Appendix: Scintigraphy of the

M. DE Roo

CONTENTS A.2.1 Tracer Substances (Radiopharmaceuticals) A.I. Introduction 155 A.2. Technical Introduction 155 A.2.1. Tracer Substances (Radiopharmaceuticals) 155 A.2.1.1 A.2.2. Imaging Methods 156 A.3. Indications 157 Tracer Substances for Spleen Scintigraphy A.3.l. Functional Spleen Scintigraphy (Using Spleen-Specific Tracers) 157 A.3.2. Non-Specific Spleen Scintigraphy 157 Sulphur or tin colloid particles (dimensions 0.2- References 159 0.5Ilm) labelled by 99mTc sodium pertechnetate are, after intravenous injection, homogeneously taken up by the reticulo-endothelial system (RES) of the ~iver, spleen and bone marrow. The scintigraphic A.l Images can be considered as a map of the functional RES, with about 85% of the radioactive particles Introduction being trapped in the liver, 5-10% in the spleen and a few in the bone marrow (in general not visible). The number of indications for the scintigraphic Under normal circumstances, the images reveal, in exploration of the spleen has strongly diminished addition to the global uptake, the mass and func• since the advent of computed tomography (CT) and tional integrity of the RES system within the liver magnetic resonance imaging (MRI). The position, and spleen, and the shape, position and volume of shape and volume of the spleen and intra splenic these organs (Fig. A.I). Tumoral lesions or areas of lesions are, in general, more accurately visualised parenchymal destruction are visible as zones of di• using CT and MRI, notwithstanding the continuous minished or absent tracer uptake. imp.rovement of scintigraphic imaging techniques by For specific imaging of the spleen, denatured the mtroduction of high-resolution digital y-cameras autologous red blood cells are used. Red blood cells and of novel scintigraphic techniques, such as (20ml) are separated and labelled with technetium SPECT (single-photon-emission computed tomo• sodium pertechnetate, denatured by means of graphy). From the foregoing, it can be concluded 20min incubation at 49.5°C and, subsequently, in• that splenic scintigraphy can bring useful additional jected into the patient. information only if the scintigraphic imaging Heating produces spherocytes characterised by demonstrates functional phenomena related to damage of red cell membrane and changes in levels diseases of the spleen (SPENCER and PEARSON 1975; of intracellular electrolytes. These red cells are sub• PETERS et al. 1983). ject to lysis and selective removal from the blood• stream earlier. These denatured red blood cells are rapidly taken up by the macrophages of the spleen. A.2 Scintigraphic imaging shows only the spleen or Technical Introduction delocalised spleen tissue. Unlike the case in spleen scintigraphy with colloid particles, spleen and Two items must be considered: the tracer substances spleen tissues are imaged without any interference and the scintigraphic technique. of other organs (FISHER and WOLF 1967).

M. DE Roo; Herendreef 26, B-3001 Heverlee, Belgium 156 M. De Roo

a b

c d

Fig. A.!. Normal colloid scintigraphy of the spleen (and liver). a Anteroposterior incidence, showing the liver and, less clearly, the spleen. b Posteroanterior incidence, showing more clearly the spleen and the right hepatic lobe. c Computed tomography (CT) of the liver and spleen. d Single-photon-emission CT at the same level as the CT image, showing the hepatic tracer distribution in a transverse slice (note the heterogeneous tracer distribution at the hilus) and, at right, the homogeneous tracer uptake in the spleen

A.2.1.2 A.2.2 Tracer Substances for the Bone Marrow Imaging Methods (Secondary Spleen Visualisation) Planar imaging (anteroposterior, posteroanterior, Indium-Ill chloride (indium behaves in a manner lateral and oblique views) is, in general, completed similar to iron) can be used for the exploration of the by SPECT when small masses of splenic tissues or red bone marrow, but the use of labelled leukocytes small intrasplenic lesions are to demonstrated. is more convenient. The baseline mechanism of However, for the latter indication, spleen scinti• 99mTc HMPAO (hexamethylpropylene amine oxime) graphy is rarely useful, owing to the greater efficacy labelling of leukocytes is the lipophilicity ofHMPAO, of CT and MRI. which allows the 99mTc to enter the cells, in this case the Planar imaging is adequate for the visualisation of leukocytes, which must be isolated before labelling. the functional disturbances of the different cellular There are also in vivo labelling techniques for constituents or the demonstration of delocalised the leukocytes (and the myelocytes and meta• splenic tissue. Imaging can be restricted to the abdo• myelocytes); in these techniques, a 99mTc-Iabelled men or, if useful, whole-body imaging can be used. anti-granulocyte antibody against the antigen sub• stance non-specific cross-reactive antigen of the leukocyte can be injected (BECKER 1995). Both labelling techniques are routinely used in scinti• graphic procedures for detection and localisation of infectious foci. Scintigraphy of the Spleen 157

A.3 It has been proven, according to the literature, Indications that susceptibility to infection after is strongly increased (TOYOTA et al. 1986). Specific A.3.1 splenic scintigraphy enables one to determine Functional Spleen Scintigraphy (Using Spleen• whether the implants have become functional Specific Tracers) (HARDING and ROBINSON 1991).

A.3.l.l Trauma A.3.l.S Splenosis The evaluation of the volume of the residual function• ally intact part of the spleen, after surgery or restora• Accidental implantation of splenic tissue (splenosis) tion after splenic trauma, can provide an indication can only be demonstrated in a reliable way by for use of spleen scintigraphy in trauma patients. specific spleen scintigraphy. SPECT is recommended in order to obtain optimal results. With this tech• nique, splenosis can be detected in 58% of the cases, A.3.l.2 while sensitivity of planar scintigraphic techniques is Mass Lesions limited to 26% (GUNES et al. 1994).

The specification of tumoral mass or masses in the left upper abdominal quadrant can provide an A.3.l.6 indication for use of spleen scintigraphy. If these Control of Therapeutic Splenectomy masses take up denatured, labelled blood cells, it can be concluded that these masses correspond to the In patients with chronic immune thrombocytopenic spleen, a functional intact part of the spleen or one or purpura, or other malignant hematologic more accessory (KOYANAGI et al. 1988). conditions, it is important to ascertain whether or not splenic tissue remains after splenectomy; this could result in a relapse of the disease (Fig. A.2). A.3.l.3 /

In polysplenia cases, it can be important to demonstrate the presence of functional spleen tissue. However, the absence of functional splenic tissue must be confirmed in patients with asplenia (sickle cell disease, leukaemia, volvulus of the spleen).

Fig. A.2. Spleen remnant (after splenectomy) caudal to the A.3.l.4 left hepatic lobe (colloid scintigraphy) Functional Result of Surgical Intervention

In children, splenic rupture occurs frequently in A.3.2 blunt abdominal trauma, because the capsule of the Non-Specific Spleen Scintigraphy spleen is relatively thin. Selective spleen scintigraphy is useful for the final evaluation of the damage to the A.3.2.l organ. After (sometimes partial) reconstruction of Colloid Scintigraphy the ruptured spleen, selective spleen scintigraphy is important for verification of the functional result of Using a colloidal tracer substance, the liver and the the surgical intervention (EHRLICHT et al. 1982; Bosc spleen are clearly visualised, allowing evaluation et al. 1984). of the position and volume of both organs, the In case of unavoidable total splenectomy, small detection of focal lesions (Fig. A.3) and the pieces of splenic tissue are implanted in the visualisation of parenchymal disease of the liver, peritoneum in order to preserve splenic function. which results in a shift of the tracer accumulation 158 M. De Roo

Fig. A.3. Colloid scintigraphy of liver and spleen, demonstrating expansive le• sions at the lateral border of the spleen, as also demonstrated by computed to• mography (lymphoma) towards the spleen and bone marrow. For liver le• sions, the overall sensitivity is about 80-85% accord• ing to the volume of the lesion; lesions less than 1.5 em in diameter are not detected. SPECT increased the yield to approximately 90%. Until the advent of CT, liver and spleen colloid scintigraphy were the most reliable exploration methods for the visualisation of focal liver and spleen disease (HARDING and ROBINSON 1991).

A.3.2.2 Spleen Scintigraphy in Haematology

The visualisation of functional bone marrow can be achieved using different tracers, such as indium-Ill transferrin or indium-Ill chloride. Whole-body images show the functional bone marrow, with only faint visualisation of the spleen. In cases with splenic myelopoiesis, the enlarged spleen shows pro• nounced tracer uptake. White blood cells labelled with 99mTc HMPAO have replaced the aforementioned tracer substances (BECKER 1995), enabling the exploration of the bone marrow and the role of the spleen in bone marrow diseases on a routine basis. In these whole-body images, the functional bone marrow is visible, with eventual shrinking or expansion phenomena. In normal cases, the spleen is visible owing to pooling of the labelled white blood cells. In cases of bone Fig. A.4. Whole-body imaging of liver, spleen and bone mar• marrow disease (with consequently diminished row after administration of white blood cells labelled by 99mTc anti-granulocyte antibody (BULL et al. 1996). Upper image: bone marrow function), the volume and the tracer normal tracer distribution in anteroposterior and postero• uptake intensity of the spleen increase, signalling anterior views, showing functional bone marrow, liver and extramedullary haematopoiesis (Fig. AA). spleen (free pertechnetate 99mTc excreted by the kidneys). Lower image: the same distribution in a case of osteo• myelofibrosis, with extramedullary hematopoiesis in liver and spleen Scintigraphy of the Spleen 159

References detection of splenosis: superiority of tomographic selective spleen scintigraphy. Clin RadioI49:115-117 Harding IK, Robinson PJA (1991) Clinicians guide to nuclear Becker W (1995) The contribution of nuclear medicine to the medicine gastroenterology. Churchill Livingstone, patient with infection. Eur J Nucl Med 22:1195-1211 Edinburgh Bosc 0, Bensoussan AL, Morin JF, et al. (1984) Splenic Koyanagi N, Kanematsu T, Sugimachi K (1988) Preoperative injuries: therapeutic orientation. Apropos of 46 cases. Chir computed tomography to facilitate the detection of Pediatr 25:1-25 in patients with hematologic disorders. Biill U, Schicha H, Biersack HJ, Knapp WH, Reiners C, Surg Today 18:101-104 Schober 0 (1996) Nuklear Medizin. Thieme Verlag, Peters PE, Lorenz R, Fischer M (1983) Splenic imaging. Stuttgart Lymphology 16:90-100 Ehrlich CP, Papanicolaou N, Treves S, et al. (1982) Splenic Spencer P, Pearson HA (1980) Radionuclide studies of the scintigraphy using Tc-99m-Iabeled heat-denaturated red spleen. CRC, Cleveland blood cells in pediatric patients. J Nucl Med 23:209-213 Toyota S, Nakagawa T, Yamaghucci N, et al. (1986) Fischer J, Wolf R (1967) Nuklearmedizinische Diagnostik in Scintigraphic imaging of autotransplanted splenic grafts der Hamatologie. Hoechst, Frankfurt by 99ffiTc-Iabeled heat-damaged erythrocytes. Radio• Gunes I, Yilmazar T, Sarikaya I, et al. (1994) Scintigraphic isotopes 35:423-428 Subject Index

A Campylobacter 78 Hematomas 7,96,131,78,82-83 Abscess 38,43,50,52,53,67,78,57, Castleman's disease 46 - Chronic expanding 131 135,142 Cat -scratch disease 78 - Subcapsular 78, 136 - bacterial 67 Cholesteryl-ester disease 57 Hemorraghe, see hematoma - candida 69 Churg-Strauss syndrome 53 Hemochromatosis, see Iron deposition - drainage 142 Collagen vascular diseases 49-53 Hemolytic Anemia 40-42 - fungal 69 Computed tomography 10,151 - Paraoxysmal nocturnal hemoglo• - imaging 68, 69 Cystadenocarcinoma, see tumors binuria 41-42Hemophagocytic syn• - salmonella 67 Cysts 7, 22, 10 1, 136 drome 58 Amyloidosis, see storage disease - "false" 102, 136 Hemosiderosis, see Iron deposition Anatomy 1 - "primary", see congenital Histology - bare area 12, 13 - "true", see congenital - Marginal zone 3 - capsule 3,29,37 - computed tomography 22, 102 - Microscopic structure 3 - colophrenic 21 - congenital 22, 102 - Pulp 3,4,37,44,49,50 - configuration, see shape - cyst -like lesion 130, 131 - Reticuloendothelial system 49, 50, - gastrolienal ligament 2,21 - echinococcal 75, 76, 77 51,59,60,61 - gastrosplenic ligament 2,10,21,32 - epidermoid, see congenital HIV 72 - inferior pole 7 - epithelial, see congenital Hypersplenism 45,57,143 - length 8, 12 - mesothelial, see congenital Hyposplenia, functional 50,51 - lienorenal ligament 2, 21 - ultrasound 22, 102 - location 10 Idiopathic thrombocytopenic purpura - margins 7 42-43 Echinococciasis 75 - pancreaticocolic ligament 21 Immunodeficiency syndrome 67,77 - phrenicosplenic ligament 2,21 Embolization 142,143 Infarction 21,32,35,38,43,50,52,53, Embryology 1,2,37 - shape 7,11,19 54,59,95,113, 115 134 - Variants, see variants - size 7,8,9,10,12,40,44,133 - acute- 96 - splenic artery 9,12,14,16,17,89 Embolization 142, 143 - chronic- 96 Epithelioid vascular tumors, see tumors - splenic hilum 2, 17 Infections 67-80 Enlargement, see - splenic vein 9,12,14,16,17,89 - fungal 135 Eosinophilic fasciitis 53 - splenic weight 8 - viral 135 - splenocolic ligament 10,21 - mononucleosis 135 - splenopancreatic ligament 32 Felty's Syndrome, see collagen vascular Iron deposition 38,40,55,60-62,63 - splenorenalligament 2,10,21 diseases - Hemochromatosis 60,61,62 - superior pole 7 Fetal spleen 17 - Hemosiderosis 40,42,43,45,60,61 - thickness 12 ibrosarcoma, see tumors - Sickle Cell Disease 38 - volume, see size Fibrous histiocytoma, see tumors - width 8,12 Focallesion(s) Juvenile chronic arthritis 53 Angiography 16,53,55 - Solitary 148 Angiosarcoma, see tumors - Multiple 148 Kaposi's syndrome, see tumors Aplasia, see variants Function 1,35,37 Kasabach-Merritt syndrome 104,138 Arteriovenous fistula, see vascular - Antibody production Klippel-Trenaunay-Weber Syndrome pathology - Cellular immunity 1 104 Asplenia, functional 50,51,133, 157 - Hematopoiesis 1,37 Atrophy, splenic 51 - Phagocytosis 1, 51 Langerhans' cell Histiocytosis, see stor- Autosplenectomy 38 age disease Leiomyosarcoma, see tumors Gamna -Gandy bodies 42, 98, 117 Beh"et's disease 53 Leukemia 44, 64 Gaucher's disease, see storage disease Biopsy 141 Lipoma, see tumors Granulomas 7 Birbeck granule, see Langerhans' cell Litteral cell angioma, see tumors Histiocytosis Leukocytoclastic vasculitis 53 Brucellosis 78 Hamartoma, see tumors Lyme disease 53 Hemangioma, see tumors Lymphangioma, see tumors Calcifications 7,22,38,50,51,59,63,72, Hemangiomatosis, see tumors Lymphangiomatosis, see tumors 74,75,76,77,125,129,131,136,148 Hemangiopericytoma, see tumors Lymphoma 64,125, 137, 138 162 Subject Index

Malaria 78-79 Splenic pulp 3,31,37 - Littoral cell angioma III Meliodosis 78 - Billroth cords 4 - Lymphangioma 107, l36, l37 Metastasis 64, 116, 120 - Platelet destruction 4,37 - Lymphangiomatosis 136, l37 MR Imaging l3,152 - Red pulp 4, l3, 18,44,49,50,58 - Lymphoma, see lymphoma - Contrast, gadolinium l3, 14 - White pulp 3,49 - Metastases, see metastases - Contrast, iron-oxide 14,22,34 Splenectomy 30,31,32,38,43,45,50, - Teratoma 116 - MR Angiography 14 81,141,143,157 - Scintigraphy 157 - Sequences l3 - Complications 35,81,145 - Signal intensity l3 - Laparoscopic 143 Ultrasound 8, 150 Myelofibrosis 45 Splenic trauma, see trauma - anterolateral approach 8 Splenogonadal fusion, see variants - color-Doppler 9 Niemann-Pick Disease, see storage Splenomegaly 9, 19,38,40,41,43,44, - intercostal approach 8 disease 45,46,49,50,51,53,54,55,56,57,58, - power-Doppler 9 Neonatal spleen, see Pediatric spleen 59,60,61,62,63,74,134,135,147 - subcostal approach 8 Splenosis 29-36,185 Overlap syndromes 53 - clinicalfeatures 31,35 Variants - computed tomography 34 - accessory spleens 3,23,32,33,43, Pancreatitis, see pseudotumors - definition 29 123 Pancreatitis, see vascular pathology - differential diagnosis 32 - aplasia 3,24 Pediatric spleen 17 - hematologic disease 31,32,35 - clefts 11, 20 Peliosis 75 - incidence 30, 31 - congenital 19 Peliosis, see vascular pathology - location 29,30 - dystopic, see wandering spleen Plain films 7 - imaging 33-34 - ectopic, see wandering spleen Pneumocystis carinii 77 - subcutaneous 30 - floating, see wandering spleen Polycythemia Vera 43 Splenuli, see splenosis - hypoplasia 3 Polysplenia, see variants Storage diseases 49, 53-62 - indentations 3 Portal hypertension, see vascular Systemic Lupus Erythematosus, see - lobulations 11, 19 pathology collagen vascular diseases - medial tubercle 11 , see vascular pathology - notches, see clefts Physiology 1 Tangier disease 57 - polysplenia 25, l33, 157 Pseudo tumor Teratoma, see tumors - position 19,20 - Fistula, colo splenic 129 Thorotrast 116 - retrorenal spleen 8 - Imaging 125 Tuberculosis 72 - shape 7,9,19 - Inflammatory 123 Thalassemia 40 - size 7 - Natural history 127 Torsion 21,27,32, l33 - spleen index 9, 11 - Pancreatitis 128 - Whirl sign 21 - splenogonadal fusion 27, 133 - Plasma cell grauloma 124 Trauma 81-88, l35 - splenoptosis, see wandering spleen - Pseudocyst, intrasplenic 128 - angiography 86 - splenunculi, see accessory spleen - Sclerosing- 124 - blunt - 81 - upside-down spleen 20 - Xanthogranulomatous 124 - clinical signs 81 - wandering spleen 21,22, l33 Puncture, accidental 142 - computed tomography 83 Vascular pathology - conventional radiography 82 - aneurysms, splenic artery 90 Radionuclide scanning, see scintigraphy - delayed rupture 82 - arteriovenous fistula 94 Rheumatoid arthritis, see collagen vas• - grading 83-86 - atherosclerosis, splenic artery 98 cular diseases - healing injury 87 - fibromuscular dysplasia, splenic Rupture 38,44,50,53,58,59,62, l35, - hematoma, see hematoma artery 98 116,78-79,153 - incidence 81 - pancreatitis 91, 144 - laceration 84 - peliosis 99 Sarcoidosis 62 - penetrating 81 - portal hypertension 90 Schistosomiasis 78 - postsplenectomy sepsis 81 - pregnancy 91 Scintigraphy 27,33,35,50,51,52,55, - ultrasonography 82 - pseudo aneurysms l36 59,155-158 - scintigraphy 157 - sequestration 98 - tracersubstances, 155 - splenosis 29,32 - trauma, 155 Tumors Wegener's granulomatosis, see collagen - tumoral pathology, 157 - Angiomyolipoma 131 vascular diseases - polysplenia, 157 - Angiosarcoma 116 Wheel-within-a-wheel-pattern 69 - asplenia, 157 - Cystadenocarcinoma 116 - postsurgery, 157 - Epithelioid vascular tumors 110 - splenosis, 157 - Fibrosarcoma 116 - bone marrow, 158 - Fibrous histiocytoma 116 Sequestration, see vascular pathology - Hamartoma 108, 125, 127 Sickle Cell Disease 37-40, 97, l31 - Hemangioma 104,125, l36 Sjogren' syndrome 53 - Hemangiomatosis 64, 125 Splenic circulation 5,37, see - Hemangiopericytoma 110 arteries, central 5 - Kaposi's sarcoma 78 - marginal-zone sinuses 5 - Leiomyosarcoma 116 - Venous sinuses 5,50,55 - Lipoma 110 List of Contributors

H.AIBE F. DECKERS Department of Radiology Department of Radiology Faculty of Medicine St. Augustinusziekenhuis Kyushu University Oosterveldlaan 24 3-1-1 Maidashi B-261O Wilrijk Higashi-ku Fukuoka, 812-8582 Belgium Japan H.DEGRYSE E.C. BENYA Department of Radiology 157 Scottswood Road University Hospital Antwerp Riverside, IL 60546-2221 Wilrijkstraat 10 USA B-2650 Edegem Belgium J.L. BLOEM Department of Radiology J. DELANOTE Leiden University Medical Center Department of Radiology Rijnsburgerweg 10 Algemeen Ziekenhuis St. Jan Brugge 2300 RC Leiden Ruddershove 10 The Netherlands B-8000 Brugge Belgium H. BORTIER University of Antwerp (campus RUCA) A. DREVELENGAS Groenenborgerlaan 171 Department of Radiology B-2020 Antwerpen Papanicolaou Hospital Belgium Thessaloniki Greece B. CORTHOUTS Department of Radiology, S.E. FALBO University Hospital Antwerp, Department of Diagnostic Radiology Wilrijkstraat 10, William Beaumont Hospital B-2650 Edegem, 3601 W. Thirteen Mile Rd. Belgium Royal Oak, Michigan 48073 USA A.I. DE BACKER Department of Radiology 1. HENDRICKX University Hospital Antwerp Department of Radiology Wilrijkstraat 10 Academic Surgical Center B-2650 Edegem Stuivenberg Belgium Lange Beeldekensstraat 267 B-2060 Antwerp M.DERoo Belgium Herendreef 26 B-3001 Heverlee C.C. HOEFFEL Belgium Department of Radiology A H6pital CO CHIN A.M. DE SCHEPPER 27 Rue du Faubourg Saint Jacques Department of Radiology F-75014 Paris University Hospital Antwerp France Wilrijkstraat 10 B-2650 Edegem Belgium 164 List of Contributors

H.HoNDA K.MoRTELE Department of Radiology Department of Radiology Faculty of Medicine University Hospital Ghent Kyushu University De Pintelaan 185 3-1-1 Maidashi B-9000 Ghent Higashi-ku Fukuoka, 812-8582 Belgium Japan B. OP DE BEECK H.IRIE Department of Radiology Department of Radiology Academisch Ziekenhuis-Vrije Universiteit Brussel Faculty of Medicine Laarbeeklaan 101 Kyushu University 1090 Brussels 3-1-1 Maidashi Belgium Higashi-ku Fukuoka, 812-8582 Japan H. RIGAUTS Department of Radiology K.rTO Algemeen Ziekenhuis St. Jan Brugge Department of Radiology Ruddershove 10 Thomas Jefferson University Hospital B-8000 Brugge 132 South lOth Street Belgium 1096 Main Building Philadelphia, PA 19107 P.R.Ros USA Department of Radiology Harvard Medical School Z.H.JAFRI Brigham and Women's Hospital Department of Diagnostic Radiology 75 Francis Street William Beaumont Hospital Boston, MA 02115 3601 W. Thirteen Mile Rd. USA Royal Oak, Michigan 48073 USA A. SPILT Department of Radiology M.KuNNEN Leiden University Medical Center Department of Radiology Rijnsburgerweg 10 University Hospital Ghent 2300 RC Leiden De Pintelaan 185 The Netherlands B-9000 Ghent Belgium w. J. STEVENS University of Antwerp (campus UIA) T. KUROIWA Universiteitsplein 1 Department of Radiology, Faculty of Medicine, Kyushu B-261O Antwerpen University, 3-1-1 Maidashi, Higashi-ku Fukuoka, 812-8582, Belgium Japan 1. STEYAERT K.MASUDA Department of Radiology Department of Radiology Algemeen Ziekenhuis St. Jan Brugge Faculty of Medicine Ruddershovelaan 10 Kyushu University B-8000 Brugge 3-1-1 Maidashi Belgium Higashi-ku Fukuoka, 812-8582 Japan T. TAJIMA Department of Radiology P.J.MERGO Faculty of Medicine Department of Radiology Kyushu University University of Florida College of Medicine 3-1-1 Maidashi Health Science Center Higashi-ku Fukuoka, 812-8582 P.O. Box 100374 Japan Gainesville, FL 32610-0374 USA E.ToTTE Department of Radiology D.G. MITCHELL Academic Surgical Center Department of Radiology Stuivenberg Thomas Jefferson University Hospital Lange Beeldekensstraat 267 132 South 10th Street B-2060 Antwerp 1096 Main Building Belgium Philadelphia, PA 19107 USA List of Contributors 165

R.VANHEE P. VANHOENACKER Department of Radiology Department of Radiology Academic Surgical Center O. 1. V. Ziekenhuis Stuivenberg Moorselbaan 164 Lange Beeldekensstraat 267 B-9300 Aalst B-2060 Antwerp Belgium Belgium H.VEREYCKEN 1. VAN HOE Department of Radiology Department of Radiology Academic Surgical Center University Hospitals K. U. Leuven Stuivenberg Herestraat 49 Lange Beeldekensstraat 267 B-3000 Leuven B-2060 Antwerp Belgium Belgium

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