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Arteriography in diseases of bone
ARTERIOGRAPHY
ARTERIOGRAPHY
IN
DISEASES
IN D I S E A S E S
OF
BONE
135
OF B O N E
BY L. MUCCHI AND F. COLUMELLA, MILAN THE percutaneous method simplifies the radiological exploration of various fractions of the arterial system ; thanks to the use of new radio-opaque preparations in angiography (preparations which are
Fig, IOS.---Subacute osteomyelitis with m a r k e d periosteaI reaction tending towards sequestrum formation.
Increased local
blood-supply, with dilated vessels and slowed circulation.
well tolerated and do not cause pain) arteriography can be carried out on the unanmsthetized subject. By this means we have been able to extend our angiographic researches on a large scale and to take up
136
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
again the subject of arteriography in diseases of bone, a subject w k h which we previously dealt in 1937, but which we had then to abandon because of the technical difficulties encountered and the dangers inherent in the use of the pharmaceutical preparations at our disposal at that time. It is probable that these same reasons were responsible for investigations by others along the same lines being few, either in Italy or elsewhere. As a result, the literature on the subject is scanty. The first workers in
Fig. IO9.--Chronic osteomyelitis with mild periosteal and synovial reaction and granulation tissue formation. Increased local and synovial circulation.
the field were Dos Santos, Lamas, and Caldas (1932), Reboul and Racine (1934), and Casal (i934) , who severally demonstrated the particular vascular reaction which occurs with malignant neoplasms of bone, and who envisaged th e possibility of a n angiographic method being used in the differential diagnosis between osteomyelitis and malignant new growths, and between these and benign tumours. Our own work in 1937 led us to the same conclusions, as did that of Farinas, in the same year. Inclan, in 1942 , also contributed to the angiographic picture of malignant bone tumours, and in 194z Lopez-Areal published an article based on the study of a wider variety of bone lesions. The latest work of Dos Santos (1949, I95O), although dealing with a greater number and variety of cases, treats almost exclusively of the same subject : the differential diagnosis between benign and malignant tumours.
ARTERIOGRAPHY
IN
DISEASES
OF
BONE
137
Our present findings are based upon the study of 68 cases of diseases of bone, of which a few, those of tumours of bone, have already been presented to the last Italian Congress of Radiology. Our researches have been carried out upon : - i. Subacute and chronic osteomyelitis.* 2. Tuberculous osteitis and osteo-arthritis. 3. Syphilitic osteitis and osteo-arthritis. 4" Dystrophic osteopathies (Keinbock's disease; Paget's disease; the effects of rickets).
Fig. I i o . - - T u b e r c u l o u s osteo-arthritis of the ulnar carpus, with relatively moderate decalcification. Fairly m a r k e d retardation of the circulation, with the blood-supply of the hand deriving almost entirely from the radial artery, while the circulation of the ulnar artery is particularly delayed and the artery itself appears very poor in branches.
5. Generalized osteitis fibrosa (Jaff6-Lichtenstein's disease). 6. Neoplasms (osteomata, chondroblastomata, osteoclastomata, myelomatosis, Ewing's tumour, osteosarcomata, and metastatic tumours of bone). From the technical point of view we shall confine ourselves to remarking that our injections into arteries have always been performed percutaneously under a local anaesthetic, using annular syringes, either in the direction of or against the blood-flow. We have preferred, of radio-opaque preparations, Pielosil or Umbradil because we feel they are better tolerated by the patient. We think it important to stress the absolute safety o f the method, provided the correct technique is employed, for, if one excepts the occasional occurrence of local spasm, of short duration and no significance, we have never encountered any untoward effects, either immediate or remote. * We have not been able to investigate any cases of acute osteomyelitis because of the early exhibition of antibiotics in their treatment , which obviates any need for radiographic examination in the acute stage.
Fig. i i i . - - T i b i o - t a r s a l tuberculosis with fairly m a r k e d decalcification. ~ross defect in the circulation of the foot, with straight arteries of a rigid, lmost endarteritie, appearance, and absence of collateral circulation,
ffig. I I z , - - D y s t r o p h i c syphilitic osteo-arthritis dth ulceration of the soft tissues (perforating ulcer f the foot).
/?
iJ
F~
> c~
Z
-I 0
Fig. I 1 3 . - - S a m e case as Fig. i i z. Very striking increase in circulation of the whole foot w i t h remarkable dilatation of the orincipal arteries and a rich arteriovenous plexus.
Fig. I 1 4 . - - P a t h o l o g i c a l fracture, w i t h compression of the head of the tibia, due to a gumma. T h e circulation is poor because of endarteritic changes in the m e d i d m arteries. T h e r e is no " m a l i g n a n t pathological c i r c u l a t i o n " present.
I40
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
Subacute and Chronic Osteomyelitis.--These conditions show a slight arteriolar and venous vasodilatation, with slight slowing of the circulation. These phenomena are seen in the whole affected area. Synovial involvement in the inflammatory process leads to increased arterial and venous flow in the membrane. In mild cases, which regress rapidly, the increase in circulation is proportionate to the degree of inflammation. (Figs. Io8, lO9. ) Tuberculous Osteomyelitis and Osteo-arthritis.--In the great majority of our cases we have noted a great diminution in the blood-supply, not only in the diseased tissues but in the whole area,
Fig. n5.--Kienbgck's disease with normal circulation.
together with a marked slowing (two to three times the normal) of the circulation in the affected part. The small arteries appear straight and rigid ; some of them look endarteritic and the absence of collateral circulation is to be noted, as well as the failure of the radio-opaque substance to reach the veins. Old cases of tuberculous infection of the knee-joints, which have been treated and cured b'y resection, show a normal circulation. (Figs. I I O , I I I . ) Syphilitic Osteitis (Gumma) and Osteo-arthritis.--In gummatous lesions we have demonstrated an isch~emia, due in all probability to the concomitant endarteritic process and inadequate collateral circulation, as is shown by the appearance of the vessels in the neighbourhood of the lesion. However, in a case of perforating ulcer of the foot with gross disorganization of bones and joints (Figs. I12, II3), we found a considerable increase in circulation in the whole foot. Dos Santos observed an exactly similar condition in a case of diffuse osteitis of the tibia. (Figs. I i 2 - I I 4 . ) Dystrophic Osteopathies.--In rickets the circulation was normal. In a case of Kienb6ck's disease (Fig. i15) although the impression is given that the local circulation is diminished, this may be doubted, for even in normal cases the vessels of the wrist are slender.
Fig. I ~6 . - - A case of Paget's disease, which shows generalized arteriosclerotic changes (the vessels are tortuous, lengthened, thickened, irregular, and appear ' bard'). In the affected bones the periosteal arterioles are increased in n u m b e r over the normal, and~in calibre, while some of them extend into the cortex.
Fig. I I 7 . - - G e n e r a l i z e d osteitis fibrosa (Jaff6-Licbtenstein's disease). T h e large and m e d i u m arteries of supply to the affected area are notably enlarged. T h e arterioles are poorly filled. There is no indication of " malignant pathological circulation ".
i4a
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THE
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In Paget's disease, on the other hand, we have been able to demonstrate repeatedly an increase in the periosteal blood-supply, confirming the anatomopathological findings. (Fig. 116.) Dysplasic O s t e o p a t h i e s . - - O u r three cases of Jaffd-Lichtenstein's disease (generalized osteitis fibrosa) have all shown a remarkable increase in the calibre of the regional vessels, arteries
Fig. I I 8 . - - A large osteoclastoma involving practically the whole of the lower femoral epiphysis.
T h e lateral
circumflex artery is considerably enlarged, with numerous branches disposed capsularly.
and veins, both large and medium, leading to a marked increase in the circulation rate. The angiographic appearances of these changes have in our experience been peculiar to this disease. (Fig. i I7.) N e o p l a s m s . - - W e can speak to-day, regarding new growths, of three basic angiographic appearances, of which the first two relate to benign and the third is characteristic of malignant tumours. I. In the first, there is no pathological circulation and only such effects on the vessels in the surrounding tissues as are produced mechanically by the presence of the tumour. 2. In the second, there is a pathological circulation, but with no signs of malignancy, which is broadly characterized by an abnormal vascularity of the surface of the tumour and enlargement of the afferent arteries. 3. In the third, there is a pathological circulation with obvious signs of ' malignancy ', which is characterized by : - -
Fig. I t g . - - O s t e o g e n i c sarcoma of the medial side of the head of the tibia. T h e popliteal artery is slightly displaced and its local branches are enlarged. T h e r e is a rich plexus of vessels in the t u m o u r , the constituent small vessels of which a r e fairly uniform in calibre, not diminishing in size as they branch, T h e opaque material is irregularly diffused in the radiographically affected area and the s u r r o u n d i n g bone, which is one of the typical appearances in " malignant pathological circulation ".
Fig. i z o . - - O s t e o g e n i c sarcoma of the shaft of the humerus in two sites, of which the clinical symptomatology pointed to subacute osteomyelitis. Radiologically, differential diagnosis was difficult. Angiography shows several absolutely characteristic appearances of malignant new g r o w t h : enlarged arteries in the t u m o u r region, ending in two ' vascular paintbrushes ' which abut on the two osteolytic foci.
144 a. b. vessels c. streaks
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Increased regional circulation. A rich vascular plexus, present no less in the depths thart Oli ihe ;urface of ti/~ ~one, with abnormal both in size and distribution. The presence of large vascular spaces in the tumour masS; ~hich appear as. irregular spots and of the opaque material. " ~'°
Fig. IRr. Same case as Fig. I2O. L a t e r exposures showing the diffusion of the opaque material in the two centres of malignant change.
Fig. 1 2 2 . - - P e r i o s t e a l sarcoma of the lower end of the femur w i t h wide extrinsic spread. Clinically it suggeste d tuberculosis of the knee.
d. The presence of non-traumatic arteriovenous fistulae, which cause a great speeding-up of the circulation in the tumour, which is evidenced by the simultaneous appearance in the connected arteries and veins of radio-opaque material in the first exposure. e. The diffusion, which is characteristic and constantly present, of opaque substance more or less densely and regularly throughout the tumour mass, which results in the Whole extent of the neoplastic changes appearing more opaque than normal bone ; that is to say, other areas are involved which do not show up as such iri a straight radiograph. This diffusion has a great practical value in determining the actual limits of the tumour. f. In relatively early cases, with little to show clinically or radiographically and which leave doubts as to the differential diagnosis between osteomyelitis and neoplasm, we have observed the
ARTERIOGRAPHY
IN
DISEASES
OF
BONE
x45
angiographic appearance described by both Farinas (~937) and Inclan (~942). This is an area of circulation, formed by small vessels, in the shape of an isosceles triangle, of which the base is
Fig. 1 2 3 . - - S a m e cases as Fig. I22. Angiography demonstrates typical evidence of malignancy : abnormal n u m b e r and size of arteries in the region w i t h a very r i c h vascular plexus in the t u m o u r of newly-formed arterioles, w i t h telangiectatic lacunae ; arteriovenous fistula and diffusion of the opaque material.
the zone of osteolysis and the apex is in contact with the end of a pre-existing artery, which is markedly enlarged in calibre : the so-called ' vascular paintbrush '. Fig. Iz8 is of a case which shows circulatory changes that we describe as 'pathological without signs of malignancy '. Figs. I I 9 - i 2 3 are of cases which we describe as showing a 'pathological circulation with signs of malignancy '.
SUMMARY Arteriography in bone pathology has proved to be an innocuous method of investigation, of easy application. It has become routine in our clinic. It facilitates the differentiation between benign and malignant osteopathies. Among the inflammatory osteopathies, there are angiographic differences between specific and non-specific forms.
146
JOURNAI~
O t ~'
"I'M J~
]fACULTY
UP'
RADIOLO(31~'I'~
Tuberculous osteo-arthritis generally shows a typical picture of severe regional isch~emia with definite slowing of the circulation, which accounts for the well-known indolence of the lesions and the inefficacy of antibiotics. In syphilitic, non-gummatous lesionsl the circulation appears to b e substantially increased, even in the ulcerous forms. In dysplasic diseases and in benign tumours the angiographic appearances allow them to be clearly differentiated from malignant lesions. T h e appearances in malignant tumours are so clear-cut and characteristic that confirmation of the diagnosis by biposy can be dispensed with. REFERENCES Dos SANTOS,R. (1949), Lyon chir., 6, 64I. - - (i95o), J. Bone Jr Surg., 32-B, i, 17. - - LAMAS,C., and CALDAS,P. (I932), Bull. Soc. nat. Chir., 48, 635. FARINAS,P. L. (I937), Radiology, 29, 29. INCLAN, A. (1942), J. Bone Jt Surg., 24, 259. REBOUL, H., and RACINE, M. (I934), J. Mdd. franG, 23, 122.
-
-
-
-
ARTERIOGRAPHY
IN
DISEASES
IN D I S E A S E S
OF
BONE
135
OF B O N E
BY L. MUCCHI AND F. COLUMELLA, MILAN THE percutaneous method simplifies the radiological exploration of various fractions of the arterial system ; thanks to the use of new radio-opaque preparations in angiography (preparations which are
Fig, IOS.---Subacute osteomyelitis with m a r k e d periosteaI reaction tending towards sequestrum formation.
Increased local
blood-supply, with dilated vessels and slowed circulation.
well tolerated and do not cause pain) arteriography can be carried out on the unanmsthetized subject. By this means we have been able to extend our angiographic researches on a large scale and to take up
136
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
again the subject of arteriography in diseases of bone, a subject w k h which we previously dealt in 1937, but which we had then to abandon because of the technical difficulties encountered and the dangers inherent in the use of the pharmaceutical preparations at our disposal at that time. It is probable that these same reasons were responsible for investigations by others along the same lines being few, either in Italy or elsewhere. As a result, the literature on the subject is scanty. The first workers in
Fig. IO9.--Chronic osteomyelitis with mild periosteal and synovial reaction and granulation tissue formation. Increased local and synovial circulation.
the field were Dos Santos, Lamas, and Caldas (1932), Reboul and Racine (1934), and Casal (i934) , who severally demonstrated the particular vascular reaction which occurs with malignant neoplasms of bone, and who envisaged th e possibility of a n angiographic method being used in the differential diagnosis between osteomyelitis and malignant new growths, and between these and benign tumours. Our own work in 1937 led us to the same conclusions, as did that of Farinas, in the same year. Inclan, in 1942 , also contributed to the angiographic picture of malignant bone tumours, and in 194z Lopez-Areal published an article based on the study of a wider variety of bone lesions. The latest work of Dos Santos (1949, I95O), although dealing with a greater number and variety of cases, treats almost exclusively of the same subject : the differential diagnosis between benign and malignant tumours.
ARTERIOGRAPHY
IN
DISEASES
OF
BONE
137
Our present findings are based upon the study of 68 cases of diseases of bone, of which a few, those of tumours of bone, have already been presented to the last Italian Congress of Radiology. Our researches have been carried out upon : - i. Subacute and chronic osteomyelitis.* 2. Tuberculous osteitis and osteo-arthritis. 3. Syphilitic osteitis and osteo-arthritis. 4" Dystrophic osteopathies (Keinbock's disease; Paget's disease; the effects of rickets).
Fig. I i o . - - T u b e r c u l o u s osteo-arthritis of the ulnar carpus, with relatively moderate decalcification. Fairly m a r k e d retardation of the circulation, with the blood-supply of the hand deriving almost entirely from the radial artery, while the circulation of the ulnar artery is particularly delayed and the artery itself appears very poor in branches.
5. Generalized osteitis fibrosa (Jaff6-Lichtenstein's disease). 6. Neoplasms (osteomata, chondroblastomata, osteoclastomata, myelomatosis, Ewing's tumour, osteosarcomata, and metastatic tumours of bone). From the technical point of view we shall confine ourselves to remarking that our injections into arteries have always been performed percutaneously under a local anaesthetic, using annular syringes, either in the direction of or against the blood-flow. We have preferred, of radio-opaque preparations, Pielosil or Umbradil because we feel they are better tolerated by the patient. We think it important to stress the absolute safety o f the method, provided the correct technique is employed, for, if one excepts the occasional occurrence of local spasm, of short duration and no significance, we have never encountered any untoward effects, either immediate or remote. * We have not been able to investigate any cases of acute osteomyelitis because of the early exhibition of antibiotics in their treatment , which obviates any need for radiographic examination in the acute stage.
Fig. i i i . - - T i b i o - t a r s a l tuberculosis with fairly m a r k e d decalcification. ~ross defect in the circulation of the foot, with straight arteries of a rigid, lmost endarteritie, appearance, and absence of collateral circulation,
ffig. I I z , - - D y s t r o p h i c syphilitic osteo-arthritis dth ulceration of the soft tissues (perforating ulcer f the foot).
/?
iJ
F~
> c~
Z
-I 0
Fig. I 1 3 . - - S a m e case as Fig. i i z. Very striking increase in circulation of the whole foot w i t h remarkable dilatation of the orincipal arteries and a rich arteriovenous plexus.
Fig. I 1 4 . - - P a t h o l o g i c a l fracture, w i t h compression of the head of the tibia, due to a gumma. T h e circulation is poor because of endarteritic changes in the m e d i d m arteries. T h e r e is no " m a l i g n a n t pathological c i r c u l a t i o n " present.
I40
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
Subacute and Chronic Osteomyelitis.--These conditions show a slight arteriolar and venous vasodilatation, with slight slowing of the circulation. These phenomena are seen in the whole affected area. Synovial involvement in the inflammatory process leads to increased arterial and venous flow in the membrane. In mild cases, which regress rapidly, the increase in circulation is proportionate to the degree of inflammation. (Figs. Io8, lO9. ) Tuberculous Osteomyelitis and Osteo-arthritis.--In the great majority of our cases we have noted a great diminution in the blood-supply, not only in the diseased tissues but in the whole area,
Fig. n5.--Kienbgck's disease with normal circulation.
together with a marked slowing (two to three times the normal) of the circulation in the affected part. The small arteries appear straight and rigid ; some of them look endarteritic and the absence of collateral circulation is to be noted, as well as the failure of the radio-opaque substance to reach the veins. Old cases of tuberculous infection of the knee-joints, which have been treated and cured b'y resection, show a normal circulation. (Figs. I I O , I I I . ) Syphilitic Osteitis (Gumma) and Osteo-arthritis.--In gummatous lesions we have demonstrated an isch~emia, due in all probability to the concomitant endarteritic process and inadequate collateral circulation, as is shown by the appearance of the vessels in the neighbourhood of the lesion. However, in a case of perforating ulcer of the foot with gross disorganization of bones and joints (Figs. I12, II3), we found a considerable increase in circulation in the whole foot. Dos Santos observed an exactly similar condition in a case of diffuse osteitis of the tibia. (Figs. I i 2 - I I 4 . ) Dystrophic Osteopathies.--In rickets the circulation was normal. In a case of Kienb6ck's disease (Fig. i15) although the impression is given that the local circulation is diminished, this may be doubted, for even in normal cases the vessels of the wrist are slender.
Fig. I ~6 . - - A case of Paget's disease, which shows generalized arteriosclerotic changes (the vessels are tortuous, lengthened, thickened, irregular, and appear ' bard'). In the affected bones the periosteal arterioles are increased in n u m b e r over the normal, and~in calibre, while some of them extend into the cortex.
Fig. I I 7 . - - G e n e r a l i z e d osteitis fibrosa (Jaff6-Licbtenstein's disease). T h e large and m e d i u m arteries of supply to the affected area are notably enlarged. T h e arterioles are poorly filled. There is no indication of " malignant pathological circulation ".
i4a
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
In Paget's disease, on the other hand, we have been able to demonstrate repeatedly an increase in the periosteal blood-supply, confirming the anatomopathological findings. (Fig. 116.) Dysplasic O s t e o p a t h i e s . - - O u r three cases of Jaffd-Lichtenstein's disease (generalized osteitis fibrosa) have all shown a remarkable increase in the calibre of the regional vessels, arteries
Fig. I I 8 . - - A large osteoclastoma involving practically the whole of the lower femoral epiphysis.
T h e lateral
circumflex artery is considerably enlarged, with numerous branches disposed capsularly.
and veins, both large and medium, leading to a marked increase in the circulation rate. The angiographic appearances of these changes have in our experience been peculiar to this disease. (Fig. i I7.) N e o p l a s m s . - - W e can speak to-day, regarding new growths, of three basic angiographic appearances, of which the first two relate to benign and the third is characteristic of malignant tumours. I. In the first, there is no pathological circulation and only such effects on the vessels in the surrounding tissues as are produced mechanically by the presence of the tumour. 2. In the second, there is a pathological circulation, but with no signs of malignancy, which is broadly characterized by an abnormal vascularity of the surface of the tumour and enlargement of the afferent arteries. 3. In the third, there is a pathological circulation with obvious signs of ' malignancy ', which is characterized by : - -
Fig. I t g . - - O s t e o g e n i c sarcoma of the medial side of the head of the tibia. T h e popliteal artery is slightly displaced and its local branches are enlarged. T h e r e is a rich plexus of vessels in the t u m o u r , the constituent small vessels of which a r e fairly uniform in calibre, not diminishing in size as they branch, T h e opaque material is irregularly diffused in the radiographically affected area and the s u r r o u n d i n g bone, which is one of the typical appearances in " malignant pathological circulation ".
Fig. i z o . - - O s t e o g e n i c sarcoma of the shaft of the humerus in two sites, of which the clinical symptomatology pointed to subacute osteomyelitis. Radiologically, differential diagnosis was difficult. Angiography shows several absolutely characteristic appearances of malignant new g r o w t h : enlarged arteries in the t u m o u r region, ending in two ' vascular paintbrushes ' which abut on the two osteolytic foci.
144 a. b. vessels c. streaks
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OF
THE
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Increased regional circulation. A rich vascular plexus, present no less in the depths thart Oli ihe ;urface of ti/~ ~one, with abnormal both in size and distribution. The presence of large vascular spaces in the tumour masS; ~hich appear as. irregular spots and of the opaque material. " ~'°
Fig. IRr. Same case as Fig. I2O. L a t e r exposures showing the diffusion of the opaque material in the two centres of malignant change.
Fig. 1 2 2 . - - P e r i o s t e a l sarcoma of the lower end of the femur w i t h wide extrinsic spread. Clinically it suggeste d tuberculosis of the knee.
d. The presence of non-traumatic arteriovenous fistulae, which cause a great speeding-up of the circulation in the tumour, which is evidenced by the simultaneous appearance in the connected arteries and veins of radio-opaque material in the first exposure. e. The diffusion, which is characteristic and constantly present, of opaque substance more or less densely and regularly throughout the tumour mass, which results in the Whole extent of the neoplastic changes appearing more opaque than normal bone ; that is to say, other areas are involved which do not show up as such iri a straight radiograph. This diffusion has a great practical value in determining the actual limits of the tumour. f. In relatively early cases, with little to show clinically or radiographically and which leave doubts as to the differential diagnosis between osteomyelitis and neoplasm, we have observed the
ARTERIOGRAPHY
IN
DISEASES
OF
BONE
x45
angiographic appearance described by both Farinas (~937) and Inclan (~942). This is an area of circulation, formed by small vessels, in the shape of an isosceles triangle, of which the base is
Fig. 1 2 3 . - - S a m e cases as Fig. I22. Angiography demonstrates typical evidence of malignancy : abnormal n u m b e r and size of arteries in the region w i t h a very r i c h vascular plexus in the t u m o u r of newly-formed arterioles, w i t h telangiectatic lacunae ; arteriovenous fistula and diffusion of the opaque material.
the zone of osteolysis and the apex is in contact with the end of a pre-existing artery, which is markedly enlarged in calibre : the so-called ' vascular paintbrush '. Fig. Iz8 is of a case which shows circulatory changes that we describe as 'pathological without signs of malignancy '. Figs. I I 9 - i 2 3 are of cases which we describe as showing a 'pathological circulation with signs of malignancy '.
SUMMARY Arteriography in bone pathology has proved to be an innocuous method of investigation, of easy application. It has become routine in our clinic. It facilitates the differentiation between benign and malignant osteopathies. Among the inflammatory osteopathies, there are angiographic differences between specific and non-specific forms.
146
JOURNAI~
O t ~'
"I'M J~
]fACULTY
UP'
RADIOLO(31~'I'~
Tuberculous osteo-arthritis generally shows a typical picture of severe regional isch~emia with definite slowing of the circulation, which accounts for the well-known indolence of the lesions and the inefficacy of antibiotics. In syphilitic, non-gummatous lesionsl the circulation appears to b e substantially increased, even in the ulcerous forms. In dysplasic diseases and in benign tumours the angiographic appearances allow them to be clearly differentiated from malignant lesions. T h e appearances in malignant tumours are so clear-cut and characteristic that confirmation of the diagnosis by biposy can be dispensed with. REFERENCES Dos SANTOS,R. (1949), Lyon chir., 6, 64I. - - (i95o), J. Bone Jr Surg., 32-B, i, 17. - - LAMAS,C., and CALDAS,P. (I932), Bull. Soc. nat. Chir., 48, 635. FARINAS,P. L. (I937), Radiology, 29, 29. INCLAN, A. (1942), J. Bone Jt Surg., 24, 259. REBOUL, H., and RACINE, M. (I934), J. Mdd. franG, 23, 122.
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