1979, British Journal of Radiology, 52,1 56
Correspondence (The Editors do not hold themselves responsible for opinions expressed by correspondents) introduction into the patient of radiopaque substances of high atomic number. These substances when irradiated produce hard scatter radiation which can obliterate complete sets of CT-scans, making them unreadable on account of artefacts.
Place of new contrast media in renal failure THE EDITOR—SIR,
It was with great interest that I read "The effect of osmotic diuresis on urinary iodine concentration" (Webb et al., 1978) in your February issue. I believe some observations from our recent experiments and calculations may be of interest and cast some additional light on the place of contrast media of reduced osmolality in advanced renal failure. In patients with normal renal function the urinary tract increases in volume during osmotic diuresis (Dorph et al., 1977) and therefore both the increase in urine flow and the iodine concentration will be of importance for the absorption of X-ray in the urinary tract. Calculations (Golman 1977) have shown that the urinary iodine concentration is the most important parameter. In renal failure the urinary tract may be chronically fully distended by the obligatory (urea) diuresis and the contrast media may be unable to produce any further increase in the diameter of the tubulus (the depth of the X-ray absorbing layer). The urinary iodine concentration thus becomes the only parameter of importance and the significant increase in iodine concentrations obtained using metrizamide instead of the ionic media during the important first 20 min after injection in the study of Webb and colleagues (during both moderate and large mannitol diuresis) could give the increase in X-ray absorption which was just necessary to obtain a diagnostically usable examination. Moreover, the reduced toxicity and pharmacological sideeffects of metrizamide compared to the common ionic media (see Acta Radiologica Supple. 335, various authors 1973; Kolbenstvedt et al., 1979) should be especially important in the presence of renal failure, as the patients may already be out of fluid balance. In children with renal failure where the doses tend to be high per kg body weight the dehydration produced by the ionic media may produce a life-threatening condition and thus the place of contrast media of reduced osmolality must be seriously considered. Yours, etc., K. GOLMAN.
Experimental Department, Malmo Allmanna Sjukhus, S-214 01 Malmo, Sweden. REFERENCES DORPH, S., SOVAK, M., TALNER, L. B., and L. ROSEN, 1977.
Why does kidney size change during i.v. urography? Investigative Radiology, 12, 246. GOLMAN, K., 1977. Physiological consideration on the excretion of contrast media. Journal Beige de Radiologie, 60, 229. KOLBENSTVEDT, A., ANDREW, E., CHRISTOPHERSEN, B., GOLMAN, K., KVARSTEIN, B., and LIEN, H. H., 1979.
Metrizamide (Amipaque) in high-dose urography. Acta Radiologica (in press).
Artefacts in CT scanning THE EDITOR—SIR,
CT-scanning is penetrating diagnostic medical practice at an amazing pace with a wide spectrum of application. Various factors of a technical nature can interfere with the diagnostic quality of the CT-scans, and among them are the
B FIG.
1. (A) A coronal section of the head of a patient with intracerebral calcification as seen before dental treatment. (B) The disastrous effect of dental fillings on control CTscans four weeks later
156
1979, British Journal of Radiology, 52, 157
FEBRUARY 1979
Correspondence In this letter we address our colleagues, the dentists, to avoid as far as possible the use of dental metal alloys and to replace them by fillings and prostheses in plastic or porcelain. We invite our colleagues the anaesthetists, to replace metallic accessories for intubation by materials in plastic. We wonder if the use of neuroleptics instead of general anaesthesia, requiring no intubation, could be the best solution. We should like to ask our colleagues the neurologists and neurosurgeons to stop using oily contrast in the examination of the central nervous system, because of the residual deposits and to substitute water-soluble contrast instead. We invite them to attempt to find ways to replace metallic clips used in surgical procedures, because they are the source of most disturbing artefacts during CT-scanning. To illustrate what we mean by artefacts produced by high atomic number substances introduced into a patient, we refer to Fig. 1A and 1 B. Yours, etc.,
Exploration of the sphenoid sinus was carried out. Bacteriological examination was negative and histology revealed non-specific inflammatory polypoidal hypertrophy of the sphenoid sinus mucosa. No evidence of tuberculosis, fungal disease or malignancy was detected. We were fairly confident that this extensive destruction of the sphenoid bone wax due to tuberculous or fungal disease and were very surprised when this was not confirmed at operation. Yours etc.,
J. A. VEIGA-PIRES, M. KAISER.
WITCOMBE, J. B. and CREMIN, B. J., 1978. Tuberculous
X-ray Department, Academisch Ziekenhuis Utrecht The Netherlands.
T. M. H. CHAKERA.
Department of Diagnostic Radiology, Royal Perth Hospital, BoxX2213, Perth, Western Australia 6001. (Received October 1978) REFERENCES erosion of the sphenoid bone, British Journal of Radiology, 51, 347-350. NEWTON, T. H., and POTTS, D. G., 1971. Radiology of the
Skull and Brain, 1, Book 2, p.735 (St. Louis, C. V. Mosby). Di CHIRO, G., and ANDERSON, W. B., 1965. The clivus.
Clinical Radiology, 16, 211-223.
Erosion of the sphenoid bone THE EDITOR—SIR,
This letter has been prompted by a recent article in the Journal (May 1978) by Witcombe and Cremin describing tuberculous erosion of sphenoid bone. The purpose of this letter is to draw attention to the fact that non-specific inflammatory sinusitis may also cause extensive lytic destruction of the sphenoid bone. Recently a 22-year-old aboriginal man was admitted to the Royal Perth Hospital with one month's history of headaches. On examination, he was apyrexial; high mental function tests, cranial nerves and rest of the central nervous system examination was normal. Skull radiographs revealed pansinusitis with destruction of the floor of the sella turcica and of the clivus. (Fig. 1). Radiological differential diagnoses offered were chronic granulomatous infection or neoplastic (lymphomatous) destruction of the sphenoid bone. Pneumoencephalogram revealed normal cerebrospinal fluid with normal basal cisterns.
FIG. 1.
Carcinoma of the cervix at the Royal Marsden Hospital, London, 1962-70: survival results THE EDITOR—SIR,
In 1944 a joint clinic was formed by the Royal Marsden Hospital and the Chelsea Hospital for Women for the treatment of cancer patients requiring radiotherapy, and four reports on the treatment results have been published (Blaikley et al, 1952, 1957, 1962, 1969). This letter presents the survival of all previously untreated patients with carcinoma of the cervix, almost 1000, seen at the Royal Marsden Hospital, London, between 1962 and 1970, some 50% of whom were also seen in the joint clinic with the Chelsea Hospital. The survival rates (Fig. 1) were calculated by an actuarial method, whereas in the earlier reports only a crude survival rate was given. However, since not more than 10% of the cases were lost to follow-up in those analyses, a valid comparison can be made between the previously published five-year survival rates and those for the 1962-70 period. The total number in all stages is 995. Fifty were in stage 1A and 254 in stage 1B. The histology of the majority was squamous cell carcinoma. Adenocarcinomata accounted for only 8% of the entire 1962-70 series and the numbers are therefore too small for an analysis of survival rate by histology. The overall five-year survival rates are compared with those of other series in Table I. There has been an improvement in the stage 1 results since the last RMH-Chelsea Hospital report for 1944-60, but the overall results for stages 2, 3 and 4 show no improvement, which is disappointing. The results in this current series are similar to those reported from other centres in the United Kingdom but they are significantly worse than those reported by Fletcher (1973).This is part of a pattern in which the survival of patients with carcinoma of the cervix in the United Kingdom is generally lower than the survival reported from North America, although the reasons for the existence of such a pattern are not certain. We wish to thank Dr. M. Lederman and Dr. V. M. Dalley for their encouragement with this study and for permission to use their data. We are also grateful to Mr. R. B. Rickford
157
Correspondence (The Editors do not hold themselves responsible for opinions expressed by correspondents) introduction into the patient of radiopaque substances of high atomic number. These substances when irradiated produce hard scatter radiation which can obliterate complete sets of CT-scans, making them unreadable on account of artefacts.
Place of new contrast media in renal failure THE EDITOR—SIR,
It was with great interest that I read "The effect of osmotic diuresis on urinary iodine concentration" (Webb et al., 1978) in your February issue. I believe some observations from our recent experiments and calculations may be of interest and cast some additional light on the place of contrast media of reduced osmolality in advanced renal failure. In patients with normal renal function the urinary tract increases in volume during osmotic diuresis (Dorph et al., 1977) and therefore both the increase in urine flow and the iodine concentration will be of importance for the absorption of X-ray in the urinary tract. Calculations (Golman 1977) have shown that the urinary iodine concentration is the most important parameter. In renal failure the urinary tract may be chronically fully distended by the obligatory (urea) diuresis and the contrast media may be unable to produce any further increase in the diameter of the tubulus (the depth of the X-ray absorbing layer). The urinary iodine concentration thus becomes the only parameter of importance and the significant increase in iodine concentrations obtained using metrizamide instead of the ionic media during the important first 20 min after injection in the study of Webb and colleagues (during both moderate and large mannitol diuresis) could give the increase in X-ray absorption which was just necessary to obtain a diagnostically usable examination. Moreover, the reduced toxicity and pharmacological sideeffects of metrizamide compared to the common ionic media (see Acta Radiologica Supple. 335, various authors 1973; Kolbenstvedt et al., 1979) should be especially important in the presence of renal failure, as the patients may already be out of fluid balance. In children with renal failure where the doses tend to be high per kg body weight the dehydration produced by the ionic media may produce a life-threatening condition and thus the place of contrast media of reduced osmolality must be seriously considered. Yours, etc., K. GOLMAN.
Experimental Department, Malmo Allmanna Sjukhus, S-214 01 Malmo, Sweden. REFERENCES DORPH, S., SOVAK, M., TALNER, L. B., and L. ROSEN, 1977.
Why does kidney size change during i.v. urography? Investigative Radiology, 12, 246. GOLMAN, K., 1977. Physiological consideration on the excretion of contrast media. Journal Beige de Radiologie, 60, 229. KOLBENSTVEDT, A., ANDREW, E., CHRISTOPHERSEN, B., GOLMAN, K., KVARSTEIN, B., and LIEN, H. H., 1979.
Metrizamide (Amipaque) in high-dose urography. Acta Radiologica (in press).
Artefacts in CT scanning THE EDITOR—SIR,
CT-scanning is penetrating diagnostic medical practice at an amazing pace with a wide spectrum of application. Various factors of a technical nature can interfere with the diagnostic quality of the CT-scans, and among them are the
B FIG.
1. (A) A coronal section of the head of a patient with intracerebral calcification as seen before dental treatment. (B) The disastrous effect of dental fillings on control CTscans four weeks later
156
1979, British Journal of Radiology, 52, 157
FEBRUARY 1979
Correspondence In this letter we address our colleagues, the dentists, to avoid as far as possible the use of dental metal alloys and to replace them by fillings and prostheses in plastic or porcelain. We invite our colleagues the anaesthetists, to replace metallic accessories for intubation by materials in plastic. We wonder if the use of neuroleptics instead of general anaesthesia, requiring no intubation, could be the best solution. We should like to ask our colleagues the neurologists and neurosurgeons to stop using oily contrast in the examination of the central nervous system, because of the residual deposits and to substitute water-soluble contrast instead. We invite them to attempt to find ways to replace metallic clips used in surgical procedures, because they are the source of most disturbing artefacts during CT-scanning. To illustrate what we mean by artefacts produced by high atomic number substances introduced into a patient, we refer to Fig. 1A and 1 B. Yours, etc.,
Exploration of the sphenoid sinus was carried out. Bacteriological examination was negative and histology revealed non-specific inflammatory polypoidal hypertrophy of the sphenoid sinus mucosa. No evidence of tuberculosis, fungal disease or malignancy was detected. We were fairly confident that this extensive destruction of the sphenoid bone wax due to tuberculous or fungal disease and were very surprised when this was not confirmed at operation. Yours etc.,
J. A. VEIGA-PIRES, M. KAISER.
WITCOMBE, J. B. and CREMIN, B. J., 1978. Tuberculous
X-ray Department, Academisch Ziekenhuis Utrecht The Netherlands.
T. M. H. CHAKERA.
Department of Diagnostic Radiology, Royal Perth Hospital, BoxX2213, Perth, Western Australia 6001. (Received October 1978) REFERENCES erosion of the sphenoid bone, British Journal of Radiology, 51, 347-350. NEWTON, T. H., and POTTS, D. G., 1971. Radiology of the
Skull and Brain, 1, Book 2, p.735 (St. Louis, C. V. Mosby). Di CHIRO, G., and ANDERSON, W. B., 1965. The clivus.
Clinical Radiology, 16, 211-223.
Erosion of the sphenoid bone THE EDITOR—SIR,
This letter has been prompted by a recent article in the Journal (May 1978) by Witcombe and Cremin describing tuberculous erosion of sphenoid bone. The purpose of this letter is to draw attention to the fact that non-specific inflammatory sinusitis may also cause extensive lytic destruction of the sphenoid bone. Recently a 22-year-old aboriginal man was admitted to the Royal Perth Hospital with one month's history of headaches. On examination, he was apyrexial; high mental function tests, cranial nerves and rest of the central nervous system examination was normal. Skull radiographs revealed pansinusitis with destruction of the floor of the sella turcica and of the clivus. (Fig. 1). Radiological differential diagnoses offered were chronic granulomatous infection or neoplastic (lymphomatous) destruction of the sphenoid bone. Pneumoencephalogram revealed normal cerebrospinal fluid with normal basal cisterns.
FIG. 1.
Carcinoma of the cervix at the Royal Marsden Hospital, London, 1962-70: survival results THE EDITOR—SIR,
In 1944 a joint clinic was formed by the Royal Marsden Hospital and the Chelsea Hospital for Women for the treatment of cancer patients requiring radiotherapy, and four reports on the treatment results have been published (Blaikley et al, 1952, 1957, 1962, 1969). This letter presents the survival of all previously untreated patients with carcinoma of the cervix, almost 1000, seen at the Royal Marsden Hospital, London, between 1962 and 1970, some 50% of whom were also seen in the joint clinic with the Chelsea Hospital. The survival rates (Fig. 1) were calculated by an actuarial method, whereas in the earlier reports only a crude survival rate was given. However, since not more than 10% of the cases were lost to follow-up in those analyses, a valid comparison can be made between the previously published five-year survival rates and those for the 1962-70 period. The total number in all stages is 995. Fifty were in stage 1A and 254 in stage 1B. The histology of the majority was squamous cell carcinoma. Adenocarcinomata accounted for only 8% of the entire 1962-70 series and the numbers are therefore too small for an analysis of survival rate by histology. The overall five-year survival rates are compared with those of other series in Table I. There has been an improvement in the stage 1 results since the last RMH-Chelsea Hospital report for 1944-60, but the overall results for stages 2, 3 and 4 show no improvement, which is disappointing. The results in this current series are similar to those reported from other centres in the United Kingdom but they are significantly worse than those reported by Fletcher (1973).This is part of a pattern in which the survival of patients with carcinoma of the cervix in the United Kingdom is generally lower than the survival reported from North America, although the reasons for the existence of such a pattern are not certain. We wish to thank Dr. M. Lederman and Dr. V. M. Dalley for their encouragement with this study and for permission to use their data. We are also grateful to Mr. R. B. Rickford
157
