Series in Radiology – serie

Recent advances in surgical procedures for the management of focal liver diseases have greatly increased the demand for diagnostic accuracy. So far these demands have been only partially met by further technical developments such as colour-coded duplex sonography, spiral CT and marked improvements in magnetic resonance imaging. It is becoming increasingly clear that liver specific contrast media are essential for utilizing these technical developments to their fullest advantage in patient care. Against this background, a workshop was held to explore the current methods of diagnostic imaging of the liver and to try and establish a profile for the future liver specific contrast media. This text presents the findings of the workshop. The pathologist's introductory and general overview is followed by chapters on the individual imaging procedures such as ultrasound, CT and MRI. The book should be of interest to radiologists from the various disciplines, and also those who plan and perform therapies, particularly surgeons and internists.

With the advent of CT we entered a new area of radiological imaging. Structures which rarely if ever were seen became apparent. In no part of the body was the impact of CT as profound as it was in the retroperitoneum. In the pre-CT area this region of the body could not be directly studied and only when gross abnormalities were present could they be appreciated. The best we could do was to try to identify a suspected process by studying its effect on surrounding organs whose position might have been affected by the growth. Urography, barium studies or angiography were employed in the hope that variation in the position of the vessels, ureter or bowel would lead us to the correct diagnosis. With computed tomography all this changed. Modern scanners, available to all today, permit us to appreciate details undreamed of only few years ago. The abundance of fat in this region helps to clearly show even the smallest of structures. We now have the ability to recognize small vessels, lymph nodes and fascial planes. We had a tool which permitted us to study structures which hitherto were only seen by the anatomist or during surgical dissection.

Complex disorders of the carbohydrate metabolism and associated complications cause many abnormalities detectable by radiography in the bones and joints. Mild clinical symptoms associated with very severe radiological changes were first rec­ ognized in relation to the gastroenterologic complications of diabetes. This phenomenon is more frequent in the skeletal system. For example, mild and painless swelling of the foot joints may often mask extremely severe bone destruction. Several other bone changes associated with diabetes are only detectable by radiography. Thus, the radiologist plays an important role in confirming these diabetic complications, furthermore he is involved in the therapeutic management of the patient. Although many details on this subject have been published, however no summarizing monograph has yet appeared. Manuals discussing diabetes include only short reviews on complications of the osseous system. The fact that the incidence of diabetes is very high, at present 1 %-2 % of the population is affected and their number is gradually increasing - dis­ plays the timeliness of this subject. Fifty years of experience with insulin therapy indicates that several important problems still remain to be solved. Insulin and modern oral antidia­ betic drugs proved extremely efficient in the management of hyperglycemia and ketosis, but the incidence of other complications has not decreased. Moreover, as the number of diabetics and their life expectancy increase, late complications become likewise more fre­ quent. Diabetic osteoarthropathy is one of these complications.

J.J. Broerse, Radiobiological Institute TNO, Rijswijk, The Netherlands, and T .J. MacVittie, Armed Forces Radiobiology Research Institute, Bethesda, MD, USA. During the past decade, relatively few new studies have been initiated on the response of different species to high-dose, total-body irradia- tion. For information on the LDSO/30d (the dose which produces 50 percent lethality within 30 days), one is generally referred to the older literature (e. g., Bond, Fliedner and Archambeau, 1965). Compari- son of experimental data reveals considerable variations in LDSD values even after total-body irradiation with conventional X rays, ranging from 4 to 6 Gy in the monkey, 7.1 to 9 Gy in the rat and from 6.4 to 9 Gy in the mouse (see also Hall, 1978). Part of the discrepancy in the LDso values can possibly be attributed to inadequacies in the dosimetry procedures and exposure arrangements employed. As far as clinical experience is concerned, there is now an appreciable amount of information available about the effect of total- body irradiation as a conditioning treatment for bone marrow transplan- tation in patients suffering from leukaemia or aplastic anaemia.The results from different centres, including the incidence of complications such as radiation pneumonitis, are considerably different. This can part I y be connected with the application of different radiation sched- ules: large single dose versus fractionated or protracted irradiation.

With the advent of CT we entered a new area of radiological imaging. Structures which rarely if ever were seen became apparent. In no part of the body was the impact of CT as profound as it was in the retroperitoneum. In the pre-CT area this region of the body could not be directly studied and only when gross abnormalities were present could they be appreciated. The best we could do was to try to identify a suspected process by studying its effect on surrounding organs whose position might have been affected by the growth. Urography, barium studies or angiography were employed in the hope that variation in the position of the vessels, ureter or bowel would lead us to the correct diagnosis. With computed tomography all this changed. Modern scanners, available to all today, permit us to appreciate details undreamed of only few years ago. The abundance of fat in this region helps to clearly show even the smallest of structures. We now have the ability to recognize small vessels, lymph nodes and fascial planes. We had a tool which permitted us to study structures which hitherto were only seen by the anatomist or during surgical dissection.

The purpose of this book is to explain the current state of the art in radiological examination, interpretation, and understanding of colonic disease. The radiologic aspects of colon disease are combined here with clinical information to serve both beginners and advanced students. Major emphasis has been placed on technique for those radiologists, residents, and technologists first undertaking modern gastrointestinal radiographic techniques. The essentials of technique are stressed so that the reader obtains a clear understanding of colon disease based on sound practical information. We believe this book is a thorough and practical text of particular interest to clinical radiologists and gastroenterologists in their everyday practice, and also for teachers, residents and medical students. Digital examination and sigmoidoscopy are the first procedures in examination of the colon. Then, the radiologic examination is the next most important procedure. Endoscopy and biopsy play a compli­ mentary role to the radiological examination. The barium enema reveals quickly and early the overall status of the colon and it can then guide endoscopy and biopsy together with subsequent treatment. Surely, if the lesion is not detected our clinical, radiologic, endoscopic, and therapeutic skills are of no use.

Complex disorders of the carbohydrate metabolism and associated complications cause many abnormalities detectable by radiography in the bones and joints. Mild clinical symptoms associated with very severe radiological changes were first rec­ ognized in relation to the gastroenterologic complications of diabetes. This phenomenon is more frequent in the skeletal system. For example, mild and painless swelling of the foot joints may often mask extremely severe bone destruction. Several other bone changes associated with diabetes are only detectable by radiography. Thus, the radiologist plays an important role in confirming these diabetic complications, furthermore he is involved in the therapeutic management of the patient. Although many details on this subject have been published, however no summarizing monograph has yet appeared. Manuals discussing diabetes include only short reviews on complications of the osseous system. The fact that the incidence of diabetes is very high, at present 1 %-2 % of the population is affected and their number is gradually increasing - dis­ plays the timeliness of this subject. Fifty years of experience with insulin therapy indicates that several important problems still remain to be solved. Insulin and modern oral antidia­ betic drugs proved extremely efficient in the management of hyperglycemia and ketosis, but the incidence of other complications has not decreased. Moreover, as the number of diabetics and their life expectancy increase, late complications become likewise more fre­ quent. Diabetic osteoarthropathy is one of these complications.

This atlas is a selection of roentgenograms of patients who visited the radiology departments at the University Hospital in Leiden between 1970 and 1978, the Free University Hospital in Amsterdam in 1979, and the radiology department at the Indiana University Medical School in Indianapolis in 1977. The most common radiological abnormalities of the small intestine are illustrated clearly, unhindered by flocculation or segmentation of the contrast fluid. The authors believe this book is a definite contribution to the goal of precise early small bowel diagnosis. However, the key to good diagnosis is not only a superb examination technique, but also the knowledge, the character, and the personal perfectionism of the physician. If these factors are optimal, then the best possible roentgenographic series will be obtained - at least as far as the technique is concerned. All patients illustrated here were examined by using the enteroclysis technique. With this method of small bowel examination, the contrast fluid is administered via an infusion directly into the duodenum instead of orally. The infusion method has added a new dimension to the usual radiological examination of the small intestine. This method is also especially suited for the comparative evaluation of motility, and the study of disturbed motility. Throughout the course of the examination, the technique can be adapted to special situations at any given moment and can be modified to produce precise diagnostic roentgenograms and diagnosis.

This book is not meant to be a textbook or a handbook of phlebography of the lower limbs. It is an atlas aimed only at teaching one how to read an interpret phlebograms, and is of considerable importance as it represents the standard investigatory method used to check the reliability of other diagnostic methods concerning venous circulation. Regarding diagnosis, nothing is more certain than the phlebographic demonstration of a thrombus; moreover, even if the thrombus is not demonstrable, as in certain phlebites. it is still possible to establish the diagnosis with adequate knowledge of the radio anatomy of the non-opacified veins and the demonstration of marked collateral circulation. Therefore this investigation must be carried out very carefully with particular attention to interpretation. The technique was first used in man in 1923 and is now employed world wide; better tolerated contrast materials render it almost innocuous; the occurrence of very few incidences of non-tolerance does not diminish the value of this method. We have purposely reduced the text to legends of the illustration and withheld the bibliography in so far as it is meant to be a teaching program by way of pictures without any reference to past or present publications.

Over the last few decades, angiography has devel­ careful analysis of his angiographic findings and a oped enormously and an extensive literature has very thorough description of vascular anatomy been published on the subject. In the last few and its many variants. The extensive clinical ma­ years, the number of publications has decreased terial also enables him to indicate those circum­ because the applications of this diagnostic method stances in which angiography can make an impor­ seem to have been almost fully explored. tant contribution to diagnosis. One of the applications for which this statement This monograph deserves the attention of all who might not be true is angiography of the upper ex­ are interested in the anatomy and pathology of the tremity. The clinical interest for this field has nev­ arm and the hand, and is particularly intended for er been as great as for other parts of the body. radiodiagnosticians and surgeons. In Maastricht, Janevski was able to accumulate an A. E. VAN VOORTHUISEN, M.D.

When compiling the present atlas our aim has been to provide the practis­ ing radiotherapist with a handbook which would help him to plan the radiation therapy of tumours of individual organs. Apart from a few ex­ ceptions, all isodose charts in this atlas show dose distributions resulting from external irradiation. Combination of external irradiation with intra­ cavitary radium therapy is presented in the treatment of carcinoma of the uterine cervix, in which case the two techniques are complementary. Thd immense material of the pertinent literature could, naturally, not have been included in the atlas. As a result of scrupulous selection, the isod-.:se charts shown may not invariably be the optimum ones, and some of them may not be the most modern. However, the usefulness of the information they provide has made us to keep them all the same. We did not intend to change the original charts in any way and stan­ dardization of the isodoses was not undertaken. Radiation parameters are given in the figure captions and, if available, information has also been provided on the phantoms used by the authors. Naturally, the isodoses presented will not automatically apply to all situ­ ations and all apparatuses without due attention to the individual patient ::Jnd technical details such as penumbra and source diameter. They merely serve as a starting point and will help to save time and work during treat­ ment planning also with the computer.

The rapid growth of fibre-optic endoscopy in recent than 7,500 examinations has been accumulated. years has had two consequences for the radiology of In part I of this study the theoretical background the stomach and the duocienum. and the technique of examination proper are de- scribed. The basic principles of interpretation of DC 1. Radiology has lost its previously rather auton- studies are stated. omous position in this field. Part II deals with the results. Chapter 5 consists of 2. As a result of the constant feed-back from the general remarks on the results, and on the comple- endoscopist, which the radiologist can and should mentary role of radiological examination and endos- have, he is in an excellent position to re-evaluate copy. Chapter 6 deals with a quantative study of and improve his own technique of examination. standard biphasic-contrast examinations in patients The author believes that the radiological exam- over a period of 3 years.This study was restricted to ination retains its value as a screening technique and malignant lesions, because it is only in this group a complementary method to gastroscopy and biop- that the definite criterion, a histological diagnosis, is sy. Only a sophisticated radiological technique will obtained. The natural history of malignant lesions fulfil these requirements. In 1973 the author devel- also makes follow-up studies possible. Results of the oped a standard examination that was called "bi- diagnosis of Early Gastric Cancer (EGC) are phasic", because it combines the advantages of included.

Recent advances in surgical procedures for the management of focal liver diseases have greatly increased the demand for diagnostic accuracy. So far these demands have been only partially met by further technical developments such as colour coded duplex sonography, spiral CT and marked improvements in magnetic resonance imaging. It is becoming increasingly clear that liver specific contrast media are essential for utilizing these technical developments to their fullest advantage in patient care. Against this background, a workshop was held to explore the current methods of diagnostic imaging of the liver and to try and establish a profile for the future liver specific contrast media. The pathologist's introductory and general overview is followed by chapters on the individual imaging procedures such as ultrasound, CT and MRI, so that each of the three is given the attention it deserves. The book will be of interest to radiologists from the various disciplines, and also those who plan and perform therapies, particularly surgeons and internists.

Magnetic resonance is a safe, non-invasive technique which can be used to produce high resolution, thin tomographic slices in any chosen plane, or true three-dimensional blocks of information. It has become the method of choice for studying the central nervous system, the vertebral column and many joints, but has not yet gained general acceptance in researching the cardiovascular system, although there are techniques for overcoming the problems of cardiac movement to produce excellent cardiovascular images. The purpose of this book is to provide the student and radiologist with a reference which can be used to identify the major structures in the body, bearing in mind that in each region a more detailed high-resolution study can usually be obtained by specialised units. The illustrations, each of which is accompanied by an explanatory line drawing, are soft tissue images based on the water content rather than the familiar X-ray shadowgram of mainly hard tissues.

MRI is assuming a dominant role in imaging of the larynx. Its superior soft tissue contrast resolution makes it ideal for differentiating invasion of tumors of the larynx from normal or more sharply circumscribed configuration of most of the benign lesions. Over ten years ago CT made a major impact on laryngeal examination because it was the first time that Radiologists were beginning to look at submucosal disease. All of the previous examinations duplicated the infor­ mation that was available to the clinician via direct and in-direct laryngo­ scopy. With the advent of rigid and flexible endoscopes, clinical examination became sufficiently precise that there was little need to perform studies such as laryngography which merely showed surface anatomy. The status of deep structures by these techniques was implied based on function. Fortunately laryngography is now behind us together with all of the gagging and contrast reactions which we would all like to forget. CT is still an excellent method of examining the larynx but it is unfortunately limited to the axial plane. With presently available CT techniques motion deteriorates any reformatting in sagittal or coronal projections. The latter two planes are extremely helpful in delineating the vertical extent of submucosal spreads. MRI has proven extremely valuable by producing all three basic projections, plus superior soft tissue contrast. Although motion artifacts still degrade the images in some patients, newer pulsing sequences that permit faster scanning are elimi­ nating most of these problems.

Magnetic resonance imaging became clinical in 1981 and since that time, has spread in the United States, Europe and Japan like wild fire. The tremendous advantages of the method consisting of safety, superb soft tissue contrast resolution, the ability to study flow, the ability to image in any plane or acquire data in 3D and an almost infinite array of sequences capable of distinguishing between disease and normal tissue, normal and abnormal blood flow make it incomparable for the diagnosis and study of multiple diseases and is particularly valuable in studying the heart and major vessels. The authors of this book have understood that the secret of success of MR imaging in the study of the heart is to combine the knowledge of anatomy of the heart, the coronary vessels, the pericardium and large vessels with the intricacies of MR imaging. This is why they go deeply into the basic principles of NMR, starting from the essentials and going then into detailed techniques of acquiring images from traditional spin echo to gradient echo and ultra fast imaging approaches, such as the multi shot and EPI. The flow phenomena are also discussed in detail from flow and magnetic field gradients diastolic pseudogating.

Carcinoma of the urinary bladder is a common (in the USA it is the fifth most common form of cancer in males and tenth most common form of cancer in females) malignan­ cy and one in which noninvasive staging by imaging plays such an important role. This book presents a complete approach to MR imaging of carcinoma of the urinary bladder from a detailed discussion of the value of MRI in the diagnosis of the urinary bladder to the history of the procedure. The technical discussion of the general principles of MRI including the optimal pulse sequences to be used and factors that influence the quality of images are included in this book. The safety factors are also presented along with contraindications. The application of a double surface coil with the field strength of O.5T provides the fine quality of the illustrations. The atlas of comparative anatomy by MRI on normal volunteers and post-mo'rtem specimens as well as MR images on patients with bladder tumors and post-surgery specimens is unique. The results of the clinical imaging stu­ dies in patients with carcinoma of the bladder, comparing the relative value of clinical staging, MR, CT and lymphography, are helpful in showing the advantages of MRI.

Following the development of gray-scale imaging, real-time scanning, Doppler examination, and high-frequency sonography, endosonography is one of the latest major breakthroughs in the history of diagnostic ultrasound. Although early attempts at inserting ultrasound transducers in natural cavities of the body can be traced back more than two decades, only in the past few years has technology allowed the development and commercialization of effective, easy-to-use endosono­ scopic probes. Because the transducer can be placed in direct contact with or close to lesions, high frequencies (up to ~2 MHz) can be used, yielding cross-sectional images of unsurpassed resolution. The availability of specially designed intracorporeal probes for specific natural cavities that are routinely explored by conventional (optical) endoscopy or palpation has significantly expanded the diagnostic applications of sonography. Transrectal and transvaginal examinations are now performed routinely in many institutions, and virtually all sonographic equipment manufac­ turers have in their line of products at least one endorectal and one endovaginal transducer. Most endosonoscopic probes connect to existing scanners, and for radiology departments, the invest­ ment for transrectal or transvaginal scanning will usually be limited to the purchase of the specific probe. In this book, clinical applications of endosonography (excluding transesophageal echocardio­ graphy) are covered by European and North American experts. Current equipment and techniques of examination are described in detail to help newcomers get started in the field of endosonography.

tic knowledge, a multidisciplinary approach is indis­ Over the past 60 years, radiology has progressively uncovered the human body. At first a fleshless skele­ pensable: clinicians, radiologists, surgeons, radio­ therapists, and pathologists must all contribute their ton for global study, the body then appeared in slices, until with present techniques its smallest respective inputs for every patient referred. More­ over, experience is acquired through knowledge of structures are revealed. The physician at the com­ cases whose diagnosis is certain, and with which new puter console is constantly amazed at the never­ ending series of organ sections and their mUltiple cases can be compared. In this way a data base is created, whether in the physician'S memory or in images arising through manipulation of the signal. Cerebral convolutions, orbital content, bone mar­ that of the computer, which is helpful in making row, the face and all its bones can now be made visi­ diagnoses. ble without any danger to the patient. A lesion can be detected, located and identified; it can be ob­ Dr.

In 1983 and 1984, I had the pleasure of being invited to Europe for the Cour- se of Hepatobiliary Surgery started by Professor Hepp and continued by Pro- fessor Bismuth. In these courses, I demonstrated many slides and movies of intraoperative echography that Makuuchi, one of my staff members, had made using the transducer that he was the first to develop. The topic of Intraoperative Echography had an enormous impact on the audience, and its use has since spread rapidly over the European countries, by virtue of the first Italian edition of Professor Gozzetti's book on Intra- operative Echography and Professor Bismuth's monograph on the same top- ic. I had been, therefore, unwittingly a very fortunate transmitter of intra- operative echography to Europe by means of Makuuchi's slide file. I am extremely honoured that the Italian Edition written by Gozzetti, Maz- ziotti and Bolondi has been dedicated to me. Also in this English Edition, Professor Gozzetti very kindly asked me to write a few words.It is an extra- ordinary pleasure for me to emphasize how this book is easy to read and understand, maybe by virtue of the profound Italian tradition of artistic expression since the Renaissance. On the other hand, a variety of series of intraoperative echographic images as well as resected specimens are arranged in an excellent manner.

Magnetic resonance imaging has already become a most valuable imaging modality in the diagnostic work-up of musculoskeletal neoplasms. While high accuracy of MRI for staging purposes has been proven, we will focus in this monograph on the characterization of primary bone and soft tissue tumors by MRI. The major purpose of this monograph is to provide an atlas of magnetic resonance features of primary bone and soft tissue tumors for radiologists, orthopedic surgeons and physiotherapists. The results presented are based on investigations of 94 primary bone and soft tissue tumors and mimicking conditions by magnetic resonance imaging. Although the scale of the material allows for statistical handling, the number of patients per subgroup is too small to come to definite conclusions. We will therefore limit ourselves to the description of and comments on a great number of cases to illustrate the diagnostic potential of this new imaging modality. We would like to thank the anonymous cooperators: referring clinicians, pathologists, nurses, technicians and secretaries whose help enabled us to present this monograph. We would also like to express our gratitude to the firms Siemens AG and Schering AG for technical support.

Publication of this book has been stimulated by 15 performed and duodenal abnormalities thus not years experience with contrast fluid irrigation visualised, occurred frequently. techniques of the small intestine and in particular All too frequently failure to maintain the proper by examinations performed and evaluated by col­ infusion rate, by many erroneously totally under­ legues. evaluated, had the result that disturbances in The classification of the X-ray pathology has motility were missed. been arranged to give a more effective application Additional and often too early administration in practice than is usually found in current of water, a measure that is seldom indicated and handbooks. Normally this classification is adapt­ tends to produce more bad results than good, is ed to that of formal anatomic pathology and quite frequently performed as a sort of panic internal medicine. In this book the classification reaction. The few indications for this procedure is based on the radiological symptomatology. ought to be known and strictly followed, super­ Thus, often completely unassociated conditions fluous application costs more time and causes are found listed as a possible cause for each unnecessary discomfort for the patient.