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Assessment of computed tomographic artefact in the pituitary fossa following needle implantation of radioactive rods
Clinical Radiology (1989)
40, 154-157
Assessment of Computed Tomographic Artefact in the Pituitary Fossa Following Needle Implantation of Radioactive Rods C. J. O ' D O N N E L L * , K. Y O N G and G. F. J O P L I N
Departments of*Radiology and Medicine, Royal Postgraduate Medical School, Hammersmith Hospital, Du Cane Road, London W12 OHS, UK Computed tomographic scans of the pituitary fossa following treatment of pituitary tumours by interstitial irradiation were reviewed for the degree of metallic artefact created by the rods. Among 50 patients treated with 90y rods alone, none showed artefact to a degree that caused technically unsatisfactory images in coronal or axial cuts. Among the seven patients who had been treated with 19SAu,either alone (two patients) or with both 19SAu and 90y rods (five patients), six had severe artefact and in five of these the images were technically unsatisfactory in both coronal and axial slices. We conclude that following implantation of 90y rods, the currently preferred isotope, the pituitary fossa can be satisfactorily assessed by computed tomography.
Interstitial irradiation of the pituitary using needleimplanted yttrium-90 (90y) o r gold-198 (198Au) rods has been in use for three decades for treatment of pituitary adenomas. Rods are implanted by a special needle into the pituitary fossa via a transnasal approach as previously described (Joplin et al., 1978). 198Au rods were initially used when a low-dose effect was sought but were abandoned in favour of 9°Y which gave better results. 90y is used as a sintered rod of spectroscopically pure Y 2 0 3 measuring 1 m m in diameter, and of variable lengths from 2 to 10 mm, dependent on the individual tumour size. One or two rods are inserted at a time but additional rods may be added at a later date if response is inadequate. One or both of the rods are usually positioned centrally within the tumour and adopt a horizontal or slightly oblique lie within the fossa. Rod implantation has been successfully used in the treatment of prolactinomas (Joplin et al., 1984), Cushing's disease (White et al., 1982; Sandier et al., 1987), Nelson's syndrome (Cassar et al., 1976), acromegaly (Cassar et al., 1981; Jadresic et al., 1987), and in high dosage has been used to effect total ablation of the pituitary to control the bone pain of disseminated carcinoma of the prostate (Khan et al., 1985). The response to treatment is monitored by clinical assessment, hormone analysis, plain films including tomography of the pituitary fossa (McLachlan et al., 1971) and, since 1981 at our institution, by computed tomography (CT) examination.
Computed t o m o g r a p h y was performed using a Siemens Somaton 2. Targeted views of the pituitary fossa were made using 2 m m collimated contiguous slices. Coronal projections mostly were used with the patient prone and with the neck hyperextended. In some patients this was not possible due to the shape or immobility of the neck or due to tooth amalgam artefact. In these cases, 2 m m contiguous axial slices were used with the patient supine and with the head held in a neutral position. Axial, sagittal and, where appropriate, coronal reformats of the pituitary fossa were also performed in all cases. A 5 cm scale is displayed on the right side of the CT image. Scans were made both before and after the intravenous injection of contrast medium unless there was a contraindication to its use. In cases where pre-implantation scans were available for comparison, post-contrast scans alone were performed post-operatively. The scans were assessed as being technically adequate if the whole pituitary fossa and its contents and local surrounds was satisfactorily displayed. This assessment was made on coronal or axial projections in 45 patients and on both projections in 12 patients. Metallic artefact was considered severe if streaks of high attenuation were seen to radiate from the rod, obscuring detail in the fossa. Lesser degrees of streak artefact were considered to be acceptable if overall detail of the structures was maintained.
RESULTS Among the 50 patients treated with 90y alone, none showed significant degradation of the image by artefact. Seven patients had 198Au implants, five in combination w i t h 90y (Table 1). Severe artefact was seen in six of these patients; this was of such a degree that the images were uninterpretable in five patients. Figure 1 shows patient number 3 of this group, where severe artefact is seen as a
Table 1 - Analysis of patients with 19SAu implants Patient
Rod type
No. o f rods
1
198Au 90y 198Au 198Au 90y 198Au 198Au 90y 198Au 90y 198Au 90y
1 3 2 2 2 2 2 2 3 2 2 1
P A T I E N T S AND M E T H O D S
2 3
All 57 available CT scans of patients with 90y only (50 patients), o r 198Au alone (two patients) or both 90y and 198Au implants (five patients) in the pituitary fossa were reviewed by one of us.
4 5 6 7
* Current address: Department of Radiology, The Royal Melbourne Hospital, Victoria, 3050, Australia.
Severe artefact
Technically interpretable scan
Yes
No
Yes Yes
No Yes
Yes Yes
No No
Yes
No
No
Yes
155
POST ROD IMPLANTATION ARTEFACT IN PITUITARY CT
(a)
(b) Fig. 1 - Patient H D , case 3 of Table l. Two rods ofg°Y and two rods of 198Au had been placed in an ACTH-secreting tumour. Post-contrast scans demonstrate (a) intense streaks of artefact obscuring detail of the pituitary, but in a more posterior slice (b) right parasellar t u m o u r extension is clearly identified.
consequence of the rods, yet useful information was obtained from a more posterior slice where right parasellar extension of tumour was identified. Seven patients had a total of more than two rods inserted. Five of these had both 198Au and 90y rods and are included in Table 1. Four had severe artefacts on their scans. The other two patients with multiple rods of 9 0 y alone, had three and four rods respectively and had no significant artefact on their scans. Twelve patients with 9 0 y rods only had both coronal and axial scans of the pituitary fossa; although both projections produced satisfactory images in all, the coronal scans produced better overall definition of the pituitary gland with the least degree of artefact (Fig. 2).
(b) Fig. 2 Patient VG with acromegaly, treated 21 m o n t h s earlier with two rods of 90y showing negligible artefact on non-contrast scans in the (a) coronal projection, and more obvious but not severe artefact in the (b) axial projection. The sella is now almost empty.
Two patients with 198Au rods in the fossa had both coronal and axial scans. There was no difference in the severe degree of artefact between the two projections. Where direct scans of the pituitary fossa were considered technically satisfactory, sagittal, coronal, and axial reformated images were invariably considered adequate. In six patients with 9 0 y implants only, there was marked high density artefact from tooth amalgam on coronal slices; all subsequent axial scans were technically satisfactory with virtual absence of artefact. In all six patients, the degree of artefact created by the amalgam was more severe than from the 9 0 y implants in adjacent coronal slices (Fig. 3).
156
CLINICAL RADIOLOGY In our study the composition of the rods appears to be the most important factor in determining the degree of the artefact. All six patients with severe artefact had 198Au rods. None of the 50 patients with 90y rods alone (the only currently used isotope) had significant metallic artefact, even in two patients with more than two rods in the fossa. Projection is also important in determining the degree of artefact seen on the image. Coronal scans of the pituitary can be very severely degraded by tooth amalgam, whereas axial scans are usually unaffected. Considering artefact created by the 90y rods alone, coronal scans produce the least degree of artefact; they cut perpendicularly across the horizontally orientated rods so that there is only a small volume of metal in each slice whereas on axial scans, although there are a smaller
(a)
(a)
(b) Fig. 3 - Patient SL with a large prolactinoma which had 5 m m of suprasellar extension, treated by two rods of 9°Y 78 m o n t h s prior to CT showing negligible artefact in the coronal projection through the centre of the fossa (a), but severe streak artefact from dental amalgam in a more anterior cut (b) on these non-enhanced scans. The t u m o u r has almost disappeared.
DISCUSSION On CT, 90y and 198Au rods appear as dense white cylinders with a fine, central black core, and associated variable intensity, radiating streaks of high attenuation. This appearance is common to all high density material on CT and is thought to be due to extreme density gradient between metal and adjacent soft tissues. Previous studies with metallic surgical clips indicate that the degree of artefact varies with the total volume of metal in each slice and with movement of the clips (Saxe et al., 1982). The composition of the metal is also important. Titanium clips have a much reduced artefact compared with 'Tantalum' clips (Gross et al., 1985).
(b) Fig. 4 Patient M R with a prolactinoma treated with two 90y rods was investigated with post-contrast scans (a) before, and (b) at 13 m o n t h s after implantation. The post-implantation scan still shows the tumour outline clearly, as well as reduced attenuation centrally within the tumour, especially above the rods.
POST ROD IMPLANTATION ARTEFACT IN PITUITARY CT
number of cuts containing metal, the CT slice is along the length of the rod resulting in a larger volume of metal being within the slice and a greater degree of artefact. Technically satisfactory images were obtained in all CT studies of the pituitary fossa following 90y rod insertion alone. The only unsatisfactory scans were seen in patients in whom 198Au rods had been implanted. We conclude that CT of the pituitary fossa following 90y rod implantation, preferably in the coronal plane unless tooth amalgam artefact precudes it, permits adequate follow-up of tumour response (Fig. 4). REFERENCES Cassar, J, Doyle, FH, Lewis, PD, Mashiter, K, Van Noorden, S & Joplin, GF (1976). Treatment of Nelson's syndrome by pituitary implantation of yttrium-90 or gold-198. British Medical Journal, 2, 269-272. Cassar, J, Doyle, FH, Banks, LM, Jadresic, A, Mashiter, K & Joplin, GF (1981). Interstitial pituitary irradiation with 90y for the treatment of acromegaly. A reappraisal. Aeta Endocrinologica, (Copenhagen), 96, 295-300, Gross, SC, Kowatski, JB, Lee, SH, Terry, B & Henikman, SJ (1985). Surgical ligation clip artefacts on CT scans. Radiology, 156, 831-832. Jadresic, A, Jimenez, LE & Joplin, GF (1987). Long term effect ofg°Y
157
pituitary implanation in acromegaly. Acta Endocrinologica (Copenhagen), 115, 301-306. Joplin, GF, Banks, LM, Child, DF, Diamant, L, Doyle, FH, Fraser, TR et al. (1978). Treatment of acromegaly by pituitary implantation of 90y. Treatment of Pituitary Adenomas eds Fahlbusch R & Von Werder KV. pp. 261 266. Georg Thieme, Stuttgart. Joplin, GF, Cassar, J, White, M, Jung, RT, Mashiter, K & Bowley, NB (1984). The role of interstitial irradiation with yttrium-90 in the treatment of pituitary adenomas. Trends in Diagnosis and Treatment of Pituitary Adenomas, eds Lamberts SWJ, Tilders FJG, Van der Veen EA & Assies J pp. 355-357. Free University Press, Amsterdam. Khan, O, Allen, J, Williams, G, Mashiter, K & Joplin, GF (1985). Repeat pituitary ablation for advanced prostatic cancer. Postgraduate Medical Journal, 61, 433-434. McLachlan, MSF, Wright, AD, Doyle, FH & Fraser, TR (1971). Sellar reconstitution and serum levels of growth hormone in acromegaly before and after pituitary implant. Clinical Radiology, 22, 502-506. Saxe, AW, Doppmann, JL & Bennan, MF (1982). Use of titanium surgical clips to avoid artefacts seen on computed tomography. Archives of Surgery, 117, 978 979. Sandier, LM, Richards, NT, Carr, DH, Mashiter, K & Joplin, GF (1987). Long term follow-up of patients with Cushing's disease treated by interstitial irradiation. Journal of Clinical Endocrinology and Metabolism, 65, 441-447. White, MC, Doyle, FH, Mashiter, K & Joplin, GF (1982). Successful treatment of Cushing's disease using yttrium-90 rods. British Medieal Journal, 285, 280- 282.
Book Review Nuclear Medicine Annual 1988. Edited by L. M. Freeman and H. S. Weissmann. Rave n Press, New York, 1988. 351 pp., $I 11.50. Each autumn the latest Nuclear Medicine Annual is published. This ninth volume once again contains reviews of radionuclide topics of current interest. The first chapter of the 1988 edition is the best, providing a balanced and thoughtful review of the current status of radionuclide skeletal imaging for breast carcinoma. The authors discuss in detail the need for this investigation in early breast malignancy. An error occurs in Table 2 which states that involved axillary lymph nodes are a good prognostic feature. The second chapter deals with the use of single photon emission tomography for abdominal problems. This contains a good deal of useful information on methodology but leaves rather in the air the question of clinical efficacy in relation to other abdominal imaging procedures. The third covers the specialised area of oesophageal transit measurements, and goes into considerable detail on the physical and physiological factors which may affect the results. The authors own experience in this field has helped to sort out the problems, so it is somewhat disappointing that they conclude that radionuclide transit cannot be used for screening and does not replace invasive oesophageal manometry. The next article, on Captopril interventional renography, contains a lot of information largely obscured in a cloud of
poor syntax and made worse by the irritating use of initials instead of full text. The conclusion is that the technique should not be the primary investigation for suspected renovascular hypertension. Next there is a well written review (yet again) on the use of radiolabelled monoclonal antibodies for imaging, and this is followed by a chapter on recent developments in the management of osteoporosis, and an interesting monograph on the effects of ager on radionuclide measurements in clinical practice. The book ends with a very personal view on the value of quantifying the transit of hepatobiliary agents through the biliary system, in which the authors claim specific diagnosis for a number of biliary disorders by these methods; a view likely to be challenged by most gastroenterologists. Generally, this volume leaves a slight feeling of depression for one working in nuclear medicine. Most of the radionuclide procedures discussed have been about for a number of years and yet their clinical place is still not established. Could this perhaps mean that they do not have one? Promise is one thing, routine clinical application another. For its research content this book is likely to find a place in most nuclear medicine libraries alongside previous Annuals; it is too cost ineffective for most individuals to purchase. D. Ackery
40, 154-157
Assessment of Computed Tomographic Artefact in the Pituitary Fossa Following Needle Implantation of Radioactive Rods C. J. O ' D O N N E L L * , K. Y O N G and G. F. J O P L I N
Departments of*Radiology and Medicine, Royal Postgraduate Medical School, Hammersmith Hospital, Du Cane Road, London W12 OHS, UK Computed tomographic scans of the pituitary fossa following treatment of pituitary tumours by interstitial irradiation were reviewed for the degree of metallic artefact created by the rods. Among 50 patients treated with 90y rods alone, none showed artefact to a degree that caused technically unsatisfactory images in coronal or axial cuts. Among the seven patients who had been treated with 19SAu,either alone (two patients) or with both 19SAu and 90y rods (five patients), six had severe artefact and in five of these the images were technically unsatisfactory in both coronal and axial slices. We conclude that following implantation of 90y rods, the currently preferred isotope, the pituitary fossa can be satisfactorily assessed by computed tomography.
Interstitial irradiation of the pituitary using needleimplanted yttrium-90 (90y) o r gold-198 (198Au) rods has been in use for three decades for treatment of pituitary adenomas. Rods are implanted by a special needle into the pituitary fossa via a transnasal approach as previously described (Joplin et al., 1978). 198Au rods were initially used when a low-dose effect was sought but were abandoned in favour of 9°Y which gave better results. 90y is used as a sintered rod of spectroscopically pure Y 2 0 3 measuring 1 m m in diameter, and of variable lengths from 2 to 10 mm, dependent on the individual tumour size. One or two rods are inserted at a time but additional rods may be added at a later date if response is inadequate. One or both of the rods are usually positioned centrally within the tumour and adopt a horizontal or slightly oblique lie within the fossa. Rod implantation has been successfully used in the treatment of prolactinomas (Joplin et al., 1984), Cushing's disease (White et al., 1982; Sandier et al., 1987), Nelson's syndrome (Cassar et al., 1976), acromegaly (Cassar et al., 1981; Jadresic et al., 1987), and in high dosage has been used to effect total ablation of the pituitary to control the bone pain of disseminated carcinoma of the prostate (Khan et al., 1985). The response to treatment is monitored by clinical assessment, hormone analysis, plain films including tomography of the pituitary fossa (McLachlan et al., 1971) and, since 1981 at our institution, by computed tomography (CT) examination.
Computed t o m o g r a p h y was performed using a Siemens Somaton 2. Targeted views of the pituitary fossa were made using 2 m m collimated contiguous slices. Coronal projections mostly were used with the patient prone and with the neck hyperextended. In some patients this was not possible due to the shape or immobility of the neck or due to tooth amalgam artefact. In these cases, 2 m m contiguous axial slices were used with the patient supine and with the head held in a neutral position. Axial, sagittal and, where appropriate, coronal reformats of the pituitary fossa were also performed in all cases. A 5 cm scale is displayed on the right side of the CT image. Scans were made both before and after the intravenous injection of contrast medium unless there was a contraindication to its use. In cases where pre-implantation scans were available for comparison, post-contrast scans alone were performed post-operatively. The scans were assessed as being technically adequate if the whole pituitary fossa and its contents and local surrounds was satisfactorily displayed. This assessment was made on coronal or axial projections in 45 patients and on both projections in 12 patients. Metallic artefact was considered severe if streaks of high attenuation were seen to radiate from the rod, obscuring detail in the fossa. Lesser degrees of streak artefact were considered to be acceptable if overall detail of the structures was maintained.
RESULTS Among the 50 patients treated with 90y alone, none showed significant degradation of the image by artefact. Seven patients had 198Au implants, five in combination w i t h 90y (Table 1). Severe artefact was seen in six of these patients; this was of such a degree that the images were uninterpretable in five patients. Figure 1 shows patient number 3 of this group, where severe artefact is seen as a
Table 1 - Analysis of patients with 19SAu implants Patient
Rod type
No. o f rods
1
198Au 90y 198Au 198Au 90y 198Au 198Au 90y 198Au 90y 198Au 90y
1 3 2 2 2 2 2 2 3 2 2 1
P A T I E N T S AND M E T H O D S
2 3
All 57 available CT scans of patients with 90y only (50 patients), o r 198Au alone (two patients) or both 90y and 198Au implants (five patients) in the pituitary fossa were reviewed by one of us.
4 5 6 7
* Current address: Department of Radiology, The Royal Melbourne Hospital, Victoria, 3050, Australia.
Severe artefact
Technically interpretable scan
Yes
No
Yes Yes
No Yes
Yes Yes
No No
Yes
No
No
Yes
155
POST ROD IMPLANTATION ARTEFACT IN PITUITARY CT
(a)
(b) Fig. 1 - Patient H D , case 3 of Table l. Two rods ofg°Y and two rods of 198Au had been placed in an ACTH-secreting tumour. Post-contrast scans demonstrate (a) intense streaks of artefact obscuring detail of the pituitary, but in a more posterior slice (b) right parasellar t u m o u r extension is clearly identified.
consequence of the rods, yet useful information was obtained from a more posterior slice where right parasellar extension of tumour was identified. Seven patients had a total of more than two rods inserted. Five of these had both 198Au and 90y rods and are included in Table 1. Four had severe artefacts on their scans. The other two patients with multiple rods of 9 0 y alone, had three and four rods respectively and had no significant artefact on their scans. Twelve patients with 9 0 y rods only had both coronal and axial scans of the pituitary fossa; although both projections produced satisfactory images in all, the coronal scans produced better overall definition of the pituitary gland with the least degree of artefact (Fig. 2).
(b) Fig. 2 Patient VG with acromegaly, treated 21 m o n t h s earlier with two rods of 90y showing negligible artefact on non-contrast scans in the (a) coronal projection, and more obvious but not severe artefact in the (b) axial projection. The sella is now almost empty.
Two patients with 198Au rods in the fossa had both coronal and axial scans. There was no difference in the severe degree of artefact between the two projections. Where direct scans of the pituitary fossa were considered technically satisfactory, sagittal, coronal, and axial reformated images were invariably considered adequate. In six patients with 9 0 y implants only, there was marked high density artefact from tooth amalgam on coronal slices; all subsequent axial scans were technically satisfactory with virtual absence of artefact. In all six patients, the degree of artefact created by the amalgam was more severe than from the 9 0 y implants in adjacent coronal slices (Fig. 3).
156
CLINICAL RADIOLOGY In our study the composition of the rods appears to be the most important factor in determining the degree of the artefact. All six patients with severe artefact had 198Au rods. None of the 50 patients with 90y rods alone (the only currently used isotope) had significant metallic artefact, even in two patients with more than two rods in the fossa. Projection is also important in determining the degree of artefact seen on the image. Coronal scans of the pituitary can be very severely degraded by tooth amalgam, whereas axial scans are usually unaffected. Considering artefact created by the 90y rods alone, coronal scans produce the least degree of artefact; they cut perpendicularly across the horizontally orientated rods so that there is only a small volume of metal in each slice whereas on axial scans, although there are a smaller
(a)
(a)
(b) Fig. 3 - Patient SL with a large prolactinoma which had 5 m m of suprasellar extension, treated by two rods of 9°Y 78 m o n t h s prior to CT showing negligible artefact in the coronal projection through the centre of the fossa (a), but severe streak artefact from dental amalgam in a more anterior cut (b) on these non-enhanced scans. The t u m o u r has almost disappeared.
DISCUSSION On CT, 90y and 198Au rods appear as dense white cylinders with a fine, central black core, and associated variable intensity, radiating streaks of high attenuation. This appearance is common to all high density material on CT and is thought to be due to extreme density gradient between metal and adjacent soft tissues. Previous studies with metallic surgical clips indicate that the degree of artefact varies with the total volume of metal in each slice and with movement of the clips (Saxe et al., 1982). The composition of the metal is also important. Titanium clips have a much reduced artefact compared with 'Tantalum' clips (Gross et al., 1985).
(b) Fig. 4 Patient M R with a prolactinoma treated with two 90y rods was investigated with post-contrast scans (a) before, and (b) at 13 m o n t h s after implantation. The post-implantation scan still shows the tumour outline clearly, as well as reduced attenuation centrally within the tumour, especially above the rods.
POST ROD IMPLANTATION ARTEFACT IN PITUITARY CT
number of cuts containing metal, the CT slice is along the length of the rod resulting in a larger volume of metal being within the slice and a greater degree of artefact. Technically satisfactory images were obtained in all CT studies of the pituitary fossa following 90y rod insertion alone. The only unsatisfactory scans were seen in patients in whom 198Au rods had been implanted. We conclude that CT of the pituitary fossa following 90y rod implantation, preferably in the coronal plane unless tooth amalgam artefact precudes it, permits adequate follow-up of tumour response (Fig. 4). REFERENCES Cassar, J, Doyle, FH, Lewis, PD, Mashiter, K, Van Noorden, S & Joplin, GF (1976). Treatment of Nelson's syndrome by pituitary implantation of yttrium-90 or gold-198. British Medical Journal, 2, 269-272. Cassar, J, Doyle, FH, Banks, LM, Jadresic, A, Mashiter, K & Joplin, GF (1981). Interstitial pituitary irradiation with 90y for the treatment of acromegaly. A reappraisal. Aeta Endocrinologica, (Copenhagen), 96, 295-300, Gross, SC, Kowatski, JB, Lee, SH, Terry, B & Henikman, SJ (1985). Surgical ligation clip artefacts on CT scans. Radiology, 156, 831-832. Jadresic, A, Jimenez, LE & Joplin, GF (1987). Long term effect ofg°Y
157
pituitary implanation in acromegaly. Acta Endocrinologica (Copenhagen), 115, 301-306. Joplin, GF, Banks, LM, Child, DF, Diamant, L, Doyle, FH, Fraser, TR et al. (1978). Treatment of acromegaly by pituitary implantation of 90y. Treatment of Pituitary Adenomas eds Fahlbusch R & Von Werder KV. pp. 261 266. Georg Thieme, Stuttgart. Joplin, GF, Cassar, J, White, M, Jung, RT, Mashiter, K & Bowley, NB (1984). The role of interstitial irradiation with yttrium-90 in the treatment of pituitary adenomas. Trends in Diagnosis and Treatment of Pituitary Adenomas, eds Lamberts SWJ, Tilders FJG, Van der Veen EA & Assies J pp. 355-357. Free University Press, Amsterdam. Khan, O, Allen, J, Williams, G, Mashiter, K & Joplin, GF (1985). Repeat pituitary ablation for advanced prostatic cancer. Postgraduate Medical Journal, 61, 433-434. McLachlan, MSF, Wright, AD, Doyle, FH & Fraser, TR (1971). Sellar reconstitution and serum levels of growth hormone in acromegaly before and after pituitary implant. Clinical Radiology, 22, 502-506. Saxe, AW, Doppmann, JL & Bennan, MF (1982). Use of titanium surgical clips to avoid artefacts seen on computed tomography. Archives of Surgery, 117, 978 979. Sandier, LM, Richards, NT, Carr, DH, Mashiter, K & Joplin, GF (1987). Long term follow-up of patients with Cushing's disease treated by interstitial irradiation. Journal of Clinical Endocrinology and Metabolism, 65, 441-447. White, MC, Doyle, FH, Mashiter, K & Joplin, GF (1982). Successful treatment of Cushing's disease using yttrium-90 rods. British Medieal Journal, 285, 280- 282.
Book Review Nuclear Medicine Annual 1988. Edited by L. M. Freeman and H. S. Weissmann. Rave n Press, New York, 1988. 351 pp., $I 11.50. Each autumn the latest Nuclear Medicine Annual is published. This ninth volume once again contains reviews of radionuclide topics of current interest. The first chapter of the 1988 edition is the best, providing a balanced and thoughtful review of the current status of radionuclide skeletal imaging for breast carcinoma. The authors discuss in detail the need for this investigation in early breast malignancy. An error occurs in Table 2 which states that involved axillary lymph nodes are a good prognostic feature. The second chapter deals with the use of single photon emission tomography for abdominal problems. This contains a good deal of useful information on methodology but leaves rather in the air the question of clinical efficacy in relation to other abdominal imaging procedures. The third covers the specialised area of oesophageal transit measurements, and goes into considerable detail on the physical and physiological factors which may affect the results. The authors own experience in this field has helped to sort out the problems, so it is somewhat disappointing that they conclude that radionuclide transit cannot be used for screening and does not replace invasive oesophageal manometry. The next article, on Captopril interventional renography, contains a lot of information largely obscured in a cloud of
poor syntax and made worse by the irritating use of initials instead of full text. The conclusion is that the technique should not be the primary investigation for suspected renovascular hypertension. Next there is a well written review (yet again) on the use of radiolabelled monoclonal antibodies for imaging, and this is followed by a chapter on recent developments in the management of osteoporosis, and an interesting monograph on the effects of ager on radionuclide measurements in clinical practice. The book ends with a very personal view on the value of quantifying the transit of hepatobiliary agents through the biliary system, in which the authors claim specific diagnosis for a number of biliary disorders by these methods; a view likely to be challenged by most gastroenterologists. Generally, this volume leaves a slight feeling of depression for one working in nuclear medicine. Most of the radionuclide procedures discussed have been about for a number of years and yet their clinical place is still not established. Could this perhaps mean that they do not have one? Promise is one thing, routine clinical application another. For its research content this book is likely to find a place in most nuclear medicine libraries alongside previous Annuals; it is too cost ineffective for most individuals to purchase. D. Ackery