓ耆鮹ﾐ狹遘ｵ靉ﾁﾅﾙ｡ﾋﾁﾒ｡ｽ靉ﾅｧ莇・ｻﾃﾐﾁﾒｳ 70-80% 眷ﾐﾁﾕ median duration of response ｻﾃﾐﾁﾒｳ 2-3 ｻﾕ羯ｻﾑｨｨﾘｺﾑｹ hormonal therapy 蘯隗狃郢 3 ｪｹﾔｴ､ﾗﾍ

4.1 Orchiectomy 狃郢ﾇﾔｸﾕｷﾕ霍ﾓ莇鬧靨ﾂ眷ﾐﾃﾇｴ狹酩ﾁﾕｼﾅ｢鰓ｧ爨ﾕﾂｧ､ﾗﾍ impotence, hot flashes,

psychologic side effect of emasculation

4.2 Estrogens 莇鱆｡・Diethyl stillbestrol 3 mg/day ｼﾅ｢鰓ｧ爨ﾕﾂｧ莇鱆｡・thromboembolic phenomena,Gynecomastia, impotence, hot flashes, gastrointestinal distress

4.3 LHRH agonist ｨﾐﾅｴﾃﾐｴﾑｺ leuteinizing hormone ｷﾕ霖ﾒ｡ﾃﾐｵﾘ鮖ｵ靉ﾁ pituitary ｷﾓ耆鯏ﾐｴﾑｺ

testosterone ﾅｴﾅｧｼﾅ｢鰓ｧ爨ﾕﾂｧ莇鱆｡・impotence, hot flashes, gynecomastia, gastrointestinal distress 盞鞴ﾁ霖ﾕ

thromboembolic complication

ｼﾅ｡ﾒﾃﾃﾑ｡ﾉﾒ眷ﾐｾﾂﾒ｡ﾃｳ・ﾍｧ篥､

｢ﾖ鮖ﾍﾂﾙ陦ﾑｺﾃﾐﾂﾐ｢ﾍｧ篥､ｵﾒﾁｵﾒﾃﾒｧ

Stage

5-Year Survival

A

B

C

80-95%

70-90%

39-63%

ﾁﾐ狹遘ﾅﾙ｡ﾍﾑｳｱﾐ (Testicular Cancer)

ﾍﾘｺﾑｵﾔ｡ﾒﾃ

1. 羯ｻﾕ 1990 ｾｺﾁﾐ狹遘ﾅﾙ｡ﾍﾑｳｱﾐ羯ｻﾃﾐ犢ﾈ莵ﾂｷﾑ鬧ﾋﾁｴ 121 ﾃﾒﾂ¹

2. 羯ｻﾕ 1995 ｼﾙ鮟霽ﾂﾁﾐ狹遘ﾅﾙ｡ﾍﾑｳｱﾐﾁﾒﾃﾑ｡ﾉﾒｷﾕ鞣ﾃｧｾﾂﾒｺﾒﾅｨﾘﾌﾒﾅｧ｡ﾃｳ・ﾁﾕｨﾓｹﾇｹ 8 ﾃﾒﾂ²

3. ﾍﾒﾂﾘ箒ﾂ爻ﾅﾕ霙｢ﾍｧｼﾙ鮟霽ﾂﾍﾂﾙ霤ﾐﾋﾇ靨ｧ 15-35 ｻﾕ

ｻﾑｨｨﾑﾂ猝ﾕ霙ｧ

1. Cryptorchidism ｻﾃﾐﾁﾒｳ 12% ｢ﾍｧｼﾙ鮟霽ﾂﾁﾐ狹遘ﾅﾙ｡ﾍﾑｳｱﾐﾁﾕ cryptorchid testis ﾋﾃﾗﾍｼﾙ鮟霽ﾂｷﾕ霖ﾕ

cryptorchid testis ｨﾐﾁﾕ､ﾇﾒﾁ猝ﾕ霙ｧｵ靉｡ﾒﾃ狃郢ﾁﾐ狹遘ﾅﾙ｡ﾍﾑｳｱﾐﾊﾙｧ｡ﾇ靨､ｹｻ｡ｵﾔｶﾖｧ 40 犢靨

2. Mumps orchitis ﾍﾒｨｨﾐ狃郢ｻﾑｨｨﾑﾂ猝ﾕ霙ｧ

3. Klinefelter痴 syndrome ﾁﾕ､ﾇﾒﾁ爍ﾕ霙ﾇ犹ﾗ靉ｧ｡ﾑｺ mediastinal germ cell tumors

ﾍﾒ｡ﾒﾃ眷ﾐﾍﾒ｡ﾒﾃ睫ｴｧ

1. 箒ﾂｷﾑ霽莉眷鯢ｼﾙ鮟霽ﾂｨﾐﾁﾒｾｺ眄ｷﾂ・ｹﾗ靉ｧｨﾒ｡､ﾅﾓ莇鬘鯱ｹ菽鞨ｨ郤ｻﾇｴｷﾕ霰ﾙ｡ﾍﾑｳｱﾐｺﾒｧ､ﾃﾑ鬧

ﾍﾒｨｨﾐﾁﾕｻﾃﾐﾇﾑｵﾔ｢ﾍｧ｡ﾒﾃ｡ﾃﾐｷｺ｡ﾃﾐ犢ﾗﾍｹﾅﾙ｡ﾍﾑｳｱﾐｹﾓﾁﾒ｡靉ｹｨﾖｧｷﾓ耆鮠ﾙ鮟霽ﾂﾊｹ罟ｷﾕ險ﾐｵﾃﾇｨﾅﾙ｡ﾍﾑｳｱﾐ

2. 羯ｺﾒｧﾃﾒﾂﾍﾒｨｨﾐﾁﾕﾍﾒ｡ﾒﾃ犹ﾗ靉ｧｨﾒ｡莇鬘ﾃﾐｨﾒﾂ｢ﾍｧ篥､莉ﾂﾑｧ paraaortic node 莇鱆｡・/P>

ｷ鯱ｧ箏ﾍﾗｴﾋﾃﾗﾍ盪雹ｷ鯱ｧ, ｻﾇｴｷ鯱ｧ, ｢ﾒｺﾇﾁﾋﾃﾗﾍｨﾒ｡｡ﾒﾃ｡ﾃﾐｨﾒﾂ｢ﾍｧ篥､莉ｷﾕ靉ﾗ雹爼雹､ﾅﾓ莇鬘鯱ｹ猴ｹﾗﾍ

萢ｻﾅﾒﾃ鰓｢鰓ｧｫ鰓ﾂ (left supraclavicular node)

3. Systemic symptom ｷﾕ霎ｺ莇・莇鱆｡・狠ﾗ靉ﾂﾅ鰓, ﾍ靉ｹ眦ｧ

4. ｼﾙ鮟霽ﾂｺﾒｧﾃﾒﾂﾍﾒｨｨﾐﾁﾕ Gynecomastia 犹ﾗ靉ｧｨﾒ｡ﾃﾐｴﾑｺ｢ﾍｧ chorionic gonadotropin ﾊﾙｧ

｡ﾃﾐｺﾇｹ｡ﾒﾃﾇﾔｹﾔｨｩﾑﾂ篥､

1. ｡ﾒﾃｫﾑ｡ｻﾃﾐﾇﾑｵﾔ眷ﾐｵﾃﾇｨﾃ靨ｧ｡ﾒﾂﾍﾂ靨ｧﾅﾐ猩ﾕﾂｴ箒ﾂ爻ｾﾒﾐ｡ﾒﾃｵﾃﾇｨｺﾃﾔ猊ｳﾅﾙ｡ﾍﾑｳｱﾐ, abdomen,

supraclavicular area 眷ﾐｵﾃﾇｨﾇ靨ﾁﾕ gynecomastia ﾋﾃﾗﾍ菽・/P>

2. Scrotal ultrasound 耆魴ﾃﾇｨ狎ﾗ靉眥｡ﾃﾐﾋﾇ靨ｧ intratesticular ｡ﾑｺ extratesticular mass

3. ﾋﾒ､靨 APP 眷ﾐ b -hCG 箒ﾂﾇﾔｸﾕ radioimmunoassay ｻﾃﾐﾁﾒｳ 85% ｢ﾍｧｼﾙ鮟霽ﾂｨﾐﾁﾕ､靨 tumor

marker ｹﾕ鯡ﾙｧﾍﾂ靨ｧｹ鯱ﾂ 1 ､靨 b -hCG ｨﾐﾁﾕ､靨ﾊﾙｧ莇鮟ﾃﾐﾁﾒｳ 10% ｢ﾍｧ early-stage seminoma 盞隍靨 AFP

ｨﾐ菽靆ﾙｧ｡ﾇ靨ｻ｡ｵﾔ羯 pure seminoma ｩﾐｹﾑ鮖ｶ鰓ｾｺﾇ靨､靨 AFP ﾊﾙｧ｡ﾇ靨ｻ｡ｵﾔｨﾐｵ鯱ｧﾃﾑ｡ﾉﾒ蘯ｺ nonseminomatous

germ cell tumor

4. ｶ鰓ﾊｧﾊﾑﾂ germ cell tumor ｵ鯱ｧｷﾓ radical transinguinal orchiectomy 狎ﾗ靉耆鱠ｴ鮠ﾅｾﾂﾒｸﾔﾇﾔｷﾂﾒ

ﾅﾑ｡ﾉｳﾐｷﾒｧｾﾂﾒｸﾔﾇﾔｷﾂﾒ

The World Heath Organization histologic classiffication of testicular germ cell tumors 莇鯤ﾖ｡ﾉﾒ

ｼﾅｾﾂﾒｸﾔｻﾃﾐﾁﾒｳ 1,000 ﾃﾒﾂ｢ﾍｧｼﾙ鮟霽ﾂｨﾒ｡ Armed Forces Institute of Pathology (AFIP) 莇鮠ﾅｴﾑｧｹﾕ・/P>

A. Tumor showing single cell type

1. Seminoma 26.9%

2. Embryonal carcinoma 3.1%

3. Teratoma 2.7%

4. Choriocarcinoma 0.03%

5. Yolk sac tumor 2.4%

(盞靆霽ｹ耆ｭ陲ﾍｧ nonseminoma ｨﾐﾁﾕﾁﾒ｡｡ﾇ靨 1 cell type)

B. Tumor showing more than one histologic pattern

1. Embryonal carcinoma and teratoma with or without seminoma

2. Embryonal carcinoma and yolk sac tumor with or without seminoma

3. Embryonal carcinoma and seminoma

4. Yolk sac tumor and teratoma with or without seminoma

5. Choriocarcinoma and any other element

｡ﾒﾃ蘯隗ﾃﾐﾂﾐ｢ﾍｧ篥､ｵﾒﾁ TNM classification

pT0: No evidence of primary tumor (e.g., histologic scar in testis)

pTis: Intratubular tumor: preinvasive cancer

pT1: Tumor limited to testis, including rete testis

pT2: Tumor invades beyond the tunica albuginea or into the epididymis

pT3: Tumor invades the spermatic cord

pT4: Tumor invades the scrotum

N0: No regional lymph node metastasis

N1: Metastasis in a single lymph node, 2 cm or less in greatest dimension

N2: Metastasis in a single lymph node, more than 2 cm but not more than 5 cm in greatest dimension; or multiple lymph nodes, none more than 5 cm in greatest dimension

N3: Metastasis in a lymph node more than 5 cm in greatest dimension

M0: No distant metastasis

M1: Distant metastasis

-- AJCC Stage Groupings --

--Stage 0-- Tis, N0, M0

--Stage I-- any pT, N0, M0

--Stage II-- any pT, N1-3, M0

--Stage III-- Any pT, any N, M1

Staging Work-up

- ｡ﾒﾃｷﾓ Radical inguinal orchiectomy ､ﾗﾍ｡ﾒﾃ remove testis 眷ﾐ spermatic cord ﾍﾍ｡箒ﾂ

inguinal approach ﾊﾓﾋﾃﾑｺ transscrotal biopsy 菽靆ﾁ､ﾇﾃｷﾓ狎ﾃﾒﾐｷﾓ耆鰾ﾍ｡ﾒﾊｷﾕ險ﾐﾁﾕ tumor recurrence ｷﾕ・scrotum 眷ﾐ inguinal node ﾊﾙｧ｢ﾖ鮖

1. Blood test, chest x-rays

2. Tumor markers : b -hCG, AFP

3. Retroperitoneal lymph node evaluation ｫﾖ隗ﾍﾒｨｷﾓ莇鰾ｴﾂ CT scan ﾋﾃﾗﾍ lymphangiography

羯ｻﾑｨｨﾘｺﾑｹ CT scan ｶﾗﾍﾇ靨狃郢｡ﾒﾃｵﾃﾇｨﾁﾒｵﾃｰﾒｹｷﾕ襍鯱ｧｷﾓ羯ｼﾙ鮟霽ﾂｷﾘ｡ﾃﾒﾂ狎ﾃﾒﾐﾊﾐｴﾇ｡眷ﾐ莇鮠ﾅ

罍ﾅ鰲､ﾕﾂｧ｡ﾑｺ lymphangicgraphy 盞靉ﾂ靨ｧ菘｡邨ﾒﾁ眞鯢靨 CT scan ｨﾐ菽霎ｺ retroperitoneal lymph node involvement 盞霈ﾙ鮟霽ﾂ｡酊ﾑｧﾁﾕ簣｡ﾒﾊｻﾃﾐﾁﾒｳ 25-30% ｷﾕ險ﾐﾁﾕ microscopic involvement of lymph node

ﾋﾅﾑ｡｡ﾒﾃﾃﾑ｡ﾉﾒ

ﾁﾐ狹遘ﾅﾙ｡ﾍﾑｳｱﾐ狃郢篥､ｷﾕ霤ﾑ｡ﾉﾒ眷鯢ﾁﾕ簣｡ﾒﾊﾋﾒﾂ｢ﾒｴﾊﾙｧﾁﾒ｡羯｡ﾒﾃﾃﾑ｡ﾉﾒｹﾑ鮖狹ﾒｨﾐ蘯隗

ｼﾙ鮟霽ﾂﾍﾍ｡狃郢 2 ｡ﾅﾘ霖ｵﾒﾁｪｹﾔｴ｢ﾍｧｼﾅｾﾂﾒｸﾔ､ﾗﾍ seminoma 眷ﾐ nonseminoma ｡ﾅﾘ霖 seminoma ｨﾐｵﾍｺﾊｹﾍｧｴﾕ

ｵ靉ﾃﾑｧﾊﾕﾃﾑ｡ﾉﾒﾊ霽ｹ｡ﾅﾘ霖 nonseminoma ｡ﾒﾃ罨鯏ﾑｧﾊﾕﾃﾑ｡ﾉﾒｨﾐ菽隍靉ﾂ莇鮠ﾅ羯｡ﾃｳﾕｷﾕ霈ﾅｾﾂﾒｸﾔ狃郢蘯ｺ mixture

of seminoma and nonseminoma ｡遞ﾐｵ鯱ｧﾃﾑ｡ﾉﾒ蘯ｺ nonseminoma

羯ｼﾙ鮟霽ﾂｷﾕ靉ﾒﾂﾘｹ鯱ﾂ｡ﾇ靨 15 ｻﾕｨﾐｾｺ yolk sac tumor ｻﾃﾐﾁﾒｳ 90% ｫﾖ隗ｨﾐﾁﾕ AFP ﾊﾙｧ｡ﾇ靨ｻ｡ｵﾔ眷ﾐ

ﾊﾒﾁﾒﾃｶ罨鰲ｻ郢ｵﾑﾇｺ隗ｪﾕ鮓ﾖｧﾊﾀﾒﾇﾐ｢ﾍｧ篥､眷ﾐ｡ﾒﾃｵﾍｺﾊｹﾍｧｵ靉｡ﾒﾃﾃﾑ｡ﾉﾒ莇鰲ｻ郢ﾍﾂ靨ｧｴﾕ

An international germ cell tumor prognostic classification 莇鮓ﾙ｡ｾﾑｲｹﾒ｢ﾖ鮖ｨﾒ｡｡ﾒﾃﾇﾔ爨ﾃﾒﾐﾋ・ﾙ鮟霽ﾂ

metastatic nonseminoma 5,202 ﾃﾒﾂ眷ﾐｼﾙ鮟霽ﾂ metastatic seminoma 660 ﾃﾒﾂﾁﾕﾃﾒﾂﾅﾐ猩ﾕﾂｴｴﾑｧｹﾕ・/P>

--Good Prognosis--

Nonseminoma:

testis/retroperitoneal primary and no non-pulmonary visceral metastases and good markers - all of:

AFP < 1000 ng/ml and

hCG < 5000 iu/l (1000 ng/ml) and

LDH < 1.5 x upper limit of normal

56% of nonseminomas

5 year progression-free survival (PFS) 89%

5 year survival 92%

Seminoma:

Any primary site and no non-pulmonary visceral metastases and normal AFP, any hCG, any LDH

90% of seminomas

5 year PFS 82%

5 year survival 86%

--Intermediate Prognosis--

Nonseminoma:

testis/retroperitoneal primary and no non-pulmonary visceral metastases and intermediate markers - any of:

AFP >= 1000 and <= 10,000 ng/ml or

hCG >= 5000 iu/l and <= 50,000 iu/l or

LDH >= 1.5 x N and <= 10 x N

28% of nonseminomas

5 year PFS 75%

5 year survival 80%

Seminoma:

any primary site and non-pulmonary visceral metastases and normal AFP, any hCG, any LDH

10% of seminomas

5 year PFS 67%

5 year survival 72%

--Poor Prognosis--

Nonseminoma:

mediastinal primary or non-pulmonary visceral metastases or poor markers - any of:

AFP > 10,000 ng/ml or

hCG > 50,000 iu/l (1000 ng/ml) or

LDH > 10 x upper limit of normal

16% of nonseminomas

5 year PFS 41%

5 year survival 48%

Seminoma:

No patients classified as poor prognosis.

｡ﾒﾃﾃﾑ｡ﾉﾒ｢ﾍｧ篥､盞霰ﾐﾃﾐﾂﾐ

* STAGE I TESTICULAR CANCER * (T_1-4 , N₀ , M₀)

Stage I Seminoma

	ﾁﾕ cure rate > 95%.
	1.  Radical inguinal orchiectomy + post-operative radiation to the retroperitoneal and ipsilateral inguinal lymph  眞鯢靨 CT scan ｨﾐ菽霎ｺ retroperitoneal lymph node involvement 盞霈ﾙ鮟霽ﾂ｡酊ﾑｧﾁﾕ簣｡ﾒﾊｻﾃﾐﾁﾒｳ 25-30% ｷﾕ險ﾐﾁﾕ microscopic involvement of lymph node ｡ﾒﾃ耆鯏ﾑｧﾊﾕｨﾖｧﾁﾕｻﾃﾐ篦ｪｹ・ｹｼﾙ鮟霽ﾂ｡ﾅﾘ霖ｹﾕ・
	2.  Radical inguinal orchiectomy with no retroperitoneal node irradiation  followed by frequent determination of serum markers, chest x-rays, and CT  scans (surveillance). ｨﾒ｡｡ﾒﾃﾇﾔｨﾑﾂ羯ｼﾙ鮟霽ﾂ 172 ﾃﾒﾂ ｷﾕ霤ﾑ｡ﾉﾒｴ鯢ﾂﾇﾔｸﾕｹﾕ鮴ｺﾇ靨 ﾁﾕﾍﾑｵﾃﾒ｡ﾒﾃ｡ﾅﾑｺﾁﾒ耆ﾁ・｢ﾍｧ篥､ｷﾕ・5 ｻﾕ 18% ｫﾖ隗ｼﾙ鮟霽ﾂ爍ﾗﾍｺｷﾑ鬧ﾋﾁｴ｡酊ﾑｧﾊﾒﾁﾒﾃｶﾃﾑ｡ﾉﾒ耆鰺ﾒﾂｴ鯢ﾂ ﾂﾒ爨ﾁﾕｺﾓｺﾑｴﾋﾃﾗﾍﾃﾑｧﾊﾕﾃﾑ｡ﾉﾒ

Stage I Nonseminoma

ﾁﾕ cure rate ｻﾃﾐﾁﾒｳﾁﾒ｡｡ﾇ靨 95%

1. Radical inguinal orchiectomy + retroperitoneal lymph node dissection (RPL) ｡ﾒﾃｷﾓ retroperitoneal

lymph node dissection ､ﾇﾃｷﾓ蘯ｺ nerve-sparing technique 狎ﾗ靉ｷﾕ險ﾐ preserve ejaculation ﾋﾅﾑｧｨﾒ｡ｹﾑ鮖

､ﾇﾃｨﾐ爲ﾒﾐ serum marker 眷ﾐｷﾓ chest x-rays ｷﾘ｡犇ﾗﾍｹ羯ｻﾕ眦｡眷ﾐｷﾘ｡ 1-2 犇ﾗﾍｹ羯ｻﾕｶﾑｴ莉ｨﾒ｡｡ﾒﾃ

ﾈﾖ｡ﾉﾒ｢ﾍｧ Testicular Cancer Intergroup ｾｺﾇ靨ｶ鰓ﾁﾕ vascular invasion ｢ﾍｧ tumor ｨﾐﾁﾕ relapse rate ｻﾃﾐﾁﾒｳ

19% 狠ﾗ靉犢ﾕﾂｺ｡ﾑｺ｡ﾅﾘ霖ｷﾕ鞴ﾁ霖ﾕ vascular invasion ｻﾃﾐﾁﾒｳ 6%

2. Radical inguinal orchiectomy without retroperitoneal node dissection ﾊﾒﾁﾒﾃｶｷﾓ莇鰾ｴﾂ

ｵ鯱ｧ､ﾓｹﾖｧｶﾖｧｻﾑｨｨﾑﾂｵ靉莉ｹﾕ・/P>

a) CT scan 眷ﾐ､靨 serum markers ﾍﾂﾙ鞳ｹ爍ｳｱ・｡ｵﾔ

b) ｼﾙ鮟霽ﾂｵ鯱ｧｾﾃ鯱ﾁ眷ﾐﾂﾍﾁﾃﾑｺ｡ﾒﾃｵﾃﾇｨｵ靉莉ｹﾕ・/P>

1. chest x-rays ｷﾘ｡犇ﾗﾍｹ羯ｻﾕ眦｡

2. serum markers ｷﾘ｡犇ﾗﾍｹ羯ｻﾕ眦｡

3. abdominal CT scan ｷﾘ｡ 2 犇ﾗﾍｹ羯ｻﾕ眦｡

4. ｵ鯱ｧｾｺ眄ｷﾂ・狎ﾗ靉ｵﾃﾇｨﾃ靨ｧ｡ﾒﾂｷﾘ｡犇ﾗﾍｹ羯 2 ｻﾕ眦｡眷ﾐｾｺ眄ｷﾂ・ｻ郢ﾃﾐﾂﾐ・/P>

狠ﾗ靉ﾋﾅﾑｧ 2 ｻﾕｼ靨ｹ莉

3. Radical inguinal orchiectomy with retroperitoneal lymph node dissection and adjuvant

chemotherapy 羯ｼﾙ鮟霽ﾂｷﾕ霖ﾕ high risk of relapse ｫﾖ隗莇鱆｡陦ﾅﾘ霖ｷﾕ霖ﾕ histologic evidence of lymphatic or venous

invasion, ｡ﾅﾘ霖ｷﾕ霖ﾕ embryonal cell histology ｡ﾒﾃﾃﾑ｡ﾉﾒﾇﾔｸﾕｹﾕ鬘ﾓﾅﾑｧﾍﾂﾙ鞳ｹﾃﾐﾋﾇ靨ｧ｡ﾒﾃﾈﾖ｡ﾉﾒｶﾖｧｼﾅｴﾕ眷ﾐｼﾅ猝ﾕﾂ

ｨﾒ｡｡ﾒﾃﾈﾖ｡ﾉﾒ｢ﾍｧ Cullen 眷ﾐ､ｳﾐｾｺﾇ靨 relapse rate after chemotherapy ｹ鯱ﾂ｡ﾇ靨 5% 狠ﾗ靉犢ﾕﾂｺ｡ﾑｺ historical

control ｫﾖ隗ｨﾐﾁﾕ relapse rate ｻﾃﾐﾁﾒｳ 50% 盞靉ﾂ靨ｧ菘｡邨ﾒﾁ羯｡ﾅﾘ霖ｷﾕ霖ﾕ｡ﾒﾃ｡ﾅﾑｺ｢ﾍｧ篥､｢ﾖ鮖ﾁﾒ耆ﾁ陦酊ﾑｧﾁﾕ

cure rate ｻﾃﾐﾁﾒｳ 95% ｨﾒ｡｡ﾒﾃ耆・chemotherapy

*STAGE II TESTICULAR CANCER* (T_1-4 , N_1-3 , M₀)

Stage II seminoma

N_1-2 ﾋﾃﾗﾍ Nonbulky disease ﾁﾕ cure rate >90% ｴ鯢ﾂ radiation (盞鞳ｹ｢ｳﾐｷﾕ・N₃ ﾋﾃﾗﾍ bulky

disease ﾁﾕ cure rate ｻﾃﾐﾁﾒｳ 70% ｴ鯢ﾂ radiation alone)

1. Radical inguinal orchiectomy followed by radiation of retroperitoneal lymph nodes

羯ｻﾑｨｨﾘｺﾑｹｾｺﾇ靨｡ﾒﾃ耆・prophylactic radiotherapy to mediastinum and neck 羯ｼﾙ鮟霽ﾂ

ﾃﾐﾂﾐｹﾕ鱠ﾁ霖ﾕｻﾃﾐ篦ｪｹ・/P>

N₃ ﾋﾃﾗﾍ bulky disease

1. Radical inguinal orchiectomy followed by combination chemotherapy (cisplatin-based

regimen)

2. Radical inguinal orchiectomy followed by radiation to abdominal and pelvic node

眞鯢靨羯ﾍｴﾕｵ cure rate ｴ鯢ﾂ radiation ｻﾃﾐﾁﾒｳ 70% 盞鞳ｹｻﾑｨｨﾘｺﾑｹﾍﾘｻ｡ﾃｳ・ﾅﾐ｡ﾒﾃ

ﾇﾒｧ眈ｹ｡ﾒﾃﾃﾑ｡ﾉﾒｴ鯢ﾂ computer ｡鰓ﾇﾋｹ鰓｢ﾖ鮖ｼﾅ｡ﾒﾃﾃﾑ｡ﾉﾒｨﾖｧｴﾕ｢ﾖ鮖

Stage II nonseminoma

ﾁﾕ cure rate > 95%

1. Radical inguinal orchiectomy followed by nerve-sparing retroperitoneal lymph node dissection

ｨﾐ耆・chemotherapy 狠ﾗ靉ﾁﾕ relapse 犢靨ｹﾑ鮖

2. Radical inguinal orchiectomy followed by nerve-sparing retroperitoneal lymph node dissection and

chemotherapy ﾊﾓﾋﾃﾑｺ chemotherapy 耆鰲ｻ郢 cisplatin-based chemotherapy 2 cycles ｫﾖ隗ｨﾐﾊﾒﾁﾒﾃｶｻ鯱ｧ｡ﾑｹ｡ﾒﾃ

｡ﾅﾑｺ｢ﾖ鮖ﾁﾒ耆ﾁ陲ﾍｧ篥､莇鮹ﾒ｡｡ﾇ靨 95% 盞靉ﾂ靨ｧ菘｡邨ﾒﾁ total cure rate ｡鈕ﾁ鞴ｴ魴靨ｧｨﾒ｡｡ﾒﾃﾃﾑ｡ﾉﾒ蘯ｺｷﾕ・1

3. Radical inguinal orchiectomy followed by chemotherapy with delayed surgery for residual

mass after chemotherapy ｫﾖ隗｡ﾒﾃﾃﾑ｡ﾉﾒﾇﾔｸﾕｹﾕ鬨ﾐ罨鬘ﾑｺｼﾙ鮟霽ﾂｷﾕ霖ﾕ retroperitoneal mass ｢ｹﾒｴ耆ｭ陦ﾇ靨 5 爿ｹｵﾔ狠ｵﾃ

ｫﾖ隗｡ﾒﾃｼ靨ｵﾑｴｨﾐ｡ﾃﾐｷﾓ莇鬢靉ｹ｢鰓ｧﾂﾒ｡ﾊﾓﾋﾃﾑｺ chemotherapy ｷﾕ鞳ｪ鱠ｴ鱆｡・/P>

BEP : Bleomycin + Etoposicle + Cisplatin 3 courses

EP : Etoposide + Cisplatin 4 courses 羯｡ﾅﾘ霖､ｹ茲鮃ﾕ・good prognosis

PVP : Cisplatin + Vinblastine + Bleomycin 3 courses

ｨﾒ｡｡ﾒﾃﾈﾖ｡ﾉﾒｾｺﾇ靨 PVB 眷ﾐ BEP ﾁﾕ anticancer activity 犢靨｡ﾑｹ盞・BEP ﾁﾕｼﾅ｢鰓ｧ爨ﾕﾂｧｹ鯱ﾂ｡ﾇ靨

ｶ鰓耆・chemotherapy 眷鯢｡鯱ｹﾂﾑｧﾂﾘｺ菽靈ﾁｴ､ﾇﾃｨﾐｼ靨ｵﾑｴ猩ﾒ｡鯱ｹﾍﾍ｡犹ﾗ靉ｧｨﾒ｡ﾍﾒｨｨﾐﾁﾕ residual teratoma

ﾋﾃﾗﾍ carcinoma ﾍﾂﾙ鞳ｹ｡鯱ｹｷﾕ鞨ﾋﾅﾗﾍﾍﾂﾙ・眷ﾐｶ鰓ｾｺﾇ靨ﾁﾕ persistent nonseminomatous germ cell malignant

element 羯｡鯱ｹｷﾕ霈靨ﾍﾍ｡ﾁﾒｨﾐ狃郢｢鯱ｺ隗ｪﾕ鮃ﾕ險ﾐｵ鯱ｧ耆・chemotherapy ｵ靉

4. Radical inguinal orchiectomy followed by chemotherapy in small volume retroperitoneal disease

ｫﾖ隗狃郢､ﾇﾒﾁｾﾂﾒﾂﾒﾁｷﾕ險ﾐﾋﾅﾕ｡倏ﾕ霙ｧ｡ﾒﾃｷﾓ retroperitoneal dissection ｡ﾒﾃﾃﾑ｡ﾉﾒﾇﾔｸﾕｹﾕ鯆ﾑｧﾍﾂﾙ鞳ｹﾃﾐﾋﾇ靨ｧ｡ﾒﾃﾇﾔｨﾑﾂ

ｶﾖｧ｢鯱ｴﾕ眷ﾐ｢鯱猝ﾕﾂ

*STAGE III TESTICULAR CANCER* (T_1-4 , N_1-3 , M₁)

Stage III seminoma

ﾁﾕ cure rate ｻﾃﾐﾁﾒｳ 70-80%

1. Radical inguinal orchiectomy followed by multidrug chemotherapy ｶ鰓ﾁﾕ residual mass

ﾋﾅﾑｧｨﾒ｡｡ﾒﾃ耆・chemotherapy ｢ｹﾒｴ ³ 3 爿ｹｵﾔ狠ｵﾃ､ﾇﾃｨﾐｼ靨ｵﾑｴ猩ﾒ｡鯱ｹｹﾑ鮖ﾍﾍ｡ﾊﾓﾋﾃﾑｺ chemotherapy

ｷﾕ鞳ﾋ・莇鱆｡・/P>

BEP 3 courses ﾋﾃﾗﾍ

PVB 3 courses ﾋﾃﾗﾍ

EP 4 courses 羯ｼﾙ鮟霽ﾂ｡ﾅﾘ霖 good-prognosis

Stage III nonseminoma

ﾁﾕ cure rate ｻﾃﾐﾁﾒｳ 70% ｼﾙ鮟霽ﾂｷﾕ霖ﾕ wide spread visceral metastasis, high tumor markers,

mediastinal primary tumor ﾁﾑ｡ｨﾐ菽靆ﾒﾁﾒﾃｶﾃﾑ｡ﾉﾒ耆鰺ﾒﾂ莇魘鯢ﾂ chemotherapy 羯ｻﾑｨｨﾘｺﾑｹ

1. Radical inguinal orchiectomy followed by multidrug chemotherapy 猴ﾁﾗﾍｹ｡ﾑｺ seminoma 眷ﾐｶ鰓ﾁﾕ

residual mass after chemotherapy ､ﾇﾃｨﾐｷﾓｨﾐｼ靨ｵﾑｴ猩ﾒ｡鯱ｹﾍﾍ｡ｷﾑ鬧ﾋﾁｴ狎ﾃﾒﾐﾁﾕｻﾃﾐ篦ｪｹ・2 ｻﾃﾐ｡ﾒﾃ､ﾗﾍ

a) ﾊﾒﾁﾒﾃｶ remove residual teratoma ﾋﾃﾗﾍ carcinoma

b) 狃郢｢鯱ｺ隗ｪﾕ鮃ﾕ險ﾐｵ鯱ｧ耆・chemotherapy ｵ靉

ﾊﾒ猴ｵﾘｷﾕ險ﾐｵ鯱ｧｷﾓ orchiectomy 羯ｼﾙ鮟霽ﾂﾃﾐﾂﾐｹﾕ・狎ﾃﾒﾐ箒ﾂｻ｡ｵﾔ眷鯢 chemotherapy ｨﾐｼ靨ｹ爐鰓莉

羯ﾍﾑｳｱﾐ莇鮖鯱ﾂ狎ﾃﾒﾐﾁﾕ physiologic blood-testis barrier ｫﾖ隗ｷﾓ耆鮹ﾕ residual cancer 羯ﾍﾑｳｱﾐ莇鮓ﾖｧ 50%

ｪｹﾔｴ｢ﾍｧ｡ﾒﾃﾃﾑ｡ﾉﾒ

1. ｡ﾒﾃｼ靨ｵﾑｴｷﾕ鞳ｪ鱚ｹ｡ﾒﾃﾃﾑ｡ﾉﾒﾁﾐ狹遘ﾅﾙ｡ﾍﾑｳｱﾐ莇鱆｡・/P>

1.1 Radical inguinal orchiectomy

1.2 Retroperitoneal lymph node dissection ｫﾖ隗｡ﾒﾃｷﾓ nerve-spaning technique ﾊﾒﾁﾒﾃｶ

preserve ejaculation 莇鱚ｹｼﾙ鮟霽ﾂ爍ﾗﾍｺｷﾘ｡ﾃﾒﾂ箒ﾂ菽霍ﾓ耆鬘ﾒﾃ､ﾇｺ､ﾘﾁ篥､ｵ勒ﾅｧ

1.3 Surgical resection of residual mass after chemotherapy

2. ﾃﾑｧﾊﾕﾃﾑ｡ﾉﾒ

2.1 犹ﾗ靉ｧｨﾒ｡ seminoma ｨﾑｴ狃郢 cell type ｷﾕ鞴ﾇｵ靉ﾃﾑｧﾊﾕﾁﾒ｡ｻﾃﾔﾁﾒｳﾃﾑｧﾊﾕｷﾕ鞳ﾋ鯡ﾓﾋﾃﾑｺ

subclinical disease ｻﾃﾐﾁﾒｳ 20-30 Gy 眷ﾐﾊﾓﾋﾃﾑｺ gross tumor 30-35 Gy, 1.5-1.8 Gy

per fraction 犢靨ｹﾑ鮖 Radiation volume 耆鬢ﾃﾍｺ､ﾅﾘﾁ para-aortic 眷ﾐ ipsilateral pelvic

node (hockey stick field)

2.2 ｼﾅ｢鰓ｧ爨ﾕﾂｧ｢ﾍｧﾃﾑｧﾊﾕ､靉ｹ｢鰓ｧｹ鯱ﾂﾁﾒ｡ﾍﾒｨｨﾐﾁﾕ犲ﾗ靉ﾍﾒﾋﾒﾃ, ､ﾅﾗ雹萍・ﾍﾒ爲ﾕﾂｹ, ｷ鯱ｧ犇ﾔｹ莇鮗鰓ｧ

羯ﾃﾐﾋﾇ靨ｧ莇鯏ﾑｺﾃﾑｧﾊﾕｻﾃﾔﾁﾒｳﾃﾑｧﾊﾕｷﾕ霰ﾙ｡ﾍﾑｳｱﾐｷﾕ鞨ﾋﾅﾗﾍｨﾐ莇鯏ﾑｺﾍﾂﾙ霆ﾃﾐﾁﾒｳ 25-100 cGy

羯ｼﾙ鮟霽ﾂ爍ﾗﾍｺｷﾘ｡ﾃﾒﾂｨﾐﾁﾕ transient oligospermia 盞險ﾐ｡ﾅﾑｺ､ﾗｹ狃郢ｻ｡ｵﾔ羯 18-24 犇ﾗﾍｹ

3. 爨ﾁﾕｺﾓｺﾑｴ

cisplatin ｨﾑｴ狃郢ﾂﾒ爨ﾁﾕｺﾓｺﾑｴｷﾕ鞴ｴ鮠ﾅｴﾕｷﾕ靆ﾘｴﾊﾓﾋﾃﾑｺ germ cell tumor ｴﾑｧｹﾑ鮖ﾊﾙｵﾃ爨ﾁﾕｺﾓｺﾑｴｨﾖｧﾁﾕ

ﾂﾒ cisplatin ﾃﾇﾁﾍﾂﾙ雍鯢ﾂ猝ﾁﾍ

ﾁﾐ狹遘ﾍｧ､ｪﾒｵﾔ (Penile Cancer)

ﾍﾘｺﾑｵﾔ｡ﾒﾃ

1. 羯ｻﾕ 1990 ｾｺﾁﾐ狹遘ﾍｧ､ｪﾒｵﾔ羯ｻﾃﾐ犢ﾈ莵ﾂｻﾃﾐﾁﾒｳ 417 ﾃﾒﾂ

2. 羯ｻﾕ 1995 ｼﾙ鮟霽ﾂﾁﾐ狹遘ﾍｧ､ｪﾒｵﾔﾁﾒﾃﾑ｡ﾉﾒｷﾕ鞣ﾃｧｾﾂﾒｺﾒﾅｨﾘﾌﾒﾅｧ｡ﾃｳ・ｨﾓｹﾇｹ 9 ﾃﾒﾂ

3. ﾍﾒﾂﾘ箒ﾂ爻ﾅﾕ霙｢ﾍｧｼﾙ鮟霽ﾂﾍﾂﾙ霤ﾐﾋﾇ靨ｧ 58-60 ｻﾕ

ｻﾑｨｨﾑﾂ猝ﾕ霙ｧ

1. uncircumcised men ｫﾖ隗ｹ靨ｨﾐ爍ﾔｴｨﾒ｡｡ﾒﾃﾃﾐ､ﾒﾂ爨ﾗﾍｧ｢ﾍｧ semega 眷ﾐ｡ﾒﾃｴﾙ眷ﾃﾑ｡ﾉﾒ､ﾇﾒﾁﾊﾐﾍﾒｴ

ｹ鯱ﾂ, semega 狃郢ｼﾅ犹ﾗ靉ｧｨﾒ｡ bacteria ｷﾓｻｯﾔ｡ﾔﾃﾔﾂﾒ｡ﾑｺ desquamated epithelial cells

2. ｻﾑｨｨﾑﾂﾍﾗ雹ｷﾕ霖ﾕ｡ﾒﾃﾇﾔｨﾑﾂﾊｹﾑｺﾊｹﾘｹ眷ﾐ｢ﾑｴ眥ﾑｧ｡ﾑｹ莇鱆｡・/P>

2.1 Human Papilloma Virus (HPV) infection

2.2 Herpetic infection

2.3 Cervical carcinoma sexual partner

ﾍﾒ｡ﾒﾃ眷ﾐﾍﾒ｡ﾒﾃ睫ｴｧ

1. ﾍﾒ｡ﾒﾃｷﾕ霎ｺｺ靉ﾂ､ﾗﾍ mass ﾋﾃﾗﾍ persistent sore, ulcer of the glans, foreskin or

shaft of penis

2. ﾍﾒ｡ﾒﾃｷﾕ霎ｺｹ鯱ﾂ羯ﾃﾐﾂﾐ眦｡莇鱆｡・inguinal lymphadenopathy

｡ﾃﾐｺﾇｹ｡ﾒﾃﾇﾔｹﾔｨｩﾑﾂ篥､

1. ｫﾑ｡ｻﾃﾐﾇﾑｵﾔ眷ﾐｵﾃﾇｨﾃ靨ｧ｡ﾒﾂﾍﾂ靨ｧﾅﾐ猩ﾕﾂｴ箒ﾂ爻ｾﾒﾐｺﾃﾔ猊ｳ primary lesion 眷ﾐｺﾃﾔ猊ｳ inguinal

area ｷﾑ鬧 2 ｢鰓ｧ

2. Incisional ﾋﾃﾗﾍ Excisional biopsy

3. CT ﾋﾃﾗﾍ MRI scan 狎ﾗ靉罨鮟ﾃﾐ狠ﾔｹ pelvic and abdominal node

ﾅﾑ｡ﾉｳﾐｷﾒｧｾﾂﾒｸﾔﾇﾔｷﾂﾒ

爍ﾗﾍｺｷﾑ鬧ﾋﾁｴ｢ﾍｧ penile carcinoma ｨﾐ狃郢 squamous cell carcinoma ﾊﾓﾋﾃﾑｺ cell type ｪｹﾔｴﾍﾗ雹・/P>

ｷﾕ靉ﾒｨｾｺ莇・莇鱆｡・ malignant melanoma, basal cell carcinoma, Bowen痴 disease (carcinoma in situ),

mesenchymal tumor, metastatic lesion

｡ﾒﾃ蘯隗ﾃﾐﾂﾐ｢ﾍｧ篥､ｵﾒﾁ TNM classification

T0: No evidence of primary tumor

Tis: Carcinoma in situ

Ta: Noninvasive verrucous carcinoma

T1: Tumor invades subepithelial connective tissue

T2: Tumor invades corpus spongiosum or cavernosum

T3: Tumor invades urethra or prostate

T4: Tumor invades other adjacent structures

N0: No regional lymph node metastasis

N1: Metastasis in a single superficial inguinal lymph node

N2: Metastasis in multiple or bilateral superficial inguinal lymph nodes

N3: Metastasis in deep inguinal or pelvic lymph node(s), unilateral or bilateral

M0: No distant metastasis

M1: Distant metastasis

--Stage 0-- Tis-a, N0, M0

--Stage I-- T1, N0, M0

--Stage II-- T2, N0, M0

T1-2, N1, M0

--Stage III-- T1-2, N2, M0

T3, N0-2, M0

--Stage IV-- T4, any N, M0

any T, N3, M0

any T, any N, M1

ﾋﾅﾑ｡｡ﾒﾃﾃﾑ｡ﾉﾒ

Stage I penile cancer (T_is , T_a , T₁ ; N₀; M₀)

1. Lesions limited to the foreskin 耆鮃ﾓ wide local excision with circumcision

2. Carcinoma in situ of the glans 耆鬘ﾒﾃﾃﾑ｡ﾉﾒ莇鰾ｴﾂ

2.1 local application of fluorouracil cream

microscopically controlled surgery

For infiltrating tumor of the glans

Penile amputation ( partial or total )
Radiation therapy
microscopically controlled surgery

4. Nd : YAG laser therapy ﾊﾒﾁﾒﾃｶ preserve cosmetic appearance 莇魘ﾕ盞霈ﾅ｡ﾒﾃﾈﾖ｡ﾉﾒﾂﾑｧﾁﾕ

､靉ｹ｢鰓ｧｹ鯱ﾂ

Stage II penile cancer (T₂ , N₀ , M₀)

1. penile amputation ｫﾖ隗ﾍﾒｨｨﾐ狃郢 partial, total, or radical amputation ｢ﾖ鮖ﾍﾂﾙ陦ﾑｺ｢ｹﾒｴ眷ﾐ

ｵﾓ睛ｹ隗｢ﾍｧ篥､

2. Radiation therapy 眷ﾐｶ鰓ﾁﾕ recurrence ｨﾖｧｷﾓ amputation

3. Nd : YAG laser therapy 狎ﾗ靉ｷﾕ險ﾐ preserve penis 羯｡ﾃｳﾕ tumor 倏遑盞霈ﾅ｡ﾒﾃﾈﾖ｡ﾉﾒ

ﾂﾑｧ､靉ｹ｢鰓ｧｹ鯱ﾂ

4. 羯｡ﾃｳﾕｷﾕ鞨ｻ郢 poorly differentiated tumor ﾍﾒｨｨﾐｷﾓ prophylactic ilioinguinal lymphadenectomy

ﾃ霽ﾁｴ鯢ﾂ

Stage III penile cancer (T_is , T_a , T₁ , T₂; N_1-3 ; M₀)

ｻﾃﾐﾁﾒｳ 50% ｢ﾍｧｼﾙ鮟霽ﾂｨﾐｾｺﾇ靨ﾁﾕ inguinal node 箏盞隍ﾃﾖ隗ﾋｹﾖ隗｢ﾍｧｼﾙ鮟霽ﾂｹﾕ鬨ﾐｾｺﾇ靨｡ﾒﾃｷﾕ・/P>

inguinal node 箏爍ﾔｴｨﾒ｡ inflammatory changes ｫﾖ隗爍ﾕ霙ﾇｾﾑｹ｡ﾑｺ ulcerated or infected penile lesion ｶ鰓

inguinal node ﾂﾑｧ箏ﾍﾂﾙ・眞鯢靨ｨﾐ耆鯆ﾒｻｯﾔｪﾕﾇｹﾐﾋﾃﾗﾍｼ靨ｵﾑｴ猩ﾒ primary lesion ﾍﾍ｡莉眷鯢ﾁﾒ｡｡ﾇ靨 3 ﾍﾒｷﾔｵﾂ・

ｨﾖｧ耆鯡ｧﾊﾑﾂﾇ靨ｵ靉ﾁｹ鰌猴ﾅﾗﾍｧｷﾕ鞣ｵ爍ﾔｴｨﾒ｡｡鯱ｹﾁﾐ狹遘

1. penile amputation followed by ilioinguinal node diissection

2. Radiotherapy ﾍﾒｨｨﾐ罨鰲ｻ郢 alturnative treatment ｶ鰓ｼﾙ鮟霽ﾂ菽鞳ｪ・surgical candidate

3. Penile amputation followed by ilioinguinal node dissection and postoperative radiation

ﾍﾒｨｨﾐｪ霽ﾂﾅｴ inguinal recurrence 莇・/P>

Stage IV penile cancer (T_3-4 , any N , M₀ ; any T , any N , M₁)

羯ｻﾑｨｨﾘｺﾑｹﾂﾑｧ菽霖ﾕﾇﾔｸﾕ｡ﾒﾃﾃﾑ｡ﾉﾒｷﾕ雜ﾗﾍﾇ靨狃郢｡ﾒﾃﾃﾑ｡ﾉﾒｷﾕ霍ﾓ耆鰺ﾒﾂ｢ﾒｴﾊﾓﾋﾃﾑｺ篥､羯ﾃﾐﾂﾐｹﾕ・ｴﾑｧｹﾑ鮖

｡ﾒﾃﾃﾑ｡ﾉﾒｷﾕ鞳ﾋ鬨ﾖｧ狃郢｡ﾒﾃﾃﾑ｡ﾉﾒ狎ﾕﾂｧ狎ﾗ靉ｺﾃﾃ犢ﾒﾍﾒ｡ﾒﾃ犢靨ｹﾑ鮖

1. Palliative Surgery of local penile lesion 狎ﾗ靉ｻ鯱ｧ｡ﾑｹ necrosis, infection, hemorrhage

2. Palliative radiation ｢ﾍｧ primary tumor, regional adenopathy or metastasis

3. Palliative combining chemotherapy

ｪｹﾔｴ｢ﾍｧ｡ﾒﾃﾃﾑ｡ﾉﾒ

1. ｡ﾒﾃｼ靨ｵﾑｴ蘯隗狃郢

1.1 ｡ﾒﾃﾃﾑ｡ﾉﾒ primary lesion ｨﾐｵ鯱ｧ remove lesion 眷ﾐ adequate margin (2 爿ｹｵﾔ狠ｵﾃ)

total penectomy ｵ鯱ｧ remove both corpora 眷ﾐｷﾓ perineal urethrostomy

1.2 ｡ﾒﾃﾃﾑ｡ﾉﾒ regional lymph node ｶ鰓ｾｺ positive groin metastasis 狠ﾗ靉狹ﾔ霖ﾃﾑ｡ﾉﾒﾋﾃﾗﾍ

ﾀﾒﾂ羯 6 犇ﾗﾍｹﾋﾅﾑｧｨﾒ｡ﾃﾑ｡ﾉﾒｨﾐｵ鯱ｧｷﾓ Bilateral pelvic and inguinal node dissection

犹ﾗ靉ｧｨﾒ｡ﾇ靨 lymphatic crossover ｷﾕ・base of penis ｷﾓ耆鰲｡ﾔｴ contralateral groin metastasis

莇・60% 盞雜鰓ｾｺ unilateral groin node ﾋﾅﾑｧｨﾒ｡ｷﾕ霤ﾑ｡ﾉﾒﾁﾒ｡｡ﾇ靨 6 犇ﾗﾍｹﾊﾒﾁﾒﾃｶｷﾓｼ靨ｵﾑｴ

蘯ｺ ipsilateral ilioinguinal node dissection 莇・/P>

2. ﾃﾑｧﾊﾕﾃﾑ｡ﾉﾒ

- ｢鯱ｴﾕ｢ﾍｧﾃﾑｧﾊﾕﾃﾑ｡ﾉﾒ､ﾗﾍ functional preservation of penis ﾁﾕﾋﾅﾒﾂ｡ﾒﾃﾈﾖ｡ﾉﾒｾｺﾇ靨｡ﾒﾃ罨鯏ﾑｧﾊﾕ

ﾊﾒﾁﾒﾃｶ､ﾇｺ､ﾘﾁ篥､莇鮟ﾃﾐﾁﾒｳ 80-90%

- ﾇﾔｸﾕ｡ﾒﾃ耆鯏ﾑｧﾊﾕ羯 penile cancer ﾁﾕﾋﾅﾒﾂﾇﾔｸﾕ､ﾗﾍ

2.1 Interstitial implantation ｴ鯢ﾂ radium needle ﾋﾃﾗﾍ iridium-192 wire ｫﾖ隗ﾊﾒﾁﾒﾃｶ､ﾇｺ､ﾘﾁ篥､

莇鮟ﾃﾐﾁﾒｳ 95% 羯｡ﾃｳﾕｷﾕ陲ｹﾒｴ｢ﾍｧ｡鯱ｹ £ 4 爿ｹｵﾔ狠ｵﾃ眷ﾐ 80% 菽霖ﾕ major

impairment 羯 function ｢ﾍｧ penis

2.2 External-beam radiotherapy ｫﾖ隗ﾊﾒﾁﾒﾃｶ control disease 莇・70-80% 羯 low-stage tumor

3. 爨ﾁﾕｺﾓｺﾑｴ莇鱆｡・cisplatin-based chemotherapy

ﾁﾕ response rate ｻﾃﾐﾁﾒｳ 30% ｻﾑｨｨﾘｺﾑｹ罨鰲ｻ郢｡ﾒﾃﾃﾑ｡ﾉﾒ狎ﾗ靉ｺﾃﾃ犢ﾒﾍﾒ｡ﾒﾃ眷ﾐﾍﾒｨｨﾐ罨鰲ｻ郢

｡ﾒﾃﾃﾑ｡ﾉﾒ猝ﾃﾔﾁ｡ﾒﾃｼ靨ｵﾑｴﾋﾃﾗﾍﾃﾑｧﾊﾕ盞霈ﾅｷﾕ鞴ｴ鯆ﾑｧ菽鞨ｻ郢ｷﾕ鞦ｹ隱ﾑｴ

References

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