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diagnosis, occurring most often in Caucasian males. Risk factors include increased age, industrial organic
solvent exposure, and smoking. Haematuria is the first sign in nearly 90 per cent of cases. Survival is
stage dependent, with lower stage cancers (Tis, Ta, T1 under TNM staging11) having a 90 per cent 5-year
survival. T2, T3, and T4+ disease have 5-year survival rates of 70, 35-50 and 15 per cent respectively.
Prostate cancer is the most common malignancy in men in North America and the fourth most common
male malignancy worldwide. Racial factors seem to play a role as it occurs more frequently in black men,
less in Asian men, with Caucasian men in between. Its incidence increases with age; it is rare in men
younger than 50 years of age. Although both minimal and advanced carcinomas tend to be asymptomatic
at diagnosis, obstructive and irritative voiding symptoms are common in those patients who have
symptoms. Metastatic disease may manifest itself as constitutional symptoms, or lumbar spine, rib or hip
pain. Diagnosis is made by transrectal ultrasound-guided (TRUS) biopsy of the prostate.
Renal Cell Carcinoma (RCCa) is an uncommon malignancy, but it is disqualifying until definitive
treatment has been completed. RCCa represents approximately two per cent of all new cancer
malignancies and has a male predominance. Peak incidence occurs from the sixth to eighth decades with
both familial and sporadic factors seen. The majority of renal tumours are incidentally discovered on
radiographic evaluations for other conditions.
Testicular tumours account for one per cent of all tumours and 0.1 per cent of all cancer deaths in men.
Testicular cancer occurs in early adulthood between 20 and 40 years and again in late adulthood over 60
years of age. Overall, the highest incidence is noted in young adult males, making these neoplasms the
most common solid tumours of men aged 20 to 34 in the United States and Great Britain. Nonseminomatous
tumours account for up to 60 per cent of testicular germ cell tumours. These tumours
include embryonal cell carcinoma, teratocarcinoma, and teratoma. Up to ten per cent of men with testis
tumours have a history of testicular maldescent and, accordingly, all patients with cryptorchidism have a
four-fold risk of testis cancer.
For these reasons, any pilot with a painless, hard scrotal mass has testicular cancer until proven
otherwise and should be disqualified from flight until definitive diagnosis is made and eradication is
complete.
Clinical features
Painless haematuria is the most common presenting symptom of bladder cancer, occurring in up to 90 per
cent of cases. This haematuria is quite intermittent so that a negative result on one or two specimens does
11 TNM staging: staging of tumours according to three basic components – primary tumour (T), regional nodes (N),
and metastasis (M). Adscripts are used to denote size and degree of involvement. 0 indicates undetectable, and 1, 2,
3 and 4 a progressive increase in size or involvement. In addition, Ta is non-invasive papillary carcinoma, and
Tis is carcinoma in situ ("flat tumour").
ICAO Preliminary Unedited Version — November 2009 III-6-17
not rule out the presence of bladder cancer. No specific physical examination technique is useful in
elucidating urothelial cancer but a history of exposure to risk factors may be helpful.
Prostatic cancer typically has benign symptoms, such as mild obstruction or irritation, until it becomes
metastatic. Therefore, any man more than 50 years old with an abnormal digital rectal examination or an
elevation in prostate-specific antigen (PSA) in the absence of recent infection should undergo
investigation to rule out malignancy. Men of African descent with a family history of prostate cancer
warrant screening at the age of 40 and Caucasian males with a similar history should be screened at 50.
The classic triad of renal cell carcinoma including haematuria, abdominal or flank pain, and an abdominal
or flank mass occurs in less than 20 per cent of all patients that present with renal cell carcinoma. Renal
cell carcinoma has classically been called the “internist’s tumour” secondary to the many paraneoplastic
syndromes, presenting with erythrocytosis or anaemia, hypercalcaemia, non-metastatic hepatic
dysfunction, dysfibrinogenaemia, hypertension, and hypercalcaemia.
The usual presentation of a testicular tumour is a nodule or painless swelling of one gonad. In about ten
per cent of all patients, the presenting manifestations may be due to metastases. A pulmonary metastasis
may present with cough or dyspnoea, whereas a supraclavicular lymph node metastasis may present as a
neck mass. Other symptoms may include gastrointestinal symptoms from a retroduodenal metastasis,
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Manual of Civil Aviation Medicine 2(4)
