דן ליבוביץ, אמנון זיסמן, יהודית קליינמן, אריה לינדנר

המח' לאורולוגיה, מרכז רפואי אסף-הרופא, צריפין

סרטן הערמונית הוא המחלה הממארת השכיחה ביותר בגברים והיארעותה מגיעה לכדי 900 חולים חדשים לכל 100,000 לשנה. איבחון מוקדם של המחלה בשלב בו השאת מוגבלת לבלוטת הערמונית, מאפשר ריפוי מלא בחלק ניכר מן החולים. האפשרויות הטיפוליות כוללות כריתת ערמונית רדיקלית, טיפול קרינתי והקפאה קריוגנית.

בניתוחים קריוגניים (נ"ק), מבוצעת הקפאת השאת בתוך הגוף על ידי החדרת גלאי לאיבר המטרה והשראת טמפרטורה נמוכה קיצונית בסביבות 180 – מ"צ. כדור הקרח הנוצר סביב הגלאי כולל בתוכו את ריקמת המטרה, וחשיפתה לטמפרטורה נמוכה קוטלת כל ריקמה ביולוגית. כיום, מהווים נ"ק אפשרות טיפולית מקובלת בחולים בסרטן הערמונית, והפעולה קיבלה את אישור מינהל המזון והתרופות בארה"ב (FDA). בסקירתנו, נדון הניסיון העולמי בנ"ק כטיפול בלוקים בסרטן הערמונית.

Preflight Assessment by Hypoxic Inhalation Test in Cardio-Pulmonary Patients 

J. Lebzelter, G. Fink, E. Kleinman, I. Rosenberg, M.R. Kramer

Pulmonology Institute, Rabin Medical Center, Beilinson Campus, Petah Tikva

Flying may expose passengers to hypoxic conditions, which may induce hypoxemia, particularly in those with chronic heart and/or lung disease. Onset of dyspnea, wheezing, chest pain, cyanosis and right heart failure can lead to urgent need for oxygen during flight. The hypoxia inhalation test (HIT) provides a safe and simple means of identifying those who may develop hypoxemia during flight.

We report our experience with 48 self-reporting patients who underwent HIT prior to pre-planned air travel. They inhaled for 15-minute periods a reduced oxygen concentration (F₁O₂ 15%) under normobaric conditions, during which O₂ saturation was monitored by pulse oximeter; electrocardiogram, blood pressure and symptoms were also monitored. O₂ saturation of 85% (PaO₂ 50 mm Hg) was considered a positive test. In the 8 cases (17%) with a positive test, 5 had chronic obstructive pulmonary disease and 3 had cardiovascular and/or combined heart-lung disease.

We calculated predicted O₂ partial pressure in altitude (PaO₂ ALT) and compared it to actual results in the 8 patients with a positive HIT. In 5, use of the predicted formula would have under-diagnosed the hypoxemia that developed during the HIT. Thus, the results of the HIT changed treatment strategy in these patients. We recommend that patients with positive tests use O₂ (2LPM or 4LPM) during flight.

HIT is practical and of potential benefit in the objective assessment of patients with various degrees of heart, lung or combined heart-lung disease. Clinicians should be aware of the relative risk of hypoxia during flight in such patients, and of the value of HIT in identifying them, leading to increase in its use.

Multilocular Cystic Mass of the Kidney: A Diagnostic Challenge

Judy Kleinmann, Simon Negelev

Urology Dept., Assaf Harofeh Medical Center, Zerifin

Multilocular cystic masses of the kidney present a diagnostic challenge because they may be malignant. Renal cell carcinoma with multilocular cysts has been reported. We present 4 cases in which the preoperative differential diagnosis was between a benign and a malignant multilocular cystic kidney mass.

Our results, combined with those of 33 previously reported cases, reveal that only 32% of cases were diagnosed correctly preoperatively. In 21% of these patients the preoperative clinical evaluation did not correctly diagnose malignancy: 24% of them yielded false negative and 21% false positive results. Angiography was more accurate than CT, US or aspiration of cysts. Frozen section was inaccurate in 55% of cases.

There is no reliable diagnostic test to distinguish between a malignant and a benign multilocular cystic mass. Invasive angiography is more accurate than other modalities. A therapeutic decision has to be made between nephron-sparing and radical surgery in each case. When nephron-sparing surgery is considered, the possible need to perform radical nephrectomy in second-look surgery must be taken into account.