1979, British Journal of Radiology, 52, 289-301

APRIL 1979

Radionuclide venography in the management of proximal venous occlusion. A comparison with X-ray contrast venography By P. G. Bentley, F.R.C.S., P. L. Hill, B.Sc, H.A. de Haas, F.R.C.S., F. Mistry, F.R.C.S., and V. V. Kakkar, F.R.C.S., F.R.C.S.E. Thrombosis Research Unit and Department of Medical Physics, King's College Hospital Medical School, London. {Received June, 1978 and in revisedform July, 1978) ABSTRACT

Ascending contrast venography often fails to show the proximal venous system when there is co-existing occlusion of femoral or iliac veins. Retrograde and pertrochanteric venography both have severe limitations in terms of invasiveness and reliability. Radionuclide venography (RNV) is suggested as a less invasive alternative. 100 patients were investigated by both RNV and X-ray contrast venography (XRV). There was a 72% overall correlation between the two methods of investigation. The proximal definition of XRV was limited in those cases with femoral obstruction. RNV, however gave progressively better views as imaging became more proximal and this was accentuated in the presence of femoral or iliac occlusion. RNV is simple and easy to perform and less invasive than XRV. The definition at calf level is such that it cannot at this stage replace XRV as the standard diagnostic procedure. However, in patients with proximal occlusions it gives more reliable information than that obtainable by ascending contrast venography.

Nine years after its introduction (Webber et al., 1969) radionuclide venography (RNV) is still at the stage of assessment. Its precise role in the diagnosis of thromboembolic disease has yet to be established. This study was undertaken to answer two questions: does RNV provide a simple method of assessment of the proximal deep vein system, especially when femoral or iliac occlusion is present, and is RNV a workable alternative to X-ray contrast venography (XRV) for general diagnostic use? PATIENTS AND METHODS

The patients studied were referred for venography and isotope lung scanning and comprised the following groups. Group I. Patients with acute symptoms or signs suggestive of thromboembolism or a positive fibrinogen uptake test (FUT). Group II. Patients undergoing reassessment after one week's heparin treatment for deep vein thrombosis (DVT). Group III. Patients undergoing reassessment after three months treatment for deep vein thrombosis. Group IV. Patients without DVT undergoing venographic evaluation prior to varicose vein surgery. Group V. Patients referred specifically for evaluation of the proximal deep venous system before, during and after thrombolytic therapy.

Radionuclide venography (RNV) The patients were examined supine on a mobile horizontal imaging table. Two specially designed 2.5 cm diameter pneumatic cuffs (Millard-London) were applied to each leg, one just above the ankle and the other just above the knee, and connected to a bellows and pressure gauge. A 60Co spot marker was placed in the midline between the legs at the level of the upper border of the patella, another just below the symphysis pubis and a third at the umbilicus. Imaging was carried out using a y-camera fitted with a diverging collimator. It was found helpful to have a persistence oscilloscope linked to the camera to provide a continuous visual display of the progress of the radionuclide. The pneumatic cuffs were inflated to 100-150 mm Hg and a 21 or 23 gauge butterfly needle inserted into a dorsal foot vein on each side. A three-way stop-cock was connected to permit injection of radionuclide followed by a saline flush. The system was tested with saline at the beginning of each examination. The patient was then positioned for imaging of the calves, with the 60 Co marker between the patellae at the top of the field of view. One mCi of "Tc m -macro-aggregated albumin (MAA) was injected into each foot, followed by approximately 20 ml saline flush. Imaging commenced and the passage of the radionuclide into the deep veins of the calf was followed on the persistence oscilloscope and recorded on Polaroid film. If necessary each calf was gently compressed once to fill the popliteal vein. If poor calf filling was observed, additional saline was injected. Imaging was complete when 50,000 counts had been accumulated (approximately 30 seconds, intensity 570 units). With the cuffs still inflated, the table was moved to position the patient's thighs in the field of the camera so that both 60Co spot markers were in view at opposite ends of the field. Images were obtained of the femoral veins after a further injection into each foot of 1 mCi MAA, and 30,000 counts accumulated (approximately 60 seconds, intensity 600 units). Finally the patient was positioned with the camera

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over the pelvis and lower abdomen. The cuffs were released and with a further 10 ml of saline flush and active ankle exercising, images of the iliac veins and inferior vena cava were obtained, accumulating 30,000 counts (approximately three minutes, intensity 600 units). Exercise continued until 30 dorsiflexions of the ankles had been performed. At this stage a persistence film of the calf region was obtained (exposure exactly one minute, intensity 600 units) followed by similar films of the thighs and pelvis at the same setting. The time taken for RNV was 15 minutes with an additional 15 minutes if a lung scan was required also. Results were available immediately on Polaroid film. X-ray contrast venography (XRV) The technique of venography used has already been described elsewhere (Kakkar, 1972). Patients were examined on a horizontal table. Tourniquets 2.5 cm wide connected to a pressure gauge and bellows (Millard, London) were placed just above each ankle and knee. The pressure in the ankle tourniquet was adjusted to 100 mm Hg and that in the proximal one to 150 to 250 mm Hg depending on the diameter of the thigh. A 21 or 23 gauge butterfly needle was inserted into a dorsal foot vein each side, secured with adhesive tape, and a trial injection of 5 ml heparinized saline (10 iu/ml) made. A vein on the dorsum of the first toe was selected where possible, although any vein on the dorsum of the foot will suffice and in rare cases use is made of the long saphenous vein just anterior to the medial malleolus. Under X-ray screening control, 25 ml of pre-warmed 60% meglumine iothalamate (Conray 280) was injected slowly. Three standard calf pictures were obtained in anteroposterior, internally rotated and externally rotated positions. The calf was then gently compressed once to fill the popliteal vein and films obtained of this region. A further 10 ml of contrast was injected and the femoral vein filled by gentle calf pressure and a film exposed. Finally, a further 15 ml of contrast was injected. The proximal tourniquet was released and calf pressure applied to fill the iliac veins and inferior vena cava. Immediately after the final film any residual contrast medium was flushed out of the deep veins by the injection of 100 ml of heparinized saline (10 units/ml) and active leg movements.

sequently all films were reviewed in the absence of clinical details. A positive XRV was defined as a filling defect, present on at least two films, or an area of non-filling with collateral circulation. A positive RNV was defined as an area of decreased radioactivity (filling defect) with or without collateral circulation; stasis of radioactivity below an obstruction or persistence of radioactivity after exercise (Fig. 1). A total of 104 patients (208 limbs) were examined. Four patients were excluded from analysis—two because XRV was omitted and two because RNV had to be abandoned for technical reasons. All the remaining 100 had both XRV and RNV performed on the same day. One third had RNV prior to XRV and two thirds had XRV first. Correlation The results are shown in Table I. There was an overall correlation between RNV and XRV of 71.5% with 16% false positive and 12.5% false negative results from RNV. In the calf, there was a correlation of 69% with 16% false positive and 15% false negative results. In the thigh, there was a correlation of 96% with 1 % false positive and 3% false negative results. In the pelvis, there was 100% correlation—although XRV was often unsatisfactory above the external iliac veins. Group I—the acute situation (Table II) In the acute situation RNV detected 28 out of 38 DVT's (73.7%) with 8.6% false negative and 19.8% TABLE I THE CORRELATION BETWEEN RNV

AND XRV

XRV Overall 4RNV

+ -

Calf |,

Thigh

+

Pelvis



i

68

32

59

32

18

2

17

0

25

75

30

79

6

174

0

183

TABLE II THE

RESULTS

An immediate assessment of each test was made and recorded in the patient's case folder. Sub290

RELATIONSHIP BETWEEN RNV THROMBUS

RESULTS AND AGE OF

Detection (%)

Persistence ( %)

Acute

73.7

50.5

1 week

86.7

57.1

3 months

39.1

17.4

DVT

APRIL 1979

Radionuclide venography in the management of proximal venous occlusion

FIG. 1. adionuclide venogram. (A)Dynamic phase. There is a filling defect within the right calf. The remainder of the right side id whole of the left side is normal, (B) Static phase. There is persistence of radionuclide in the right calf distal to the filling defect.

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false positive results. Persistence of radionuclide five had positive RNV. In the remaining four limbs after exercise (hot spot) was seen in 19 out of 38 with negative XRV, RNV was positive in three due (50%) of those with thrombi. to persistence of radionuclide in superficial veins. Fibrinogen uptake test (FUT) (Table III) Thirteen limbs in which the FUT had become positive postoperatively were examined. Thrombus was demonstrated in the deep veins in nine, of which

Extent of thrombus (Table IV) RNV detected seven out of 13 (53.8%) minor thrombi in the calf (defined as those present in soleal veins alone, or in tibial veins but less than 5 cm in overall length). Persistence occurred in five (38.5%).

TABLE III

TABLE IV

POSITIVE FIBRINOGEN UPTAKE TEST (FUT)—CORRELATION BETWEEN RNV AND XRV

THE RELATIONSHIP BETWEEN RNV RESULT AND EXTENT OF THROMBUS

XRV

DVT

Detection (%)

Persistence (%)

Thrombus present Thrombus absent

Minor calf

53.8

38.5

9

4

Major calf

80

60.0

RNV positive

5

3

Femoral

92.0

50.0

RNV negative

4

1

Iliac

100.0



FIG. 2. X-Ray contrast venogram. There is occlusion of the femoral vein which is replaced by collaterals. There is no filling of the more proximal deep venous system.

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FIG. 3. Radionuclide venogram (same patient as Fig. 2). (A) Dynamic phase. The whole deep venous system on the left is replaced by collaterals. The right side appears normal, (B) Static phase. A little radionuclide persists in superficial veins of the right calf only.

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FIG. 4. Radionuclide venogram before thrombolytic therapy, (A) Dynamic phase. The deep venous system on the left side is totally occluded up to the inferior vena cava with pooling of isotope in collateral circulation. The right side appears normal. (B) Static phase. Radionuclide has cleared from the normal right side, but there is persistence on the left up to the level of the common iliac vein.

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FIG. 5. Radionuclide venogram after three days thrombolytic therapy, (A) Dynamic phase. The left femoral vein is now partially open; radionuclide is trapped distal to the common iliac vein and reaches the inferior vena cava via a collateral, (B) Static phase. Radionuclide persists on the left in the upper femoral and external iliac veins.

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FIG. 6. Radionuclide venogram after five days thrombolytic therapy, (A) Dynamic phase. The major veins now appear normal indicating lysis of all thrombus, (B) Static phase. There is now no abnormal persistence of radionuclide.

296

FIG, 7, (A) Retrograde cavagram. Examination performed during pulmonary angiography by passage of catheter into left common iliac vein from above. Appearances suggestive of inferior vena cava (IVC) occlusion, (B) Radionuclide venogram. The IVC appears normal, (c) Ascending cavagram confirms normal IVC.

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FIG. 8. Intraosseous venogram. There is apparent filling defect at the lower end of the inferior vena cava. The lumbar veins also fill. (B) Per femoral venogram (same patient as 8A). The iliac veins and inferior vena cava are shown to be normal.

RNV detected larger calf thrombi (those in tibial veins and greater than 5 cm in length) in 20 out of 25 cases (80%). Persistence was noted in 15 (60%). In the femoral region, 12 out of 13 (92%) thrombi were detected by RNV (Figs.2 and 3). The one case where RNV failed was that of a 5 cm non-occlusive thrombus localized to the lower femoral vein, with normal deep veins above and below it. Group II—after seven days heparin treatment (Table II) This group excludes any minor calf thrombi, as these are not treated with heparin. RNV detected 12 out of 14 (86.7%) thrombi; persistence was noted in eight (57.1%). Group III—after three months treatment with warfarin (Table II) RNV detected nine out of 23 (39.1%) thrombi; persistence was noted in four (17.4%).

Group IV—patients without DVT being assessed prior to varicose-vein surgery RNV was falsely positive in five out of 16 (31.2%) due to persistence of isotope in superficial veins. Group V—the proximal deep venous system Sixteen patients with proximal occlusions were studied specifically to assess the iliac veins and inferior vena cava. RNV gave a clearer outline of the iliac veins and lower cava than XRV but the test was especially useful for monitoring the progress of patients undergoing thrombolytic therapy (see Figs. 4, 5 and 6) and clarifying confusing X-ray appearances in the inferior vena cava (see Figs. 7A, B, c). DISCUSSION

In patients with complete occlusion of the proximal femoral vein, ascending contrast venography

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Radionuclide venography in the management of proximal venous occlusion (XRV) often fails to give adequate information about the patency of the iliac veins and the presence or absence of fresh thrombus (Fig. 2). This is of great importance in the assessment of the efficacy of treatment of these thrombi and in the determination of the length of treatment with thrombolytic therapy. There are three main alternative forms of investigation in common use, applicable to this situation. The per-femoral "Seldinger" venogram, the trans-trochanteric venogram and the retrograde venogram, performed via direct jugular puncture. The per-femoral venogram has the obvious disadvantage of being invasive and is particularly dangerous in those cases where partially attached femoral thrombus may be dislodged by the procedure. It suffers from the added drawback that direct femoral puncture is not possible when there is total occlusion of the lumen by thrombus. The trans-trochanteric approach has been advocated (Lea Thomas and Fletcher, 1967) but is invasive and requires the administration of a general anaesthetic. Considerable difficulties in interpretation may also be encountered (Figs. 8A and B). The retrograde approach via the jugular vein is well known and may easily be performed at the same time as pulmonary angiography. However it is also invasive and, as with the trans-trochanteric method, liable to misinterpretation (Fig. 7A, B, and c). There is therefore a need for a simple, noninvasive method of assessing the deep venous system proximal to an occlusion. Radionuclide venography (RNV) appears to fulfil most of these criteria. First described in 1969 by Webber, RNV has undergone preliminary evaluation in several centres. The initial results have been encouraging but it has not yet become accepted as a routine diagnostic procedure. The purpose of this study was to establish its value as an addition to XRV in proximal venous occlusion and so evaluate its role in clinical practice by direct comparison with XRV. RNV was found to be a useful addition to XRV in the upper thigh and pelvis. In 11 of 16 patients with occlusion of the femoral or iliac veins (or both), conventional ascending venography (XRV) failed to demonstrate the deep venous system proximal to the occlusion, because it was not possible to obtain an adequate concentration of contrast medium in these veins. RNV however suffered from no such disadvantage, as when the passage of radionuclide was slowed or diluted due to occlusion or collateral circulation even better y-camera images were produced than those obtained when the radionuclide was more rapidly traversing normal veins. In the

presence of occlusion RNV gave pelvic venous images not obtainable with XRV. The overall correlation between RNV and XRV was 72%. Most of the discrepancy was due to poor correlation in the calf, especially with minor thrombi, and the occurrence of false positive results in almost one fifth of cases. However, when only those calf thrombi requiring treatment (those greater than 5 cm in length in the tibial veins) are considered, RNV detects 80%. In the femoral region, only one thrombus was missed, giving a correlation of 0.90/ VZ, / 0 .

The basic mechanism of action of RNV has been the subject of considerable debate. The initial studies (Webber et al., 1969) demonstrated uptake of isotope in the region of thrombophlebitis in the arm suggesting that MAA or microspheres directly labelled thrombus. This hypothesis was supported by in vitro studies (Webber et al., 1974) demonstrating adherence of MAA to blood clots. These findings were further corroborated by reports of abolition of persistence of isotope by heparin (Hayt et al., 1977). Later, good correlation between hot spots and "tagged" thrombi was reported in the clinical situation (Henkin et al., 1974) and adherence to presumed endothelial damage at the site of femoral vein puncture demonstrated (Vlahos et al., 1976). However, it has now been suggested, following in vitro studies, animal experiments and observations on humans, that persistence of radionuclide is more a result of venous stasis distal to an acute occlusion than true adherence to thrombus (Ryo et al., 1976). We have investigated this phenomenon in patients with incompetent perforating veins but no evidence of DVT (group IV) and also in those with thrombosis, comparing the radionuclide scans obtained immediately before treatment (group I), after seven days heparin therapy (group II), and after three months oral anticoagulation (group III). Persistence was seen in 50% of group I, 57% of group II, 17.4% of group III and 31.2% of group IV. Persistence usually occurred distal to the area of thrombus, suggesting a mechanical obstruction as the cause of the accumulation of radionuclide rather than adherence to thrombus. This was further borne out by the presence of persistence in group II (after a week's continuous heparin treatment) and especially in group IV in whom incompetent perforating veins were known to be present in the absence of thrombosis. We conclude therefore that there is no evidence that 9 9 Tc m MAA directly and consistently labels thrombus. It is interesting to note that in three out of the four cases where XRV was normal in

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the presence of a positive FUT, RNV showed persistence in the superficial veins (Table III), suggesting that radionuclide had accumulated distal to areas of superficial thrombosis. It is accepted that in up to one fifth of patients developing a positive FUT, no thrombus is demonstrable in the deep veins on contrast venography (Gallus, 1975). In these cases it is assumed that either subintimal fibrin deposition has occurred or thrombus has undergone rapid spontaneous lysis or that thrombus is in the superficial veins alone. There is no ideal investigation for the diagnosis of acute DVT. The clinical features of this condition are notoriously confusing, with an accuracy of only 50% when based on clinical examination alone (Lambie et al., 1970), and contrast venography remains the established diagnostic standard against which all other investigations must be compared. XRV is accurate and safe in the hands of those performing it regularly; however, it is invasive (Thomas, 1972) and there is a variable degree of discomfort for the patient together with a relatively high overall cost. Iodine sensitivity reactions may occur and the large hyperosmotic intravenous fluid load is undesirable in those patients with compromised cardiac function, although 60% W/V contrast media (1480m osmol/1) give less complications than the stronger solutions (Malins, 1978). The alternative less invasive diagnostic procedures in common use are the fibrinogen uptake test, Doppler ultrasound method and impedance phlebography. The former (Kakkar, 1977) is well suited to the screening of operative patients but requires at least 24 hours before results are available, precluding its use as an urgent diagnostic method. In addition, it fails to give information about the deep venous system proximal to the inguinal ligaments (Browse, 1972), or to indicate the morphological extent of a thrombosis. The Doppler ultrasound technique (Milne et al., 1971) detects only complete occlusions of the major veins and must be regarded as a crude screening test for massive thrombi. The impedance plethysmograph shows promise as a useful screening test (Strandness and Sumner, 1972), but even if accurate will only serve to indicate those patients requiring contrast venography. RNV is certainly less invasive than conventional venography. Little expertise is necessary, and apart from the insertion of a fine needle into a dorsal vein of each foot the investigation may be performed by non-medical personnel. The additional information obtained by the simple change of site of injection of radionuclide from arm vein to dorsal foot vein suggests that RNV should be adopted in patients with

suspected thrombo-embolismundergoing lung scintigraphy. The radiation dose from RNV appears to be very much less than that received during XRV. The dose to the lung from RNV is 1.2 rad (ICRP 17, 1969) with an estimated fetal dose in a pregnant woman of 0.025 rad. The skin dose during XRV is 6 rad for the two abdominal films alone, with an estimated fetal dose of 1.2 rad. It would seem that, with its specificity for the major veins of the pelvis, RNV should be well suited for use in suspected thrombo-embolism of pregnancy. CONCLUSION

At the present stage of development, RNV will not replace XRV as the standard diagnostic procedure in suspected thrombo-embolism apart from those centres with scanning facilities where XRV is not available. However, RNV is a useful addition to XRV in those patients with occlusions of the major veins where conventional venography is difficult and at times confusing, and it appears to be the method of choice for monitoring the progress of patients on thrombolytic therapy for major venous thrombosis. ACKNOWLEDGMENTS

We thank the consultant staff of Kings College Hospital for allowing us to investigate their patients and the Kings College Hospital Research Trust for financial assistance. We are grateful to Dr. J. J. Barrett and Dr. J. Laws for their constant encouragement during this study and constructive criticism in the preparation of the manuscript. We would also like to acknowledge help given by several members of the Departments of Nuclear Medicine, Medical Physics and Radiology; Mr. Blewitt for photographic assistance and Mrs. S. Docksey for typing the manuscript. This study was supported by the MRC programme grant No. G 937/756. REFERENCES BROWSE, N. L., 1972. The I 125 fibrinogen uptake test. Archives of Surgery, 104, 160-163. GALLUS, A.

S.,

1975.

I 125 fibrinogen leg

scanning in

Fratantoni, J. and Wessler, S. (eds): Prophylactic therapy of deep vein thrombosis and pulmonary embolism. DHEW Publication No. (NIH) 76-866, pp.77-99. HAYT, D. B., BLATT, C. J. and FREEMAN, L. M.,

1977.

Radionuclide venography: its place as a modality for the investigation of thromboembolic phenomena. Seminars in Nuclear Medicine, 7, 263-281. HENKIN, R. E., YAO, J. S. T., QUINN, J. L. and BERGAN, J.

J., 1974. Radionuclide venography (RNV) in lower extremity venous disease. Journal of Nuclear Medicine, 15 171. ICRP, 1969. Protection of the patient in radionuclide investigations. A report prepared for the International Commission on Radiological Protection Publication no. 17, 78. (Pergamon Press, Oxford). KAKKAR, V. V., 1972. The I 125 labelled fibrinogen test and phlebography in the diagnosis of deep vein thrombosis. Milbank Memorial Fund Quarterly, 50, 206-229. 1977. Fibrinogen uptake test for detection of deep vein thrombosis—a review of current practice. Seminars in Nuclear Medicine, 7, 229-244.

300

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Radionuclide venography in the management of proximal venous occlusion LEA THOMAS, M. and FLETCHER, E. W. L., 1967. The tech-

niques of pelvic phlebography. Clinical Radiology, 18, 399-402. LAMBIE, J. M., MAHAFFY, R. G. and BARBER, D. C , 1970.

Diagnostic accuracy in venous thrombosis. British Medical Journal, 2, 142-143. MALINS, A. F., 1978. Pulmonary oedema after radiological investigation of pheripheral occlusive vascular disease. Lancet, 7,413-415.

STRANDNESS, D. E. and SUMNER, D. S., 1972. Ultrasonic

velocity detector in the diagnosis of thrombophlebitis. Archives of Surgery, 104, 180. THOMAS, M. L., 1972. Phlebography. Archives of Surgery, 704,145-159. VLAHOS, L., MACDONALD, A. F. and CAUSER, D. A., 1976.

Combination of isotope venography and lung scanning. British Journal of Radiology, 49, 840-851. WEBBER, M. M., BENNETT, L. R., CRAGIN, M. and WEBB, R.,

1969. Thrombophlebitis—demonstration scanning. Radiology, 92, 620-623.

MILNE, R. M., GRIFFITHS, J. M. T. and GUNN, A. A., 1971.

Postoperative deep vein thrombosis. Lancet, 2, 445. RYO, U. Y., COLOMBETTI, L. G., POLIN, S. G. and PINSKY,

by sciniti-

WEBBER, M. M., POLLAK, E. W. and VICTERY, W. K., 1974.

S. M., 1976. Radionuclide venography: significance of delayed washout; visualization of the saphenous system. Journal of Nuclear Medicine, 17, 590-595.

Thrombosis detection by radionuclide particle (MAA) entrapment: correlation with fibrinogen uptake and venography. Radiology, 111, 645-648.

Book reviews Positioning and Technique Handbook for Radiologic

Bone tumors, General Aspects and Data on 6221 Cases {3rd

Tech-

nologists. By S. B. Conte and D. H. Kemme, pp. xiii + 259 + Index, 1978 (C. V. Mosby Co., St. Louis; distributed in UK by Henry Kimpton Publishers, London), £7*15. ISBN 0-8016-1031-1. Written by two technologists this pocket size paper-back book is a simple elementary introduction into basic radiographic techniques. The authors in their preface write "basic text books serve to introduce the essential knowledge required for quality performance, but more definite reference works must be accessible to provide the detailed information that exceeds the purpose of the text book". The book makes no pretentions to be any more than an introduction into its subject. In its 265 pages the book is divided into 13 sections, each one concerned with the radiographic positioning of a particular system, or anatomical region. Sections 1 to 8 deal with the bony skeleton, and 9 to 12 with myelography, the digestive and urinary systems, and mammography. The final section has 46 pages under the title of positioning of cerebral, cranial and facial bones. The format is interesting in that each page is perforated and punched to enable the reader to remove pages or sections and insert them in a binder. Each position is demonstrated by an appropriate photograph and this visual presentation is the book's main strength, although the reviewer found the variety of facial expressions of the model a detraction. The use of personalized views with their descriptive projections is a feature of the text. The few radiographs reproduced are restricted to the digestive system and some contrast media examinations. There are some photographic errors in positioning and centring particularly with extremity radiography which are not clarified in the text, as are the subject-cassette positioning errors on pages 90 and 226. On page 114 two of the three photograph captions are incorrect, and on page 190 the anterior oblique view is confused with posterior oblique projection. Easily read, this interesting book provides an introduction into simple radiographic positioning. Its attraction is the space provided after each projection is described and illustrated for the reader to enter his own notes and comments, and thus build up a personal radiographic technique notebook.

edition). By D. C. Dahlin, pp. xii + 445, illus., 1978 (Charles C. Thomas, Springfield, Illinois, U.S.A.), $32.75. Bone tumours are notoriously perplexing lesions and continue to present commanding problems in both diagnosis and management. The wide variety of described entities and the rarity of some serve to compound the difficulties. It is therefore of immense help when an internationally recognized authority on the pathology of these tumours allows us to share his accumulated experience. Dahlin first presented his personal experience of more than 2000 consecutive unselected cases in text book form in 1957. The present, third edition, now encompasses 6221 cases. The classification which is a modified version of that propounded by Lichtenstein, is now generally accepted. The details are presented in a clear didactic style which, at the same time acknowledges areas of difficulty and dispute. These are highlighted in carefully selected prose including, for example, "a practical working definition is to regard as Ewing's tumours those highly anaplastic, small round to oval cell sarcomas that have the clinical and roentgenographic characteristics of a primary osseous lesion". There are invaluable histograms in each chapter depicting the age distribution and sites of occurrence of each tumour. The illustrations of histology are in black and white but are clear and readily comprehensible to the non-pathologist. This volume is in no sense a treatise on the radiological investigation and appearances of bone tumours. The Author naturally holds the view that histology and cytology must be the final arbiter in diagnosis and the radiological content of the book is essentially limited to these features which are obvious to an experienced histopathologist. The illustrations of radiographs are uniformly poor and there is no mention of the role of more sophisticated radiological investigations. Fundamental to any consideration of bone tumours is an accepted classification with specific definitions. These are presented in such a lucid way in this book that it is virtually obligatory reading for all radiologists who see or may see bone tumours. It should be perused by students preparing for Fellowship. As it is remarkably cheap, it should be acquired immediately for inclusion in the libraries of all working departments and teaching units.

P. J. RICHARDSON.

301

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