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back pain or other bone pain, central and peripheral nervous system dysfunction, and venous stasis.
Diagnosis
Malignant urothelial cells can be observed on cytological examination of the urinary sediment or bladder
washings. However, cystoscopy is required in any patient with haematuria of malignant potential. Renal
parenchymal and upper urinary tract contrast imaging (IVU or retrograde pyelography) is also mandatory
to rule out a potential renal cancer or urothelial upper tract malignancy. Contrast enhanced CT and
ultrasound are valuable in diagnosing renal parenchymal pathology, with the CT potentially aiding in
tumour differentiation. MRI may be required to rule out malignancy in a patient with poor renal function.
Carcinoma of the prostate is commonly diagnosed via ultrasound guided, trans-rectal biopsy in any man
with an abnormal digital rectal examination or elevated PSA. Transperineal biopsy of the prostate may be
necessary in men with rectal anomalies.
The primary differential diagnosis of a testicular mass includes testicular cancer, testicular torsion,
epididymitis, or epididymo-orchitis. Less common problems include hydrocele, hernia, haematoma,
spermatocele, or syphilitic gumma. Ultrasonography of the scrotum is basically an extension of the
physical examination. Any hypoechoic area within the tunica albuginea is markedly suspicious for
testicular cancer. Initial studies to rule out metastasis include postero-anterior and lateral chest x-rays as
well as abdominal CT scanning.
Tumour marker proteins are relatively specific and have an easily measurable assay for a patient
suspected with testicular cancer. Alpha-foeto protein (AFP) may be produced by pure embryonal
carcinoma, teratocarcinoma, yolk sac tumour, or combined tumours, but not by pure choriocarcinoma or
seminoma. Syncytiotrophoblastic cells have been found responsible for the production of hCG12, which is
found in all choriocarcinomas, around half of embryonal carcinomas, and up to ten per cent of pure
seminoma. Lactate dehydrogenase (LDH) levels are found to correlate directly with tumour burden in
germ cell tumours.
Management
12 hCG: human chorionic gonadotropin
ICAO Preliminary Unedited Version — November 2009 III-6-18
Urothelial carcinoma mandates urological evaluation, treatment, and very close follow-up. Lower grade
cancers may often be managed transurethrally and, at times, with intravesical chemotherapeutic agents
that warrant close surveillance. Upper tract tumours such as ureteral tumours typically require complete
excision with the ipsilateral kidney as these are very difficult to survey and treat with a direct urothelial
chemotherapeutic agent. Most cases do not respond to radiation or systemic chemotherapy. All patients
with urothelial malignancies require regular surveillance, which may preclude regular flying duties.
Renal cell carcinoma is also a surgical disease when organ confinement is apparent. Laparoscopic, open,
and even percutaneous ablative technologies may provide the best treatment for this disease. Metastatic
disease may respond to adjuvant immunomodulation (IL-2, interferon), improving survival in select
patients upon excision of their primary tumour. This latter population obviously does not meet the
requirements of fitness for flight.
Management options for patients with clinically organ-confined adenocarcinoma of the prostate (stages
T1-T2) include observation, radiation therapy, and radical prostatectomy. However, 75 percent of
patients, when merely observed, will experience local progression and 20 per cent will develop metastatic
disease. Radical prostatectomy may provide the greatest cure rate but it often results in impotence and
incontinence. Primary radiation therapy consists of 60 to 70 Gy of radiation to the prostate and is
associated with acute and chronic proctitis and urethritis, impotence, and occasional rectal stricture,
fistula and bleeding. Advanced prostate cancer is treated with surgical or medical castration and
hormone therapy; it disqualifies an individual from aviation duties. PSA is a useful prognostic marker;
after treatment, progressive elevation of PSA is an indication of recurrent disease.
Non-sematomatous germ cell tumours have a reported cure rate in excess of 95 per cent in low stage
disease treated with bleomycin-etoposide-cisplatinum (BEP) chemotherapy after orchiectomy. Higher
stage disease may have similar cure rates if treated with retroperitoneal lymph node dissection in
combination with the above therapy. Salvage chemotherapy in the event of tumour recurrence is very
effective, but the patient must be closely followed with chest x-rays, abdominopelvic CT imaging, and
tumour marker levels.
Potential late complications of BEP chemotherapy include decreased renal function, Raynaud’s
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Manual of Civil Aviation Medicine 2(5)
