\tA

it. i_^ers We regret that some of the pages in the microfiche "• copy of this report may not be up to the proper legibility standards, even though the best possible copy was used for preparing the master fiche. Al

FOUNDATIONS OF RADIATION PROTECTION. 5tevens, D.J. Commonwealth X-ray and Radium Laboratory, 30 Lonsdale Street, Melbourne, Vic. 3000

For more than 40 years, the International Commission on Radiological Protection (ICRP) has published, from time to time, recommendations with respect to the basic principles upon which radiation protection may be based. ICRP points out that it is the responsibility of national protection bodies to apply these recommendations through such means as regulations or codes nf practice. The ICRP has stated that its recommendations are intended to guide experts. It is essential that regulations or cades of practice prepared by national Protection bodies should be complemented by soundly based standards of practice, carefully drawn up working rules and proper training and indoctrination of all personnel using the various sources of ionizing radiation in :1 medical practice. In the paper tD be presented, the principles upon which the basic recommendations of ICRP are founded will be. discussed. The responsibilities of national protection bodies and of users of sources of ionizing radiation in medical practice will be outlined. The paper is intended to provide an introduction to the papers which follow in the Symposium on Radiation Protection and which discuss important facets of the radiation protection problem.

.M A2

PERSONNEL RADIATION DOSIMETRY.

Sundbbrn. Lennart. WHO Regional Office for the Wester'n Pacific, P.O. Box 2932, Manila, Philippines. The aims and value of monitoring of personnel working in areas where they might be exposed to ionizing radiation of intensities significantly above the background radiation level will be discussed. Besides checking the exposure of the individual wearing a dosimeter, monitoring is also useful, e.g., for pointing out deficiencies in personnel training, poor working techniques and equipment malfunction, A brief review of the. methods available for personnel radiation dosimetry will be presented. This will include the advantages and disadvantages of using gaseous ionization, photographic film, radio-photbluminescent glass and thermo- luminescent dosimeters. The techniques for calibrating the dosimeters and the maintenance of personnel exposure records will also-be^discussed. Particular attention will be' given to problems involved in connection with the medical use of ionizing radiations and radioactive substances.

II it •3 A3

RADIATION PROTECTION AND THE PREGNANT WOMAN.

Villforth, J.C. Bureau of Radiological Health, United States Public Health Service, 5600 Fishers Lane, Rockville, Maryland, 20852.

The statistics of the X-ray experience of pregnant womsn in the United States in 1963, who delivered live babies will be presented. There is a potential for genetic and somatic damage to the offspring of these women. The theoretical indications .for abortion in those women who receive abdominal or pelvic radiation in an early unknown state of pregnancy will be discussed. The pregnant woman who presents with a medical problem requiring the use of radiation of the abdomen will be discussed from the stand- point of benefit versus risk. The employment of the pregnant woman as a radiation worker either as radiologic technologist or nuclear technician must be considered. The U.S. National Council on Radiation Protection and Measurements recommends that the i dose to the fetus from occupational exposure of the expectant mother should not exceed 0.5 rem during the entire gestation period. A4

RADIATIDN PROTECTION AND THE YOUNG PATIENT.

Hood, J.H. Sub-Departmsnt of , University of Queensland, Royal Brisbane Hospital, Herston, 4029, Queensland. This papsr is concerned with the practical aspects of paediatric and with measures that can be taken to minimise exposure of the young to ionizing radiation .v The extent to which a particular problem is pursued will depend upon the condition of the patient and conscience of the investigator. - being to some extent intangible these will not be discussed. ' Reference will be made amongst-other things to gonadal protection, centring, collimation, choice, use and adjustment of image amplifiers, rapid serial filming and cineradiology and the influence of the processing on dosage.

1 A5

RADIATION PROTECTION IN WARDS AND OPERATING THEATRES.

Williamson B.D.P.. Paris N.F. and Samsen L.

National Radiation Laboratory, Radiation Protection Service, Department of Health, Department of Medical Sciences, P.O. Box 1456, Christchurch, Yodse, Bangkok 1, New Zealand. Thailand. While, in diagnostic X-ray examinations, the radiation hazards which arise from possible exposure to the primary beam, to leakage, or to scattered radiation are invariant, the conditions under which radiological examinations are performed in operating theatres and wards differ significantly from those in "the X-ray department itself. In wards and operating theatres there are no permanent protective barriers; there is a need for various staff to be in close proximity to the patient during exposures; and X—ray equipment is often operated by personnel without specific radiological training. Whether is used inside or outside the X—ray department, it presents a greater radiation hazard than any other radiological technique, especially where obsolete equipment is used. Radiation protection measures can be effective only if the reasons for them art fully understood by the radiological personnel. Since this understanding depends largely on adequate training, those countries with a severe shortage of trained personnel, may have some serious protection problems. Two examples are cited where the combination of obsolete fluoroscopy equipment and untrained staff has lead to severe radiation injury. The radiation hazards of radiotherapy in wards and operating theatres depend very much on the techniques used. Nevertheless in developing countries, and even in developed countries, radium usage still presents the greatest hazard. RADIATION PROTECTION IN .

Stanford. R.W.

Department of Medical Physics, Royal Perth Hospital, Perth, Western Australia, 6000. The rapid increase in the volume and scope of work in which radio-isotopes are used for diagnostic examinations has brought problems of radiation protection which differ in certain respects from those previously experienced. High activity short lived doses eluted from columns pose radiation risks to laboratory technical staff. The high rate of consumption raises problems of laboratory discipline and organization in avoiding errors in administration of doses. Significant dose rates at the surface of syringes and in the vicinity of patients may result in high integral doses to clinical and para-clinical staff. There is need for wider understanding and training in this field. The purpose of this paper is to present the results of measurements and the assessment of credible hazards.

1% I 1

4 A7

RADIATION ACCIDENT5 AND THEIR MEDICAL MANAGEMENT. Jammet. H.P. Department of Radiation Protection, Atomic Energy Commission Centre of Nuclear Studies, Fontenay-aux-Roses (5eine) • France.

In considering radiation accidents, it is usual to distinguish between external irradiation and radioactive contamination. With external irradiation separate considerations apply to whole body and partial body exposure. With radioactive contamination, a distinc- tion must be made between skin contamination without incorporation of radioactivity in the body and contamination which gives rise to incorporation of radioactivity in the body. Despite the great differences in the nature of radiation accidents, certain basic rules for action can be established. In the case of external irradiation, action must be taken, without delay, to obtain as much information as possible on dosimetric aspects. Clinical and biological investigations must also be performed since these may permit a more precise diagnosis and give indications for any necessary therapy. These dosimetric investigations should be directed towards establishing the physical nature of the radiation source, the spatial distribution of the radiation in the occupied area, and the distribution of radiation in the person exposed. Personal dosimeters carried by an expcsed person, and induced radio- activity when neutron irradiation occurs, can provide valuable information. A reconstruction of the accident with a comprehensive dosimetric study is often very useful. If there is uncertainty with respect to the radiation dose, clinical and biological assessments must be performed as soon as possible. Apart from exceptional cases, therapy is not urgent in the case of accidental external irradiation. ( In most cases of accidental radioactive contamination, on the other hand, therapy may be urgent and takes precedence over precise radioactivity measurements and clinical ana biological assessments. Nevertheless, assessments of the level af radioactive contamination, and of the dcse commitment incurred, must be performed. Because of the different characteristics of the various radio-active contam- inants, there are fundamental differences in the various metabolic processes which apply. These differences are also reflected in the processes through which radioactivity is incorporated in the body. Therapy in cases of accidental internal contamination is based on metabolic data and physico-chemical aspects of the contaminant.

i! A8

SURGICAL ASPECTS OF SPACE OCCUPYING LESIONS OP THE LIVER

Professor H.A.P.Dudley Department of Surgery, Monash University Medical School, Alfred Hospital, Prahran, Victoria, 3181. Australia.

A so-called "western" nation such as Australia produces a pattern of hepatic space occupying lesions which mirrors the incidence of its gastro-intestinal problems. The majority of these are trauma and secondary malignant disease. The increased availability of scinti- scanning techniques has altered surgical practice in three ways. First by enabling a more accurate pre-operative diagnosis to be made; secondly by leading to the easier, and more effective detection of trauma; thirdly by altering the sequence of investigation so that a diagnosis can be reached more expeditioualy.

The only unusual lesion which Australian surgeons must remember is hydatid cyst. Its differential diagnosis will be discussed.

»•••' • A9

SPACE OCCUPYING LESIONS IN THE LIVER IN KOREA AND THEIR DIFREHENTIAL DIAGNOSIS. Bahk. Yong Whee Department of Radiology Catholic Medical College & Center St. Mary's Hospital Seoul 100, Korea Both primary hepatoma and amoebic abscess are probably the most common sysee occupying lesions of the liver in Korea. In addition, metastatic carcincmata to the liver and pyogenic abscess impose a difficult diagnostical program. 198 The hepatoscan with colloidal Au has been used extensively at a pattern of St. Mary's Hospital, Catholic Medical College since 1962, and recently of its blood clearance rate of the colloidal radiogold has also been utilised to help the interpretation of the liver scan. When injected a and in a subcritical dose, the clearance rate of colloidal particles from scinti- the peripheral blood represents hepatic blood flow **iich may or nay not be altered under certain pathological conditions. ways. First .de; secondly The clinical material consisted of 17 cases of primary hepatoma, 23 cases of metastatic carcinoma, 33 eases of amoebic abscess and :auina; thirdly 9 cases of pyogenic abscess. In each patient the clearance rate w&s ;is can be assessed immediately before liver scanning. The observed data of . each diseaee were tested statistically and grouped into significantly delayed, not significantly changed or significantly accelerated. The results were correlated with the scan findings. :emember is It is seen that blood clearance rates were significantly delayed L. in primary hepatoma (p<0.005) not significantly changed in pyogenic abscess (p>0.05) and significantly accelerated in metastatic carcinoma (p<0.001) and amoebic abscess (p<0.001). AlO

THE ANGIOGRAPHIC EVIDENCES OF THE PRIMARY CARCINOMA OF THE LIVER.

Yu, Chun

Department of Radiology Veterans General Hospital Taipei, Taiwan Republic of China

The majority of the primary carcinoma of the liver is hypervascular. Tumor vessels and tumor stains can be demonstrated by the selective celiac or hepatic arteriography. Venous thrombosis and arteriovenous shunt are not common arteriography findings and so-called 'Avascular primary carcinoma of the liver' is rare. The latter is most likely due to central necrosis of the tumor. To our knowledge, cystic and cavity- like form of the primary carcinoma of the liver has not been reported.

This presentation would include all the rare angiographic findings of the primary carcinoma of the liver as mentioned above and its differential diagnosis from other disease would be emphasized.

Hepatic or inferior vena cavography is a very useful procedure in the diagnosis of primary carcinoma of the liver, particular- ly in avascular form. In addition, the operability of the primary carcinoma of the liver can be predicated by the venographic study. If invasion or tumor thrombus is demonstrated in the major hepatic vein of inferior vena cava, tumor is operable.

Erom our experience, venography is a complementary procedure to the arteriography studies of the primary carcinoma of the liver. All

".3?5§&--- LIVER. of the Primary Liver Cancer Kido, C. Department of Diagnostic Radiology, Aichi Cancer Center Hospital, Chikusa-ku, Nagoya, Japan. In the field of radiological diagnosis of hepatic cancer, perivascular, liver- has made a great contribution to the elective interpretation of the morphological changes and, better still, sriovenous the selective hepatic angiography as a routine method has 'Avascular now made further precise diagnosis of liver cancer possible. t likely due and cavity- The vascular patterns in 60 histologically verified cases 1P n reported. of primary liver cancer were observed.

: findings Materials consist of 56 male and 4 female adults aged 19 i its to 73 of whom 8 were diagnosed as cholangiocarcinoma and ad. the rest as hepatoma including 48 differentiated and 6 anaplastic ones. useful f, particular- 1) Well-differentiated hepatoma: Vascular proliferation primary (88 %), tumor stain (71 %) and A-V shunt formation (50 %) study. If generally constituted the special feature of this group. atic vein 2) Anaplastic hepatoma: Hypervascularity and tumor stain were found in 67 % and A-V shunt formation in 17 %. Occasionally, vascularization had grown very complex. dure 3) Cholangiocarcinoma: Hypervascularity and tumor stain lie liver. were observed in 67 %. No A-V shunt formation was seen. Obliteration and collateral formation were found in one case. On the base of these results, the relationship between histological and angiographic findings of primary liver cancer will be discussed. A fetoprotein test was successfully completed in some cases of this series. An evaluation of this serum test for hepatoma will be made by comparing it with the result of findings of angiography. A12

RADIOLOGICAL ASPECTS OP HEPATIC TUMOURS IN HONG KONG.

Wong W. L.

H. & H. D. Institute of Radiology, Queen Mary Hospital, Hong Kong*

To cope with the advance of elective surgical procedures, more sophisticated radiological examinations than the plain abdomen and barium meal were employed in the investigation of hepatic tumours.

The purpose of this paper is to show the common radiographic features of 30 hepatocellular, 9 cholangio- and 9 metastatic carcinomas. Nine non-neoplastic cases of cirrhosis and cholangitis have been included in the study for comparison. All the cases were referred from Medical and Surgical Onits of the University of Hong Kong from 1968 to 1970 and pathologically proven. Clinically inoperable cases were not examined by arteriography. Unproven cases were not included.

Hepatocellular carcinoma.was seen mostly in males and in a wide age-group spread from 25 to 72. Whereas cholangio-carcinoma showed an almost equal sex distribution and an older age-group of 40 to 75. Presence of cirrhosis in cholangio- and hepatocellular carcinoma cases was not uncommon and more often in the latter. Hypervascularity and increased density were demonstrated in more than 6<$> of the hepatocellular carcinoma. Encasement effect was seen most frequently in cholangio- carcinoma and visualisation of veins only in hepatocellular carcinoma and not in the other conditions.

Selective coeliac arteriography was found to be most informative. Jurther valuable information could be obtained from splenoportovenography especially in left lobe lesions and significantly in which only cholangio- carcinoma showed 100# involvement of the portal vein. A13

A STUDY OF RADIOGRAPHIC SIGNS IK HEPATIC AMOEBIASIS. TaJLwatte. S.N.B. Department of Kadiology, General Hospital, Colombo, Ceylon. This study was undertaken to observe the X'ray signs of Hepatic >re Amoebiasis, and to determine their value in the diagnosis and id barium assessment of progress of the disease. Although in most cases Hepatic Amoebiasis was diagnosed clinically, in a significant few, a gave the first indication features of the disease. Changes in level and contour of the diaphragm, and pleuro-pulmonary included manifestations were studied. edical Elevation, increased convexity, and flattening with a shagginess I970 and in outline, were the diaphragmatic changes observed. mined by Pleuro-pulmonary changes consisted of basal loss of translucency, band shaped atelectases, consolidation, abscess formation, and pleural thickening or effusion. wide The progress of- these changes, was a reliable guide to the response Ned an to treatment. Localized bulging of the diaphragm was indicative of impending cases rupture of a liver abscess into the thorax. Rupturing abscesses and pointed to the oblique fissure of the lung, and gave a triangular tocellular shadow in lateral chest radiographs. agio- Deterioration of the clinical state of a patient, without progressive ;inoma and elevation of the diaphragm, was suggestive of an enlarging abscess situated close to the inferior surface of the liver. Rupture of a liver abscess occurred superiorly into the lung, native, pleural cavity or sub-diaphragmatic space, or inferiorly into the peri- renography toneal cavity. One ruptured anteriorly through the abdominal wall. cholangio- In left lobe liver abscesses, diaphragmatic changes were less marked. Distortion and displacement of the shadow of the stomach, gave an indication of the situation and size of the abscess. Contrast media introduced into an abscess cavity, gave useful information of the extent of the abscess, and its progress with treatment. Calcification was observed in a few healed abscesses. A14

COW-AitlSOM OF HEPATIC ANGIOGRAPHY WITH itETICOLOKKDOTHELIAL AND TiiANSCATHETEtt AI MiiCitOAGGiiEGA'rED itADIOISOTOlrE SCANKIfciG. W« c< Andrews, J.T. and Hare« W.S.C. G< c<

Departments of Nuclear Medicine & Kadiology, 71 The iioyal I'telbourne Hospital, A: Victoria, 3050, Australia. i] O] v< Hepatic angiography is a veil established procedure in the diagnosis and assessment of intrahepatic tumours. Reticuloendothelial liver scanning is also a valuable procedure and offers similar information in an alternative -way, s More recently a diagnostic method has been evolved utilizing both hepatic w artery catheterization and radioactive isotopes. In 10 patients a study was t made of liver tumours by the infusion of macroaggregated radioisotopes via an t hepatic arterial catheter. All cases have also a reticuloendothelial radio- t isotope liver scan and an hepatic angiogram. In seriK cases treatment was given with cytotoxic drugs via the intra hepatic catheter. In 1 patient a therapeutic dose of ?0-Yttrium microspheres was delivered via the catheter. This treatment needs be restricted to those patients wuo demonstrate a marked tumour infusion of the macroaggregated m radioisotope. One case was treated successfully by a hemihepatectomy. Serial v studies were made in several patients to assess the results of treatment. tl c< •.•mV A15

ETEtt ANOMALOUS INFERIOR VENA CAVA WITH DILATED AZYGOS VEIN Weerasena, M. and Jayasinghe, M. deS.

Cardiac Investigation Unit, General Hospital, Colombo, Ceylon.

Seven cases of anomalous inferior vena cava were found among 700 consecutive right-heart catheterization. In all these the Azygos vein which functioned as the inferior vena cava drained into the superior vena cava. In our series of catheterisations one patient in three with detrocardia had an anomalous inferior vena cava. and is In all seven cases the lateral chest X-ray did not show the LVB way. shadow of the inferior vena cava. The chest PA film in those LC with normal position of the heart showed a prominent shadow in ' was the superior mediastinum. These two radiographic features are ria an the only pre-ahgiographic investigations which gives a clue to idio- this anomaly.

When suspected on thoracic roentgenograms catheterisation should be performed through the saphenous vein. Right heart )heres catheterisation through the saphenous vein routinely and the ;hose importance of detecting this anomaly prior to surgery is id mentioned. When this condition is diagnosed at catheterisation Serial via the saphenous vein care should be taken not to catheterise the main pulmonary artery, specially the right branch, or the w coronary sinus.

feud A16

ASSESSMENT OF MITRAL VALVE BY TRANS-SEPTAL ANGIOCARDIOGRAPHY STUDB AND ITS VALUE IN CLOSED TRANSVENTRICULAR MITRAL VALVOTOMY ON LE Parthasarathy, L.R., Cheriyan, T.J, and Mathew, Annie

Southern Railway Hospital, Bjark, Madras-23 (India) Depart Closed transventricular valvotomy for mitral stenosis is the treatment of choice in India. Closed valvotomy is preferred as: Univer The incidence of Juvenile Mitral Stenosis is very high and in Uppsal; my hospital over a 10-year period we had operated on 422 cases out of which there were 140 cases below 20 years. Valve replacement is not suitable or feasible for Juvenile types of Mitral Stenosis in India. Valve replacement is again not suitable in India as it is considered as a luxury and the A patient had to be on anticoagulants for a long time. Hetro and Homografts have not stood the test of time. Open-heart surgery and oth is available in India in only one or two centres. clinica Hence the accepted method of treatment is transventricular valvotomy using our own. indigenous dilators. Surgery is mostly in left based on clinical findings with investigations like Phonocardio- gram. Electrocardiography, X-ray, Fluoroscopy and Barium Swallow. cular w 80% of-our eases can be assessed by these simple methods as stated above which have definite clinical signs and symptoms. contraf But the problem comes regarding the 20% of the cases who do not present any symptoms but suddenly come with pulmonary hyper- accomj tension and pulmonary oedema, due to valve disease getting into a critical level. It is impossible to assess clinically and wai whether the mitral valve is critical or not and the patients suitable for surgery in the absence of pulmonary hypertension. by the j Hence we tried to evaluate the mitral valve by the trans septal angiocardiography and we found- that it has paid a good dividend uniforn in assessing the mitral valve in closed mitral valvotomy. A17

STUDIES ON THE ACUTE EFFECTS OF CLINICAL ANGIOCARDIOGRAPHY ON LEFT VENTRICULAR FUNCTION

BjOrk, L. Department of Diagnostic Radiology University Hospital Uppsala, Sweden

A method for semi-automatic calculation of pressure-volume loops and other expressions for left ventricular work and power has been used in clinical angiocardiography. This technique permits measurement of changes in left ventricular function on a beat to beat basis. A decrease in left ventri- cular work could be demonstrated in patients, 5-8 sees after the injection of contrast medium for angiocardiography. At this stage the decrease was not accompanied by change in left ventricular or aortic pressures or in heart rate and was interpreted as caused by a direct depressing effect on the myocardium by the presence of contrast agent in the coronary circulation. There was no uniform dose-concentration-response relationship. A18

CINE ANGIOGRAPHY OF LEFT VENTRICULAR ANEURYSMS CORONAR

Steiner. R.E. Benness

Department of Diagnostic Radiology, Departm Royal Postgraduate Medical School, univers DuCane Road, SYDNEY. London, W.12. N.S.Wc

In this communication the value of left ventricular cine angiography combined with coronary arteriography in the Th^h diagnosis of "fibrous left ventricular aneurysms" as defined fron^th by Edwards and its ability to differentiate these from functional aneurysms defined by Gorlin, will be described. The Two groups of patients were studied, in the first group thSCb there are ten patients with fibrous aneurysms, confirmed at be open heart surgery with subsequent resection of the aneurysm. There were 11 patients in the second control group. In nine of these patients the left ventricle was inspected at open heart surgery when a bypass procedure was carried out, and in two at post mortem. In none of these 11 patients was there evidence of a fibrous aneurysm. In fibrous aneurysms' of the left ventricle an area of immobility, or paradoxical pulsation, occupies almost the entire distal half of the left ventricle, whereas the proximal unaffected ventricle in the sub-valvar region contracts normally. A definite fixed neck is rarely seen, but cine angiography usually differentiates between normal and abnormal muscular contraction. Contrast medium retention is commonly seen in the aneurysm. Associated coronary disease is common with major obstruction, usually of the anterior descending branch of the left coronary artery. Conclusions: A small apical area of abnormal ventricular contraction is the angiographic feature of a functional aneurysm. These aneurysms can be distinguished from the true fibrous aneurysm by their relatively small size and lack of chamber enlargement. A19

CORONARY ANGIOGRAPHY, SONES OR JUDKINS ?

Benness, G.T.

Department of Surgery, University of Sydney, SYDNEY. 2006. Australia.

The technique, results and complications of the methods described by Sones and Judkins will be reviewed. Complications from the same techniques but by other workers will be reviewed.

The results using both these methods in Sydney will be described and illustrated. Complications will be reviewed and the basis of the current approach to coronary angiography will be defined.

T A20

THORACIC SKELETAL DEFORMITIES AND CARDIAC MURMURS

Weerasena M.. M.B.B.S fCevlon*). D.M R D (London)

The Cardiac Investigation Unit, General Hospital, Colombo, Ceylon*

One hundred and two cases out of 950 investigated at the Cardiac Investigation Unit at the General Hospital, Colombo, have been analysed. These cases are shown to have varying degrees of Thoracic skeletal deformities causing clinical signs and symptoms. The signs and symptoms with which these patients presented are discussed. 80$ of these patients were between 10 and 30 years old. All these Patients were proved to have no organic heart disease at Cardiac catheterisation and selective Cardio-Angiography. That skeletal deformity of the chest may present as cases of atrial septal defect is emphasised. Contrary to popular belief association of precordial thrills without orsranic heart disease have been spotlighted.

"-Saii M A21

PUELIOHARY ANGIOGRAPHY AND AOBTOGRAIHT IS ONE SIDE BESTHOSED IUHG Suck Rin Kang M.D.

Department of Radiology m National Medical Center Seoul, Korea

To detect the pulmonary circulation in totally destroyed lung the author made pulmonary angiography and for adult patients. They were 20 years and 39 years old males and 33 years and 21 years old females. None of the cases tuberculos bacilli were found and the opposite estigated lung were essentially clear. Therefore the destruction were thought ospital, to be non-specific inflammatory disease. to have ausing In all four cases were made and it was proved that -•*M ms with the left lung were completely destroyed with sac formation. *m of these se TECHNIQUE AND METHOD OF EXAMINATIONS ase at >graphy. By percutaneous catheterization a Grey Odman's Catheter was is introduced to the right ventricle through puncture of the right :rary to femoral vein. 40c.c. of 76$ urografin was injected by 6 Kg pressure rlthout using Gidlund automatic pressure syringe. And 6 pictures per a second for 5 seconds, altogether 30 pictures are taken. As aortography a Grey Oftman's catheter was introduced to the aortic arch through puncture of the right femoral artery through percutaneous puncture. 40c.c. of 76$ urografin was injected by 6 Eg pressure using Gidlund automatic pressure, syringe. As pulmonary angiography 6 pic- tures per a second for 5 seconds, altogether 30 pictures were taken. In 4 patients the following same findings were obtained. The main pulmonary artery in the destroyed lung were completely occluded and even the remnant of the opening were not recognized. All the m pulmonary arterial blood goes to the opposite lung. On the other hand the destroyed left lung were blood supplied by re<&indent bronchial arteries which is considerably hypertrophied. 1 A22 lUMHOQRAPHT IN SUJQAPGfiE.

Khoo. F.Y.. Chia. K.B. and Vaithilinganu K.

Department of Diagnostic Hadiology and Department of Hadiotherapy, Outram Eoad General Hospital, Singapore 3, Bepublio of Singapore. in analysis f-~ made on 223 cases of seen from October 1967 to Hay 19711 with histological confirmation. Chinese constituted 825S of patients. Diseases were classified into four groupst Carcinoma, Fibroadenoma, Mammary Dysplasia, and Miscellaneous. All cases were clinically examined toy two radiologists before the formal or first X-ray report was made. Subsequently, one radiologist reread the mammograms, but without the benefit of clinical findings in order to assess the usefulness of mammography by itself; this constitutes the second X-ray interpretation. Eesultsi 1_. Carcinoma. 90 oases. The clinical impression was available in only 73 oases, and was $6$, correct. The first X-ray diagnosis was correct in 93$, and the second X-ray review was 71$ oorreot. 2. Fibroadenoma. 56 oases. The clinical impression supplied in 40 oases was 6Zf> correct. The first X-ray diagnosis was 6ljS correct, and the second 52j6« 3_. Mnmmq-py Dysplasia, 40 cases. The clinical impression available for 25* cases was correct in 8 cases (32%). The first X-ray diagnosis was correct in 32$, and the second X-ray review 3O5C £. Misoellaneous Oroup. 37 cases. The clinical impression was available in 34 oases, and was correct in 21$. The first X-ray diagnosis was correct in I656, and the second X-ray assessment 8$. It oan thus be seen that mammography with clinical data attains praotioally the same degree of accuracy in diagnosis as in clinical examination for oases of carcinoma (over 90$), fibroadenoma (60$) and mammary dysplasia (32$). The accuracy of both clinical and X-ray impressions was low in the miscellaneous group (21$ and 16$ respectively). Interpretation of mammograms without the aid of clinical data was found to yield lower positive results in all categoriesi 71$ correct for °*5oinoma| 54^ *°* fibroadenoma, 30$£ for mammary dysplasia, and only 856 for the miscellaneous group. A23

AVASCULAR CARCINOMA OF THE KIDNEY - THE IMPORTANCE OP RENAL PUNCTURE IN DIAGNOSIS. Hare, William S.C. Department of Radiology, University of Melbourne, The Royal Melbourne Hospital, Victoria, 3050, Australia.

October The macroscopic and microscopic pathology of 32 primary mstituted carcinomas of the kidney, excluding transitional cell carcinoma Carcinoma, of the renal , was studied in detail. The findings were )B were correlated with the radiological appearances in each case on first selective renal arteriography. In 7 cases the tumours were the virtually avascular on arteriography both with and without the >rder to preliminary injection of intraarterial adrenaline. ites the In this series radiological avascularity was associated with was two features: (1) extensive necrosis throughout the tumour, and (2) a papillary histological pattern in the viable tumour. -ray This particular histological picture was seen in 6 of the 7 radiologically avascular tumours, but was not seen in any of the supplied tumours which had a pathological circulation.on arteriography. $ correct, Although cystic degeneration in a tumour would result in nical JS). The avascularity, this was not a feature in these cases. ay review The relative frequency of avascular tumours in this series sion was emphasises the fact that renal arteriography alone is unreliable •ray in differentiating carcinoma of the kidney and simple cyst. it 8>5. Renal puncture should be employed in all avascular space lesions rttains with injection of contrast medium. Furthermore, if a cyst is linical punctured, it is essential that the outlined cyst on the films (60$) and should account for the entire space lesion on the , if X-ray carcinoma of the kidney is to be excluded. respectively). ;a was i correct da, and A24

HOV-OPAqOB CALCULI IH THB UHIHARY TRACT.

Or* Divan Chand Aggarval I'ray Clinic 10-B, Kasturba Gandhi Marg, lev Delhi-1 IMDIA.

Hon-opaque urinary calculi are relatively very rare* These present as filling defects daring intravenous pyelography. In the bladder these calculi shift in position as the patient is turned in different positions* In our series the calculi vera aalnly of uric acid insplte of the fact that the blood uric acid in our patients vaa within nerval Halts. A25

OPTIMUM CONTRAST MEDIUM DOSES FOR CALYCEAL VISUALIZATION. A CONTROLLED STUDY IN MAK

Fischer. H.W.. Rothfield. N.H.. Carr. J.D.

Department of Radiology University of Rochester School of Medicine 260 Crittenden Boulevard Rochester, New York 14620

Controversy still goes on concerning the optimum dose for vis- re* jrelography. ualization of calyces in excretory urography. Because of this a study was performed on human volunteers with normal renal function, is the each subjectrundergoing three urograms at progressively increasing doses. A dose range from 0.5 to 2.0 ml/kg body weight was tested. Calyces were assessed for clarity in definition and degree of dis- .d lnspite tention on 5 and 15 minute films by observers not knowing the vithiD dosage schedule.

The evaluation data indicates there is no benefit in extending the urographic dose above 1 ml/kg. Adequate radiologic documen- tation will be presented.

til A26

RENAL ARTERIOGRAPHY IN PAEDIATRIC RADIOLOGY - A FIVE YEAR SURVEY.

SPRAGUE. P.L. Department of Radiology, Royal Children's Hospital, Victoria, 3052, Australia.

The use of the Seldinger method of percutaneous catheterisation for aortography and renal angiography in the ivestigation of renal masses and renal diseases in infancy and childhood is described.

The clinical material encountered during a five year period is reviewed. The angiographic findings in 15 cases of cystic and cyst-like conditions of the kidneys are presented and the value of the procedures is discussed.

Ic • A 27

URVEY. THE VISUALISATION OP THE LOWER URETER WITH THE IMAGE INTENSIFIER Craig, C. and Grant., R.E.

21 High Street, Launceston, Tasmania 7250

Under certain circumstances it is very desirable that the isation lower ureter be photographed during the intravenous pyelogram f renal examination. A typical instance is when there has been a history of possible colic and where there is a small shadow near ibed. the ischial spine which could be either a calculus or a phlebolith. The authors previously took part in two series of iod is attempts to visualise the lower ureter (1 and 2). In one series probanthine was injected intravenously. In the other the Valsalva manoeuvre was carried out just before the lower -like tract was photographed. While some success was obtained in these series it was found that they were not sufficiently e reliable.

The purpose of the present study is to demonstrate that provided there has been sufficient filling of the pelvis of the kidney the lower ureter can be visualised with the image- intensifier and photographed. The technique is described and methods of overcoming difficulties are suggested. The main difficulty has to do with the fact that the area where the ureter may appear has to be watched sometimes over a period of time that makes It obligatory to safeguard the patient against too much radiation. In working out a technique to cover this difficulty indigo carmine was given intravenously to patients who were to be cystoscoped and the ejection of the dye from the ureters into the bladder was accurately timed. This was correlated with observations made through the image-intensifier The modification of technique that resulted from this study is described. A28

THE DOUBLE NEPHROTOMOGRAM PI Lopez. F.A. a Department of Radiology D< Montefiore Hospital and Medical Center w 111 East 210th Street p Bronx, New York 10467 B The significant role played by nephrotomography in the radiological investigation of renal mass lesions is well accepted. Drologic surgeons t frequently accept the results of nephrotomography in deciding whether w patients should be subjected to laparotomy, especially in elderly or i poor risk patients. d The differentiation of malignant renal neoplasms from cyst is predicated upon the vascularity, infiltrative character and thick irregular border of the former. The nephrogram obtained following the rapid injection of contrast media will occur in two phases, a vascular and a tubular phase. It would seem logical to evaluate both types of nephrogram in determining the nature of a renal lesion'. The purpose of this presentation is to reconaend a? part of nephrotomography an early series in order to obtain a vascular nephrogram, to .describe the technique used in securing such a study and to illustrate some of the applications of double nephrotomography in diagnostic uroradiology. A29

PELVIC PNEUMOGRAPH* AS AN AID IN DETERMINING THE CAUSES OF MENSTRUAL DISORDER. Derek Wanqwiwatana and Karoon Mansuwan Department of Radiology Women's Hospital Phya Thai Road Bangkok, Thailand Although pelvic pneumography was first described more than 50 years ago, the method has not been used extensively, probably partly due to anfamiliarity with the procedure and undue concern about possible complication. This paper is presented to illustrate it's value in delineating the causes of menstrual disorder and also to stimulate its wider use. The contrast gas is introduced by transabdominal needle puncture on the left side lateral to the border of the rectus abdominis muscle just below the costal margin. 1,000 to 1,200 ml. of nitrous oxide gas were introduced intra- peritoneally. Put the patient prone and tilt the head end of the table down to m 40* trendelenburg. Prone and oblique radiographs are taken with the central ray directed at the tip of the coccyx. 42 cases of pelvic pneumography had been performed at Women's Hospital in a period of 2J£ years. The procedure was very helpful in the diagnosis of Polycystic ovaries and congenital anomaly of the genital organ. In other cases it yielded contributory and confirmatory information such as in endometriosis, etc. Complications from pelvic pneumography are few and not serious. The procedure is safe, simple and inexpensive as compared to colpotomy and culdoscopy. A 30

ANGIOGRAPHY IN CHRONIC RENAL DISEASE TF

, Y- He Deoartment of Radiology, M. University of Tokyo, Qi Hongo, Tokyo, Japan K< Massive dose urography combined with nephrotomography and renal H< angiography constitute the two major roentgenodiagnostic tools for evaluation of chronic renal failure. The purpose of this presentation is to discuss the angiographic evaluation of chronic It renal disease based on the review of angiographically studied 121 op patients. re tu The kidney diseases studied include chronic nephritis (16 cases) essential hypertension and benign nephrosclerosis (72 cases), P* chronic pyelonephritis (18 cases), malignant hypertension (1 case) and gout (M cases). Of these, 23 patients had severe renal function impairment or chronic renal failure. Cc bi The angiographic findings obtained could be considered to oi consist of two categories,i.e., the angiograms related to impaired renal function and those connected with the inherent pathology of each disease. di Reduced caliber of main renal artery, decrease in the thickness of glomerular zone or cortical blush and diminished intensity of nephrogram result from the decrease in functioning renal parenchyma a and are common to every kidney disease process with chronic renal P function impairment.

The role of radiologic diagnosis in chronic renal diseases lies t< not only in estimating the functioning renal parenchyma but in differentiating among the diseases that cause chronic renal c . failure. Chronic renal diseases could be classified into the following groups according to some angiographic features. Group 1. includes chronic glomerulonephritie, benign nephro- sclerosis and many other parenchymatous kidney diseases. In this group with impaired renal function, the angiograms show non-specific intrarenal small vessel abnormalities in addition to above-mentioned •renal damage pattern'. Group 2. is represented by chronic pyelonephritis. The nephro- graphic abnormality associated with calycine change is the most important feature. Group 3. consists of diseases that constitute specific angio- graphic entities such as malignant hypertension, polyarteritis nodosa and polycystic disease. Gouty renal disease cases show varied angiographic findings probably corresponding to the varied inherent pathology of this disease.

f :

Jfe- A 31

TREATMENT OF CARCINOMA OF UTERINE CERVIX

Ho. J.H.C.

M. & H. D. Institute of Radiology, Queen Elizabeth Hospital, Kowloon, Hong Kong.

Carcinoma of the cervix is the commonest female cancer in Asia. It is treated primarily by radiotherapy with surgery reserved for operable residual or recurrent disease following a full course of radiotherapy. The exceptions are stages 0 and 1A (micro-invasive) tumours in young women where cone biopsy or hysterectomy wi' preservation of the ovaries may be preferable.

The radiotherapy techniques consist of two basic types - intra- cavitary and external irradiation. All techniques employed today are but local variations of the two used either alone or in various forms of combinations.

The advantages and disadvantages of the various techniques are discussed.

With the availability of megavoltage beam units the delivery of an adequate dose of radiation to the pelvic walls no longer presents a problem.

A technique which is simple, inexpensive and not time-consuming to apply is described together with a treatment policy presented for consideration for routine adoption, especially in centres which have limited facilities and a large turnover of patients. A32

RADIATION TREATMENT OP INVASIVE CANCER OP THE CERVIX IN QUEENSLAND.

Roberts,S.J, and Bourne,R.S.

The Queensland Radium Institute, Brisbane Base Hospital, Queensland, 4029, Australia. Radiation is the generally-accepted method of treating Stage 3 and 4 cancer of the cervix, but there is argument as to whether Stage 1 and 2 cancer of the cervix is best treated by surgery, radiation or a combination of the two. This paper reports the results obtained in the only large Australian centre using radiation alone as the routine treatment for all stages of cervical cancer. A study was made of the 476 patients with this disease treated at the Queensland Radium Institute in the years 1959 - 1963 inclusive. All have been staged according to the protocol of the International federation of Obstetricians and Gynaecologists. The stage incidence within the group was found to be,very similar to that reported in other Australasian series. All Stage 0 cases were excluded. Radical radiotherapy - in this centre a combination of intracavitary radium and megavoltage X-rays to the pelvis - was applied to almost all the patients. Palliative radiotherapy - usually intracavitary radium alone - or no treatment was indicated in a small percentage of the patients because of extreme age and/or advanced disease. The overall management of the patient, treatment techniques and dosages are described. The crude 5 year survival rate for the 476 patients was 57.7J& and that for Stage 1 was 78.556. The authors conclude that radical radiotherapy gives good results in the early stages of the disease but that there is still room for improvement. Methods, by which this improvement may be realised, are suggested and ' discussed. A33

BHSLAND. CARCINOMA CORPUS UTERI - EVALUATION OF SURVIVAL AND TREATMENT TECHNIQUE IN THE ROYAL ADELAIDE HOSPITAL

Ahmad, A. Radiotherapy Department, Royal Adelaide Hospital, South Australia 5000. itage 3 and 4 Stage 1 and 2 Intracavitary irradiation followed by surgery is the accepted or a combination mode of treatment at present in the Royal Adelaide Hospital for carcinoma of the uterine body. re Australian Intracavitary techniques will be described and discussed as ill stages of also dose distribution figures. treated, at the Survival rates will be presented and compared with figures 3ive. All have from other centres. federation of hin the group was asian series. Al intracavitary to almost all the radium alone - patients because ;ement of the

57.7# and that od results in the or improvement, ggested and A34

THE COMPLICATIONS OF FULL PELVIC IRRADIATION WITH PARTICULAR EMPHASIS TO EXTERNAL BEAM THERAPY

Ozarda. Ahsen T. and Shahbazian, Armen Department of Radiation Therapy Ellis Fischel State Cancer Hospital Columbia, Missouri 65201 U.S.A.

The purpose of this presentation is to show the complications associated with high dose full pelvic irradiation through para 1 lei-opposing portals, either alone or with one course of intracavitary radium. We analyzed 62 patients with uterine carcinoma who received more than 5000 rads to the entire pelvis by external beam therapy. Of these patients, 29 were treated with one course of intracavitary radium in addition to the external beam irradiation. In this study, only severe complications which required surgical intervention are reported. The overall incidence of these complications was 20$. Two patients expired as a result of these complications. Four patients developed such complications in the group of 33 who received only external beam therapy. In contrast, eight patients developed complications in the group of 29 who received both external beam therapy and one course of radium. As to the specific locations of these complications, eight were in the rectosigmoid region, three in the ileum, and two in the skin and its subcutaneous tissue overlying the sacrum. No clinically significant urinary bladder complications were found. As to the occurrence of these complications, the greatest in- cidence was between 7 and 15 months following the completion of irradiation. The age of the patients and the stage of the disease had no bearing on the occurrence of these complications. The external beam therapy was given by using either a telecobalt therapy device or a 2 Mev Van De Graaf friit. The weekly tumor dose rate for a five days per week schedule was between 1000 and 1300 rads mid pelvic dose. In most instances, the external radiation dose was found to be- more than 6000 rads with one full course of intracavitary radium therapy within an overall treat- ment time of 38 to k5 days. It is concluded that the above mentioned radiotherapeutic approach carries an incidence of morbidity three to four times the acceptable level and its routine use is not justifiable. A35

\ EMPHASIS TO THE USE OF MODERN 'AFTER-LOADING' RADIUM APPLICATORS FOR CARCINOMA CERVIX AS DEVISED AND USED IN KOALA LUMPUR* Dr. Perdamen Sin^h. D.M.R.T.. F.I.C.S. Department of Radiotherapy & Nuolear Medicine, The General Hospital, Kuala Lumpur, Malaysia.

Facing an increasing load of Carcinoma of Cervix each succeeding year ions associated with insufficient number of radiotherapists oalled upon to do radius osing portals, insertions using the conventional Manchester radium system, it became nedessary to devise some form of 'after-loading' applicators to contain the existing radium in mn in order to minimise exposure to personnel ved more than 5000 particularly the radiotherapist* ;e patients, 29 it ion to the external With some trials and modifications since 1968, a ayetea has been devised which has shown itself to be of immense value in standard radium applications in matters of reducing radiation to personnel, simplicity surgical intervention of procedure, maintenance of fairly standard radiation geometry, was 20%. Two elimination of radium sterilisation, ease of removal and storage* patients developed ternal beam therapy. Daring the years 196°. and 1970, these applioatore consisting of an group of 29 who intra-uterine tube and a pair of detachable ovoids in the shape of m. As to the 'golf clubs' have been used in 130 patients. The advantages and e rectosigmoid disadvantages are disouesed. From each of these three units polythene bcutaneous tissue tubings protrude through which the brass capsules containing the radium adder complications tubes are introduced being hooked to a stillette which runs through a he greatest in- spring wire like a ^camera shutter - release*!. 'Sammy' capsules are used n of irradiation. for X-Ray pictures followed by the insertion of radium oapeules. bearing on the Difficulties ha^e been encountered with gross abnormal anatomy oaused by tumour and in narrow vaginal canals. Modifications then become lecobalt therapy necessary. Nevertheless it is a practical, useful, cheap and simple rate for a five •after - loading* device. elvic dose. In more than 6000 rads an overall treat- Guidance and encouragement given ,by the Head of Department, Dr. S.K.Dharmalingam is acknowledged* c approach carries e level and its A 36

REMOTE-CONTROLLED AFTER-LOADING RADIOTHERAPY APPARATUS

H. Yamashita. School of Medicine, Keio Univ. 35-Shinanomachi, Shinjuku-ku, Tokyo, Japan S. Makino. Medical equipment Div., Tokyo Shibaura Electric Co., Ltd. Kawasaki, Japan

Intracavitary radium therapy has been replaced by remote-controlled after- loading intracavitary method with a view to reducing the radiation hazard to the staff and the patient.

The greatest advantage of this method is that the manual handling of the radio- active source is made entirely unnecessary, thus permitting the to spend time, in the preparatory stage, for more accurate positioning of the appli- cator in relation to the tumour position. An introductory account is given of the Remote-controlled After-loading Appa- ratus developed by Tokyo Shibaura Electric Co., Ltd. under the direction of Professor Yamashita, Keio University. The apparatus developed is provided with an X-ray fluoroscopy unit in conjunc- tion with an image intensifier and a TV monitor so as to check and correct the position of the applicator for predetermination. The apparatus is so designed that a dummy source may be inserted into the app- licators, before loading, and that the image of the source may be displayed on the TV screen. The actual source is then inserted into the applicator by remote-control through the flexible-drive tube. The general construction of the apparatus are as follows: 1. Loaded with Caesium-137: five sources, 12 ci in total, are available. 2. The source container is designed as mobile type. 3. Five flexible-drive tube are available. 4. The treatment couch is equipped with a 9nfi image intensifier, a TV camera, and an optical system. The TV monitor is placed in the control room. To summarize the features of the present apparatus; it is designed to allow eye-checking of the positioning in conjunction with the X-ray fluoroscopic unit, so as to perform secure and accurate treatment by reproducing accurately the dose distribution which is considered to be important in intracavity therapy. Hereafter, we will make attempts at more convenience in hailing many experi- ence of practical use. A 37

A NEW METHOD OF INTRACAVITARY RADIOTHERAPY - TREATMENT OP CARCINOMA OP THE UTERINE CERVIX USING THE RALSTRON -

Wakabayashi, M., Ohsawa, T., Mitsuhashi, H.f Kikuchi, Y., Mita, M. and Saito, K. Department of Radiology, Hokkaido University School of Medicine, Sapporo, Japan 060 High dose rate intracavitary radiotherapy of carcinoma of the uterine; cervix could be achieved using Co-60 of 10 Ci-order as ed after- the source which gave the dose rate of 1,000 rad/min. at point A. azard to the Two or three doses of 500-2,000 rad (massive irradiation) were given with one week interval (split course) to deliver a total dose of 4,000-6,000 rad at point A. of the radio- The above described method has been applied to the treatment ographer to of carcinoma of the uterine cervix which could also be used in the of the appli- cases with cancer of maxillary sinus and intra-oral tumor. A remotely controlled afterloading system (RALSTRON) was Loading Appa- developed independently by us in 1964 to perform this treatment :tion of method. General principle of RALSTRON treatment is shown in the cine film presentation of this Congress. it in conjunc- Five year survival rate of approximately 30% has been obtained correct the for stage III A,B carcinoma of the uterine cervix treated by this modality. into the app- Irradiation under hyperbaric oxygen was subsequently performed isplayed on in an attempt to decrease total treatment dose. The patient was placed in a hyperbaric air chamber of 3 atmospheric pressure. Oxygen of the same pressure was inhaled via the mask during the -control RALSTRON treatment. Three different treatment modalities were carried out to find out the optimal time-dose relationship: ailable. 1) Group A; two doses of 500 rad at point A with, one week interval, total dose being 1,000 rad. , a TV camera, 2) Group B; two or three doses of 725-750 rad at point A with )1 rocm. one week interval, total dose being 1,225-2,000 rad. ied to allow 3) Group C; three doses of 1,000 rad at point A with one week -oscopic unit, interval, total dose being 3,000 rad. :ately the dose jrapy. There seemed to be the best result obtained in Group C although number of the cases treated was still small and follow-up period I many experi- has been short for adequate evaluation. A38

CARCINOMA OP THE OESOPHAGUS - A SURGICAL VIEWPOINT

Dr.John Clarebrough. St.Vincent's Hospital, Victoria, Australia.

With the help of the Anti-Cancer Council of Victoria, some aspects of the epidemiology and pathology will be presented. The surgical approach to the disease will be considered with regard to aims of treatment and technique available. The results of surgical treatment in Victoria will be presented with a critical review of the long term survival. A surgical attitude to carcinoma of the oesophagus will be defined having regard to the above considerations. A39

CARCINOMA OF OESOPHAGUS, DIAGNOSTIC VALUE IN CLASSIFICATION AND ON PLANNING OF TREATMENT. 4

Dusdee Prabhasawat. Department of Radiology, Slrlraj Hospital, University of Mahidol, Dhonburi, THAILAND

Nearly 200 cases of dysphagia were sent to our department for oesophagography during the past year and the diagnosis of carcinoma of oesophagus was made in about 40 cases. All of these casesawere studied with videotape and cineradiography using 70 mm. and 35 mm. films, 4 frames and 30 frames per second respectively in order to study the motility and given special attention to classified as the basis of TNM.

Concerning the planning of treatment, we have studied nearly 200 cases during the five year period. All of these cases have been treated in our hospital. The study was made in order to correlate' the picture of oesophagrams with the method and result of treatment which will be discussed. A 40

RADIOLOGICAL PHYSIOPATHOLOGY OF THE ESOPHAGUS WITH CARCINOMA Kobayashl,T. Department of Radiology, Faculty of Medicine* Shlnshu University, Matsumoto, 390, Japan. Our radiological studies have provided to date the information bearing on the commonest location of occurrence of esophageal carcinoma and age Incidence. The materials to be presented consist of chest roentgenograms of 295 oases of esophageal carcinoma treated by Irradiation at the Department of Radiology of Shinshu University Hospital, and 2081 cases of mass survey with fluororadiography for cancer detection of the esophagus. Carcinoma of the esophagus was found most often in 7th decade, and arlsed most frequently in the middle and lower thirds of the thoxaoio esophagus. On the chest roentgenograms, kinking or buckling of the descending aorta due to degenerative or athero- sclerotic change is followed by esophageal narrowing at the level of lower third. We call the section of the esophagus crossed by the descending aorta the "K"-point. More than one half of primary carcinoma of the esophagus developed just above the K-point. On the photoroentgenograms of the esophagus of mass survey, there is an apparent anatomical and physiological change with advancing ages producing a new physiological or functional narrow- ing by aortic pressure described above as the K-point. The incidence of carcinoma of the esophagus appears to be variable aooording to regions and oountries. Since substances known or suspected to be carcinogenic to animals have been demonstrated in foodstuffs consumed by humans, most etiological studies on gastrointestinal cancer in man have tended logically to conoentrate on the role of diet. However, the number of published studies on humans Is small. It is perhaps useless to try to find one single hypothesis concerning carcinogenic factors. It has occurred to us the region of the esophagus above this benign narrowing could be a possible potential site for neoplasm. A41

PREOPERATIVE IRRADIATION IN TREATMENT OF CARCINOMA OF THE ES0PHA6US

Yamashita, H., Okura, J. and Nagase, T. Department of Radiology, Medical School, Keio University. 35 Shinanomachi, Shinjuku, Tokyo, Japan.

Since 1963, a total of 117 patients with cancer of cervical and thoracic esophagus were subjected to combined treatment with preoperative irradiation and surgery, and the results obtained with this group were compared to those of surgery alone in 229 cases. Curative resectability of the radiation group increased up to 65 percent against the comparable 26 percent of the non-radiation group. The five-year survival rate of the radiation groups was increased up to 25 percent as compared to 14 percent of the non-radiation group. Our method of preoperative irradiation was discussed in relation to the curative resection and changes in the mode of lymph node metastasis from pathologic standpoints. Our method of combined treatment for the esophageal cancer with preoperative irradiation and surgery is an effective method of treatment at present, in order to extend the operative indication It and curative resection, thus improving the results of the postoperative long-term survival rate. 4 A42

ROENTGENOLOGIC AND ESOPHAGOFIBERSCOPIC DIAGNOSTICS OF ESOPHAGEAL CANCER: ITS EVALUATION.

Shinohara, S., and Ito, Y.

Department of Radiology Kagoshima University School of Medicine 8-3 Shiroyama-cho, Kagoshima, JAPAN

In the diagnosis of esophageal cancer it is important to evaluate the intraluminal changes with endoscopic examination as well as barium contrast sturdy. We have performed the flexible esophagofiberscopy in combination with x-ray examination and compared with x-ray and fiberscopic findings. Esophagograms were classified into four types, i.e. polypoid, funnel- shaped, saw tooth-shaped, and spiral type, and these roentgenographs types were compared with esophagofiberscopic findings. For evaluation on quality of tumor combined use of fiberscopy and x-ray examination has been proved useful.

The esophagofiberscopy and biopsy under fiberscopy have revealed as to contribute to the detection of small or early esophageal cancer if double contrast study Is taken as well.

Also, in the diagnosis of esophagocardiac cancer ttie biopsy, under fiberscopy has been considered as to be useful to differentiate whether esophageal or gastric origin. The other hand, for evaluation of extraluminal involvement, especially to the posterior mediastinum, in esophageal cancer the direct retrograde azygography has been proved very advantageous.

These results will be demonstrate with roentgenographs and fiberscopic findings. A43

SIUDY ON X-RAY FINDINGS OP EARLY ESOPHAGEAL CANCER

Yamada,A.t Kobayashi.S., KawaitB.. Fujimoto, A., and Nakayama, K. Department of Surgery Institute of Gastro-enterology Tokyo Women's Medical College. 10, Kawa&a-cho, Shinjuku-ku, Tokyo, Japan So far the results of treatsments for the esophageal cancer have been unsatisfactory. It is very important to find it in its early stage. We define the lesion with its infiltration limited within submucosal layer as early cancer. In the period from 1965 to 1970 a series of 669 were diagnosed as esophageal cancer, of which 367 were inoperable (59.5$) and early cancer was detected in the male (with a sex ratio of 7 to 3 ) and the age ranged from 50 to 60 as in other advanced cases. The complaints are often of short duration; within 4 months. In almost all cases there were some subjective complaints. The only exception was in one case in which it was found in a physical check-up. Roentgenologically, there were 6 cases of the protruding type, 3 cases of the serrated type and one case of the superficial type while in advanced cases almost all were of ulcerative type. In order to find a small lesion, we perform the double cont- rast examination. This examination is subdivided into 3 parts as follows: 1. Air is swallowed together with barium sulfate. This technique gives us almost as true an image of the esophagus as it really exists. However, the entire stretch of the esopha-^ gus cannot be always fully viewed. 2.The swallowing of barium is immediately followed by air passing through a tube into esophagus. A clear-cut image can be obtained. This examination may give a patient dis- comfort. 3. Air introduced into the stomach beforehand comes back up into the esophagus on swallowing barium sulfate. This method can be performed after the gastric examination, though this leads to over-distention of the esophagus.

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L TLMONARY AifOEBIASIS

Dr.L.R.Pfcrthasarathy and Dr.M.G.Varadarajan.

Southern Railway Hospital, Madras-23, (India)

Amoebiasis has a world-wide distribution and has been a problem in "•« tropical and developing countries with low economical resources. Pulmonary amoebiasis forms the second commonest complication of extra-intestinal amoebiasis in South-India. Pulmonary amoebiasis is a metastatic lesion from the colon or the liver via the portal system and inferior venaoava. More frequently pulmonary amoebiasis results by direct infection by the contiguity from the liver which is the seat of hepatitis or more commonly an actual abscess. The present paper is based on a review of the Radiological appearance in 57 oases of this lesion (pleure pulmonary 35 and Hepato pulmonary 22) encountered during the last 10 years. (1960-70) which includes 49 males and 8 females with the ages ranging from 20-60 years; the maximum incidence being in the age group of 21-40 years.

Pulmonary amoebiasis presents in various ways as dia- phgramatic irritation, pleurasy with effusion, amoebic emphysema, pneumonitis and lung abscess due to rupture of liver abscess through the diaphragm. Some typical Radio- logical appearances suggestive of pulmonary amoebiasis can be seen even though demonstration of Entaemoba Hystalitica was not possible at the Initial stage. The Radiographic findings varied with the location and siza of the lesion and on the extent of associated secondary infection. The place of Bronchb-graphy in differentiating amoebic abscess and lung abscess due to other causes can also be demonstrated, ^he primary object of pneumoperitonium to distinguish between supra diaphragmatic extension of amoebic liver abscess and primary pulmonary or pleural diseases due to other causes can also be demonstrated. A45

THE RADIOLOGICAL ASSESSMENT OP SUSPECTED LUNG CANCER.

Jameson, J.B.

Department of Radiology, The Princess Margaret Hospital, Christchurch, New Zealand. has been a with low The demonstration of a possible lung neoplasm on a chest is the second X-ray is only the beginning of a radiologist's responsibility iasie in ;ic lesion in such a case. There should follow thereafter a logical im and inferior sequence of investigations, radiological and otherwise, the results by x which is the extent of which will depend on the facts that emerge. icess. The ogical ilmonary 35 The scheme which we use has evolved from 15 years of close last 10 years, co-operation between the writer and a thoracic surgeon and is with the lence being based on an experience of over 700 cases of proven lung cancer which have passed through our unit.

9 as dia- Plain chest films, fluoroscopy with barium swallow and unoebic rupture of mediastinal are the basic radiological examinations cal Radio- which are carried out in all patients. Other techniques, sbiasis can Systalitiea including bronchography and aspiration biopsy are performed Lographic as required. tie lesion tion. The bic abscess Our experience has shown that this systematic approach to B demonstrated, nguifch between the problem enables a definitive diagnosis to be made in most abscess and cases without resort to thoracotomy. It further provides her causes complete and generally accurate information about the presence and degree of lymph node spread. The end result is a better selection of patients for surgery, fewer 'failed' thoracotomies and improved control with radiotherapy.

f A4*

CLINICAL EXPERIENCES ON ANGULATED BASAL VIEW OF THE CHEST.

Tokuro Nobechi, M.D., Mutsuhia FuJioka, M.D. , Yoahihiro HiramatBU, M.D., Fumiko Hayashi, M.D., YoshihaTU Tamakawa, M.D. &, Etsuko Fujimaki, M.P.

Department of Radiology, St. Luke's International Hospital, 10-1, Akashi-cho, Chuo-ku, Tokyo, Japan.

The postero-basal portion of lungs is obscured by overlap of the diaph- ragmatic shadow on the routine postero-anterior projection. The portion may be properly projected on roentgenogram by X-ray beam caudally tilted from the straight antero-posterior projection, as reported by Besnick who designated the projection as "angulated basal view". The authors, independently from Resnick, have been used the angulated basal view in order to detect the earliest change of pulmonary fibrosis which frequently starts in the basal segments of the lungs. After mensu- ration of sixty lateral films of the chest of various patients, the authors reached the conclusion that 30 degree caudal angulation is the most appropriate for antero-posterior view of basal segments. Although our primary purpose of this technique was to find the earliest change of pulmonary fibrosis, we found this technique is also very useful for the observation of various changes such as neoplasm and atelectasis especially when changes are on both lungs and lateral film is not useless by the superimposition of the shadows of both lungs. A47

UNUSUAL CAUSES OF FLUID IN THE LUNGS.

Jefferson, N.R. ramatBu, M.D., Jimaki, M.P. Department of Diagnostic Radiology, Southland Hospital, Kew, Invercargill, New Zealand.

Normal anatomical cardiopulmonary structures for the transport of fluid, their physiological control, and pathological processes which interfere with their normal activity are we.ll documented and understood by Radiologists. For this we are indebted to the detailed observation and research by many clinical and radiological colleagues of a previous generation. This,combined with the results of much efficient research ap of tbe diaph- carried out during the last decade by members of our own generation,has enabled us to make a more accurate interpretation of certain lung The portion patterns caused by abnormal formation and- distribution of fluid in the audally tilted lungs. by Besnick who This field of Investigative Radiology has not only clarified our knowledge of many abnormal pulmonary opacities not previously recognised the angulated but it has also assisted our clinical colleagues to elucidate many of their haemodynamic problems with reference to the heart and lungs. nary fibrosis . After mensu- It is now well established that X.Ray appearances of fluid in the lungs can be of greatest value to the Clinician from the point of view of ents, the early Diagnosis and also regarding Treatment and Prognosis. Lation is the As Diagnostic Radiologists we are able to differentiate between two its. haemodynamic syndromes - Pulmonary Arterial Hypertension (Capillary and Venous pressure usually normal) and Pulmonary Venous Hypertension find the earliest (Capillary and Venous pressure usually elevated). In the latter also very useful condition the chest film presents evidence of fluid in the lung in two main situations - interstitial or intra-alveolar. id atelectasis n is not useless Radiologists are aware of common causes of abnormal collections of fluid in the lungs but it is necessary to know cf certain unusual and more recently recognised causes. Certain such cases admitted to the Southland Hospital, Invercargill, New Zealand, during the past year are presented, with transparencies of appropriate radiographs, pathological specimens and histological sections. A48

EOSINOPHILIC IMMUNE DISEASES OF LUNGS Blum, C.K. and Freeland, R. Department of Radiology, Hairmyree and Assoc. Hospitals, Lanark, and Chest Clinics, Glasgow, Scotland.

Anaphylactic, allergic and immune responses in the lungs and respiratory tract are common in a variety of Noxae. The immunological mechanism of local ant igen-ant ibody reaction or of generalised tissue reaction delineates the radiological appearances. The interrelationship between pulmonary infiltration with or*without asthma or eosinophilia, eosinophilic recurrent pneumonia, eosinophilic granuloma of lung, pulmonary vasculitis and Wegener's granuloma is strongly suggested, and pertinent radiological features are described. Lung biopsies were only rarely performed in the 40 cases observed. A case o< a rare tumour-like eosinophilic granuloma of solitary type confirms the potential variability and interchanging features of pulmonary immune-reactive lesions.

i ''-,• A49

PULMONARY HYDATID DISEASE - A RADIOLOGICAL STUDY Mukerji Asoke and Roy Sadhan Chandra tale, Departments of Radiology and Surgery N. R. S. Medical College Hospitals, Calcutta, India. Incidence of hydatid disease is commoner in India than thought of. Pulmonary in the involvement in hydatid disease in India, in a collective series of 380 cases of Noxae. showed an incidence of 20$. Present study is based on a hospital series of m-antibody 50 cases of pulmonary echinococcosis. es the Radiology plays a distinct role in the diagnosis of hydatid disease of the lungs. Routine views of the chest were combined with projections from different 'lit rat ion angles. X-ray appearances&re characteristic though variable. Commonest finding .c recurrent was that of a simple cyst. Other findings were (1) perivascular pneumocyst •y vasculitis with a rim of gas at the periphery, (2) water-lily sign-due to membranes pertinent floating on the surface of the fluid (5) pneumocyst-with fluid level and (4) ring shadow from a completely empty cyst. Pericystic pneumonitis was seen in i the 40 40$ cases. Bronchography was done in some cases and pulmonary angiography in a few. Cysts were distributed equally on both sides and there was a 2:1 pre- granuloma ponderance in favour of the lower lobe of the lungs. There were multiple cysts r and in some cases. Majority of the cysts (73.3i£) fell between 5 and 10cm size. » lesions. Correct preoperative radiological diagnosis was possible in large percentage of cases; in others diagnosis of bronchogenic or metastatic carcinoma, lung abscess or tuberculoma were made. Cysts may be missed due to their small .ize or inadequate views of the lungs. However, properly conducted radiological examination is of inestimable value in the diagnosis of pulmonary bydatid disease. A 50

CIHE EUSTACHIOGRAPHY

Tuenchit Khampirad, M.D. B.Khampirad, M.D. Department of Radiology, Mahidol University, Ramathibodi Hospital, Bangkok, Thailand.

Good operative results in middle ear surgery as well as prognosis in ear disease depends upon several factors. Normal eustachian tube function is one of the essential factors. This presentation is aimed at improving the understanding of some radiological applications for the otolaryngologist. The presentation will demonstrate briefly normal anatomic physiology of the eustachian tube as well as the special radiological procedure by means of cine radiography to evaluate eustachian tube function in both normal and pathologic conditions.

35 cases were examined, 8 cases had a clinical diagnosis of chronic adhesive otitis media. By way of cine radiography we demonstrated normal function of the eustachian tube and this was confirmed at the time of surgery. The prognosis for chronic adhesive otitis media as well as i other middle ear diseases with definite knowledge of the status of V eustachian tube is promising for surgical correction.

It is suggested that examination of eustachian tube function by means* of cine radiography should be performed in all cases of chronic adhesive otitis media. It should also be done pre-operatively for cases that are to have middle ear surgery in which the evaluation of eustachian tube function can not definitely be determined clinically.

I j- A51

CLINICAL. EXPERIENCE WITH A NEW INJECTIBLE ROENTGEN CONTRAST MEDIUM

Bjork, L., Erikson, U., Ingelman, B.

Department of Diagnostic Radiology

University Hospital

Uppsala, Sweden irognosis lian tube L is aimed A newly synthesized contrast medium Ph DZ 59B (proposed non pro- ;ions for prietor y name: iozomic acid) has been compared in double blind studies .efly normal with conventional contrast agents in clinical angiocardiography, peripheral jecial late eustachian arteriography, abdominal aortography, selective arteriography, selective coronary angiography and cerebral arteriography. In all these studies this of chronic new contrast medium gave less subjective adverse effects than other contrast strated normal media tested. It also affected the circulatory status of the patient less than he time of contrast agents (measured as changes in heart rate, blood pressure and ECG). s well as atus of This new contrast agent causes less damage to the endothelial linings of vessels, ducts and than conventional contrast media, with the same ition by means iodine content and has been successfully used in hystero salpingography, onic adhesive arthrography and . sases that are LChian tube A 52

EXPERIMENTAL WITH A NEW CONTRAST MEDIUM CHC

Bei Erikson, U. , Bjork, L., Ekholm, J., Ingelman, B. , Lindblad, G. Dej Department of Diagnostic Radiology Und SYI University Hospital N.£ S-750 14 UPPSALA 14, Sweden

wi] Myelographies in dogs have been performed using a new contrast wi] Sec medium, Ph DZ 59B. The contrast medium was injected in the sub- wi] cor arachnoidal space which was filled from the lumbar part up to the basal cisterns. The dose varied from l/2 to 2.4 ml/kg bodyweight. Only very bjj wiJ slight adverse effects were seen in the dogs which were not anaestesized dos dif or premedicated. The myelograms were of good quality. use A53

M CHOLANGIOGRAPHIC EXCRETION STUDY.

Benness, G.T.

Department of Surgery, University of Sydney, SYDNEY. 2006. N.S.W. Australia.

The results of an extensive study of the above in dogs and man will be described. Firstly, the influence of protein binding ist will be presented, and its influence on hepatic transport explained. Secondly, factors influencing the hepatic output of these agents will be described and finally, factors influencing the biliary concentration of cholangiographic agents will be explained. .sal The most important factor in cholangiographic studies is the very biliary contrast concentration and factors which influence this will be emphasised. Particular attention will be given to the sized dose and rate of administration of contrast agents, the value of different infusion agents and the effect of other drugs frequently used in clinical medicine. A 54

AH EVALUATION OF THE ROLE OF PRETESTING IN THE PROBLEM OF SERIOUS REACTIONS TO UROGRAPHIC CONTRAST MEDIA

Harrv W. Fischer. M.D. and Vivienne L. Doust. M. B.

Department of Radiology Wayne County General Hospital and Department of Radiology University of Michigan Ann Arbor, Michigan 46104

A study has been nade into the value of the pretest before intravenous urography in avoiding death and serious reactions to the examination. A Questionnaire was sent to 347 teaching; hospitals in the united States, seeking information on pretest- ing practice and the incidence of major complications and death

Replies were received from 242 hospitals, of which 217 sup- plied data suitable for analysis. The series covers approximate ly 3.8 million intravenous urograms performed in the last ten years, in which 74 deaths occurred.

Hospitals were grouped according to pretesting practice 45% of hospitals always pretest before an intravenous urogram, 30% pretest in some specific instances only, and 25% do not pretest at all.

Analysis of the data showed that the differences in death rate between the three groups has no statistical significance. We therefore conclude that the pretest as practiced is of no value in avoiding death or major complication to intravenous urography. TO1 ESC

Pi

De Un 26 BO

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TOWARD LESSER TOXICITY OF ANGIOGRAPHIC MEDIA (CEREBRAL) . RECENT EXPERIMENTAL EVIDENCE.

Fischer, H.W. Department of Radiology University of Rochester School of Medicine 260 Crittenden Boulevard Rochester, New York 14620 Using a standardised technique in which contrast media is in- jected into the carotid artery of the dog and the changes in heart rate and blood pressure are precisely measured, a dimer of iothala- mate, a trimer of iothalamate, and the dimer iozomate have been in- vestigated The animals response to the monomer as sodium and methylglucamine salts have been used as a base for comparison The results generally support the information obtained previous- ly from this laboratory of the lesser toxicity of the methylgluca- mine cation, and the value of decreased osmolality afforded by linkage of molecules Comments will be made on relative value of these features and their applicability to choice by the clinician

43> i A56

A THREB-YEARS STATISTICAL STUDY OF THE SIDE EFFECTS OF DIFFERENT CONTRAST MEDIA FOR EXCRETORY UROGRAPHY.

Kuan. Virginia Yu-Chln.

Department of Radiology, Veterans General Hospital, Taipei, Taiwan, Republic of China.

35, We have been prlviliged to use different kinds of contrast media for Intravenous urography In the past three years. I made a comparative study of varisou reactions produced in the patients who had this procedure at the Veterans General Hospital during a period of three years starting from April 9, 1968 to April 8, 1971. The contrast media that we used for I.V. urography Include the following three kinds: (1) Fortombrlne H, 70%/w/v I solution, (2) Hypaque 50% sodium and (3) Urografin 76% .

Our hospital is primarily serving veterans so we have less female patients as welf/young patients. The male patients were 3143 (80%) while the female patients were 782 (20%). Total patients were 3925.

As far as the age distribution of the patient is concerned I have '':{•' divided them into ten age groups with one decade for each group. The age groups from 40 to 59 years of age cover the highest percentage of the patience which is over 62.9%. A great majority of reactions, regardless of involvement of various anatomical systems, usually-occured about five minutes after completion of I.V. Injection. This was especially true for those involving the gastro- intestinal system (58.3%) and the skin (20.5%), all being milder reactions.

The results of our study are as follows: Group (1) produced reaction In 279 patients out of 1711 users (16.3%). Group (2) produced 175 reactions out of 1537 users (11.3%). Group (3) produced 52 reactions in 534 patients (9.74%).

In conclusion, Urografin causes less side effects in patients than Hypaque or Fortombrlne.

q ,~.. -, A57

DIAGNOSIS OF THYROID CANCER WITH SELECTIVE ANGIOGRAPHY

Homma, M., Kali, S., Okuhara, M. and Tatsuno, I.

Department of Radiology, Yamanaka National Hospital and Kanazawa National Hospital, Ishikawa Prefecture, Japan.

The selective thyroid angiography was practiced for the purpose of the differential diagnosis and the decision of therapeutic indication of thyroid tumors.

The method is based on Seldinger technique. The origin of thyroid artery is usually approached by catheterization from the femoral artery. The serial radiography is indispensable in this study.

In our study, thyroid cancer clearly showed tumor stain, new formation and irregular shape and size of blood vessels. These findings were characteristic in thyroid cancer compared with benign thyroid tumors. The peripheral and deep seated impalpable metastasis and scintigraphic negative lesion were also clearly delineated in thyroid cancer.

The selective thyroid angiography was useful not only for our purpose but also for determing the surgical excised range and the collimation of radiation therapy, and for the determination of local recurrence in suspected cases. A58

TREATMENT RESULTS IN CANCER OF HEAD AND NECK BY RADIOTHERAPY.

Tsukamoto. K.. Taketa, C. and Umegaki, Y. Department of Radiology National Cancer Center Hospital Tokyo, Japan During the past three and a half years since the establishment of National Cancer Center Hospital in Tokyo in May 1962 to December I 1965 we had treated 406 cases of head and neck cancer patients in the Department of Radiology who had not been treated in other hospital previously. Most of these cases were irradiated with 6MeV X-ray of our linear accelarater. Depending upon the site and extention of the tumor, however, we have used high energy electron beam therapy especially for tumor of the oral cavity and its lymphnode metastasis in neck region. Rotational Co-60 beam therapy for nasopharynx tumor and interstitial radium therapy for tongue cancer were also used.

5-year survival rate of these patients are as follows: Oral cavity cases 49 out of S4 or 58.3$, nasopharynx 9/24 (37.5$), oropharynx 11/30 (33$), hypopharynx 8/19 (42.1$), larynx 74/91 (81.4$), maxillary sinus 20/51 (39.2$). In these 5-year survivors, however, cases in which recurrence have occured after the completion of radiotherapy but who were fortunately controlled by surgical treatment after the radiotherapy are also included. Cases which were cured by radiotherapy alone are for oral cavity 50.0$, nasopharynx 37.5$, oropharynx 30.0$, hypopharynx 26.3$, larynx 45.1$ and maxillary sinus 21.6$ respectively.

After we had obtained above mentioned results we made some progresses in the following points: 1; The use of computer to obtain accurate and speedy synthesis of isodose curve for the treatment planning of cancer in this field. 2) For the treatment of cancer of maxillary sinus combined therapy I of intra-arterial infusion of 5-Fu or Mitomycin with radiation appeared to be more effective than the use of radiotherapy alone and as a result case of total maxillectomy was markedly reduced. 3) Combined intravenous use of bleomycin with radiotherapy is effective to reduce the dose of radiation for the treatment of some cancer in oral cavity, thus necrosis induced by radiation was reduced. A59

DIAGNOSTIC SIGNIFICANCE OF AXIAL TRANSVERSE TOMOGRAPHY OF MAXILLA CANCER

Matsuda, T.,* Makino, S. ,** and Gohke, H. **

*Department of Radiology, **Medical Appliance Division, Nagoya National Hospital, Tokyo Shibaura Electric Co. Ltd. Nagoya, Japan. Kawasaki, Japan.

The present report describes a diagnostic significance of axial transverse tomography in an application to X-ray diagnosis of maxilla cancers.

Use was made of the axial transverse tomograph of horizontal type (Toshiba), which is capable of rotating through 220" with a magnification factor of 1. 27 while rotating the X-ray tube and film in the same direction at the same speed,

30 cases of maxilla cancers were diagnosed by normal radiography, uni- directional tomography or axial transverse tomography, and the results were analytically compared. Unnoticed or uncertain findings on maxilla cancers by normal radiography or uni-directional tomography were revealed or confirmed by axial trans- verse tomography paticularly in the following observations:

1) - to confirm whether anterior and posterior walls of maxillary sinus are not destroyed; 2) - to made sure the existence of proceus pterygoideus; 3) - to make clear the state of sphenoid sinus and ethmoidal sinus; 4) - to make evident the lesion of frontal sinus by separate observation of anterior and posterior walls of maxillary sinus; 5) - to make apparent the lesion of mucosa of maxillary sinus.

To summarize, three diagnostic significances may be cited of axial trans- verse tomography:

1) - possibility of early discovery of the lesion present on the mucosa. 2) - discovery of lesions which might be undistinguishable by conventional diagnostic method such as those of frontal sinus or mucosa of maxillary sinus. 3) - Confirmation of the findings on layergrams together with the extension of the maxilla cancer, which is possible only with the axial transverse tomograph. A60

TREATMENT OF CANCER OF MAXILLA Si,nqh.A.D.; Joseph.L.B.M. and Simon. G.T. Departments of Radiotherapy, Surgery and Dentistry Christian Medical College Hospital* Vellore* India* Primary cancer of Maxilla is not a common condition,comp- rising about 1-2 per cent of all malignancies. 76 new cases (57 male and 19 female) suffering from cancer of Maxilla attended the Christian Medical College Hospital during the period from January 1963 to December 1966 .Treatment policy consisted of a full course of radiation therapy with a stationary model of telecobalt-60 unit(followed by palatal fenestration six weeks later.Modif led Wedge Filter Technique was usedto achieve the uniform isodose distribution in the irradiated volume.It cons- isted of adding smaller fields to the full anterior and lateral fields. Analysis of the follow up results revealed that these cases could be separated into four main groups. First group consisted of 25 cases who had full course of radiation therapy but didi not have fenestration operation.Second group was of I those (21 cases) v/ho had radiation therapy as well as fenestr- ation.Third group of 12 patients had radiation therapy and radical surgery While the fourth group consisting of 18 cases had no treatment either because they were far too advanced or they absconded after thier first visit .The second group had the best result* This paper consists of two parts: first is the description of the Modified Wedge Filter Technique and the second is the presentation of results of treatment .This study clearly shows that Radical Radiation therapy with a supervoltage apparatus followed by a relatively rninor surgical procedure gives the best result in this condition* It also confirms that a team of Radiotherapist, Surgeon and Dentist is very essential to tackle this problem. A61

ROIE OP RADIOTHERAPY IH THE M&NaGEMENT OF CHILDHOOD EUSTACHIAN TUBE OBSTRUCTION. Duval Peter J. Radiotherapy Registrar, Radiotherapy Department, Royal Prince Alfred Hospital, Camperdown, 2050* Sydney, Australia.

External irradiation of the eustachian system for recurrent otitis media and/or conduction deafness in children appears to be an effective and safe method in cases where tonsillectomy and adenoidectomy have failed. Of 119 children treated, 65% had complete relief of symptoms, &% had delayed relief, 8% had partial relief, and 19% had no relief of symptoms. Measurements were made recently to evaluate the do3e received by the thyroid gland and gonads. Using orthovoltage or telecobalt irradia- tion, the thyroid gland received an average total dose of 16 rads and gonadal dose was 204 mrads. Although the maximum permissible dose to the thyroid gland is exceeded by this method of treatment, the gonadal dose is well below the maximum permissible level and in fact is only twice the normal annual background radiation. In the light of our present knowledge the dose received by the thyroid gland is well below the alledged threshold dose of carcinogenicity. A62

THE TREATMENT OF NASOPHARYNGEAL CARCINOMA.

Ho. J.H.C.

M. & H. D. Institute of Radiology, Queen Elizabeth Hospital, Kowloon, Hong Kong.

This cancer is very common in China and South East Asia, affecting most frequently peopie of Chinese descent. Malays have t-G a frequency intermediate between Chinese and Indians.

It is treated mainly by radiotherapy, but the technique has not yet been standardized, and the present U.I.C.C. stage classification is unsatisfactory. A new classification which will give a better guide to treatment policy and to prognosis is presented, and a radiotherapy technique evolved from experience gained in treating a large number of cases over the last two decades described. The technique takes into consideration the natural history of the disease, the anatomy of the volume to be irradiated as well as past treatment results and complications.

! -' •IΓ A63

NASOPHARYNGEAL CANCER IN MALAYSIA. MX QENERAL IMPRESSIONS OF THE DISEASE DURING THE PAST 10 YEARS. Dr. S.K. Dbarmalingam

Department of Radiotherapy and Nuclear Medicine, The General Hospital, Kuala Lumpur, WEST MALAYSIA.

Radical treatment of Nasopharyngeal causer is a radiotherepeutie ch&llengt in this part of the world. Radiotherapy will probably remain the sheet-anchor of treatment for years to COM. Between 1961 and 1970, l8Mt eases of Nasopharyngeal Cancer, mostly diag- nosed on clinical grounds as far as the primary is concerned but positive histology on neck node biopsies, have been referred to my Department for treatment. They were predominantly Chinese, while Malays were less and Indians few. In recent years more Malays are coming in for treatment. The youngest re- corded was 8 years while the oldest was 8o. Average age was between 30 and 55, the peak being betweea kO and *t9. No figures on survival are presented as we do not have a National Cancer Registry. Most patients came in too late, though the primary seemed controlled in most cases, the majority died of disseminated disease. Those presenting with cranial extensions seemed to have worse prognosis.* There ic much scope for research in this field as abundant clinical material is available in Malaysia. Work is underway to elucidate relative incidence among the Chinese sub-groups of Chinese born in Malaysia and those born in China. The acquisition of two 6-MEV Linear accelerator* and a ky-KEV Betatron in 1968 has made available aor* sophisticated treatment for the. patient. It is yet to be seen if this improves survival in pationta with early Naso- pharyngeal Cancer. I A 61 if TREATMENT PROBLEMS IN NASOPHARYNGEAL CARCINOMA Tan. B.C. Radiotherapy Department, Outram Road General Hospital, Singapore 3. Nasopharyngeal Carcinoma is the most common malignancy treated with radiotherapy in Singapore. It occurs most frequent- ly among Chinese and affects mainly those in the 3rd to 5th I decades of life. Radiotherapy must be planned to cover adequately the primary lesion, the base of and the cervical lymph nodes. 82% of cases present with lymph node secondaries and 3O>o with cranial nerve lesions. The following techniques have been used: (1) 2 l'ateral cervico-facial fields delivering a midline dose of 4|OOO-4,5OO rads/6 wks. with deep X-rays. Although generally adequate for .the lymph nodes, recurrences occurred in the nasopharynx. (2) 2 lateral cervical + 2 anterior oblique fields. A dose of 5»5OO rads/7 wks. was delivered to the midline. "si Accurate set up was difficult and recurrences sometimes occurred in the choana and orbit. (3) 2 lateral cervico-facial + 1 direct anterior facial fields. Accurate beam direction was eaeier and results improved. Of 545 cases referred for treatment 412 cases (76$) completed their radiotherapy and the crude 5 year survival rate was 23.5$. Some of the reasons for incomplete treatment are discussedL Where growth was confined to the nasopharynx, the crude 5 yr. survival rate was 50$. Females had a slightly better prognosis than males. Complications of treatment were rare. (4) Present method of treatment makes use of telecobalt therapy for the primary lesion and deep X-rays for the cervical nodes. A dose of 6,000-6,500 rads/7 wks. was delivered to the 80$ isodose in the nasopharynx and an incident dose of 4|OOO-4,5OO rads to the cervical nodes. Greater accuracy was achieved and the patients appeared to tolerate the treatment better.

i A65

CARCINOMA OF THE NASOPHARYNX IN INDONESIA Soesilo, R.H. and Suryawidjaya,

Department of Radiology, R.S. Dr. Tjipto Mangunkusumo, Dj. Diponegoro 71. Djakarta.

I. Geography. frequent- 5th Carcinoma of the nasopharynx occurs frequently in Indonesia, as in all countries around the South China Sea, in comparison with other countries. primary 8Z% of II. Race iranial Most cases are found among the population of Chinese origin, but? according to statistics, they amount to only 2.5% of the whole population of Indonesia. s dose igh III. Age

Among the natives the highest frequency of this disease is lose between the age of 40 to 49 years, while among the Chinese between 50 to 59 years. Lmes IV. Sex fields, Carcinoma of the nasopharynx is found three tines more jved. frequently amongst males compared with female patients. ral V. Management atraent a) When supervoltage therapy was not yet available, these cases were treated by the application of radium followed by ide 5 yr. external orthovoltage X-ray irradiation. ?o gnosis b) Since 1957 we treated these cases with external gamma irradiation using a Cobalt60 unit with a source strength, of the 3000 curie. ias an c) Since the introduction of intraarterial perfusion with }des. cytostatics we also try using Methotrexate. red to id

A66

PROBLEMS OF INSTALLATION AND MAINTENANCE OF X-RAY EQUIPMENT IN TROPICAL AREAS.

Daetz. Peter

Siemens Indonesia, Kebon Sirih 4, P.O. Box 2469, Djakarta, Indonesia. All X-ray engineering services have particular requirements with respect to space, equipment, storage, electrical supplies, hand-over-service, spare parts and staff. However there are J.: special problems in tropical areas. A W.H.O. Symposium, held in Singapore in November 1970, on the Use of Medical Radio- logical Apparatus and Facilities confirmed that X-ray engineer- ing problems are similar in many countries. In order to guarantee smooth and efficient installation of X-ray equipment, careful preliminary work such as planning of rooms and their layout is essential. Changes introduced after this can cause difficulties during the installation and add considerably to its cost. It is important that adequate consideration should be given to the electrical supply requirements of the X-ray equipment. Whether the X-ray department should be air conditioned or not raises a number of matters for consideration. On completion of an installation an important responsibility of the X-ray engineering services is the handing over of the equipment to the radiologist and his staff and in this regard instructional manuals are very valuable aids. After-sales- service and the maintenance of an adequate stock of spare parts are essential. Where large areas are involved an after-sales service network, arranged by government instrumentality, by the supplier or by the two in parallel, is necessary. The staff for X-ray equipment installations and for service should include engineers and technicians with sound theoretical and practical training in radiological and darkroom techniques. This staff will often find it necessary to improvise. The different methods of training staff will be discussed. The paper to be presented is based on the experiences of Messrs. Siemens Medical gained in many tropical countries.

! f; A67

PMENT DIAGNOSTIC RADIOLOGY FOR DEVELOPING AREAS - A SYSTEMS ENGINEERING APPROACH.

Chamberlain, Richard. H.

Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PENNSYLVANIA, 19104. lirements In modern medical practice one-third to one-half of all supplies, crucial medical decisions are dependent on radiological iere are information. Only one-third of the world's population has Lum, held access to fully modern radiology or is rapidly approaching ladio- such development. The remaining 2.5 billion persons are engineer- largely beyond its reach. Throughout the world a large proportion of diagnostic ation X-ray films are of inferior quality. They are uncertainly alanning exposed, insufficiently collimated, poorly developed and roduced difficult to interpret. Fully modern radiology demands bion and expensive, complicated equipment, elaborate service and adequate maintenance, qualified radiologists and highly-trained X-ray technicians. The problem is how to provide diagnostic cay radiology of comparable high quality to practitioners who number are less well trained, in remote locations, where the work load is too low to justify elaborate installations and highly-trained personnel. pnsibility of the The Technamatic Radiology System does much to approach regard this goal. It embodies new concepts of radiological needs, sales- equipment, operations and training, and has evolved from a iare parts diligent search for the best solutions known at this time. ber-sales It forgoes elaborate and exotic examinations for the time y, by the being, and concentrates on improving the yield of information from simple film studies of chests, and abdomens, which involve the greater bulk of human ills and where significant service remedial action is more likely to be available. leoretical schniques. There is every hope that the Technamatic System can be The further improved, and it is adaptable to current needs in many parts of the world. Its most outstanding characteristics are: assured high-quality X-ray films; wide range of diagnostic ces of radiological procedures; assured reproducibility of results; ries. feasible costs; practical, deliverable diagnostic radiology service; and optimal radiological safety and efficiency. I

THE UNITED STATES PERFORMANCE STANDARD FOR DIAGNOSTIC X-RAY SYSTEMS.

Villforth. J.C. Bureau of Radiological Health, LJSPHS 5600 Fishers Lane, Rockville, Maryland 20852. Under authority of the Radiation Control for Health and Safety Act of 1968, the U.S. Department of Health, Education, and Welfare I has the responsibility for an electronic product radiation control program designed to protect the public health from electronic product radiation. As parii of this program, it is necessary to develop radiation safety performance standards applicable to products tohich emit electronic product radiation. A performance standard for diagnostic X-ray systems was prepared in cooperation with manufacturers of.X-ray equipment components, assemblers of. X-ray systems, user groups, and radiation protection specialists of other governmental agencies. To further assure the reasonableness and technical feasibility of the requirements, care- ful consideration has been given to recognized national and inter- national radiation protection guidelines, J^tate regulations, and the latest available scientific and medical data with respect to electronic product radiation. As in certain national radiation protection guidelines, the stand- ard contains provisions for limiting the amount of leakage radiation from the tube housing assembly and beam-limiting device, and for assuring the quality of the beam, e.g., by use of aluminum filtration. Depending upon whether an-X-ray system is stationary or mobile, and' used for general applications or for limited applications, there are several methods a manufacturer may use to make certain that the X-ray beam is limited to the size of the image receptor and is properly aligned during radiographic or fluoroscopic examinations. Some requirements which have not previously been stated in nation- al and international recommendations, but which are included in the standard, also relate to beam limitation and to exposure output. These are: 1) Positive beam limitation for general purpose, station- ary equipment, 2) Reproducibility and linearity requirements. For fluoroscopic X-ray equipment, the standard requires that the exposure rate at the position where the X-ray beam enters the patient must not exceed five roentgens per minute unless special high level controls are provided. Limitation is also established on the radiation transmitted through the primary barrier of the fluoroscope, such as the fluorescent viewing device. 5ince the standard is applicable to X-ray machines imported into the U.S., it is anticipated that the standard will have an impact on equipment used in other countries. A69

' SYSTEMS. PROPOSAL TO ESTABLISH THE ASIA AND OCEANIAN COMMITTEE TO THE STANDARDIZATION OF ELECTRO-MEDICAL EQUIPMENT CONCERNING TO TC-62 OF I. E. C.

Yamashita. H.

Chairman, Japanese National Committee of I.E.C. TC-62 School of Medicine, Keio Univ. Safety 35-Shinanomachi, Shinjuku-ku, Tokyo, Japan Welfare control Iwai. Y. lie product 3velop Medical Equipment Div., Tokyo Shibaura Electric Co., Ltd. :ts Kawasaki, Japan prepared International Electro-technical Committee (I.E.C.) set up ients, Technical Committee TC-62 in 1967, to consider the international Dtection standardization of X-ray equipment for medical use. The ssure the following subcommittees were established:- bs, care- 5C-62A Common aspects of electrical equipment used in medical i inter- practice. 5, and the 5C-62B X-ray equipment operating up to 400 kV and accessories. bo 5C-62C High energy radiation equipment and equipment for nuclear medicine. the stand- SC-62D Electro-medical equipment. radiation (Meeting of TC-62; Baden-Baden in 1968, Kyoto in 1969, nd for London in 1970 and Brussels in 1971) filtration. Already 19 Working Groups are working actively in each problem bile, and" and many drafts of recommendations are in preparation. Safety there are requirements, radiation protection, interchangability performance, t the X-ray terminology etc. are discussed not only from the standpoint of roperly the construction but also with respect to the installation of equipment. in nation- However these recommendations on the construction and the ed in the installation should be very closely related to the operation utput. of equipment. On this point, the users of the equipment also e, station- should take part in the Technical Committee. nts. On this occasion, we would like to propose the establishment of that the a group including, not only the manufacturers, but also all kinds the patient of peoples concerned with electro-medical equipment among tbs igh level countries in Asia and Oceania, where our common comments or the problems on prepared standards of I.E.C. TC-62 could be discussed luoroscope, from special standpoints of Asia and Oceania. rd is ment -ffl A70

ZOOM IMAGE AMPLIFIER AND THE EVALUATION DF ITS CLINICAL APPLICATION.

Isome, 5. and Tsuda. M.

Bokuto Hospital, Tokyo, Japan. Zoom Image Amplifier, developed by Shimadzu Seisakusho Ltd. in 1969, has an effective viewing field variable from 5 inches to 11 inches continuously. We attempted various improvements to this equipment and obtained satisfactory results on telefluoroscopy, 70 mm fluorography and cine- fluorography«

The features of the practical diagnosis with Zoom Image Amplifier are as follows. 1 . The appropriate size of the viewing field can be selected by zooming during telefluoroscopy without missing the abjective part. si' 2. It becomes easy to detect the diseased abnormality by zooming up especially at smaller viewing field, because the resolving power at smaller field becomes higher. The image size at 5 inches field becomes 2.2 times larger than that of 11 inches field.

3. From the diagnostic point of view, the image quality of 70 mm spot fluorogram through Zoom Image Amplifier at small field is almost comparable to that of direct radiogram.

4. Though the X-ray dose.necessary for 70 mm spot fluorography at small viewing field is considerably 3/. greater than that for large field, it is still far less than that for direct radiography. Consequently, both the X-ray exposure to the patients and the load of X-ray tube are remarkably lessened.

The lecture will explain the mechanism and features of Zoom Image Amplifier, and will illustrate some of the clinical applications of Zoom Image Amplifier by movie film. A71

PRINCIPLES OF MANAGEMENT APPLIED TO A DIAGNOSTIC X-RAY DEPARTMENT.

Tucker, W.G.5.

Department of Radiology, The Queen Elizabeth Hospital, Woodville, S.A. 5011, Australia.

10 Current problems in organisation and direction of an :om X-ray Department are discussed. The selection and IUS training of staff, delegation of responsibility, r communications, work load and improving methods of work are considered. The possibility of operations research solving problems involved in the execution of the Department's aims and objectives is investigated. ige It is contended that the application of Principles of Management and their close study by the Radiological executive will improve departmental performance, help solve the Radialogical manpower problems and benefit these patients whose need is greatest.

*-'-'-$.

3f ir A72 I THE AETIOLOGY OF NASOPHARYNGEAL CARCINOMA

Ho» Depar M. & H.D. Institute of Radiology, Aichi Queen Elizabeth Hospital, Chiku Kowloon, Hong Kong. Ba the d Of tumours of the nasopharynx it is carcinoma of the squamous type, avail more often undifferentiated than differentiated, which occurs with high On th frequency in southern Chinese, irrespective of their place of domicile, of ob and which has a close association with an infection by a herpes virus neigh immunologically resembling Epstein-Barr virus. Of the ancient pathological skull specimens previously suspected to bear marks of Se damage by nasopharyngeal carcinoma, only the one derived from a male (154 pre-Christian Nubian described by Derry(1909} is considered a possibility. sarco It is not known when the disease was first described in China. The evidences which will be presented tend to suggest that the high risk of Hy the disease in southern Chinese is determined by a combination of genes demoi which are not sex-linked or related to the ABO blood group, but the were possibility of co-factors has hot been excluded. No such factor has with been found, but southern Chinese salt fish and a viral factor are most suppl deserving of a thorough investigation. The nature of the close association istii between nasopharyngeal carcinoma and an EBV-like herpes virus infection which is. not influenced by geography or ethnic origin is not known. A high frequency of carcinomas has been found in Friesian cows in Hong Kong in the posterior part of the nasal cavities, probably the analogue of the the nasopharynx in man. The difference in the patterns of age-distribution and 6f nasopharyngeal carcinoma in Hong Kong and Sweden may be due to a difference in aetiology.

i '.- A73 - • z^

Angiography of Gastric Malignancy

Kido.C. Sasaki.T.

Department of Diagnostic Radiology Aichi Cancer Center Hospital Chikusa-ku, Nagoya, Japan

Barium examination, endoscope and diagnostic cytology are useful for the diagnosis of gastric malignancy. Especially double contrast technique is available for showing mucosal aspects in the early stage of gastric cancer. On the other hand, angiography of the stomach is employed for the purpose of observing the state of infiltration in the gastric vail and vith neighbouring organs.

Selective angiography was performed in l6o cases with gastric malignancy (154 gastric cancers, 5 gastric reticuloearcomas and 1 gastric leiomyo- sarcoma). Super selective angiogrphy was done in some cases.

Hypervascularity and tuor-stain are very important findings and were demonstrated in the area corresponding to the main lesion. These findings were revealed in 32% of gastric cancers and leiomyosarcoma. In the cases with reticulosarcoma, the ratio of ocenrence was kO$. Gstric arteries supplied to the extra-gastric lesion, however, had pathological character- istics such as luminal irregularity, interruption and dilation.

Angiography of the stomach is useful not only to show the invasion to the gastric wall and also to know the existence of the liver metastasis and variation of the gastric arteries preoperatively.

-:m& ':¥ ft I A74

ANGIOGRAPHY IN THE DIAGNOSIS OF GASTRO-INTESTINAL BLEEDING. THE ANO Wilkie, Sorby, W.A. Departm Univers Department of Radiology The Roy The University of New South Wales Victori The Prince Henry Hospital Little Bay, N.S.W. 2036, Australia. With cathete Gastro-intestinal bleeding remains a difficult diagnostic and therapeutic common. problem with a resultant high mortality rate as shown by several surveys. method vertebr The use of selective and superselective arteriography to demonstrate the artery. precise site of bleeding rests on the experimental evidence of Baum and the lef Nusbaum in 1963. Since then these and many other authors have reported on the capabilities and usefulness of this technique. A re aortogr This paper reports our experiences with this method. Lesions demonstrated extracr include stress ulcer of duodenum, caecal ulceration, portal hypertension and vertebr oesophageal varices. In all carotid In our experience this technique is very valuable and will undoubtedly left ve become widely used in those institutions where there are adequate staff and was dom equipment. in a fu

The briefly The imp cerebre I

i ••{.-- A75

THE ANOMALOUS LEFT VERTEBRAL ARTERY.

Wilkie, R.C. Department of Radiology, University of Melbourne, The Royal Melbourne Hospital, Victoria, 3050, Australia.

With modern techniques, selective percutaneous transfemoral catheterisation of the cerebral arteries has become increasingly common. When studying the vertebro-basilar system by this method it is usual to introduce the catheter into the left vertebral artery which normally arises from the left subclavian artery. Anomalies in development of the proximal portion of the left vertebral artery have considerable significance.

A retrospective survey of 300 patients, who underwent arch, aortography for a variety of reasons including suspected extracranial vascular disease and trauma, revealed that the left vertebral artery arose directly from the aortic arch in 5%. In all cases the site of origin was between the left common carotid and left subclavian arteries. In those cases where the left vertebral arose from the arch, the right vertebral artery was dominant in just over 50%, and equal in size with the left in a further 10%.

The embryology of the left vertebral artery will be described briefly and reference made to other anomalies of the origin. The implications of these findings with respect to catheter cerebral angiography will be discussed. ft I A76 ay- Si BSHAL ANGIOGRAPHY FOR PRIOR AND FOLLOWING TRANSPLANTATION

Hem. Jane C.Y. Department of Radiology National Taiwan University Hospital Taipei 100, Republic of China Since September 1968, fifteen cases of rsnal transplantation had been performed in the NTDH . I Angiography of the renal donor prior to transplantation has its great valve in decision that which side kidney is going to be used. ?y the Sel&inger's percutaneous technique abdominal aortogram was made to id; demonstrate the size, number and length of renal arteries and their branches in the kidneys. Condition of parenchyma, size and contour of the kidneys were determined by nephrogram. Fyelogram showed the renal calyces, and ureters. Renal function was also investigated. Selective renal angiography followed tfa* aortography was performed with the same catheter. By this method renal veins, additional to the more detailed •renal artery and nephrogram, were demonstrated. This technique is the simplest and safest and satisfied to obtain the knowledge of renal arteries, veins and ureters to decide which side kidney is suitable for transplantation. Angiography following renal transplantation was also performed for six patients. By the limits of this brief experience angiography has its greatest valve in assessing the status of the larger renal vessels, particularly to demonstrate the presence of stenosis or occlusion as the cause of hypertension or oliguria. Harrowing of the renal artery due to rejection phenomenon is the end result of decrease in size of the interlobular and arcuate arteries and the renal artery. This process stops at the anastomotic site. For the successful renal recipient the renal angiogram established normal appearance throughout the arterial, nephrotic flffl pyelographic phase. Balarged graft kidney was demonstrated and agreeable to the results reported in the literatures. A77

SELECTIVE RENAL ANGIOGRAPHY IN ACUTE RENAL FAILURE. DUE TO INFECTIOUS DISEASES. Arthachinta, S., Sitprija, V. and Kashemsant, U. Department of Radiology, Faculty of Medicine, Chulalongkorn University, id been Chulalongkorn Hospital, Saladang, Bangkok, Thailand. i great valve Acute renal failure occasionally develops in several infectious diseases such, as in Leptospirosis, Malaria and rae made to Septicemia. sir branches kidneys We have used selective renal angiography in attempts to 3, pelvises and demonstrate arterial changes, and to correlate with clinical severity of the disease as well as other laboratory parameters. nned with the t detailed Various degrees of cortical arterial constriction were found in our cases. The patterns and degrees of arterial constriction in these cases were then compared with those cases iin the of acute renal failure of other causes, for example, hepatorenal ie kidney is syndrome. far six In few of our cases, follow-up angiography was performed at its the time of complete recovery, and demonstrated improvement of cortical arterial construction as compared to the angiography as the performed at the time of acute renal failure. due to interlobular the igiogram ind xeeable II

I A78 f !:- OUR EXPKRLKHaaS IN AORTOGRAPHY

|4 Dr.A.N.K.Henon and Dr.L.R.Parthasarathy. •S3 |j Consultant, |K| Southern Railway Hospital, ft Perambur, If Madras-23, (India)

p This paper outlines the experiences gained at the Southern 1| Railway Hospital, Madras, in the investigation by Aortography S; of all patients of different age groups, with suspected or ff known pathology in the thorax and abdomen. The use of Seldinger $; method of percutaneous catheterization for aortography has not been ?j: favoured by us since the changes of thrombus and embolic phenomena *;. occur frequently at the site of the femoral artery in Indian subjects % which are much smaller than European-or American "patients. We prefer to do aortography with operative arteriotomy either in the •: elbow or over the femoral for any age group and it has been found that f, this has been a very satisfactory procedure. All the investigations ':\ viexe done under local anaesthesia after basal narcosis. We have '§'' used also in some cases, intravenous Droperidol and this has been •If very satisfactory. Some of the younger group need no sedation ~&z and may be secured in a "brat—board" and only minimal restraint is ;?f required. We have used mostly Conray 480 as contrast media. The ]§ arterial catheters are positioned at the most suitable site with the aid of an Image Intensifier. The films are taken using a rapid cassette changer. Intravenous Pyelography is not normally performed as a separate procedure by films of the pyelogram produced after ; these studies are taken. This investigation has been done for a variety of conditions for both thorax and abdomen and has been found to be very satisfactory. The authors do not claim any originality for the technique but ]i only wants to point out a few of the pathological conditions that occur in this part of the country. This method of investigation has been found to be also very useful in the diagnosis of intra-abdominal i tumours in childhood. A79

SPLENIC ARTERIOGRAPHY

Palmer, F.J.

Department of Radiology The University of New South Wales The Prince Henry Hospital Little Bay, N.S.U. 2036, Australia. srn ?hy Thirty selective coeliac and/or superselective splenic arteriograms hava been reviewed. The normal anatomy and common variations of the splenic Linger circulation are discussed. not been lenomena The techniques of coeliac and superselective splenic arteriography are m subjects briefly described including methods of increasing the diagnostic accuracy We in various conditions and pharmaco-angiography of the splenic circulation. in the l found that The abnormal appearances seen in several pathological disorders are 3tigations illustrated and discussed including splenic haematoma, splenic hydatid s have cysts and lymphomas. The value of arteriography in assessment of the is been splenic and portal venous systems is stressed and the appearances in ;ion gastric and oesophageal varices illustrated. It is considered that splenic :aint is arteriography is preferable to direct splenoportography in many cases. i. The i with the :apid performed after for a >een jue but is that jation has i-abdominal I A80 I: RADIOLOGICAL EVALUATION 01"" REPLACEMENT

Gibson. R. D.

Department of Radiology, Christchurch Hospital, Christchurch 1, NEK ZEALAND

Replacement arthroplasty of the hip of the McKee Farrar or Charnley type has been in widespread use for several years.

Standardised radiography is required to assess minor changes in alignment of the prosthesis in relation to the underlying bone.

Arthrography reveals a narrow plane between the plastic cement and the adjacent bone which can be used to assess loosening of the prosthesis if symptoms should recur following arthroplasty. The existence of this plane between the cement and adjacent tissues indicates that the cement acts by distributing the load between the metal prosthesis and bone as widely as possible rather than forming a firm bond between the cement and the bone.

Sclerosis or fracture in the subjacent bone may indicate loosening without the necessity of arthrography.

If.

. TUMOtHtAL CALCINOSIS

Palmer, P. E. S.

Department of Radiology University of California Davis, California 95616 USA

Tumoural calcinosis is a disease in which soft tissue calcification occurs most commonly in the limbs. The areas are small in most cases but can grow to considerable size. In many patients it is harmless but in some it has proved fatal. It is most comnonly seen around the hips and upper legs but is also seen around the shoulders, the scapulae, the elbow, and the feet. Its histology is easily recognized and its radiological features are characteristic. It seems to have a considerably increased incidence in peoples of east, west, and the lower central Africa. No racial or family explanation has been found and the disease in Africa does not differ from other cases seen on other continents. One theory is that it results from sleeping on earth or other hard beds. The recognition of this disease throughout the Asian and Oceanian area might help to solve the problem of its aetiology. Unfortunately it is usually mistaken for calcification within a bursa or a parasite. More than fifty cases will be des- cribed. Si A82

AN KPBUKNCE 0? HYPERPARATHYROIDISM IN NORTHERN INDIA.. Gil

A.. Ran K.. and Sridhar. C.B. Ari ^ ... =^r.:&-i Department of Medicine (Endocrinology) Dei Radiology and Surgery, UnJ All India Institute of Medical Sciences, Pa< New Delhi, 16. INDIA. Pa< The study of clinical profiles, biochemical findings, radiological features I and histological findings of ten cases of hyperparathyroidism over last 7 years tui ii-v at a speciality olinic (New Delhi) in North India are presented. th: pre Si The age group encountered was 9-51 years, if males and 6 females, the if duration rf disease varied between 2-7 years before presentation at the clinic. Skeletal involvement was universal. Bone or join/b pains, multiple pathological ric fractures or bony deformities were presenting features except for one case nic renal calculus disease was not seen in -this series. Symptoms of hypercalcaemia or gaatro-intestinal system involvement was not met with in this geographic situation. exi Hypercalcaemia was present in 8Q£ of instances while raised urinary calcium boi excretion ( > 200 mg in 2k hrs.) was not met more than in W$ cases. gr« Associated radiological changes in this series lite epiphyseal fuzzing and abi Looser1 s zones were net with one case and two cases respectively. In the absence.of any primary oauses, the role of excess parathormone on bone is worth discussion. These three cases were also associated with phenomenon of 'hungry SU] none s* following operative procedure of parathyroidectomy.

Nine of the ten oases proved to have single adenoma histologically, the other one had chief cell hyperplasia. anc

pi A83

GIANT-CELL TUMOR OF THE PATELLA. A CASE REPORT. Arsjad, D. Department of Radiology, University of Andalas, Padang General Hospital, Padang, West Sumatra, Indonesia. atures Among the tumours in the region of the knee, giant-cell 7 years tumor of the patella is a somewhat unusual occurrence. For this reason, this case report of a 17-year-old male is presented. ie ie clinic. The patient first became aware of swelling and pain in the >logical right knee about one year before. Pain was often present at ise night as well as during activity. ilcaemia ihic Roentgenogram of the right knee in the antero-posterior and lateral view, taken on admission, shows a large destructive and expansile lesion of the patella with a paper-thin cortex of the calcium bone. The tumor has a multilocular appearance and there is no periosteal reaction of the adjacent bone. Routine roentgeno- graphic examination of the chest failed to reveal any ag and abnormalities. ie Ls worth Giant-cell tumor of the patella was diagnosed and removed by hungry surgery. Specimen of the excised tumor mass was examined pathologically and it was identified as a giant-cell tumor.

":S.=S* .,••*

•i'M A84

THE USE OF KNEE ARTHROGRAPHY IN THE DEMONSTRATION OF ANTERIOR CLINICAL CRUCIATE LIGAMENT Whitehous and Magnvi Departmen Wolfe, R.D. Universit Ann Arboi

From 2 Department of Radiology, entity as medical 1 Mount Zion Hospital and Medical Center were Rayr 5JK distal pi) San Francisco, California, U.S.A. cleaned x chloride,

Becaus With the advent of double contrast arthrography, as epidemio] in the Ur popularized especially by Freiberger and by Butt.and Mclntyre, Chemists x-ray exa a preoperative evaluation of the integrity of the menisci and hygiene s corporate the collateral ligaments can usually be accurately made. Most years of reported series show this accuracy to be greater than 90%, a A cont comparisc quite satisfactory percentage for any radiographic procedure. Of the Injuries to the anterior cruciate ligament have been much less have an a could be amenable to contrast visualization and most authors do not Twenty-fi tional 16 even mention the use of arthrography in cruciate evaluation. phalange* Additions A specially stressed flexed lateral projection to demon- os calcis 4 patient strate the anterior cruciate ligament has been developed. up for a

When normal, the ligament is almost always uniformly visualized. Diffei variants, When partially or completely torn, this is also usually appa- arthritis derma, ar rent. A summary of the radiographic and surgical correlation In pai in several hundred arthrograms will be presented. of the o< - consider: diagnosis A85

CLINICAL AND RADIOLOGIC COURSE OF OCCUPATIONAL ACRO-OSTEOLYSIS. Whitehouse, W.M., Ditchek, T. , Dinman, B.D., Dodson, V.N.. and Magnuson, H.J. Departments of Radiology and Industrial Health University of Michigan Ann Arbor, Michigan, U.S.A. From 1963-68, descriptions of various aspects of a new disease entity associated with the plastics industry appeared in the medical literature of five different countries. Chief manifestations were Raynaud's phenomenon in the hands and lytic lesions in the distal phalanges. Because it seemed to occur in workers who cleaned reactor vessels used in the polymerization of vinyl chloride, the disease was called occupational acro-osteolysis.

Because of the increasing numbers of cases appearing, a thorough 7 epidemiologic study was carried out in the vinyl chloride industry -" in the United States and Canada, supported by the Manufacturing Chemists Association. This included medical questionnaires, x-ray examination of the hands, job history and industrial hygiene survey. A total of 5,011 employees in 32 plants of 19 corporations were studied, representing a total of 21,510 man- years of experience in the industry. A control population of 2,407 adult males was also studied for comparison.

Of the total population of 5,011 workers, 1,302 were found to have an x-ray abnormality of the hands, the majority of which could be well identified as unrelated to acro-osteolysis. Twenty-five cases were established as acro-osteolysis and an addi- tional 16 were classified as "possible" cases. The distal phalangeal lesions showed a wide spectrum of differing appearances. Additional lesions in the sacro-iliac joints, ulnar styloid, 7 os calcis, patella, and lesser trochanter have been observed in L " 4 patients selected for more intensive study and detailed follow- -,;:; up for a period of 3 years. Differential diagnostic considerations include developmental variants, old trauma, hereditary acro-osteolysis, rheumatoid arthritis, rheumatoid spondylitis, hyperparathyroidism, sclero- . * derma, and other collage** diseases. ' ,;j In patients presenting with Raynaud's phenomenon, evaluation f of the occupational history and roentgen findings will enable the :ss • consideration of occupational acro-osteolysis in the differential A diagnosis. i\ A86

KSBRIBNCES OP IMS INEECTION IN PBNANG ISLAND WITH SPBCIil. HEF&SNCB 70 THE ROLE THB RADIOLOGICAL CHANGES OBSERVED IN CASES WITH BONE INVOLVEMENT.

Knlaveeraalraat. K.. and Chee. C.5. Margies on

Department of Radiology, Health Department , Departmen General Hospital, * Penang, Uhiversit Fenang, Malaysia. The Princ Malaysia. Sydney, 1 Taws is a disease of publio health iaportance in the rural areas of Malaysia affecting mainly children below 15 years of age. It has been Diagn brought under yaws elimination prograune by the Ministry of Health, Malaysia of the te with W.H.O. assistance since 19%. In spite of the good results following t this campaign resurgence of the infection has been found in the S.W. Lymph District of Penang Island (Balik Pulau). involveme radiologi The oases of yaws reported by District Hospital, Balik Pulau for the vena cavo period 1.1.70 to 31.5*71 are reviewed in this paper. Special attention lymphangi is given to oases with bone involvement and the radiological changes inferior observed before and after standard therapy with long acting penicillin. A total of 733 oases of clinical yaws are included in this study. Of this In th total 21 oases show evidence of bone involvement. Most of these patients The Princ with bone lesions have been radiologioally investigated and folic wed up merits of at periodic intervals after standard penicillin therapy. cavograph Our experiences show that the bone lesions are principally confined to the lever parts of the ezfcreaifcies with virtual absence of bone involvenent in the rest of the skeleton. In addition only the earlier radiological Manifestations of bone involvement are seen. With early treatment olinioal improvement and radiological resolution of such lesions are I demonstrated.

1. Ihe Director-General of Health, Malaysia for permission to present this paper* 2. The Chief Consultant Radiologist, Malaysia for his advice. 3* The Medical Officer and Staff of District Hospital, Balik Pulau for assistance in the preparation of this paper* A87

THE ROLE OF DIAGNOSTIC RADIOLOGY IN TUMOURS OF THE TESTIS.

Margieson, G.R. Department of Diagnostic Radiology, University of New South Wales, The Prince of Wales Hospital, Sydney, 2031, N.S.W.

Diagnostic radiology is useful, not only in staging malignant tumours of the testis, but also in accessing the progress of therapy.

Lymphangiography may demonstrate, but not necessarily exclude, involvement of lymph nodes. Added information may be obtained by other radiological procedures, such as intravenous pyelography and inferior vena cavography. Involved lymph nodes that have not been lymphangiographically visualised may cause displacement of kidneys, ureters, inferior vena cava or testicular vein.

In this paper, several cases from the Institute of Radiotherapy, The Prince of Wales Hospital are illustrated.' These cases show the merits of lymphangiography, intravenous pyelography and inferior vena cavography in both diagnosis and accessment of therapy.

\: I

TESTICULAR TUMOURS 1960 to 1969 Dr.T.F.Sandeman Peter MaoCallum • Clinio, Melbourne, 3000. Australia. A review of all cases of tumour of the testis seen in the urologieal service at the Peter 1 MacCalluE Clinic between 1960 and 1969 inclusive Sff is presented. Detailed examination is made of the germinal tumours primarily treated there in respect to pathology, age distribution, possible aetiological factors, treatment and prognosis. The Pathological Classification of Pugh (1964) is used and reviewed as to its usefulness in guiding therapy and outlook. A more detailed staging system is proposed which more clearly reflects ,4 i'i the outlook and assists in the determination of dosage and extent of radiation in seminoma pi] testis. This requires some modification of the investigations usually proposed substituting an inferior vena cavagram for lymphography. A 89

THE PLACE OF RADIOTHERAPY IN THE SELECTIVE MANAGEMENT OF MALIGNANT DISEASE OF THE TESTIS.

Atkinson. L., Ewing. P.P., de Wilde. F.

Institute of Radiotherapy, e The Prince of Wales Hospital, Sydney, Department of Radiotherapy, eter St. Vincent's Hospital, Sydney.

the There is little doubt that the best management of seminoma of the testis, without demonstrable metastases is simple orchidectomy and removal of cord to the internal ring, followed by irradiation. There is not Le general agreement on the best technique for the irradiation. There is wide disagreement over the respective places of surgery and radiotherapy for germ cell tumours of the testis other than is seminomas; especially in those cases where there is either no, or relatively ing slight, involvement of the para aortic nodes, and no distant metastases. Irradiation is not so effective in controlling lymph node metastases from teratomas as it is for those from seminomas. The question is whether surgery should be used, and if so, both on cases where there is, and on those where there is not, evidence of para aortic metastases. Surgery carries the real morbidity of a greater or lesser degree of impotence. The best results are obtained, obviously, in those surgical cases where there is no pathological evidence of metastases in the glands, but any impotence in this group is an added price for any increased survival in those surgical cases where the glands are involved. A series of 140 cases of testicular malignancies, treated by simple orchidectomy and para aortic radiation is examined, together with other published evidence, and a proposal is put forward for the selection of patients in the teratoma group for surgery. The question of radiation dosage to the surviving testicle from different radiation techniques is also examined. A 90

THE HEMANGIOMA OF KAPOSI

Palmer, P. E. S.

Department of Radiology University of California Davis, California 95616 USA

The Haemangioma first described by Kaposi more than a hundred years ago occurs in all races but is exceptionally common in the people of tropical Africa. Here it may reach an incidence of over 10% of all malignancies. Equally interest- ing it becomes a disease of children and of young people and is quite often rabid- ly fatal. In patients who live further north or south of the Equator the disease is less varilant and approaches the pattern seen in Europe and America. Patients may live 20 years with the disease and die of some other reason. Further evid- ence of an immunological aspect is the development of this carcoma in patients who are on imuno-suppressive therapy for other'benign and unrelated conditions. The radiologist can demonstrate not only the soft tissue tumors but the tumors within the bone. Arteriography shows that each tumor has an isolated blood supply and the response to chemo therapy is usually thrombosis of the supply vessel. The tumors can also be demonstrated by the lymphangiograms. Treatment is best by chemotherapy with the help of radio therapy and occasion- ally surgery. This disease has' never been satisfactorily mapped throughout the Asian and Oceanian- areas, nor is the individual response of patients known. This s information is based on a personal knowledge of over 200 patients as well as a E review of the literature. A91

TREATMENT OP A JUVENIIE LARYNGEAL ANGIOMA. WITH A BETA RAY THERAPY APPLICATOR

Bourne, R.G. and Taylor, R.G.S.

The Queensland Radium Institute, Brisbane Base Hospital, Queensland, 4029, Australia. rears ago jpical Africa. ially interest- This paper reports the use of a Beta Ray Therapy Applicator for the treatment of an infant with a laryngeal angioma. :e often rabid- :r the disease Lea. Patients For many years, orthovoltage x-ray therapy has been considered the most irther evid- satisfactory treatment with least mortality for this uncommon but serious Ln patients condition. However, if there is no preceding tracheostomy, such treatment may conditions. be followed by increased respiratory distress. If there is preceding 3 but the tracheostomy, decanulation is frequently difficult and may take years to achieve. isolated Obstruction of the tracheostomy tube can result in sudden death. Recently, it 5 of the has been postulated that conservative management may be adequate, because it is iograms. known that cutaneous angiomas may regress spontaneously. However, because of i occasion- the narrow airway in the infant, continued growth while waiting for spontaneous coughout the regression may require prolonged nasotracheal intubation with its attendant s known. This problems or worse still, tracheostomy. s well as a As the Beta Ray Therapy Applicator reported is applied directly to the «»«= angioma at direct laryngoscopy, it retains the advantages of irradiation by giving an adequate dose to the angioma with very low dose to the adjacent tissues, both factors reducing the likelihood of tracheostomy. The case history of a patient successfully treated by this method is described.

The applicator consists of a very thin gold foil containing the beta emitting decay products of radon. Details of its preparation, measurement and mounting on a handle suitable for use with microlaryngologLcal instruments are given.

• -:~M i I A92 1 RADIOTHERAPY OP MENINGIOMAS. Bradley. J. M. Peter MacCallum Clinic, 278 William Street, § MELBOURNE. ^OOO.

The effects of radiotherapy on the clinical aourse of forty-three patients suffering from meningiomas of the central nervous system who were referred for treatment in the years 1956 - ii 1969 are reported.

Three of the tumours were within the spinal canal and the remainder arose in the cranial cavity, fourteen in the posterior cranial fossa and twenty-six in the supratentorial region.

The ages of patients ranged from nine years old to seventy-two years.

A number of long term survivors are re- ported. The radio-sensitivity of meningiomas is discussed and some conclusions are made with respect to the radiation tolerance of the central nervous system. A93

THE TREATMENT OP EURiaTT'S IXEPHCMA. IE T.P.H.G. - A DISASTER. Reay-Young. P.S. Angau Radiotherapy Centre, Lae. T.P.N.G. The 2 year survival rate of children with Burkitt's Lymphoma in T.P.N.G. is 29fo and the 5 year survival rate, assuming the children lost to follow up have died is Qfa. 57 cases, included in this series on a strict histopathological and clinical basis are analysed for age, anatomical site and modes of onset. Since 1564 Cyclophosphamide, as advocated by Burkitt has been used as the sole method of treatment in 47 cases. 6 patients had palliative irradiation and died in the 1st year. 4 patients hsd curative irradiation. Of these one is alive at 4 years, one at 3 years, one at 2 years, all free of disease and one cannot be traced. 2:J" It is suggested that the use of Cyclophosphamide alone was initially a necessity but that now a more intelligent and discriminating approach should be made where supervoltage radiotherapy facilities are available. il

i A94

CLINICAL APPLICATION OF SHORT-LIVED RADIOISOTOPES. (LIVER SCANNING WITH 113m-In COLLOID)

Ogiso, A., Akutsu, T., Yoshida, R., Umeno, K., and Matsumoto, K.

Department of Radiology, Saiseikai Utsunomiya Hospital, Utsunomiya City, Tochigi Pref., Japan. 99m-Tc and 113m-In are less harmful to the patients than the other radioisotopes, such as 198-Au, 131-1, 203-Hg, etc., since their half lives are shorter, so that they can be given in larger doses and used in scanning the brain, lung, liver, spleen, kidney, placenta, bone marrow, cardiac pool, etc. 113m-In is produced from 113-Sn — 113m-In generator by milking. Due to its short half life, the generator can be eluted several times a day, and can be used for a long time because the half life of 113-Sn is 118 days.

The simplified preparation of reliable scanning agents is made possible by use of a closed generator system and pre- sterilized vials containing the appropriate chemicals to make the specific radiopharmaceuticals. Liver scanning with 113m-In colloids was tried on about 50 cases, such as hepatitis, cirrhosis, tumours, etc. In this way clear and diagnostically use-ful images were obtained in all cases.

The uptake of injected 113m-In colloids in the liver was 85% 11 on average in normal cases, and liver radiation dose from 2mCi 113m-In colloid was about 0.85 rads.

Contamination of 113m-In by 113-Sn was identified by the hematoxylin method, and it was less than 0.003%.

113m-In. has proved to be a very useful isotope in liver scanning. A95

USE OF THE GAMMA CAMERA TO ASSESS THE EFFECTS OF EXERCISE, HYPOXIA AND HYPERCAPNIA UPON THE DISTRIBUTION OF HUMAN PULMONARY BLOOD FLOW. Counsell J.T., Dugdale L.M., Ritchie B.C., Smith M.M. Department of Medicine Department of Nuclear Medicine Prince Henryte Hospital Alfred Hospital St. Kilda Road Commercial Road Melbourne Prahran Victoria Victoria Australia Australia '

The distribution of pulmonary blood flow has been measured previously by using multiple fixed or moving detectors. Simul- taneous detection of the distribution of whole lung blood flow has not been possible until the advent of the gamma camera. We have used a gamma camera^with a computor print out, for more accurate measurement of the distribution of pulmonary blood flow in normal subjects, using two isotopes, 1131 M.A.A. and technetium-99m.

On exercise, a shift of pulmonary blood flow occurs towards the apical regions of the lung. Hypoxia, induced by breathing 10$ O2 in N2,or a single breath of 100? N2,produces a similar redistribution of blood flow to the apices. The effects of rebreathing with a rising PCO2 causes a less marked redistri- bution away from the base of the lung.

This method offers a rapid and accurate method of exploring the physiological factors affecting the distribution of pulmonary blood flow. A 96

THE ROLE OF CAESIUM-S31 SCABBING IN THE INVESTIGATION OF THYROID NODULES. RADIO-ISOTi

Dugdale, L Murray. IcP.C, McKay. W.J, and Indyk. J.S. Department Department of Nuclear Medicine and Department of Surgery, Alfred Hos The Prince of Wales Hospital, Victoria, Randwick. 2031, Australia. Australia.

Continuing experience with 1^1Ce as a scanning agent has confirmed Diagnos our initial studies which suggested that this radio-nuclide was of tests avai value in the investigation of thyroid disease. using sele capabiliti In particular, " Cs scanning has been found to be useful when a to difficu thyroid nodule has been shown with 1'1I or 9°miji |, non-functional. Accumulation of 131cs in such nodules to a greatect ro extene t than in The pre paranodular tissue is usually associated vith malignancy. As a result pancreas s we have adopted the policy that the demonstration of a "hot" 131Cs the state nodule should not only be an indication for surgery but also' the need ratio of a for frozen sections. Consequently, although a few "false positives" differenti have been encountered, there have been several patients who underwent execrine t surgery only because of the finding of a hot 13* Cβ scan but in whom that invol thyroid carcinoma was unexpectedly diagnosed Mstologically. Diagnos Failure of a nodule to accumulate 1^Cs favours a benign pathology. associatio "False negatives" are unusual but have occurred. To date, however, signs in m such "cold" ^31 Cs nodules associated with malignancy have only been encountered in patients in whom the diagnosis of thyroid carcinoma was strongly suspected because of the clinical findings. However, it f; is not as yet suggested that a "cold" 131cs scan excludes malignancy nor that this finding should over-rule indication for surgery on clinical grounds.

.<£) A97

RADIO-ISOTOPE PANCREAS SCANNING. Dugdale, L.M.

Department of Nuclear Medicine, Alfred Hospital, Victoria, 5181. Australia.

Diagnosis of pancreatic disease remains difficult in epite of all the tests available. Introduction of radio-isotope scanning of the pancreas, using selenomethionine, offers a significant advance in diagnostic capabilities, but the technique has not been widely adopted probably due to difficulties in technique and interpretation.

The present study covers the first two hundred patients on whom pancreas scans were performed in this unit. Of these, sixty seven had the state of the pancreas proven by surgery or autopsy. By use of the ratio of apparent uptake in liver and pancreas, there has been a good differentiation between normal and abnormal function of pancreatic execrine tissue giving reliable differentiation between normal gland and that involved in chronic pancreatitis.

Diagnosis of pancreatic tumour is however, not as accurate, but the association of a liver scan with the pancreas scan gives additional signs in many cases, often permitting the correct diagnosis to be made. A98

COMPUTER AIDED DIAGNOSIS ON SCINTIGRAMS. STUDIES ON AND IRON R3 YASUKOCHI.H*, SUZUKI,T* and KOHNO,H+ Areekul, S.,

•Department of Radiology, +Central Research Laboratory, Department c Branch Hospital, Hitachi,Ltd. Faculty of Medicine, Higashikoigafuchi 1-280, Faculty of Ti University of Tokyo. Kokubunji-city, Mahidol Univ Mejirodai 3-28-6, Bunkyo-ku, Tokyo, Japan Bangkok, Thi Tokyo, Japan. Anaemia c that such ana We have already reported on the computer aided diagnosis of thyroid scintigrams using Bayes1 rule after abstraction of blood loss. diagnostic factors by the use of doctors1 eyes. In this paper the results of which we have tried to abstract the factors Blood IOSE automatically by the aid of computers are presented. radioactive ^ per worm pe: As an object, the thyroid scintigrams were again elected and it was in' because of its small area and popularity as the examination. 64% (range 4] Before abstracting the diagnostic factors, original scintigrams were memoried as the number of counts in every 5mm square. the intestine iron reabsorl The separation of both lobes was performed by the change of of 89% of iro] the differentiated value of the curvature of the isocount curve with severe z at the first level of counts divided by ten between maximal counts and back ground counts. The factors concerning the area, 51Cr-labe: the longest and shortest diameters, the angle and the position plasma prote were calculated separately in each lobe using the value of moment. albumin equi- of the intrave Defect areas were abstracted by the abnormal changes of the 4 days faecal curvature and the roughness of each area of outline which were egg/g faeces, calculated within every thirty degrees of angle diversing from of faeces and the center of the lobe. between the £ measured in By this method about eighty percent of the pathological informations on thyroid were correctly abstracted as evaluable factors from scintigrams. The calculation was now limited because of the economical reason, however, further calculations may aid in more correct diagnosis of the thyroid scintigrams, and this technique will be applied to the scintigrams of other organs.

KS- A99

STUDIES ON BLOOD LOSS, PLASMA PROTEIN LOSS, IRON ABSORPTION AND IRON REABSORPTION IN HOOKWORM PATIENTS IN THAILAND.

Areekul, S., Devakul, K., Chantachum, Y., and Vii'avan, C.

Department of Radioisotopes, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.

Anaemia caused by hookworm is common in Thailand and it is well known that such anaemia is probably due to iron deficeincy resulting from intestinal blood loss.

Blood loss, iron absorption and iron reabsorption were determined using radioactive *Cr and *9Fe in 15 patients with hookworm anaemia. Blood loss per worm per day was found to be 0. 097 ml (range 0. 039-0. 260) in 15 patients and it was inversely proportional to the total amount of hookworms. About 64% (range 41-83) of the iron loss caused by hookworms was reabsorbed in the intestine in 6 patients studied. There was a linear relationship between iron reabsorbed and iron loss and the state of iron deficiency. An average of 89% of iron given orally was found to be absorbed in 9 hookworm patients with severe anaemia.

"Cr-labelled human serum albumin was also used to study the loss of plasma protein in 15 hookworm patients. The results showed that they lost albumin equivalent to that in 21 to 128 ml of plasma per day or 0. 06 to 2. 74% of the intravenously administered ^lCr-albumin appeared in the subsequent 4 days faecal collection from patients harbouring 1,200 to 20, 000 hookworm egg/g faeces. There was a direct relationship between the number of egg/g of faeces and the faecal 5lCr-albumin excretion and an inverse correlation between the serum albumin concentration and the amount of 51Cr-albumin measured in the stool.

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A100 1

EDUCATION IN RADIOLOGY Felson, B.

Department of Radiology, Unive:: ity of Cincinatti Medical Center, Cincinatti, Ohio, U.S.A. There are a lot of ways to train radiologists most of which i will work well if well-performed. In the U.S. there is a strong trend in medicine toward self-learning through the use of a variety of audiovisual methods. Radiology is ideally suited toward this mode. However, the problem has been that there is not enough learning material available and not enough experience with audiovisual methods. No one knows the direction to take, so much talk and little action is going on in this area.

In Cincinatti, we have developed a simple way to provide a wide choice of audiovisual methods inexpensively which permits a choice of directions to take, including TV tape, TV cassette, slide talk, movie, talking teaching file, etc. This method will be presented. AM

Education and Training in Radiology in Korea: Bast, Present and Future. Hee Seup Kim. M. D. Department of Radiology Ewha Women's University Medical College Seoul 110 Korea In Korea, clinical, radiology was introduced for the first tins in 1923, and developed under the Japanese colonialism until the liberation in 1%5. The radiological activity was decentralized. During the Korean war (1950- 1953) much of the radiological institutions and equipments were destroyed and lost. Following the war, a new system was imported from the United States through Armed Forces Medical Group. In the 1950's many students were trained in overseas including the New and Old Continents. 1. Past: This the stage of development in the field of Radiology in Korea and in effect was the age of struggle for independence followed by devastating period of war. Educational training was only for the technician and no specialty system existed. The first lecture in Radiology was started in 1940 and this was followed by gradual promulgation in other medical colleges throughout the nation. 2. Present^ This is the period of reconstruction. In many aspects including educational programme, studying facilities and institutions, both short and long term projects have been launched. There are now some 110 Boardmen (6B.T% of all society members) including 30 members abroad. Important institutes beside 13 .Medical Colleges include Radiological Research institute, Atomic Energy Office and Cancer Rosoital, Nuclear Medicine has formed its own society in 1961. Recently, Korean-Japanese Joint Symposium was held on "The Recent Development in Radiological Society, some 317 papers have been published. The majority of the papers are concerned with Radiodiagnouia (77%) and Nuclear Medicine (13.2?). About 10$ consists of radiotherapy and radiophysics and biology. 3. Future: The plans are now in active engagement to install betatron, linear accelerator and reactor. The training system, both under the postgraduate, is now being studied extensively so that the imoorted system will meet practical demands and requirements, i.e., natrualisation. Sr-f

3>' A102 §3 PRESENT STATUS OP THE TRAINING OF RADIOLOGISTS IN JAPAN. ii Okuhara,M. and Yasukochi,H. Chairman and vice chairman, Committee of Examining Board, Nippon Societas Radiologica, c/o Akamon Abitation No.301, Hongo 5-29-13, Bunkyo-ku, i Tokyo, Japan. Training system of radiologists in Japan has been started from April 1966, under the authorization of Nippon Societas Radiclogica after long period of discussion. m Training of radiologists is performed according to the "Regulations on Training system of Radiologists" in our m society. Under this regulations about one hundred hospitass have been recognized to be suitable for training radiologists as a starting circumstance. Examinations for board were carried out in the field of x-ray diagnosis, radiotherapy and nuclear medicine, and from last time, the field of general common sense including radiation hazards is also added. As a transitory process, several hundreds doctors have been registered by their carrier, just as those by the examination, however, this process is now finished and the evaluation of training hospitals is how being discussed to elevate the activity. I The present, status of Radiology in Japan is not yet truely established. Host of x-ray diagnosis are performed in other faculties without deep considerations, however, most of radiotherapy and nuclear medicine are centralized and carried out by radiologists. There exists and opinion to divide the radiology into •Si!.-. more specialized department, however, we consider that to develope and to organize the general radiology is more Hi-.' important process in Japanese medical situation. Otherwise, the specialized department may be obliged to follow the present radiology in Japan. In this point, we believe that the registration of Radiologists may elevate the mean activity of radiologists and consequently to elevate the Japanese medical situation. i 1

A103

THE UNDERGRADUATE AND POSTGRADUATE EDUCATION OF RADIOLOGY IN INDONESIA.

S.iahriar Rasad.

Department of Radiology, University of Indonesia, Faculty of Medicine, Salemba 6, Djakarta,Indonesia.

Some data on the geography and statistics of Indonesia are given as background information. Adequate training in radiology to medical undergraduates is essential.Although this training is principally basic in character, the prospective K.D.,who is very likely to practice medicine in some remote place of the country,is expected to be able to obtain the maximum from his radiological tool.

He is first of all taught and trained to distinguish the abnormal from the normal,rather than jump at diagnosis!then, through critical observation and logic thinking,he is expected to build up a diagnosis.

The prospective M.D. is also trained to act,whenever neces- sary, as radiographer and technician,thus,to work in the dark room and occasionally repair minor damages of equipment.He should be also fully familiar with the radiological aspects of prevalent diseases in the country,such as tuberculosis, tropical diseases and acute conditions.

The postgraduate training of radiologists has a somewhat different character. Since every radiologist is likely to become involved in the teaching of radiology at any of the numerous medical schools in Indonesia, in addition to his detailed education in the specific areas of radiology,he is also trained to give lectures, participate in conferences and conduct researchaetivities.

The Department of Radiology of the University of Indonesia, Faculty of Medicine also accommodates the School for Radio- graphers and the School for X-ray engineers,both conducted mainly by radiologists.

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A101

EDUCATION IN TIIB RADIOLOGICAL SCIENCES IN AUSTRALASIA - THE CONTINUING ROLE OF THE COLLEGE.

Svme. James. Warden of the Membership, The College of Radiologists of Australasia. This paper will consider firstly the role of the College of Radiologists of Australasia, almost from its inception in 19^9-50, in supervising the training of medical graduates in Diagnostic Radiology and in Radiotherapy and in examining for the award of its Diploma in either specialty, successful candidates being eligible for membership. The necessity for such a uniform examination in Australasia will be stressed and a resume presented of current thought and possible future trends with regard to its standard, the details of its syllabus and the period and form of training required. It will be advocated that the curriculum include some knowledge of the diagnostic and therapeutic potential of Nuclear Medicine in complementing radiological methods, although those practising this specialty have decided against association with this College. The mechanism for admission to College ranks of those holding acceptable alternative qualifications will be described.

Media provided for continuing education of College members will next be mentioned, including the Journal; regular scientific meetings, often attended by distinguished overseas visitors; travelling fellowships permitting either interchange of senior membere between-Australia and New.Zealand or experience farther •field for junior members; and periodic examinations in ustralasia by the Faculty of Radiologists of London for its fellowship. The growing importance of Radiology and Radiotherapy in modern undergraduate medical curricula will then be remarked, with emphasis on the opportunity thus afforded for recruitment to these specialties. The continuing role of the College in ensuring the training of technical staff () to a uniform standard will be noted.

In conclusion reference will be made to past assistance from the College to South-East Asian countries in some of these activities, with an assurance of continued support.

3 A105

COMPUTERIZED DATA. PROCESSING SYSTEM FOR MASS SURVEY OP THE UPPER GASTROINTESTINAL TRACT. Kazuo Inamoto. M.D?. Takaichiro Suzuki. M.D?* and Ha.iime Matsuda. M.D? Department of Radiology, **Department of Field Research. The Center for Adult Diseases, Osaka, Higashinari-ku, Osaka, Japan. The recent spread of mass examination of the stomach has contributed greatly to the detection of the early gastric cancer in Japan. As a matter of course many persons are examined at regular intervals and their personal medical records are written and stored. The increasing work load and much confusion in the data-process of a large quantity of clinical information impose an urgent need for increasing efficiency. In this respect, computers and computer programs are making the useful and indispensable tools for the doctors and their co-workers who devote themselves to the study of mass survey. Since 1968, all the medical data concerning the patients who were examined about the upper G.I. tracts in the Department of Mass Examination of the Center for Adult Diseases have been entered into the computer system and stored in the magnetic tapes. In this system we accomplished composing the Optical Mark Reader Document on which the mark spaces that correspond to the pertinent words or statements in the reports on the clinical history, X-ray examination, endoscopic and cytologic study are arranged. These mark spaces are turned into machine readable form when they are smeared with pencil. In the present investigation the authors attempted to systematize the X-ray findings on the upper G.I. tracts concerning the anatomical site, shape, dimension, number, grading and other informative data of the lesion to make them suitable for the computer analysis. In these last three years in which the system was used in the Department of Mass Examination of the Center for Adult Diseases, more than 60,000 .'m* examinations of the upper G.I. tract were covered by this method in lieu of ordinary descriptive one. Finally, the value of computer analysis concerning the detection of the early gastric cancer is discussed.

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RADIOLOGICAL FINDINGS IN PSEUDOMEMBRANOUS COLITIS. Sherbon. K.J. Department of Radiology, Royal Prince Alfred Hosoital, Camperdown. N.S.W. 2050, Australia. Pseudomembranous colitis is well known to surgeons and pathologists as a potentially life-threatening surgical complication, particularly in patients receiving broad spectrum antibiotics. Patients in this setting are often very ill and there is little call for radiological investigation. However, the three patients of this series, all with rectal biopsies showing changes of pseudomembranous colitis, had much less severe ilnesses and were studied by barium enema. The examinations showed mucosal abnormalities suggestive of ulcerative colitis. The possibility of pseudomembranous colitis should be kept in mind in certain patients with barium enema findings indicating a colitis because of the therapeutic and prognostic features of this disease, as distinct from other forms of colitis. A107

GASTROESOPHAGEAL REFLUX AND "ASTHMA"; COMMON BED-MATES

Wolfe, R.D.

Department of Radiology

Mount Zion Hospital and Medical Center

San Francisco, California, U.S.A.

In recent years, the incidence of gastroesophageal reflux with or without demonstrable hiatus hernia has been appreciated with increased frequency. Numerous excellent articles have documented the multitude of ways in which the symptoms of reflux can present. Only a few articles, however, have impli- cated repeated aspiration secondary to reflux as a contributory etiological agent in chronic pulmonary patients. None have emphasized what I feel to be the true incidence of this

relationship. This study is an evaluation of a large number of consecu- tive patients presenting to a Radiology department for upper gastrointestinal examination. Utilizing a questionnaire, the . group was divided into those admitting to some chronic respira- tory problem and those who denied any respiratory difficulty. The results confirm the impression that gastroesophageal reflux not infrequently leads to chronic cough, chronic bronchitis and "intrinsic" asthma. Treatment directed at the respiratory pro- blem is ineffectual if the reflux goes unchecked. A few case reports will be presented to further support these findings. cm

i A108

"DUODENITIS' — A MYTH OR A REALITY? CORROSIVE: I

Bhardwaj, O. P., Aggarwal, H. H., Bazaz Mallick, G. and Chuttani, H. K. Abdul Ghani

Departments of Radiology, Medicine and Pathology, Department General Hog Maulana Azad Medical College & Irwin Hospital (Delhi University), Kuala Lumpv New Delhi — INDIA Malaysia. There are patients who present clinical features suggestive of duodenal ulcer in whom in spite of a careful radiological examination, no ulcer is demonstrated. Corrosiv These patients have remained an enigma for the radiologists as well as for the in West Ma] physicians. These subjects however, sometimes do have some radiological abnor- biggest gro malities in the duodenum. The significance of these abnormalities is not apparent. Chinese and are cases c This study was undertaken to evaluate the role of duodenum in the genesis of dyspeptic symptoms and work out their relationship with the radiological features, The clii acid gastric secretion and mucosal morphology. out, the cc The material for the present study consisted of: the time of (i) Patients with vague upper gastrointestinal symptoms. pharynx anc Pain felt 3 (ii) Patients with clinical features of duodenal ulcer but in whom corrosion, no definite ulcer crater is visualised on barium meal study. survive the (iii) Patients with symptoms of group (ii) but in whom an ulcer is or both. demonstratH (iv) Normal subjects with no gastrointestinal symptoms to serve as Kadioloj controls. oesophagus, segments of Following Investigations were carried out: (a) Barium meal examination of upper gastrointestinal tract. Dhe at a (b) Acid gastric secretion studies. our cases (c) Duodenal biopsies from apex of duodenal bulb. stomach dm li Radiologic! The results revealed that patients belonging to the group (ii) namely non -I'!' ulcer dyspepsia had a significantly higher gastric acid output as compared to the The popi controls and the patients with nonspecific symptoms. Radiological features cause sevei included marked irritability, prominent folds and irregularity of mucosal pattern oesophagus

1 of the duodenum in these patients. Histology of the duodenal mucosa revealed both adds "i£- -; abnormal changes. These radiological and morphological features were absent in of the oes( the patients with nonspecific symptoms and normal control subjects. There was that in ca: significant correlation between acid gastric secretion and radiological features in duodenum bi these patients. i-V.-V' Radiological changes in the duodenum with increased gastric acidity and abnormal morphology is suggestive of inflammation of duodenum "Duodenitis".

IKl A109

CORROSIVE POISONING IN HIESP MAIATSIA.

Abdul Qhani. Hussain b. Department of Radiology, General Hospital, Kuala Lumpur, Malaysia.

Corrosive poisoning by caustic soda and formic acid is relatively common in West Malaysia, where women in their late teens and twenties form the biggest group of patients. The incidence is high among Malaysians of ' Chinese and Indian origins but negligible among the Malays. Most of these are cases of attempted suicide.

The clinical course depends on the amount ingested, the amount vomited out, the concentration, the speed of ingestion and the gastric contents at the time of ingestion. Corrosion is seen in and around the mouth, the pharynx and the oesophagus. Ensuing oedema causes dyspnoea and dysphagia. Fain felt in the chest and abdomen indicates oesophageal and gastric corrosion, with or without peritonitis. About two thirds of the cases survive the acute stages and develop strictures of the oesophagus or stomach or both.

Radiological appearances: Almost invariably, there is stricture of the oesophagus, which can be mild or severe, generalised or localised with segments of relatively normal oesophagus which can subsequently dilate.

The stomach is not always involved. However, a significant number of our cases show varying degrees of deformity of the dependent parts of the stomach due to stricture. Clinically, the features are of pyloric stenosis. Radiologically, they resemble carcinoma of the stomach.

The popular belief is that acids leave the oesophagus unaffected but cause severe corrosion of the stomach while alkalis severely corrode the oesophagus but leave the stomach unaffected. Our experience shows that both acids and alkalis can and do cause corrosion and subsequent stricture of the oesophagus and the stomach. We have therefore made it a routine that in cases of corrosive poisoning, the oesophagus, stomach and the duodenum be examined, with repeat barium studies if necessary. AUO

UNUSUAL RADIOLOGICAL PATTERNS OF ABDOMINAL TUBERCULOSIS.

Chawla, S.. Mukerjee. P., and Maheshwari, H.B.

Departments of Radiology, Surgery and Pathology Lady Hardinge Medical College and Hospital, NewDelhi-1, India.

Though tuberculosis has been largely eradicated from the developed countries, it is still quite common in India.

During the past ten years, in the Lady Hardinge Medical College Hospital, three hundred and sixty-seven female patients were operated upon, with a pre-operative diagnosis of abdominal tuberculosis. Barium studies were carried out in three hundred and twenty-six patients pre-operatively and the remainder underwent emergency surgery without detailed radiological examination.

In two-third of the total number of patients operated upon, histopathology confirmed the diagnosis of abdominal tuberculosis. An analysis of these cases showed that more than 85 percent of the patients had ileo-caecal tuberculosis, with or without involvement of the small bowel, which conformed to the usual text-book description. The remaining patients showed unusual radiological appearances. In seven patients, pyloric or duodenal obstruction was caused by extrinsic pressure from enlarged tuberculous mesenteric lymph nodes. Another seven patients showed high jejunal strictures though jejunum is reported as an uncommon site for tuberculosis. In one patient, intussusception was caused by a hypertrophied ileo-caecal tuberculous mass. In eighteen patients, there was large bowel involvement, in the form of single or multiple strictures or extensive right sided colitis simulating ulcerat're colitis. Another unusual feature was the formation of radio-opaque enteroliths in 17 cases.

Since tuberculosis is still prevalent specially in the developing countries of the world and it can simulate radiologically many other diseases like Crohn's disease, ulcerative colitis and malignancy, it is useful to recognise its protean manifestations.

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X-RAY DIAGNOSIS OF PROTRUDING LESIONS OF THE STOMACH

Ohtake, H. and Tarusawa, T.

Department of Radiology, Iwate Medical University, 19-1 Uchimaru, Morioka City, 020, Japan

The results of X-ray diagnosis of the protruding lesions of the stomach such as Borrmann I-type cancer, I- and Ila-type of early cancer, gastric polyp and gastric submucous tumor were analysed. According to Yamada, et'al. these lesions were grouped by appearance into gently sloping type, sessile type, subpedunculated type and pedunculated type. The longest diameter of each lesion was of significance in diagnosing. Most of the gently sloping type were submucous tumors. As to polyps, smaller ones were of sessile type mostly, and bigger they became in order of subpedunculated type and pedunculated type. Malignant tumors such as Borrmann I-type cancer, I- and Ila-type of early cancer were either of sessile type or subpedunculated type, having more than 20 mm in diameter. Thus a differentiation of benign lesions from malignant ones could be made provided that exact form and size of tumor were determined. It is required therefore to try every means to get enough appearance of the protruding lesion ??SS5 on X-ray films for a correct diagnosis. A112

BSSAI ON THE SUPPORTING HOLE OF GBAVITX IN THE DEVELOPMENT OF GASTfiODUODKNAL ULC3R. Sukonto Kartoleksono Department of Radiology, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia. The radiodiagnostician has in his daily stomach-examinationwork the opportunity to note a considerable downward shift of the stomachic antrum which is filled with bariumsulphate, when the patient is moved from the lying into the erect position. This shift is at least of the same length of half a vertebral height; if it is less, some fixing process involving the antrum or whole stomach should be noted or suspected. This influence of gravity causes stretching and narrowing of the bloodvessels and capillaries along the lower part of the lesser curvature or its nearest sides, rendering the mucosal cells which they supply le*ss capable to withstand the regular attacks of gastric juice, for proper bloodsupply is essential for gastric mucosa. Besides that the peristaltic movements also cause periodical narrowing of the capillaries. The wealth of anastomosing vessels has no significance in this case. Furthermore the antral mucosa, stretched by foodcontents and gravity will cause more gastrinrelease, resulting in increased acidity which in turn enhances the pepsin secretion. For certain individuals this influence of gravity may through the years be too much. Patients and wouldbe patients susceptible to ulcer formation are said mostly of restless nervous types who are the whole day more in the erect position than in the lying position. From the three stomach.types: the steerhorn, the normal and the long types, the normal has the greatest incidence of peptic ulcer. It might be recommendable to find out by means of radioisotopes whether there exists any significant and workable difference in allvascularity in a certain point of the lower part of the lesser curvature in the erect and lying position and whether the possibility exists by this simple way to select patients and wouldbe patients of peptic ulcer.

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EMERGENCY BARIUM STUDIES IN THE INVESTIGATION OP HAEMATEMESIS AND MELAENA -

Narinder Singh. X-Eay Department, Gerenal Hospital, •:.] Seremban, ; Malaysia.

In 1965 a study was initiated in the General Hospital, Seremban, Malaysia, > in the early diagnosis and treatment of haematemesis and melaena. All such cases in the study were admitted ijito the Acute Surgical Ward. • Contrast studies of the upper gastrointestinal tract were considered an essential early investigation. When the patient was considered fit to be -2. moved, after the usual resuscitative procedures, a barium study using fine- ,t£ particle barium suspension (Micropaque) was undertaken in the X-Ray Department £| using a 700 M.A. set. t As there is only one radiologist to serve the needs of nearly 2,000 hospital " : beds and a population of nearly 480,000 people, it was decided to use a 4 film barium study technique without screening. •'•<]- The patient is given 4 ounces of barium suspension by mouth and 4 films g are taken in the supine, right posterior oblique, right lateral and right K anterior oblique positions. '•&•?- Over 400 cases were investigated by this method from June 1965 to May 1971 ;vf without any serious complications. An overal diagnostic accurauy of about T: fo was obtained, The commonest lesion found was Duodenal Ulceration in which ' a diagnostic accuracy of 90$ was obtained, in Gastric Ulcer, about 70$ accuracy. •-£ Other common lesions diagnosed were Neoplasms (benign and malignant) and Varices. /.; Our barium studies contributed significantly towards an early and accurate 1,-j diagnosis of the lesions. When surgical intervention was necessary, the ff>; surgeon did not mind the presence of barium in the stomach. This investigation i ,s is now an accepted procedure in the early investigation of Haematemesis and t^7 Malaena in our hospital. §{=•&> A114

F. E. S. Palmer Professor of Radiology, University of California at Davis H. D. McGlashan Senior Lecturer in Geography, University of Tasmania-Ho"bart.

"Geographical Pathology for Radiologists"

Medicine has become so hypnotized by microbiologists and biochemists that it looks down a microscope (preferably an electron microscope) or in a test tube (preferably a micro-analyzer) for the answers to all its problems. In so doing it neglects all the information already available. Long ago, cholera was eradicated from London by "geographical pathology." The wit of Dr. John Snow solved the problem before anyone knew or saw its causal organism. We are sadly neglecting much knowledge which is available through individual doctors who have years of experience in their own localities. All of us know that cancer varies geographically; many other diseases vary equally as widely and this must have equal significance. In Africa, we started with isolated hospitals, rural clinics and mission hospitals, and evolved a method which produces statistically significant information from a background totally lacking in statistics of any sort. Of course a computer was involved, but only after we nearly drowned in the deluge of figures; from a simple origin came numerous trials which involved radiologists in particular, because who knows the pattern of disease in a hospital or a countryside better than the radiologist, and who has less bias? Later, a survey was made to show the spatial distribution pattern of specific illnesses and to relate them to local environmental patterns. Using such simple mapping techniques, with the aid of a central computer, allowed association to be made between oesophageal cancer with local alocholi • drinking, and this led to significant findings in aetology. This is but one example of the use of a large scale technique which can be applied over huge areas with the help of individual and isolated doctors. The African methods could be applied all over Southeast Asia, and Oceania. Facilities to make the maps with a computer are available in Australasia- Prom this conference coulJ. flow a wealth of knowledge from all who practice, in these areas. Where it would lead is unknown, but much is being lost as countries become standardized and local cultures disappear. With them go vital clues which might then make looking down a microscope worthwhile,instead of merely interesting A115

TRANSPLANTATION ANTIGENS AND SUSCEPTIBILITY TO CANCER WITH REFERENCE TO HODGKIN'S DISEASE Forbes, J.F., Morris, P.J, and Madigan, J. Department of Surgery University of Melbourne Royal Melbourne Hospital Victoria, 3050, Australia and The Cancer Institute Melbourne, 3000

It has been established that susceptibility to leukaemia in mice is closely related to the major system of transplantation antigens of mice CH-21. More recently, several workers have demonstrated a close linkage between genes controlling the immune response to synthetic antigens and transplantation antigen genes.

We have studied 127 patients with Hodgkin's disease and demonstrated a significant association with two HL-A antigens, W5 and HL-A11. These associations are most marked in subgroups of patients. Family studies have demonstrated a normal segregation of the antigens suggesting that certain patients have a genetic predisposition to their disease. Further studies of lymphoma patients suggest that transplantation antigens may be involved in other malignancies as HL-A12 has a significant association with the group comprising lymphosarcoma, follicular lymphoma, and reticulum cell sarcoma. These associations may reflect involvement of immune response genes in the oncogenic process.

Studies of various racial groups (Chinese, Malays, Indians and New Guinea natives! have shown that each, have distinct HL-A antigen profiles. If the antigens were related to cancer susceptibility, then this variation in antigenic profile could be important in determining variable racial cancer incidences.

•VβI A116

INCIDENCE AND DISTRIBUTION OF CANCER IN CEYLON,

FERNANDO, H.K.T.

General Hospital, Colombo, Government Cancer Institute, Ceylon.

Incidence and distribution of Cancer vary from country to country. Such variations are believed to be due to racial and environmental factors. Our investigations seem to indicate that the incidence of Cancer in Ceylon is about 110 per 100,000 of the population. Ceylon is predominantly an Oral Cancer country. Cancer arising in the oral cavity comprise around 50$ of all Cancers in Ceylon. The commonest site of Cancer in the mouth is the cheek, which accounts for about 60#. Investigations reveal that local habits play a distinct role in the high rate of Oral Cancer in Ceylon. This high incidence was associated with the habit of chewing of tobacco with betel leaf, betel nut and slaked lime. The lower part of the cheek opposite the molar and premolar teeth appears to be the commonest site of Oral Cancer. This is the site where, the mixture of tobacco, betel leaf and slaked lime is kept for hours after chewing, and this possibly explains the greater frequency of Cancer of the cheek. Carcinoma of the Cervix takes second place to Oral Cancer in Ceylon* The incidence of Cervical Cancer is about 20J*. Multiple pregnancies, neglect of post partum trauma, among the rural population, are said to be some of the factors responsible for the high ratra" e of Cancer of' Cervix~ " . In Ceylon besides the Oral Cavity and Uterine Cervix, ttthoe Pharynx and Oesophagus are affected more frequently than in other countries. From the distribution of Cancer in Ceylon a large proportion of Cancer occurs in the easily accessible regions of the body, namely the Oral Cavity and Uterine Cervix. These forms of Cancer appear to be associated with the habits, customs and other exogenous factors prevalent in the country. AU7

MALIGNANT DISEASES TREATED AT THE JOSE R. REYES MEMORIAL HOSPITAL, MANILA, PHILIPPINES. ( 10 TEARS SDRTET)

LOPEZf LEQlj fr. Department of Radiology Jose R. Reyes Memorial Hospital ttisal Avenue, Manila fhilipplnev A total of 8,432 cases of aalignaneies was treated at the Jose R. Reyes Memorial Hospital in a 10 year period from 1959 - 196f. Non malignant conditions like keloid and hemangioma were excluded from the list. Although the JRRMH is not exclusively a cancer hos- pital but a general hospital, it caters to * large segment of the population of the Philippines particularly referrals from other gorernment hospitals without radiotherapy faci- lities. It has a radiotherapy department with 1

IP A118

THE CYCLOTRON PROJECT IN NATIONAL INSTITUTE OF RADIOLOGICAL SCIENCES

Umegaki,Y.,Tsunemoto,H. KasugafT. and Furuse,T.

Department of Clinical Research and Pathology, National Institute of Radiological Sciences, 4-9-1 Anagawa,Chiba, Japan 280

A medical cyclotron is now under construction at National Institute of Radiological Sciences. This cyclotron is designed to be used both for radiotherapy and nuclear medicine. The maximum energy for particles is 60 MeV for proton, 35 MeV for deuteron, 93 MeV for Helium-3 and 70 MeV for alphaparticle. Both fast neutron and proton will be used for the purpose of radiotherapy.Treatment rooms are designed to do direct view irradiation under the surgical exposure of tumor. During past 3 years, certain preliminary works have been carried out using 2 MeV neutron? generated by Van de Graaf generator.Remarkable enhancement was observed,for some kind of radioresistent tumors of human and experimental animals, in the therapeutic ratio.Especially the RBE value for B16 melanoma in vivo was as high as 13.3 [determined by DQ] or 11.3 [determined by p1Q-2]. Clinical experience showed also a marked radiosensitivlty of malignant melanoma to the neutron. These results suggest a growing possibility to control radio- resistent tumors by high LET radiations.

V t

i .; AI19

CAfiACTERISTICS OF A 35 MEV LINEAR ACCKLERATOH AND DOSIMETRY OF PULSED • RADIATIONS.

Takeshlta, K., Antoku, S. and Sunayaehlki, T. '.!.

Department of Radiation Biology, Research Institute for Nuclear Medicine and Biology• Hiroshima University, v Hiroshima, 73^, Japan. :J

The NEC-Varian linear accelerator in this institute is being used ' for radiological studies by instantaneous exposures similar to that of '^~ ths atomic bomb and for radiation therapy with moderate dose rates. The operation of this unit is divided into two systems, "research mode" ? and "therapy mode". ;; In the research mode, electron energy can be changed continuously j| between 5 and 39 MeV. Beam current is 320 mA at peak with an average ip# of 90 uA at nominal operation of 25 HeV. At this level of operation, !£| X-ray output is 14,500 rad/min at a distance of 100 cm from the target. ' :'-::\ In the therapy mode, six specific energies are programmed over the -:: range of 5 to 30 MeV by 5 MeV interval for electrons, and an energy of IS & MeV for X-rays. 0 To use ionization chambers for dosimetry of pulsed radiations from :.--> the accelerator, the ion-recombination and energy dependence of the -r ; ionization chambers were studied by comparing them with chemical and |; ^ thermoluminescence dosimeters. :'p| The collection efficiencies of an Ionex and a Radocon dosimeters i&| v determined expe?iuentally agreed Kith those calculated using 750 -.:; V-cm-esu" as a constant μ Xn a theoretical formula. The sensitivity ^> changes by radiation and energy were established for the both S^ ionization chambers. i;^: A120

STUDY OF ELECTRON THERAPY WITH LINAC

MatBuda. T. .* Making, S. ,** and Shigemura, N. **

•Department of Radiology, **Medical Appliance Division, Nagoya National Hospital, Tokyo Shibaura Electric Co. Ltd. Nagoya, Japan. Kawasaki, Japan.

Basic and clinical study of electron therapy with a Toshiba 13MeV Linac is reported.

I. Characteristics of electron beam from this linac are:

1) Available energies: 12MeV5 lOMeV and 8MeV. 2) Maximum radiation output: 1000 R/min. at lm. 3) Irradiation field: set selectively from 2cm.fi to 18cm/4 at lm. 4) Dose distribution: as homogeneous as ±3% within an irradiation field of 18cmj£ at lm, even for high exposure. Dose distribution near surface:

Surface dose and build-up due to electron beam from the linac were measured using a shallow chamber. A similar measurement was also performed on a Siemens 18MeV Betatron and the results were compared for relationships with energy, scattering foil and treatment cone, m. Change of the skin by electron therapy.

107 cases of electron therapy with the linac were studied and compared with those treated with electron beam from the betatron. Change of the skin with electrons from the linac proved less serious and quicker recovering than with electrons from the betatron.

IV. Cure effect.

Based on clinical expediences from 107 cases treated with the linac and from 676 cases with the betatron, it is inferred that electron therapy with the Linac is only applicable to superficial tumours within 3. 5 to 4cm from the body surface; however, its cure process and effect, as far as the author's experience is concerned, do not greatly differ from electron therapy with the Betatron. A121

NEUTRON DETECTION BY.FISSION TRACK RECJISTRATION

Iida,H., Koshijima,T. and Takahara,H.

Training Division, National Institute of Radiological Sciences,

9-1f 4-chome, Anagawa, Chiba-shi, Japan.

An easy practical method for neutron detection with fission fragment tracks in solid was investigated.

A neutron detector was developed by us. For the track registrating solid, the dosimeter glass (FD-P8-3, Toshiba) and the cellulosetriacetate sheet were used. On the solid, a little solution of uranylacetate or thoriumchloride, easily obtainable common reagent, was dropped and dried up served as fissionable layer. In order to investigate the effect of the thickness of fissionable layer on track density, we tried an experiment on samples that had various thickness of the layer.

There was a linear relationship between track density and neutron flux. For the thin fissionable layer, the fission track density depended on the thickness of layer, and the saturation thickness was about 5 mg/cm . The combination of a dosimeter glass with uranylacetate had a sensitivity of 1.9 x 10 tracks/neutron for Ra-Be neutron. l|l 1 A122

DYSOSTOSIS MULTIPLEX WITHOUT MUCOPOLISACCHARIDUEIA.

Kozlowaki, K.

Royal Alexandra Hospital for Children, CAMPERDOWH Hew South Wales 2050.

A new classification of congenital bone disease was proposed at the Congress of Paediatric Radiology in Rome 1970.

The subgroup of mucopolisaccharidosis and mucolipidosis will be discussed. Both of these groups are usually characterised clinically by gargoyle-like features and radiographically by "dysostosis multiplex". In the majority of cases the diagnosis can be established on the basis of radiographic findings especially_ if exact clinical data are available. Qualitative mucopolisaccharide investigations may be necessary t& prove the exact diagnosis.

Two cases of severe "dysostbsia multiplex" - one from Poland, another from Australia - will be presented. Both showed no increased secretion of mucopolisaccharides in urine. They were diagnosed as Mucolipidosis 1 (pseudopolidystrophic dwarfism), probably a heterogenous group of diseases characterised by severe "dysostosis multiplex" without increased mucopolisaccharides excretion in urine.

It is important for record and prognostic reasons that an exact diagnosis be established in this difficult group of diseases. This can best be done in specialised centres as has been demonstrated in Paris (France), Kiel (Germany) and Poznan (Poland).

Such a centre is being established at the Royal Alexandra Hospital for Children in Sydney. Skeletal - survey films, photographs of the patient and basic biochemical tests, (Ca.P, alkaline phosphatase, spot test for mucopolisaccharides, slit lamp examination of the cornea, urine chromatography) if possible should be available in cases sent for consultation. i#?Si

IK: A123

APPARENT ACHONDROPLASIA IN INFANCY.

Dr.Valerie Mayne. Royal Children's Hospital, Parkville, 3052, Australia.

We have 3ust passed through an era in which the condition of "short-limbed dwarfism" was synonymous with achondroplasia. During this period those children who survived were often accurately diagnosed during the subsequent years. However, in the case of stillbirths or those who died in infancy, the correct diagnosis was frequently never made and for clinicians particularly interested in this field, only inadequate clinical information and x-rays remain.

Conditions which can be fairly accurately differentiated from achondroplasia are discussed, e.g. asphyxiating thoracic dystrophy thanatophoric and diastrophic dwarfism, achondrogenesis, the Ellis-van-Crevald syndrome, and also spondyloepiphyseal dysplasia congenita.

The importance in distinguishing these conditions can be considered in terms of prognosis for the individual e.g. subsequent crippling deformities in diastrophic dwarfism. Anticipation of complications is paramount in other cases such as the development of renal failure in asphyxiating thoracic dystrophy. However, the moi ' important application is undoubtedly in providing genetic counselling either for the patient or his family. A124

PAEDIATRIC RADIOLOSICAL ANAESTHESIA

T.C.K. Brown and H.G.Hiller. Departments of Anaesthesia and Radiology, Royal Children's Hospital, Parkville, 3052. Australia.

The management of children for radiological procedures is a neglected field of anaesthesia. Among the most technically difficult anaesthetics in paediatrics are those for and bronchography.

This paper will discuss the ways in which the anaesthetist can make the-patient comfortable and at the same time provide the optimum conditions for the conduct of the procedure and for obtaining good quality films ( for example by maintaining a normal PCO_ during cerebral angiography),

A variety of problems face the anaethetist particularly during pneumo- encephalography, bronchography and cerebral angiography. These include postural changes and their effects on blood pressure, airway control and the positioning of equipment.

A few comments on anaesthetic techniques and agents employed will be included.

mif m 1

A125

THE FUNCTIONAL DIAGNOSIS BY CINEFLUOROGRAPHY IN DENTISTRY. • f Fu.jiki YoshishiKe , "I Professor: -V i, Department of Oral Radiology, ; ' Gifu College of Dentistry, v Gifu, Japan. ]/-• In the field of dental roentgenology, the application [ cinefluorography is one of the latest informative methodes. The function of mastication and phonation are important problems in dentistry. By this method, thevarious functional : stages of;,movement are able to_be seen and recorded directly. ;"•• This visualization of the movements makes it "possible to solve the uriknovm rprbblems in these physiologic studies;. *- Iri dentistry, the application of cinefluprbgraphy is k divided into two main purposes: diagnosis and research. - • Then how should it be utilized? K What is the value of it? * I would like to explain how to use it in dentistry. .;v= Part 1. Development of cinefluorography. \ Part 2. Diagnostic use of cinefluorography. g§ , Abnormal jaw movement. '"jS Passavant's phenomena in cleft palate. |pt Improvement of swallowing by speech appliance* ?t| Part 3. Quantitative analysis of cinefluorography. ?i Analysis of jaw movement. | Part 4. Quantitative analysis of cinefluorography. || The effect of the outline form of denture base ^ on movility of complete denture. Itfl "Denture dislodgement in mastication." |te|ife;. i0% A126

LATERAL PALATOGRAPHY - A STUDY OF VEIO-PHARYNGEAL CLOSURE. By Dr. K.N.Kamdar, MBBS, DMRD(Lon-), MSR(Eng.), FICS, FCCP(USA), FICA(New York) and Prof. F.K.OZa, MS(USA), OTR (USA) *****

In modern surgery and other methods of treatment for cleft palate and other defects in and around the nasopharynx, speech therapy plays an important role. To help in treatment of these patients efficiently and to understand the normal velo-pharyngeal closure and its pathological variations, radiology can offer its contribution by demonstration of the movements of the soft palate. This can be convenietly done by taking lateral tele- radiographs of the soft palate, in various positions and phooations. This method is helpful in evaluating the effective length of the soft palate, the pharyngeal depth, the height of the soft palate and various other measurements, by producing certain sounds like alveolgrs, bilabials, velars, dentals, nasalsetc. which determine the movements of the soft palate. The aim of the study, is to ascertain the position of the normal soft palate and its range of movements, as well as the degree of obstruction to the air passage in various conditions. The methods were adopted on patients with nasality of voice, and defective articulation of sound, with due importance given to palatal paralysis, post-operative tonsil-adenoid problem (TAR) and functional as well as psychological causes, with different degrees of incompetence. Conclusion; The study of velo-pharyngeal closure in adults and children, done during normal position and with various phonations indicates that the soft palate exhibits an osci- llatory movements, the degree of elevation of the soft palate varies with different sounds (the elevation varies inversely with its length), and the posterior pharyngeal ridge is a compensatory reqaonse in cleft palate for velo-pharyngeal closure. *****

1 A127

TUB CHILD WITH AN ENLARGED HEAD. Thomas. V.H. Department of Radiology, Royal Children's Hospital, Victoria, 3053, Australia. Head enlargement is a relatively frequent cause of presentation to a paediatric neurological unit, and may be the result of one of a variety of causes. Investigation is largely by radiological means, and is ideally prompt and thorough in an attempt to plan treatment before brain damage progresses. Many of the conditions are amenable to surgical management but unfortunately childhood intracranial malignancy is also relatively common, and often presents as head enlargement due to obstruction of C.S.F. flow. Here, accurate localization of the lesion is required for assessment of palliative procedures. The radiological features of a number of lesions will be presented together with an evaluation of the signs of raised intracranial pressure in childhood, and examples of problems involved with neurosurgical procedures. A128

SPINAL. DYSRAPHISM. Kakarla Subbarao. Department of Radiology, Institute of Medical Sciences and Osmania Medical College, Osmania and fliloufer Hospitals, Hyderabad, A.P., India.

Spinal dysraphism encompasses a multiplicity of lesions resulting from the defective closure of the primitive neural tube. It indicates the common origin of the deformities from failure of development in the median dorsal region and includes abnormalities in the cutaneous, muscular, osseous, vascular and neural tissues, which may occur separately or together. An analysis of 175 such cases is made, which were studied in our institutions between 1964 and 1969. 90% of these cases have presented# with meningoceles or myelomeningoceles in. the back and the remainder 10^ with a variety of clinical manifestations such as regional muscular atrophy, sensory impairment with segmental root distribution, paraplegia, bladder and rectal disturbances and some with foot deformities and cutaneous manifestations such as a dimple or a dermal sinus. The role of radiology in the study of these anomalies by routine radiography and by myelography has been commented upon previously, but a categorical classification of spinal dysraphism has been attempted for the first time. The radiological recogni- tion of spina bifida aperta with meningoceles and myelomeningo- celes is not much of a problem. The problem arises in the study of occult forms of spinal dysraphism with a bizarre neurological deficit which demand a careful and detailed study of the spine followed by myelography. Myelographic recognition of midline septa dividing the menin- ges, and the varying defects resulting from the space occupying lesions such as dermoids, lipomas and neurenteric cysts is imp- ortant. The identification of conus medullaris and the assess- ment of its level is significant in Arnold-Chiari malformations. It is also imporant to locate the conus, myelographically and outline the thin bands and fibrous septa that often produce tra- ction or pressure over the cord and are responsible for the sym- ptoms. Early recognition of these have certainly helped the neu- rosurgeon in correcting some of these defects.

I Mil. A129 '•%

AUTGTOMGGRAPHY OF THE CALCIFIED PINEAL - A SIMPLE AID TO THE ASSESSMENT OF ITS POSITION Faithfull. G. R. Department of Radiology, Repatriation General Hospital, Concord, N.S.W. 2139 AUSTRALIA Assessment of the position of the calcified pineal gland in the routine axial skull views is of considerable importance but also often of considerable difficulty, because of ite projection over the dense midline bony skull. A method of autotomography of the calcified pineal gland is described, simplicity being the keynote, as the method is suggested for use in small departments where usual tomographic equipment may not be available.

mBS-5 A130

RADIOLOGICAL METHODS OF DEMONSTRATION & EVALUATION OP MALABSORPTION SYNDROME OF THE SHALL INTESTINES.

Dr. g> N. Kamdar HSB5(BOB. ) BMHDt ,MSH(Eng.) ,FICS(TJSA) ,FICA(NY) ,FCCP(USA)

Section of Diagnoatic Radiology, University of Bombay* LTMG Medical College ft Hospital, Sion, Bombay 22. O-1O, Commerce Centre, Bombay 34-WB (India).

The non-apecific radiological manifestations associated with steatorrhoea have been described under idiopathic steatorr- hoeas, oaeliac disease & tropical sprue, and other diseases, of defective digestion,due to biliary and pancreatic lesions* Sped fie radiological features of other conditions like jeju- nitis, regional ileitis, diverticulosis and infestations due to giardia lamlia and asceriasis, are discussed.

Various radiological techniques for the demonstration of mal- absorption syndromes, have been evaluated, by study of series of cases, with clinical diagnosis of malabsorption syndrome* Assessment of flocculation of barium, width of the small bowels, and the faecal fat content has been made: the results are evaluated on the diagnostic importance, and the real help that a radiologist can offer to a clinician and to the gastro- enterologies in association with other teats. Complicated and less important methods have been eliminated, because of elaborate procedures with lees practical utility. Some cases of protein-loosing disorders of the gaatro-intestinal tract, including ulcerative colitio.and regional enteritis have been discussed* Results & Conclusion: The main features of the small bowels in primary or secondary ateatorrhoeas are, disorganisation of the auooaal pattern dilatation of the jejunum, flocculation and hypomotility. Thf e features in most eases of untreated stea- torrhoeas were not pathognomonic; these changes also occur in other diseases. A detailed examination for this purpose is Jβ necessary. m m ft

Ri- A131

ENTEBOLITHIASIS PROXIMAL TO STENOSING LESIONS OF THE BOWEL. -

Chawla, S.

Department of Radiology, > Lady Hardinge Medical College and Hospital, NewDelhi-1, India.

Enterolithiasis is a rare entity and occurs as a result of stasis in the intestinal tract. Enterolith formation in duodenal, jejunal, ileal and Meckel's diverticula and proximal to carcinoma and post-operative strictures, has often been reported in the literature.

There are very few reports of enterolith formation proximal to •> granulomas of the bowel. In Lady Hardinge MedicaJ. College Hospital, " i> during the last 12 years, thirty-one patients showed radio-opaque :t calculi on plain X-Ray of the abdomen. Barium studies carried out - in thirty patients showed stenosis of the bowel, distal to the enteroliths ; in all cases. Twenty four patients were operated upon. The enteroliths were found in the ileum or in the proximal colon. In some patients, these were lying in a closed loop of the bowel between two strictures ^β while in others, there was only one distal stricture. Histopathology |if showed stenosis due to tuberculous lesion of the bowel in seventeen IJs, patients and due to non-specific ileitis and colitis in seven. During :?* this period, no case of enterolith formation in a diverticulum or proximal \ to carcinoma of the bowel, was seen. &

The enteroliths vary in number, size, shape and extent of radio- :V

opacity. These have to be differentiated radiologically from vesical ;S; calculi, gall stones and renal calculi, depending upon their site, number •% and radiological appearances and intra-venous pyelography and ftfe may be necessary. Their wide mobility on serial |f ~ films is a characteristic feature and barium study outlining the distal -ll stricture confirms the diagnosis. lg! A132

PEPTIC VUSa. AND THE VAGAL TBIAD.

'Ti Johnaop Sathvabama Johnson Department of Badlology and Madlcine, Christian Ifedical College Hospital, Vellore - 4, India*

A comprehensive study was made on hundreds of patients with radiologieally or surgically proved peptic ulcers. An attempt la made to correlate the clinical findings with the radiological findings and to assess the improvement radiolo- gically after the various surgical procedures*

The patients were subjected to a full barium meal and augnented histamine test after undergoing a thorough physical examination* ; Surgery and follow-up were done on the selected eases*. All follow-up cases had barium meal studies repeated on This study brought out an interesting complex presenta- tion of radiological changes in the oesophagus and small -Intestines in association with peptic ulcer. These changes Included functional alterations in the oesophagus, and Motility and secretary changes in the duodenum, Jejunum and ileum. These are most'probably due to "Hyper-Vagal-State". The various surgical procedures viz.,, gastrojejvinostony with vagotomy, partial gastrectomy, pyloroplasty were followed up to see if any one procedure is better than the other in decreasing or abolishing the radiological changes in the oesophagus or small intestine* The existing concepts of the aetiology of peptic ulcers and the treatment were weighed critically. i:

iz-yp. A133

EMPHYSEMA OF THE STOMACH WITH PORTAL VEIN GAS.

VaUKhan B.F.

Department of Radiology, ROYAL ADELAIDE HOSPITAL, SOUTH AUSTRALIA, 5OOO The case histories and radiological appearances of two patients with sub mucous gastric emphysema second- ary to gastric dilatation are presented. In both patients intra hepatic portal vein gas was displayed. The aetiology of gas in the gastric wall and in the portal vein is 'briefly discussed.

Sffv. f

i A134

X-RAY DIAGNOSIS OF GASTROINTESTINAL TRAGT BY ROTATION-MULTIDIRECTION RADIOGRAPHY

T.Kurokawa, M.D. * S. Nishivama, M.D.** S. Makino*** and K. Hoshi***

• Cancer Institute Hospital TOKYO, JAPAN **Nishiyama's Gastrointestinal Clinic HACHINOHE AOMORI, JAPAN *** Tokyo Shibaura Electric Co., Ltd., KAWASAKI JAPAN

By a conventional X-ray table it is difficult to detect a small change of an upper part and an anterior wall of the stomach. Then we developed and tried to uee a new apparatus called Universal Gyroscopic X-ray TV apparatus.

This apparatus can tilt as same as the conventional table. And the patient, the X-ray tube unit, the spot-film device and the image intensifier can be rotated in one unit in the range of 360" and also 90° to the opposite direction at any angle of tilting. Moreover, only the patient can also be rotated in the range of 90° to the both direction. The patient is to be fastened to the table-top with special fastening bands, and dizziness and uncomfortable feeling are perfectly prevented. The spot-film' device is designed to use roll film, 30cm width and 2, 500cm long, so that seriography can be performed.

As result of clinical uee, the conventional radiographs are also taken. Moreover this apparatus is remarkably effective for detecting small changes of the cardia and the upper part of the corpus by the back-to- belly exposure at the right decumbent position, of the anterior and the posterior wall of the antrum' by the back-to-belly exposure at the left decumbent position. At this position Hypotonic Duodenography can be made easily. Therefore, by using this apparatus it is easy to detect diseases which the conventional unit can not detect enough.

1 A135

RADIOLOGICAL APPEARANCES IN PORTAL HYPERTENSION DUE TO OBLITERATIVE PORTAL VENOPATHY AND CIRRHOSIS OF LIVER

Bhardwaj, O. P., Gulati, P. D., Gupta, D. N. and Chuttani, H. K.

Departments of Radiology, Medicine and Pathology, Maulana Azad Medical College & Irwin Hospital (Delhi University), New Delhi—INDIA.

Portal hypertension in Northern India is due to two main causes i.e. cirrhosis of liver and obliterative portal venopathy, Latter condition is of unknown aetiology where there is intra hepatic obstruction due to lesion in the small radicles of portal vein with no or minimal hepatic cellular dearrangemeru. Detailed radiological study of these two conditions was carried out in order to bring out their distinctive features. Investigations included barium swallow for oesophageal varices and percutaneous portovenographic study of portal vascu- lature by serial radiography. Besides these radiological investigations, clinical features, haemodynamic investigations, biochemical and histological profiles of the patients were studied. Correlation of these parametres was carried out. Following conclusions were drawn. Oesophageal varices were more frequent and extensive, splenic vein and collaterals were more dilated and tortous in obliterative portal venopathy as com- pared to cirrhosis of liver. Left main intrahepatic branch of portal vein was wider than the right in obliterative portal venopathy while in cirrhosis normal pattern was maintained. Intrahepatic portal vasculature was almost normal and extended upto the periphery of the liver in cases of obliterative portal venopathy while in cirrhosis the vascular pattern was seldom normal and extended only upto middle or inner third of liver. Constricted intrahepatic branches with truncated peripheral ends with or without dichotomous arrangement, without any distortion or sweeping was a common feature in more developed cases of obliterative portal venopathy. Distortion of intrahepatic radicles and sweeping with loss of dichotomous arrangement was commonly seen in cirrhosis of liver. Intrahepatic branches were markedly contracted with grannular pattern in places of secondary branches and there was pooling of contrast medium in the distended main portal vein branches in advanced cases of obliterative portal veno- pathy. In contrast, markedly contracted and branchless intrahepatic radicles were seen in advanced cases of cirrhosis of liver.

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I 18 A136

STEREOSCOPIC OBSERVATION OF GASTROINTESTINAL DISEASE Y. Sato Sate Gastrointestinal Clinic Fukuyama City, Hiroshima, Japan. I have invented a nev z-ray apparatus with the aid of Toshiba electric company by which I can take not only plain but also stereoecopic photographs under the fluoroscopic observation of x-ray television. My x-ray tube has two focuses at a distance of 6.5 cm, and this apparatus has been able to accomplish the transition of multiple diaphram collimeter and cassette within 0.5 second. Stereoscopic observation has many uses in the diagnosis of gastro-intestinal disease. I will show you the following pictures by stereoscopic elide on the screen. 1. Stereoscopic struture of cardia. (cancer, varix) 2. Separated observation of the gastric front wall, back wall and the intestinal shadow, (cancer, ulcer) 3. Elevated and excavated mucosal surface (early gastric cancer) 4. Stereoscopic observation of the hypotonic duodenography, (acute pancreatitis, chronic pancreatitis, cancer of pancreas, cancer of duodenum, enlarged lymph nodes) 5- Cancer of caecum. 6. Cancer of sigmoid colon. 7. Extrinsic pressure of the tumor on the gastro-intestinal wall, (pararenal cyste, tuberculom, retroperitoneal ecarcom) A137

CARCINOMA. OF THE OESOPHAGUS IN AFRICA

Palmer, P. E. S.

Department of Radiology University of California Davis, California 95616 USA

Carcinoma of the oesophagus is very common in certain parts of southern Africa and yet extremely rare elsewhere. It varies not only in its incidence in various populations but in its site distribution in the oesophagus. Inten- sive study has brought no conclusive evidence as to its aetiology. A detailed review of 200 patients seen within a period of 18 months in Rhodesia leads to the conclusion that in the majority of cases the patient lives as long and as happily with an oesophageal tube through the growth as by any other means of treatment, whether surgical, radiotherapy, or chemo therapy. An intensive study by radiologists throughout the Asian and Oceanian areas could lead to adequate geographical mapping and possibly some correlation with the African studies. Somewhere there must be a common denominator but so far it has not been revealed.

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A138

HISTOLOGICAL STUDY OP CARCINOMA OF THE ESOPHAGUS . WITH PREOPERATIVE IRRADIATION Yoshinsasa Tanaka Department of Radiology, Tenri Hospital, 200 Mishima-Cho, Tenri, Nara-Ken, Japan. The introspective study of irradiated cancer tissue histolo- gically is very important for the improvement of radiotherapy. Thirty four cases of carcinoma of the esophagus with preoperative irradiation were selected and the distribution of the remained cancer cells, the relationships between capillaries and remained tumor cords,and correlation of total dosis and remained cancer cells were examined. We had also studied relation between histological findings and X-ray or endoscopic findings. These cases were irradiated through two parallel opposing fields using 6 Mev Idniac, weekly dosis of 1,000 R were delivered. Total tumor dosis was 4-6,000 R. According to the degree of radiation effects classified as following 4 groups. l)Cancer cells were found widely in all around of subcuta- neous or muscular tissues of the ulcer. ( I Type: 5 Cases) 2) Large cancer nest was found mostly in the edge of ulcer, sporadically in the center of ulcers. ( II Type: 18 Cases) 3)Cancer cells were found sporadically in the center of the ulcers, not in the edge of ulcer. ( III Type: 5 Cases) 4-) Cancer cell was completely disappeared in which Bleomycin was combined with radiation in 4 cases. ( IV Type: 6 Cases) The number of capillaries were few in the peripheral region surrounding a remained tumor cord compared with another normal tissues. m

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m A139

THE HISTORY, AETIOLOGY AMD DISTRIBUTION OF HODGKIN'S DISEASE

AND THE LYMPHOMAS

Professor P.E.S.Palmer.

Professor of Radiology,

University of California at Davis.

Thomas Hodgkin wrote a paper describing "his" disease in 1832.

He then wrote a textbook in 1836 putting forward a theory for the

causation of cancer; by the end of that same text he had contra-

dicted his own ideas. This sets the pattern for Hodgkin*s disease.

For years it was debated whether it was a cancer, or whether it

could be a granulomatous condition. The majority now agree that it is a malignant neoplasm; the minority still publish papers to prove II them wrong. Probably, both sides are right. It has a known

familial tendency, a variable age occurrence, a debatable group

distribution and no significant geographical pattern.

Burkitt's lymphoma has almost opposite characteristics. A world

wide distribution, as significant for its absences as for its

appearances; a group space and time association which is almost

predictable and a tumour antigenicity. Its occurrence in areas where

chronic malaria is common and its changing pattern in New Guinea

following malarial eradication strongly suggests a relationship, but

not necessarily a common vector. It's opposing frequency relative to the leukaemias may only reflect an altered host response, an idea I strengthened by the ability to progress from lymphoma to leukaemia. I A140

THE PATHOLOGY OP LYMPHOMAS

Dr.Philip Ironside. Cancer Institute Board, 276 William Street, Melbourne 3000 Australia.

The subject is briefly reviewed with particular reference to classification. The reasons for the development of the current systems of classification are indicated. Areas of diagnostic uncertainty in relationship to follicular lymphomas and malignant histiocytosis are described and illustrated.

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A141

ROLE OF DIAGNOSTIC RADIOLOGY INCLUDING LYMPHOGRAPHY IN MALIGNANT LYMPHOMAS. Ohteke, H. Department of Radiology, Iwate Medical University, 19-1 Uchimaru, Morioka City, 020, Japan. As for the radiological checks of the malignant lymphoma, X-ray examinations of the chest and the gastrointestinal tract, pyelography, lymphography and if necessary, X-ray examinations of the bones have been performed, among which X-ray examinations of the gastrointestinal tract and lymphography were focused in ite present paper. We experienced rather often the cases in which malignant lymphomas had metastasized to the gastrointestinal tract especially tht stomach. Although their prognosis were usually unfavorable, prolongation of life was successful by radiotherapy. This fact encourages that the X-ray examinations of the gastrointestinal tract should be done as early as possible on the patients having trouble in the abdomen. Lymphography has also been done on a number of cases of malignant lymphomas. In cases of the head and neck, abnormal findings in lymphography were found frequently in retroperitoneal lymph nodes. On this fact, lymphography is very useful to determine the extension of malignant lymphoma. An advantage was also recognized in that the reduction of lymph nodes in size were observed by radiotherapy through a serial X-ray photography. A142

LYMPHOMAS - ROLE OF NUCLEAR MEDICINE.

YASUKOChI,Ht and ORII,H+.

•DEPARTMENT OF Radiology, •Division of Radiation Research, Branch Hospital, Research Institute, Faculty of Medicine, National Cancer Center. University of Tokyo . Tsukiji 5-1-1, Chuo-ku, Me j•rodai 3-28-6, Bunkyoeku, Tokyo, Japan. Tokyo, Japan.

Malignant lymphomas are sensitive diseases for radiotherapy, and many patients are cured only by irradiation. In our study about 400 cases had been irradiated and the results were already reported.

The results were natural, thefe the suitable irradiation with correct diagnosis may cure the most of cases. On the contrary unsuitable plan or incorrect diagnosis may lead the patient to uncomfortable prognosis. The correct diagnosis of the staging is very difficult. In this point, the li-tiitation is to find the occLlt metastases beyond the first step lymph nodes regions.

Recently, radioisotope technique becomes popular in our country. Many attempts are tried to survey the metastases of the disease. In these techniques 67Ga-citrate deposit scanning and 198Au-colloid indirect radiolymphography are selected for determining the stage of the disease.

The nature of 67Ga-citrate in the body is not well known, but it is very suitable to check the metastases of reticulum cell sarcoma at present.

The indirect radiolymphography has many difficulties as in direct lymphography using contrast media. But the advantage of the indirect radiolymphography are its simple technology and physiological procedures for the patients.

The interpretation of our series will be presented and reported. The present role of radioisotope techniques in out country will be introdiced at the meeting. te mp

I'M •• A143

RADIOTHERAFT OF LTOHOHA, Swing. Donald. Peter. Radiotherapy Department, Frinoe of Wales Hospital, RAHDWICK, sxnror, N.S.W. 2031. Radical x-ray therapy of Kbdgkin'e disease stages I to in and of the other lymphomas stages I and H has been evolved progressively over the years 1967 to 1970 lay members of the Haend.c-I4y1npha.tie Clinic at the Prince of Wales Hospital* In Hodgkin's disease, a policy of radical radio-therapy similar to that reported in Kaplan's earlier publications was adopted. This has been modified twice and in 1970 the protocol was extended to thai; now recommended by Kaplan with some minor variations whloh will be desexibed* During 1970 almost all patients in stages I to HI have had laparotomy and spleneotomy. In the other lymphomas, (giant follicular lymphoma, lymphosarcoma and retieulum cell sarcoma) a slightly less radical approach has been adopted. Radical radiotherapy is given only for stages I and II, laparotomy is not reoomaended and stages III and IT are treated with ehemotberapy. It is hoped that our ezperleno* with these earlier stages will later perait us to assess whether we should treat these patients as radically as Hodgklns* Our experienoe with thirty-five patients with Hodgkin'e disease stages I to HI seen between January 1968 and December 1970 will be desoribed* A144

RADIOGRAPHY AND PLANNING ASPECTS (ON THE TREATMENT OF LYMPHOMA)

Last. Vera. Radiotherapy Department, Prince of Vales Hospital, BANDWICK, SYDNEY, N.S.W. 2031.

The Prince of Wales Hospital uses a modified "Kaplan technique" for the treatment of malignant lymphomas. The whole of the involved, or potentially involved lymph node region is irradiated. The size of the treatment volume is dependant on the extent and staging of the disease and frequently covers an irregularly shaped area eictending from the base of the skull down to and including the para-aortic and pelvic nodes. Treatment is generally given in tiro consecutive stages, one irradiating the "mantle" region and the other the "inverted T" region. Large, irregularly shaped, opposing anterior and posterior fields are used. The main problems encountered are concerned with: 1) Providing accurate and reproducable field shaping. 2) Achieving dose uniformity throughout an anatomical region of varying thickness and contour. The localization films required and the methods used to give the prescribed field shaping will be described, together with the technique of casting angle-edged lead blocks and the use of verification port films. Dose uniformity is achieved using a "poor man's compensating system", i.e. thinner regions are given less treatment and thicker regions more. "Look-up tables" have been calculated to show the number of extra or shielded treatments required at an anatomical site, related to its S.S.D. and thickness measurements, and also tho monitor units neoessary to give the prescribed midpoint dose. No other calculations are required for individual patients. Measurements made to check the dosimetry technique and the lung, spinal cord and gonad doses received will be discussed, as well as the problems of matching adjacent fields and minimising skin doses. A145

CHEMOTHERAPY IN THE MANAGEMENT OP LYMPHOMAS.

Cooper. I.A.

Department of Haematology, Pete? MacCallum Clinic, Cancer Institute, Melbourne, Victoria, 3000, Australia.

Since 1943 when the alkylating agent nitrogen mustard vas first used therapeutically a large number of chemical agents have been developed, which can be shown to be effective in controlling the progress of various malignant diseases. When used singly such drugs produce their effect over a variable time which is usually directed by the development of resistance to the drugs by the tumour cells.

Lymphomas, in particular Hodgkin's disease, have proven to be responsive to a wide variety of drugs possessing different modes of action at cell level. There is a clear theoretical basis for combining such anti-neoplastic agents in order to obtain a therapeutic gain in the treatment of such neoplastic diseases.,

While irradiation has proven to be the treatment of choice for the more limited disease, chemotherapy is considered the more appropriate in the more generalized disease, via. - stage IV disease.

The aim of chemotherapy in such cases is one of attempting to attain a complete remission of the disease and then maintain this state.

During the past three years a study using combination chemotherapy (four drugs) has been carried out at the Peter MacCallum Clinic - more particularly in patients suffering from Hodgkin's disease. Up to the end of two and one half years 55 patients, 31 male and 24 female had been treated under a strict protocol - each receiving 10 days courses of therapy in each of six months. All but 4 of these patients had received prior therapy either chemotherapy or radiotherapy. At the time of assessment, 83.6 per cent of all patients had achieved complete remission. The median length of such a remission has been estimated at 28 months - a marked contrast to the length of remission achieved by the use of a single drug, or two drugs in combination. i A146 mI

THE USE OF BRADYKININ IN ARTERIOGRAPHY Clinical report

Erikson. U.

Department of Diagnostic Radiology- University Hospital mi S-750 14 UPPSALA 14, Sweden

Since 1961 we have used bradykinin in routine peripheral arterio- graphy. Its vasodilative effect has been of great value especially for studying the vessels in the fore arm and lower leg and the arteriograms give more information then the conventional technique without vasodilators. No complications have been noted. Intraarterial infusion of bradykinin before abdominal and renal arteriographies also increases the information content of both the arterial and venous fase of these examinations.

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BRANCH INVOLVEMENT BY DISSECTING AORTIC ANEURYSM - AN AORTOGRAPHIC STUDY.

Svme. James. : Department of Radiol' r, University of Melbourne , The Royal Melbourne Hoapital 3050, Victoria, Australia.

An aortic dissection sac may reduce blood flow in any branch by compressing its true lumen, but may itself supply blood to the affected vessel if there is a local intimal tear. If , aortography is performed by an arterial catheter technique, • detection of such changes in either thoracic or abdominal , branches may explain certain clinical features and may help 'i assess the length of aorta involved, the feasibility of surgical treatment and perhaps prognosis. The findings in branch arteries at aortography are similar to those in the aorta itself* They are described here in detail and illustrated by observations on branches at various levels • from the coronary to the common iliac arteries in a personal ,': series of 15 cases. [!r In two cases the major aortic arch branches were affected by • • a dissection originating distal to the left subclavian artery; ' in one it probably began adjacent an anomalous right subclavian. ] There was a definite tendency to involvement of the left lower ~- intercostal arteries and the left renal artery, to be expected from the usual situation of the sac posterolaterally on the left : • at these levels. In a few cases one kidney, usually the left, : ••; functioned satisfactorily in spite of poor filling of its [_''• artery by contrast injected in the true aortic lumen at the ||., thoraeo-lumbar junction; an attempt is made to explain this. Mtli

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IF A148

ARTERIOGRAPHY IN SURGICAL MANAGEMENT OF THROMBOANGIITIS OBLITERANS

Yong. N.K.. Lambeth. J.T.. Singh. J.

Departments of Surgery and Radiology University of Malaya Kuala Lumpur, Malaysia

Emphasis in previous studies of patients with thromboangiitis obliterans --'AS; . has been correctly placed upon the occlusive lesions in the small peripheral arteries and veins. The efficacy of sympathectomy ir management is recog- nized, but it is generally felt that bypass grafts are seldom indicated.

It is our purpose to show that in the course of the natural history of our patients with thromboangiitis obliterans that percutaneous arteriography IS demonstrated a significant number of segmented occlusions in the medium I sized arteries.

In thirty patients with histologically confirmed diagnoses of thromboangiitis ft; obliterans, six were selected for bypass grafts around occluded segments in medium sized arteries on the basis of arteriography findings. Five of those operated upon had a successful result with prolonged clinical improvement of the operated limb.

Surgically amenable arterial segmental occlusions in our patients with thromboangiitis obliterans, detected by percutaneous arteriography, is more common than generally reported.

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RADIOLOGICAL FINDINGS IN PRIMABT ARTERITIS OF AORTA r, A» H» wml ^nnnt*aj. T« J» Departments of Radiology and Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. Primary arteritis of the aorta, which occurs mainly in young females and most frequently in non-Caucasian races, is a single clinico-pathological entity of unknown aetiology. The essential pathological lesion is a non-specific panarteritis affecting one or more segments of the aorta. The characteristic histological change is found in the media where there is gross destruction of the elastic fibres resulting in dilatation and sometimes fibrosing stenosis of the aorta. The proximal portions of various branches of the aorta become involved in the pathological process with stenosis or occlusion of their lumen. Thus a variety of symptom-complexes may occur depending on which segment or segments of the aorta are affected, Takayasn's syndrome involving the aortic arch being one of them. Very rarely the pulmonary artery may show changes. The clinical diagnosis is suggested when inequality of the peripheral arterial pulses is discovered especially in young females. Confirmation of the diagnosis is dependent on the radiological demonstration of disease of the aorta either localised or diffuse in the absence of syphilis. Radiology is also useful prior to determining surgical intervention, particularly in those cases where the abdominal aorta is affected with resultant renal artery stenosis and hypertension.

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STENOSING AORTITIS Bhargava, S. and Rajani, M. Department of Radiology, All India Institute of Medical Sciences Hospital, New Delhi-16 (India). Various publications dealing with "Non-specific" or #K "Idiopathic" aortitis have so far mainly confined themselves to a study of a part of the aorta or some isolated aspects of the disease process. It is lately appreciated that such a disease known by different names in different parts of the world is most likely the same, the only difference is the interest of the workers in a particular field of study. Surprisingly there are very few reports dealing in toto with the clinical, radiological and pathological aspects of this interesting entity. This study presents our experience of 40 such cases as seen in this part of the world. The clinical assessment and radiological examination including aortograms were routinely carried out. The extent and the number of narrow segments in the aorta and/or the main branches were determined. The resultant multisystem involvement was studied with reference to the cause and effect of circulation comprised to a variable degree.

In addition to the age and sex distribution of this disease, involvement of the arch of the aorta alone or with the descending thoracic or abdominal aorta or the latter alone, was seen with equal frequency.

A very high incidence of renal vessel involvement, either alone or in association with aortic narrowing, was noted. With the exception of the ascending aorta and the coronaries none of the other visceral vessels were immune to involvement. Twelve patients were subjected to surgical procedures in an attempt to relieve their systemic hypertension that was considered to be due to renal vessel involvement alone or as an added factor.

Pre-operative pressure gradients across a narrowed segment were recorded. There were 4 complete autopsies in this study confirming the Stenosing Aortitis and Panarteritis. A151

OUR EXPERIENCES IN AORTOGRAPHY Parthasarathy, L.R. and Menon, A.N.K. Southern Railway Hospital, Madras-23, India. This paper outlines the experience gained at the Southern Railway Hospital, Madras, in the investigation by aortography of all patients of different age groups, with suspected or known pathology in the thorax and abdomen. The use of Seldinger method of percutaneous catheterisation for aortography has not been favoured by us since the chances of thrombus and embolic phenomena occur frequently as the size of the femoral artery in Indian subjects is smaller than the European or American patients. We prefer to do aortography with : '• operative arteriotomy either in the elbow or over the femoral artery for any age group and it has been found that this has been a very satisfactory procedure. All the investigations were done under local anaesthesia after basal narcosis. We have used also in some cases intravenous droperidol and this has been very satisfactory. Some of the younger group need no sedation and may be secured to a "brat-board" and only minimal restraint is required. We have used mostly Conray 480 as contrast media. The arterial catheters are positioned at ;' . the most suitable site with the aid of an image intensifier. %•- The films are taken using a rapid casette changer. Intravenous pyelography is not normally performed as- a separate procedure but films of the pyelogram produced after these studies are taken. This investigation has been done for a variety of conditions both for thorax and abdomen and has been found to be very satisfactory. The authors do not claim any originality for the technique .: but only want to point out a few of the pathological conditions ; ?.. that occur in this part of the country. This method of ^ investigation has been found to be also very useful in the r|i. diagnosis of intra-abdominal tumours in childhood. ;?

-E A152

Angiography of Gallbladder Malignancy Kido, C, and Sasaki, T. Department of Diagnostic Radiology, Aichi Cancer Center Hospital, Chikusa-ku, Nagoya, Japan.

At Aichi Cancer Center Hospital 35 cases of cancer and one of leiomyosarcoma in gallbladder were diagnosed during the last 5 years, all of which were confirmed by subsequent surgery or autopsy. Angiography was done in 19 out of these 36 cases. Gallbladder cancer is not only extremely difficult to be diagnosed preoperatively, but it is also of unfavorable prognosis. This study on the angiographic findings of gall- bladder cancer was made in order to evaluate the usefulness of selective angiography, on the assumption that this technique might serve as a method for the diagnosis of gallbladder malignancy. Histologically, adenocarcinoma was proven in 12 cases, papillary adenocarcinoma in 2, anaplastic carcinoma in 3 and mucodermoid and leiomyosarcoma in each 1. ' The result of selective angiography may be summarized as following; the cystic artery itself presented dilatation in 10 cases, hypervascularity to different extent in 16 cases and tumor stain in 13 cases. These blood vessels had a tumorous nature as well as luminal irregularity and hardening in 13 cases, and displacement or interruption due to the swelling of the gallbladder had occurred in 3 cases. Seven cases presented a slight displacement to the left of the gastroduodenal artery attributable to a swelling of retroperitoneal lymph nodes, enlargement of the choledochus, or infiltration of the tumor into the liver or pancreas.

Among our series, 15 cases were diagnosed preoperative ly by angiography as gallbladder malignancy and 2 erroneously as cancer of the pancreas. Thus angiography enables a high rate (78 %) of successful diagnosis. These cases will be presented and discussed in order to emphasize the usefulness of selective angiography. m A153

AUSTRALIAN STANDARDS OF RADIOACTIVITY AND RADIATION DOSIMETRY,

Richardson, J.F.

Commonwealth X-ray and fiadium Laboratory, 30Lonsdale Street, Melbourne, Victoria, 3D0D, Australia Under the Commonwealth Weights and Measures (National Standards) Act (196D - 1966) the curie (Ci) is prescribed as the legal unit for the measurement of the activity of radionuclides and the roentgen (R) is prescribed as the legal unit for the measurement of exposure to X- and gamma- radiations. The Australian Atomic Energy Commission has the responsibility for maintaining Commonwealth Standards of measurement of activity. The Commonwealth X-ray, and Radium Laboratory has the responsibility for maintaining (a) working standards of measurement of activity and (b) the Commonwealth Standard of measurement of exposure to X rays generated in the range 50 to 250 kV. Both the Australian Atomic Energy Commission and the Commonwealth X-ray and Radium Laboratory have the responsibility for maintaining working standards of exposure to X rays of energies greater than 250 kV, which includes the X rays generated in linear accelerators and the gamma rays emitted by radionuclides. The arrangements made for establishing official Australian standards of measurement of activity and exposure, and the primary standards developed in the Commonwealth X-ray and Radium Laboratory, are briefly described. A154

RADIATION PROTECTION IN INDONESIAN HOSPITALS.

Sombu Pillav. 5.

Division of Radiological Services, Ministry of Health, Djakarta, / Indonesia. In Indonesia, during the last sixteen years, radiation protection monitoring has been carried out by several institutions. The methods used and the procedures followed depended very much an the. monitoring' equipment and the technical staff available. The several reorganisations made in the Ministry of Health of Indonesia has not resulted in a systematic radiation protection survey in Indonesian hospitals. Before the issue of the 5tate Regulation on the Application of Radioactive Isotopes and Radiation in 1969, radiation protection surveys were not compulsory. The above regulation is made under the Atomic Energy Act of 1964.and the administ- ration of it is the responsibility of the National Atomic Energy Agency, as the competent authority. How.ever difficulties have been experienced in applying the-regulation and there is a trend to modify the regulation and delegate the authority for radiation control in the medical field to the Ministry of Health. The—radiation protection in Indonesian hospitals is ' reviewed in the paper. Short term consultants on radiation protection have been made available to Indonesia by the World Health Organization. The suggestions of these consultants are being taken into account in planning a radiation protection laboratory. Strengthening of the radiological services including those relating to radiation protection may require aid from international organizations or foreign institutions.

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PROBLEMS OF RADIATION HEALTH AND SAFETY IN THAILAND. 5amsen. Laksana

Radiation Protection Sexvice, Department of Medical Sciences, Yodse, Bangkok - 1, Thailand.

In Thailand, the Radiation Protection Service (RPS) was established under the Ministry of Public Health through a tripartite agreement between the governments of New Zealand and Thailand, and the World Health Organization. The responsibilities of the RPS caver all matters of radiation protection and calibration arising fiom all uses of X rays and the operation of a radiation monitoring film service for occupationally exposed persons. The RPS has been primarily concerned with a countrywide X-ray, survey to' evaluate the overall radiation protection situation. As of 31 December 1970, the number of registered X-ray machines was 658 units (plus 7 cobalt-60 teletherapy units) of which about 44 per cent were in the Bangkok-Thonburi metropolitan area. The total number of radiation workers in Thailand was 1600 or about 46 persons per million population. The results of the radiation film monitoring service showed average values of 3*6 mR/week and 9.7 mR/week for X-radiation and X + Y radiation exposures respectively. Generally most of the radiation hazards arose from unsafe working practices rather than through lack of material protection. There are serious problems in the surveying of installations in rural towns and these lengthen the time necessary to complete a countrywide survey. Misunderstanding of the objectives of the RPS, lack of co-operation with.the RPS survey team, limitation of transport facilities etc. are among the difficulties which have beset the survey.

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I A156

TRENDS IN X-RAY EXPD5URE IN THE UNITED 5TATE5.

Villforth. J.C.

Bureau of Radiological Health, United States Public Health Service, 5600 Fishers Lane, Rockville, Maryland, 20852.

The presentation is based on the comparison of findings from the U.S. national X-ray Exposure Study in 1970 with a similar study in 1954. Statistical data will be presented giving estimates of the U.S. population X-ray experience in terms of the number of persons X-rayed, X-ray visits, types of examination and exposures. The estimates are categorized by a variety of demographic and X-ray facility characteristics. The data were derived from a nationwide household survey of a representative sample of the U.S. population and a follow-up phase to the X-ray facilities identified in the initial survey.

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A157

ABSORBED DOSE CONSIDERATIONS IN THE USE OF RADIOPHARMACEUTICALS IN NUCLEAR MEDICINE. Keam. D.W.

Commonwealth X-ray and Radium Laboratory, 30 Lonsdale Street, Melbourne, Victoria, 3000, Australia.

When considering the use of a radiopharmaceutical for a particular patient the physician must first decide whether or not the proposed procedure will help in evaluating the clinical status of the patient or will be of therapeutic value to the patient. If the answer is yes, then the decision must be taken as to how much activity must be administered to obtain the required information or result. In diagnostic applications the activity administered should not exceed that which will result in an acceptable value of absorbed dose to the critical organ, this value being dependent on the age and various other factors relating to the subject being investigated. In therapeutic applications the activity administered should be sufficient to produce the desired effect without any detrimental side-effects. #1 The problems and uncertainties in absorbed dose estimations are discussed and the relevant doses resulting from the administration of radioisotopes in a number of currently used nuclear medicine procedures are given. The possibility of reducing these doses in some instances is discussed. A158

WHO ACTIVITIES IN RADIOLOGY

Dr. L. Sundbom WHO Regional Office for the Western Pacific P.O. Box 2932 Manila, Philippines

The activities of WHO In the field of radiology have fallen under the term "radiation health" which includes the basic radiation sciences, radiation hygiene and radiation medicine. The basic radiation sciences such as radiation physics, radio- chemistry, radiobiology, radiobiochemistry and radiation genetics form i the background for all decisions and measures to be taken with regard to hygiene and protection measures as well as to the medical use of radiation. Radiation hygiene Is concerned with radiation effects on man In a broad sense and with all measures to limit these effects so no serious harm may occur. It may be divided into, e.g., radiation pathology, radiation epidemiology, radiation environmental hygiene, irradiation hygiene, and prevention and therapy of radiation effects. Radiation protection partly overlaps with radiation hygiene and its aim is to prevent or moderate radiation exposure of man.

Radiation medicine covers the whole field of diagnostic radiology, radiotherapy (incorporating the therapeutic use of sealed and unsealed radioisotopes) and the diagnostic use of radioisotopes. Furthermore, radiation medicine Includes medical radiation physics as a specialty of physics which is deeply connected with physicians' work.

There is, therefore, a need for close co-operation between a broad spectrum of scientific specialties, including natural scientists of different-types, physicians of different specialties, physicists with different backgrounds and working concepts, engineers, etc. This wide- spread field explains why WHO with its limited resources can only give attention to those problems with the highest priority and cannot equally cover all relevant subjects. Some examples of the activities of WHO will be given. A159

CONGENITAL ABNORMALITIES OP THE THORAX

Professor B.Felson. Department of Radiology, Cincinnati General Hospital, CINCINNATI. U.S.A.

Every radiology department has a large number of congenital intra- thoracic anomalies but pays little attention to them and doesn't appreciate how frequently they occur. Excluding cardiac anomalies, there is a wide variety of congenital lesions,most of which are readily recognised and diagnosed. To prove this point, you will be shown cases given the opportunity to diagnose a number of congenital anomalies from chest films. Each of them will then be discussed and illustrated with additional case material.

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i A160

BASICS OF BARIUM COATING OF MUCOSAL SURFACES

Fischer, H.W. and Schwartz, S.

Department of Radiology, University of Rochester School of Medicine, 260 Crittenden Boulevard, Rochester, New York 14620. Despite long usage of barium sulphate as an alimentary tract contrast material little is known of the reasons why some barium preparations appear preferable to others, a notable exception being the work of Miller.

Using strips of dog and human colon mucosa, the adherence and coating properties of various barium formulations were assessed in vitro by simple visual inspection and by the x-raying of the strips employing a water phantom. These properties were found to be related to the physical factors of concentration of barium viscosity, and the zeta potential of the barium particles. The physical factors were dependent upon additives to the formulations such as carboxymethylcellulose.

si?'Si A161

Fharmacoduodenography ( Hypotonic duodenography ) with simultanous cholangiography by drip injusion.

YAMAGISHI Yoshihiko, M.D., SAITOH Tatuo, M.D., KATO Tomizo, M.D., ITO Tadashi, M.D. (Department of Radiology, Nippon Medical School; 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan)

Since 1964 we have studied and reported on the hypotonic duodeno- graphy as the pharmacoduodenography, and furthermore we have also used combined cholangiography by drip infusion, emphasizing an effectiveness on the x-ray diagnosis not only in the duodenoum itself but also in the adjacent organs, the biliary system and the pancreas.

Our procedure is as follows : First, in the morning, a radiopaque duodenal tube is inserted through the mouth or the nostril till the tip is at the middle portion of the descending duodenum.

Simultaneously, a drip infusion of 200ml of 5% glucose solution and 40ml of 30% Biligrafin is carried out.

Then, 20mg or 40mg of Buscopan is injected intramuscularly. After 5-10 minutes 15ml of 2% Xylocain viscous is injected through the tube into the duodenum. . •

After 5-10 minutes, 30ml of barium suspension or Gastrografin is 'v Injected and x-ray examination is performed with exposures taken at many positions and through different projections including double contrast method by insufflating air through the tube.

Due to this technic, the duodenal loop becomes hypotonic, and the biliary tract is well visualized in many cases.

We can prove the effect of Buscopan and Xylocain viscous in the duodenum i electromyographically. -V !! In conclusion, we emphasize that the pharmacoduodenogrjphy combined || cholangiography by drip infusion is available in the x-ray diagnosis of _'. the duodenum, the pancreas and the biliary tract. Finally, we present interesting cases summarizing our experiences. - i; m A162

STUDY OH EARLY CANCER OP THE CARDIAC REGION

Kobayashi,5., Yamada,A«t Kawai.B., Fujimoto,A, and Nakayama.K. Department of Surgery Institute of Gastro-enterology Tokyo Women's Medical College 10, Kawada-cho, Shinjuku-ku, Tokyo, Japan X-ray findings of the surrounding area of the esophago-cardia m .junc Ti on. The lesions in the cardiac area, at present, still difficult to detect roentgenographsally. Of 214 cardiac cancers operated upon in our institute, early cancer with its infiltration limited within the submucosal layer was found in only 8 cases (3.7$). This is due to the fact that the lesions at the cardia might often be overlooked because of the difficulty of finding it. As in 15$ to 20$ of the cases there were symptoms of upper abdominal pain resembling those pains coming from gastro-duodenal ulcers. Therefore, the doctor could unknowingly err and put the patient on medicine for a benign disease. Out of 214 cases, 151 cases(or 70.5$) were located at the less- er curvature;30cases(or 14.0$) at the posterior wall; 11 cases(or 5.1$) at the anterior wall;8 cases (or 3.7$) at the greater curv- ature; 14 cases(or 6.5$) eircumferentially infiltrated. We perform the double contrast radiograph at the cardiac area with 150 to 200 ml of barium and 150 to 200 ml of air in the foil- owing manner: She patient is first in the supine position and must be ratat- ed 60 to 120 and then we must change the pt's posture with his head tilted down at the angle of 30 to a semi-recumbent position until the best approximation is obtained. Therefore, the double contrast radiograph in this position shows the frontal view of the esophago-cardia junction area, the lesser curvature (anterior part) and the posterior wall. ' We adopted this method as a routine. During the 3 year period from 1968 to 1970, a series of more than 10,000 cases were examined. Consequently, 36 small lesions measuring within 2x2 cm. were detected, among which 4 cases were early cancer. We will demonstrate by slides a few early cancers at the cardi- ac area which we have detected with the double contrast examina- tion. y 1 A163

CONTBOVEItSIES SXPLAIJED: IHATU3 H33NIA AND OESOPHAGO-GA3TRIC JUNCTION.

Chandrahasan Johnson A. Sathvabama Johnson and Doag Siirl.-rpttanam T. Department of Radiology, Medicine and Pathology, Christian Ifedical College Hospital, Vellore - 4, India,

Hiatus hernia and oesophago-gastric junction are subjects extensively covered by literature* But they still remain ill understood, a current topic of controversy between the surgeons, Physicians, Radiologists, Endoscopists, i&nometrologists, Psy- chiatrists, Physiologists, Cardiologists, Neurologists, Pathologists and even Anatomists. This paper is the result of analysis of over 30,000 oesophageal studies. Essentially a radiological study, it included careful history taking, correlating history and physical findings combining operative follow-ups; pressure studies; cine radiography; endoscopies; and nost-aorten (pathological) findings in a few selected cases* The controversies starts with the anatomists, over the presence of the lower oesophageal sphincter, the phrenic ampulla, the vestibule, the vmcosal junction; picked up by the manometrists - worried about the problem of reflux and factors preventing reflux; further carried on by the physicians-and surgeons worried about •the factors Maintaining the oeso-ihago-gastrlc junction from herniating into the thoracic cavity through the hiatus. The radiologists add to the aura of mystery by quoting the incidence of hiatus hernia from almost less than 5 T» to over SO %, An attempt is made to satisfactorily explain these controversies on the basis of a "Dynamic concept" of the oesoinagus under the action of vagal tone, modified by the size of the hiatus and the competency of the lower-oesophaceal-sphincter. The location, aetiology and evolution of the oeso-jhago-gastric ring (3ehatzkyfs Sing) the Barrett's columnary-lined-oesophagus and other controversial findings of the mucosal junction (playing an important role in the occlusial mechanism) are explained on different types of grouping of the oesophagus. 5A

A164

"THB RADIOLOGY OF OBSOPHAGO-OABTBIC ANASTOMOSIS" Blum, C.K. and Freeland, R. Halmyree and Assoc. Hospitals, Lanark, Scotland* '•"T*^'- -J

The radiological features of oesophago-gastric anastomosis following radical oesophagectoay for oesophageal malignancy and extensive fibrosing oesophagitis are analysed. The different level of anastomosis is of little

:»..s importance in the swallowing and emptying mechanism, and there is no difference in the results following a Rt. or Lt. thoracic approach. Regurgitation is rarely observed, and the emptying rate of the stomach is not impaired following bilateral vagotomy. The need for pyloric myotomy has not been confirmed. Follow-up examination of 22 cases of ©esophagectomy gave satisfactory end results in fibrosing oesophagitis and considerable prolongation of subjective wellbeing with an increase of survival time in malignant diseases. A165

PNBUMOIODOVENTRICULOGRAPHY IN THE DIAGNOSIS OF LESIONS WITHIN OR ADJACENT TO THE MIDLINE CAVITIES. Chang, T.

Department of Radiology, National Defence Medical Center, Veterans General Hospital, Taipei, 113, Taiwan, Republic of China

During the past four and a half years 375 intracranial lesions were encountered in the Hospitals affiliated to the National Defence Medical Center, Taipei, Taiwan. 93 Pneumoiodoventriculographies were done in 90 cases. All these lesions were situated within or adjacent to the midline cavities or in the posterior cranial fossa.

The radiological investigation of a small space-occupying lesion situated within or adjacent to the midline cavities or in the posterior cranial fossa is difficult. Echoencephalo- graphy, Gammaencephalography, Cerebral Arteriography or even Pneumoventriculography plus Tomography are of no help in some occasions. On the other hand, Pneumoiodoventriculography, because of its positive contrast and higher gravity than C.S.F. usually gives more information about the size, anatomical location of the lesion as well as the exact site of the obstruction with, or without dislocation of midline structures.

In this series there was no serious complications, except occasional feverishness, headache, nausea and vomiting developed after the procedure and lasted for a short duration. Unpleasant sequelae has been reported in the literatures, but it is quite rare. From our limited experience Pneumoiodo- ventriculography is a very useful procedure for exploration of lesions within or adjacent to the midline cavities, brain stem and the posterior cranial fossa associated with intracranial hypertension. Furthermore, its accuracy and reliability outweigh the extremely rare late disadvantages.

J Si!"

A166

PlflEALOMAS TOD, P. A., JAMIBSON, E. a., PORTER, A. J.

DBPART1BNTS OF RADIOLOOY AND BEUROSURGERY, Royal Brisbane Hospital Hereton Brisbane. Australia*

The radiological appearances of a series of eleven plnealomas Iβ described* Thia includes a series of six operative cases without mortality, a new approach being used.

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A167

OCCULT HYDROCEPHALUS. Perrett, Lance V. Department of Neuroradiology. Royal Adelaide Hospital, Adelaide, 5000, South Australia. The diagnosis of occult normal pressure hydrocephalus has become important as srentriculo - atrial shunting may result In relief of ataxia and dementia. Differentiation from atrophy is important as shunting is less likely to help the latter. Plain films, air encephalography and C.S.F. isotope transport studies were used. Plain films were normal. Encephalography showed ventricular dilation which was greater than those patients with atrophy. The angle formed by the roofs of the lateral ventricles was smaller than in atrophy. There was evidence of subarachnoid obstruction, usually in the basal cisterns, but this was usually shown to better advantage by C.S.F. isotope studies. Conclusion:- Pneumoencephalography and C.S.F. transport studies were complimentary in diagnosing occult hydrocephalus and suitability for shunting. li

m A168

A BE" TECHNIQUE OP SELECTIVE INTERNAL CAROTID ANGIOGRAPHY

Suck Bin H.D.

Department of Radiology National Medical Center 18-79 Ulchiro 6 Ka, Choong-Ku Seouli Korea

She author used catheter method more than 1,000 cases and experien- ced not a single serious complications. For selective internal carotid angiography the author used following technique. Patient in supine position the examiner puncture the common carotid artery at the thyloid level which is about 2 - 3 cm above the ordinary common carotid-puncture. After puncture the common carotid artery the examiner turn the needle top 180° and the needle opening directed to the cervical spine, so as to prevent the guide wire proceed to the external carotid artery. Next, the patients head bend downwards as much as possible. Then the guide wire naturally go into the internal carotid artery (Pig.l). With this new technique among 143 examinations successful internal carotid angiography were 116 examinations (81.9/0 and 27 cases (l8.1?i) failed internal carotid angiography and common carotid angiography were done. For control 95 examinations were performed in usual Seldinger method and only 44 examinations (46.3?0 succeeded internal carotid angiography and remained 51 examinations (53.7/0 made with common carotid angiography. More experienced skillful hand will succeed much more percentage of selective internal carotid angiography by the author's method. A169

LIPOMA OF THE NERVOUS SYSTEM

Sukthornya, C.

Department of Radiology, ChiangMai Medical School, ChiangMai, Thailand.

Lipoma of the nervous system is a rare disease. It rises question regarding its etiology, associated clinical phenomena and management. Since a physician rarely sees this lesion more than once in his active career, recently we encountered two patients with lipoma of the nervous system whose typical clinical and radiological features merit recording. Case I

A 20-year-old Chinese girl entered the Hospital because of have seizure and "dissocial behaviour". She recalled that her first episode of seizure started when she was 6 years of age and had increased in severity and frequency. -

Plain X-ray of the skull in frontal view shows a central area of radiolucency (fat density) with a rim of calcification noted at its margins. Carotid arteriography and pneumoencephalography $_ were also performed. A preoperative radiological diagnosis of | lipoma of the corpus callosum was given and was confirmed by J pathological diagnosis. '

Case II A 38-year-old Thai lady was admitted to the Hospital complaining of muscular spasm of both legs for 8 months and difficulty on walking for 3 months. Examination showed poor ; muscle power of the lower limbs with exaggeration of all ;: reflexes and positive pathological reflexes. Plain X-rays of | the lumbar spine reveal thining of the pedicles of T9 to 112 |: with also enlargement of the vertebral canal. The density in 1 the region of the enlarged canal is being that of a "radiolucent r or fat" density. A preoperative radiologic diagnosis of "lipoma of the spinal cord" was given and was confirmed by a pathological diagnosis. A170

TEACHING RADIOLOGY IN A BRAND NEW MEDICAL SCHOOL.

Palmer. P.E.5.

Department of Radiology, University of California, Davis, California 95616, U.S.A. IF The Medical School at the University of Davis was started four years ago. It now takes in 100 new students every year. Radiology came on the scene three years after the school had started. Since then teaching has been integrated from the first year onwards. A Radiologist teaches in association with almost all other preclinical and clinical specialists. Every opportunity to correlate Radiology with the clinical and pathological pictures is ski accepted. The whole program for the Medical School is undertaken in prefabricated buildings and in association with an existing hospital. A. Medical School is possible wi-Ehout expensive architecture, and Radiology takes its place equally with all other methods of teaching right from the start of the curriculum. A171

MEDICAL RADIOLOGY IN INDONESIA

Iljas, Gani

Department of Radiology, Medical School University of Indonesia, Salemba 6, Djakarta, Indonesia. All matters relating to medical radiology in Indonesia are coordinated and supervised by the Radiological Division of the Ministry of Health, Republic of Indonesia.

This body provides the planning for radiological facilities in hospitals throughout the country. At the present time it runs a School of Radiography and a School of X-ray Engineers in Dr. Tjipto Mangunkusumo Hospital in Djakarta.

Manpower in the different sections of medical radiology is still in great shortage (radiologist, medical physicists, radiographers and X-ray engineers). Training in the para- medical level is now being actively carried out in close cooperation with the W.H.C.

The training of radiologists is done in close cooperation with the Medical Schools and the Indonesian Society of Radiology. Data will be shown regarding the radiological facilities/ number of radiologic personnel at-Ehs different levels available at the present time, etc.

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61 A172

PREPARATION OF MATERIAL FOR TEACHING RADIOLOGY. Hood, J.H. Sub-Department of Radiology, University of Queensland, Royal Brisbane Hospital, Herston, 4029, Queensland, Australia. Successful teaching of Radiology depends on availability of suitable material, properly indexed with clinico-pathological correlation. This paper describes the systems used in this department for collecting suitable radiographs, indexing, filing, duplication and slide preparation. ^Various technical procedures utilised are discussed in some detail so that * / may be implemented elsewhere, if so desired.

it A173

RECENT CHANGES IN MEDICAL AND RADIOLOGICAL EDUCATION IN THE UNITED STATES.

O'Loughlin, Bernard J., M.D.

Department of Radiological Sciences University of California, Irvine California College of Medicine Irvine, California 92664

Recently there have been great changes in the curriculum of most of the United States Medical Schools. These changes have sometimes been minor ones, but in most instances they have altered fundamentally the educational pat- terns established by Abraham Flexner in his 1910 report to the AMA and the Carnegie Foundation.

Before that time, American schools required an average of only two years training. They were proprietary and had few if any scholastic entrance re- quirements. Many states licensed practitioners who had simply served apprenticeships.

Following Flexner's recommendations, the American medical schools were patterned after those in Germany (with some minor British modifications). Accent was on intensive and prolonged study of the "basic sciences", both as preparation for medical school and in its first two "basic science" years. Medical school was standardized at four -years and four years of college preparation became the rule. Graduation was followed by a year cf internship. Now nearly all U.S. students take an additional three to six years of postdoctoral "residency" training.

For the past 5-6 years, a revolt against the rigid, germanic "lock-step" medical school curriculum has been brewing and has now erupted with the formation c£ several new patterns of medical education. These will be discussed in some detail.

Most of the new curricula intend to shorten the time of medical studies. Many intend to allow move flexibility and more options. Some of the results have been unexpected. Some have elicited reactionary trends. These will be described.

More recently the internship has been absorbed into the residency years. Continuing education is emphasized and re-examinations are being proposed. Changes in the residency have been made by Internal Medicine and Radiology. This latter will be elaborated upon. A174

COMMUNICATION IN RADIOLOGY

Fischer, Harry W.

Department of Radiology, University of Rochester School of Medicine, 260 Crittenden Boulevard, Rochester, New York 14620

With the increased volume of radiologic work due to expansion of usage of all types of examinations, and due to the increasing complexity of certain radiologic procedures, a worldwide shortage of radiologists exists, which will not be alleviated in the near future.

Of the proposed solutions to this dilemma, one of the most attractive is to have the radiologist become more efficient in his daily activity. The various means of communication whereby the radiologist communicates with the patient, with members of his own department, and with personnel in the hospital and outside the hospital will be considered, and their advantages and disadvantages discussed. These include the proper use of electronic intercoms, television, the computer, light signals, film filing and retrieval systems, electronic recording, scheduling of patients and miniaturization techniques. A175

BONE SCANNING WITH RADIOACTIVE BARIUM

Hosain, F., Syed, I. B., Dugal, P. and Wagner, H. N. Jr.

Division of Nuclear Medicine, The Johns Hopkins Medical Institutions, Baltimore, Md.21205, USA.

Bone scanning is valuable for the detection of early skeletal metastases. Unfortunately, an ideal bone scanning agent is not yet available. At present, the choice lies between strontium-85, strontium-87m and fluorine-18. Radioactive gallium or calcium-47 did not offer any significant improvement. Recently, technetium-99m labelled tripolyphosphate and weakly chelated dysprosium-157 of the rare earth elements have been reported as potential bone scanning agents. We, and other investigators, have been evaluating , radioactive barium as a potential bone scanning agent. ' We have performed bone scans with barium-131 (T^ = 12 d, E^ = 124-496 keV), barium-133m (T^ = 39 h, Eγ = 276 keV) and barium-135m (Tj^ = 29 h, Er = 268 *• keV). Barium belongs to alkaline earth group, and its behaviour is similar | . to calcium and strontium. Intravenously injected radioactive barium, in [ ionic form, is rapidly cleared from the blood due to accumulation in the skeleton and secretion into the gastrointestines. Two scans, following laxatives, obtained at 1 and 2 days help to differentiate bone lesions from the interferring fecal radioactivity. This is important particularly ; for the region between thoracic to pelvic, otherwise a scan after a few hour i is good for extremities. Excellent images were obtained with gamma camera. |j Although barium is a toxic element, we have a minimum safety factor of 5000 ' as determined from the LD-50 in mice and the lowest specific activity in the l. dose. The radiation doses to the total body and skeleton were calculated to be 0.3 and 1.2 rads from one mCi dose of Ba-135m. Relative radiation doses can be represented as Sr-85 > Ba-131 > Ba-133m> Ba-135m» F-18. , A176

RADIOISOTOPE SURVEY FOR BONE METASTASES OF THE.CARCINOMA OF THE BREAST USING 87mSr ^j> WHOLE BODY SCANNER. II Uchiyama, G., Kakehi, H., Arimizu, N., Yui, N. and Saegusa, T. Department of Radiology, Chiba University Hospital, Chiba, Japan. The periodical X-ray bone survey of the entire skeleton after the surgery of the carcinoma of the breast is somewhat troublesome and may miss bone metastases when patients complain of no pain.

The bone survey using Sr and the whole body scanner, which allows examination of the entire skeleton within half an hour, is relatively easy, and sensitive enough to detect most metastatic tumours of bone.

Thirty three patients who had had the first skeletal scans within three months after surgery were selected for the study. About 10% of them were proved to have bone metastases by the first scans even though they had not complained of pain. This suggests the need of radioisotope bone survey before surgery, at least in the group with third stage carcinoma of the breast.

A case with positive scan without any X-ray changes at that time later shews destruction of bone in the lumbar spine as expected.

About 10% false-positive cases including spondylitis deformans were clarified by rescans of X-ray findings. No false-negative cases were so far found in this series. A177

RADIOISOTOPE STUDIES OF THE RETICULO-ENDOTHELIAL SYSTEM R. Sephton and J.J•Martin Nuclear Medicine Department, Cancer Institute* William Street, Melbourne, 3000, Australia

This vork concerns the value and interpretation of scan investigations of organs containing reticulo-endothelial cells - liver, spleen and bone marrow - which include in their scope evaluation of certain aspects of reticulo-endothelial function as a whole. Extensions to the conventional scan procedure involve monitoring clearance kinetics for the tracer colloid,, and assessing Its eventual distribution between the three reticulo- endothelial components, (liver, spleen and bone marrow) QQin For the several COARSE and FINE preparations of Tc sulphur colloid and Au198 colloid used in this study, the following background information is relevant. The hepatic and splenic reticulo-endothelial system exhibit high (1002) extraction efficiencies towards COARSE colloid, as do lymph nodes for this material when lymph borne. Foi FINE colloids, splenic and lymph node efficiencies are considerably reduced (402) though hepatic efficiency is still quite high (70-80%). The marrow reticulo-eadothelial system appears indifferent to colloid particle size though its efficiency is not reliably known. A routine investigation (scan) incorporates kinetic studies at liver and head (or heart) sites following tracer injection, with subsequent simultaneous scanning of liver /spleen and pelvic marrow fields. Instrumentation requirements are dual detectors and dual recording facilities. The kinetic tracings measure colloid clearance rate and cardiac output* and thus assess reticulo-endothelial flow as A fraction of the cardiac output. Anterior and posterior views of the two scanned fields, together with profile scans using slit collimatlon, show the distribution of colloid between the three reticulo-endothelial containing organs, plus of course focal defects within them. In effect thens as well as the scan views, the distribution of the circulation to the reticulo-endothelial system comes under examination*

Experience of malignant conditions, gained through the frequently requested liver scan, suggests that such detailed information assists significantly in an overall clinical evaluation and incidentally, throws interesting light on such aspects of "reticulo-endotheliai activity" in various pathophysiological circumstances. Of some special interest are the malignant lymphomas where the more comprehensive appraisal of the reticulo-endothelial system seems more illuminating than the liver picture (scan) itself, which is usually unremarkable* §;•• A178

SCINTIGRAPHY: A DIAGNOSTIC AID IN HODGKIN'S DISEASE Haage, H., Be Cher, R. and Gremmel, H.

Radiologische Klinik Universitat Kiel Kiel, West-Germany

In the course of three years 68 patients ( 32 female, 36 male ) suffering from HODGKIN'S disease were submitted to 190 scintigraphic investigations of liver, spleen, lungs, lymphatic system and skeleton. A detailed report is given on methods of investigations, value and results. The results concerning the classification of the indi- vidual case are of special interest because of its possibly m considerable effects on therapy and prognosis. Relationship between histological type and affected organs is discussed. A179

LONG-TERM RESULTS OP RADIOIODINS TREATMENT OP HYPERTHYROIDISM

Anno, Y.

Department of Radiology, Tottori University School of Medicine, Yonago, 683, Japan.

Hypothyroidism after radioiodine therapy of hyperthyroid- ism has been supposed to develop in Japan fewer than in Europe or America. To make sure of the fact, 1124 patients treated in five institutes with ^ I from one to twelve years previously were examined. These were about one tenth of the estimated number of patients thus treated in Japan during the corresponding period. Average dose of ^ I in the examined patients was similar to that in the latter. The rising incidence of hypothyroidism after ^ I treat- ment was found in a lower rate than those reported by several western authors, and reached about 20$ in the patients 12 years after the treatment. On the other hand, about 5$> of all patients were still hyperthyroid one to ten years after the beginning of radioiodine treatment. This suggests that the lower incidence rate of hypo- thyroidism Jα Japan may be mainly due to the lower dosage of Wl

i •• ft?

It' A180

->:>.-V RADIOISOTOPIC ASSESMENT ON DEVELOPMENT OF RADIATION PNEUMONITIS AND FIBROSIS

Shinohara, S.. and Arikawa. K.

Department of Radiology Kagoshima University School of Medicine 8-3 Shiroyama-cho, Kagoshima, JAPAN

According to the spread of supervoltage radiation therapy for intra and/or extra thoracic malignant lesion, radiation pneumonitis and fibrosis have become frequent event. The effects of thoracic irradiation are incompletely reflected by x-ray changes. Scanning of the lung with 0*IMAA (macroaggregated albumin) is an additional method for the investi- gation of altered pulmonary perfusion due to the effects of irradiation

For prospective study of earlier detection of radiation pneumonitis and/or fibrosis than by chest radiography, the sequential pulmonary arterial perfusion rate in irradiated upper lung region were investi- gated with patients who received incidental pulmonary irradiation for postoperative cobalt 60 teletherapy of breast cancer.

The relative pulmonary blood flow rate to irradiated upper lung region was calculated by the method measuring the area enclosed by time activity curve which was obtained from scanning on both upper lung region with special collimator after intravenpus injection of 30-50 Mm microcuries of "iMAA.

In more than half of the patients the pulmonary blood flow rate decreased coincidentaly with increasing radiation dose during a period of treatment. If we postulate that the decreasing degree of 50% at the time of 4 weeks following treatment is available as an indicator for appearance of radiation pneumonitis, incidence' of pneumonitis was higher in the m group of less than 50Z than In the group of more than 50%. A181

tIC BASIS OF

B. W. HOLLOWAY DEPARTMENT OF GENETICS MONASH UNIVERSITY CLAYTON, VICTORIA 3168

A genetic approach to the stuay of radiation sensitivity of micro- organisms has shown that a variety of genetic elements can contribute to radiation response including both chromosomal and extra-chromosomal genes.

The characterization of a range of mutants with different radiosensitivities has enabled the enzymology of radiation response to be studied, and it is clear that micro-organisms possess a variety of enzymatic repair mechanisms which operate to minimize the lethal and other effects of radiation induced leaions to the DNA. The repair mechanisms are known to be also concerned with other normal functions of the cell, such as genetic recombination. Thene studies provide a model, not only for a fuller understanding of the nature of radiation damage in higher organisms, but point to ways in which the radiation sensitivity of higher organisms may be varied experimentally. m A182 Sfcf! life'' EFFECT OF X IRRADIATION ON HYDROXYUREA IN VIVO SYNCHRONIZED HEMOPOIETIC CELLS. G. S. Hodgson. Biological Research Unit, Cancer Institute, 278 William Street, Melbourne, Victoria 3000, Australia.

Hydroxyurea is a useful drug for in .vivo cell kinetic studies, as it can be used to accumulate cells in the pre-DNA synthesis phase of the cycle. The effect of X irradiation on hydroxyurea synchronized erythropoietically committed progenitors and on stem cells has been studied. While erythropoietic progenitors show a marked- increase in radidsensitivity after hydroxyurea treatment, cycling stem cells do not. It is postulated that the difference in response may reflect the difference in the number of cell generations the two types of cells have to undergo before giving rise to the end product cells assayed. A183

COMBINED TREATMENT OF MALIGNANT TUMOR WITH IRRADIATION AND BLEOMYCIN.

Yamashita, , Nagase, K Amino, S.2^, Gomi, M. Kamata, R. ' and Kaneda, K. '

Department of Radiology, Medical School (M.) Keio Univ. ' 35 Shinanomachi, Shinjuku, Tokyo, Japan. Tokyo M. Univ.2), M. Gikei Univ.3), Nippon M. Univ.4)and Cancer Inst. Hosp.5)

Systematical combined treatment of malignant tumor were performed with irradiation and administration of Bleomycin, and remarkable good results were obtained.

As tumor dose, 5000-7000 rads were irradiated with Gamma rays of Co-60 or X-rays of 4-6 MeV Linac. In some cases electron beams of Betatron or brachy- therapy were used at.tumor dose of 6000-9000 rads\ Bleomycin was given with daily dose of 15 mg in 2 times a week, and the total dose were 150-300 mg. In 37 cases, both irradiation and Bleomycin performed in same time, and in 11 cases Bleomycin was preceded and in.4 cases postponed to irradiation.

Total numbers of patients was 52. Main sites of the tumor were as follows: Cancer of esophagus in 16 cases, cancer of the tongue in 8 cases, cancer of maxillary sinus in 6 cases, cancer of the pharynx in 6 cases, cancer of larynx in 4 cases, brain tumor in 4 cases and the others in 6 cases.

Complete disappearance of the tumor was seen in 33 cases (63%), effective results in 18 cases (35%), and non-effective results in one case (2%). Side effects were fever in 15 cases, epidermatitis in 10 cases, epilation in 3 cases, stomatitis in 5 cases, and fibrosis of the lung in 3 cases. Although in most cases the tumor was rather advanced, primary cure rate of 63% was fairly excellent. m---

AIM

One-Shot Infusion of Anti-Cancer Drug through the Celiac Artery for Liver Metastasis.

Kido, C. Department of Diagnostic Radiology, Aichi Cancer Center Hospital/ Chikusa-ku, Nagoya, Japan.

Liver metastasis is very difficult to treat surgically because of its multiple simultaneous occurrence and wide scatter- ing. Therefore, the intra-arterial administration of anti- cancer drugs in the hepatic artery had drawn wide attention (Ecker and Miller). Regional administration obtained some local effect such as shrinkage or disapperance of a tumor and alleviation of pain. Liver metastases are generally revealed after radical surgery for primary lesions. So it is desirable that administration is done instead of surgery.

One-shot infusion of anti-cancer drugs was done into the celiac or common hepatic artery by a catheter which was introduced by Seldinger's method.

A total of 56 cases of liver metastases was treated by this method. All cases were followed after the administration of drugs. In spite of shrinkage or disappearance of the tumor, nine casqs which received only one administration of Mitomycin-C died within five months. On the other hand, ten cases which were treated two or more times survived longer than five months and four cases which were treated three or four times survived for over one year. The longest survival was 21,5 months.

Therefore, one-shot infusion of M.M.C. into the celiac artery should be recommended to treat liver meteistasis from cancers of the stomach. In order to prolong the survival of patients with liver metastases, the treatment should be repeated several times with two to three-month intervals.

No noteworthy effectiveness appeared in the case of colon and rectal cancer and so on, therefore we are attempting to improve the result, for example, by choice of different drugs, combination with other anti-cancer drugs or radiotherapy. A185

RADIOTHERAPY IN HYPERBARIC OXYGEN - A REVIEY/ OF 500 CASES TREATED, 1964 TO 1971

HARVEY, N.D.M. Radiotherapy Department, Royal Adelaide Hospital, ADELAIDE. S. Aust., 5000.

Radiotherapy in hyperbaric oxygen was introduced and has developed since as part of the routine work of the radiotherapy service. It has been used in a wide variety of cases principally in the treatment of locally advanced and recurrent disease. All but a few cases have been treated conscious at 3 atmospheres absolute, the majority as outpatients, by techniques which have become progressively simpler with experience. Tumour control in those groups of head and neck cancer suitable for analysis appear considerably improved in comparison with results previously obtained. A prospective random comparison with irradiation in air for cancer of the lung shows a small but significantly increased survival for cases treated in oxygen. Dosage fractionation is standardised at 450 rsds twice weekly to a maximum of 4,500 to 4,950 rads. Normal tissue damage with these dosages has been generally acceptable and safely permits both planned, preliminary infusional chemotherapy, or subsequent salvage by interstitial irradiation or surgery. A186

LCXJMi TUMOR BLOOD FLOW AND RADIOSENSITIVITY Yoshlmasa Tanaka Department of Radiology, fEenri Hospital, 200 Mishima-cho, Tenri, Nara-Ken, Japan. The radiosensitivity of tumor tissue depends on not only radiosensitivity of tumor cell itself but surrounding enviromental factors of cancer cells. In the latter, the condition of capillaries, i.e. blood flow is an important factor determining the variations oxygenation within a solid tumor. In this study, we determined tumor blood flow(T.B.F.) by the method of resorption of Xe 135 and relationship between tumor size and blood flow, various factors influencing T.B.F., correlation of T.B.F. and radiosensitivity, and changes of this value by fractionation. Small amount of Xe 133 was injected intra-tumorally, and Xβ l^3 clearance curve are obtained using scintillation recorder. Ehrlichs transplanted mice tumor, superficial human tumors and cervical cancer were used and the following results were obtained; a) T.B.F. was decreased markedly as the tumor size increase at 0.3-1.0 enr and then reached plateau. b) Physico-chemical factors such as the vasoactive drugs and microwaves were tried before measurement. These drugs mostly decreased or had no effect on T.B.F., microwaves sometimes increased T.B.F.. c) Radiosensitive cervical cancer showed nearly three times higher T.B.F. values than that of radioresistant ones. d) In Ehrlichs transplanted tumors, it was found that tumors having greater T.B.F. showed higher tumor curability. A187

FRACTIONATION IN RADIOTHERAPY OF HEAD AND NECK CARCINOMAS

Ho. J.H.C.

M. & H. D. Institute of Radiology, Queen Elizabeth Hospital, Kowloon, Hong Kong.

In the past when knowledge of radiobiological effects was scanty, one was inclined to protract a course of radiotherapy giving a large number of small daily fractions and be guided by the delayed normal tissue reaction and tumour response. This practice is no longer justifiable. Radiotherapists are now trying to find the optimal time -dose relationship in the treatment of different types of tumour at various sites, "which have different tissue tolerance. This had led tc the development of the concept of the nominal standard dose (NSD) by Ellis.

For some tumours an increase in dose beyond a certain level found by experience to be effective does net improve treatment results, but for the majority of tumours the results appear to improve with increasing dose levels. For these cases the limit is set by the tissue tolerance in the high-dose region.

The results of clinical trials on the effectiveness of tumour control and tissue reaction, immediate and delayed, of three dose schedules (250 rads of 5.6 MeV photon?- tumour dose 4 times weekly to 6,000; 350 rads twice weekly to 4,200; and 420 rads twice weekly to 5,040) in the treatment of carcinoma of the nasopharynx, a region which contains bones and air cavities in addition to soft tissue, are presented and discussed together with the results of treatment of cervical lymph nodes by 7 weekly fractions of 600 and 580 rads.

Judging from the results of these trials it is felt that the giving of fewer but larger fractions per week in the treatment of head and neck tumours is fully justified. AUTHORS INDEX

ABDUL GHANI, H.B. - A 109 EKHOLM, J. - A 52 AGGARWAL, H.H. - A 108 ERIKSON, U. - A 51, A 52, A 146 AGGARWAL, S.P. - A 24 EWING, D.P. - A 89, A 143 AHMAD, A. - A 33 AHUJA, M.M.S. - A 82 AKUTSU, T. - A 94 AMINO, S. - A 183 FAITHFULL, G.R. - A 129 ANDREWS, J.T. - A 14 FELSON, B. - A 100, A 159 ANG, A.H. - A 149 FERNANDO, H.K.T. - A 116 ANNO, Y. - A 179 FISCHER, H.W. - A 25, A 54, A 55 ANTOKU, S. - A 119 A 160, A 174 AREEKUL, S. - A 99 FORBES, J.F. - A 115 ARIKAWA, K. - A 180 FREELAND, R. - A 48, A 164 ARIMIZU, N. - A 176 FUJIKI, Y. - A 125 ARSJAD, D. - A 83 FUJMAKI, E. - A 46 ARTHACHINTA, S. - A 77 FUJIMOTO, A. - A 43, A 162 ATKINSON, L. - A 89 FUJIOKA, M. A 46 FURUSE, T. - A 118

BAHK, Y.W. - A 9 BAZAZ MALLICK, G. - A 108 GIBSON, R.D. - A 80 BECHER, R. - A 178 GOHKE, H. - A 59 BENNESS, G.T. - A 19, A 53 GOMI, M. - A 183 BHARDWAJ, O.P. - A 108, A 135 GRAST, R.E. - A 27 BHARGAVA, S. - A 82, A 150 GREMMEL, H_ - A 178 BJORK, L. - A 17, A 51, A 52 GULATI, P.D. - A 135 BLUM, C.K. - A 48, A 164 GUPTA, D.N. - A 135 BOURNE, R.G. - A 32, A 91 BRADLEY, J.M. - A 92 BROWN, T.C.K. - A 124 HAAGE, H. - A 178 HARE, W.S.C. - A 14, A 23 HARVEY, N.D.M. - A 185 CARR, J.D. - A 25 HAYASHI, F. - A 46 CHAMBERLAIN, R.H. - A 67 HILLER, H.G. - A 124 CHANG, T. - A 165 HIRAMATSU, Y. - A 46 CHANTACHUM, Y. - A 99 HO, J.H.C. - A 31, A 62, A 72, A 187 CHAWLA, S. - A 110, A 131 HODGSON, G.S. - A 182 CHEE, C.S. - A 86 HOLLOWAY, B.W. - A 181 CHERIYAN, T.J. - A 16 HOMMA, M. - A 57 CHIA, K.B. - A 22 HOOD, J.H. - A 4, A 172 CHUTTANI, H.K. - A 108, A 135 HOSAIN, F. - A 175 CLAREBROUGH, J.K. - A 38 HOSHI, K. - A 134 COOPER, I.A. - A 145 HSU, J.C.Y. - A 76 COUNSELL, J.T. - A 95 CRAIG, C. - A 27

IIDA, H. - A 121 ILJAS, G. - A 171 DAETZ, P. - A 66 INAHOTO, K. - A 105 DANARAJ, T.J. - A 149 INDYK, J.S. - A 96 DEVAKUL, K. - A 99 INGELMAN, B. - A 51, A 52 DE WILDE, F. - A 89 IRONSIDE, P. - A 140 DHARMALINGAM, S.K. - A 63 ISOME, S. - A 70 DINMAN, B.D. - A 85 ITO, T. - A 161 DITCHEK, T. - A 85 ITO, Y. - A 42 DODSON, V.N. - A 85 IWAI, Y. - A 69 DOUST, V,L. - A 54 DUGAL, 2. - A 175 DUGDALE, L.M. - A 95, A 97 DUVAL, P.J. - A 61 JAMESON, J.B. - A 45 MADIGAN, J. - A 115 KM: JAMIESON, K.G. - A 166 MAGNUSON, H.J. - A 85 JAMMET, H.P. - A 7 MAHESHWARI, H.B. - A 110 JAYASINGHE, M. deS. - A 15 MAKING, S. - A 36, A 59, A 69, A 120 JEFFERSON, N.R. - A 47 A 134 JOHNSON, A.C. - A 132, A 163 MANSlFiAN, K. - A 29 JOHNSON, S. - A 132, A 163 MARGIESON, G.R. - A 87 JOSEPH, L.B. - A 60 MARTIN, J.J. - A 177 MATHEW, A. - A 16 MATSUDA, H. - A 105 MATSUDA, T. - A 59, A 120 KAII, S. - A 57 MATSUMOTO, K. - A 94 KAKEHI, H. - A 1,6 MAYNE, V. - A 123 KAMAIA, R. - A 183 MENON, A.N.K. - A 78, A 151 KAMDAR, K.N. - A 126, A 130 MITA, M. - A 37 KANEDA, K. - A 183 MITSUHASHI, H. - A 37 RANG, S.R. - A 21, A 168 MORRIS, P.J. - A 115 KARTOLEKSONO, S. - A 112 MUKERJEE, P. - A 110 KASHEMSANT, U. - A 77 MUKERJI, A. - A 49 KASUGA, T. - A 118 MURRAY, I.P.C. - A 96 KATO, T. - A 161 KAWAI, B. - A 43, A 162 REAM, D.W. - A 157 KHAMAPIRAD, B. - A 50 NAGASE, T. - A 41, A 183 KHAMAPIRAD, T. - A 50 NAKAYAKA, K. - A 43, A 162 KHOO, F.Y. - A 22 NISHIYAMA, S. - A 134 KIDO, C.-A 11, A 73, A 152, A 184 NOBEGHI, T. - A 46 KIKUCHI, Y. - A 37 KIM, H.S. - A 101 KOBAYASHI, S. - A 43, A 162 KOBAYASHI, T. - A 40 OGISO, A. - A 94 KOHNO, H. - A 98 OHSAUA, T. - A 37 KOSHUMA, T. - A 121 OHTAKE, H. - A 111, A 141 KOZLOWSKI,. K. - A 122 OKUHARA, M. - A 57, A 102 KUAN, V.Y.C. - A 56 OKDRA, J. - A 41 KULAVEERASINGAH, K. - A 86 O'LOUGHLIN, B.J. - A 173 KUROKAKA, T. - A 134 ORII, H. - A 142 OZA, R.K. - A 126 OZARDA, - A.T. - A 34

LAMBETH, J.T. - A 148 LAST, V. - A 144 LINDBLAD, G. - A 52 PALMER, F.J. - A 79 LOPEZ, F.A. - A 28 PALMER, P.E.S. - A 81, A 90, A 114 I LOPEZ, L.R. - A 117 A 137, A 139, A 170 PARIS, N.F. - A 5 PARTHASARATHY, L.R. - A 16, A 44 A 78, A 151 MC GLASHAN, N.D. - A 114 PERRETT, L.V. - A 167 MC KAY, W.J. - A 96 PORTER, A.J. - A 166 PRABHASAWAT, D. - A 39 PRAKASH, A. - A 82

RAJANI, M. - A 150 RAM, K. - A 82 RASAD, S. - A 103 REAY-YODNG, P.S. - A 93 RICHARDSON, J.F. - A 153 RITCHIE, B.C. - A 95 ROBERTS, S.J - A 32 ROTHFIELD, N.h. - A 25 ROY, S.C. -A 49 SAEGUSA, T. - A 176 VAUHILINGAM, K. - A 22 sArro, K. - A 37 VARADARAJAN, M. G. - A 44 SAITOH, T. - A 161 VAUGHAN, B.F. - A 133 SAMSEN, L. - A 5, A 155 VnXFORTH, J.C. - A 3, A 68, A 156 SANDEMAN, T.F. - A 88 VIRAVAN, C. - A 99 SASAKI, T. - A 73, A 152 SATO, Y. - A 136 SCHWARTZ, S. - A 160 SEPHTON, R. - A 177 WAGNER, H.N. Jr. - A 175 SHAHBAZIAN, A. - A 34 WAKABAYASHI, M. - A 37 SHERBON, K.J. - A 106 WANGWIWATANA, D. - A 29 SHIGEMORA, N. - A 120 WEERASENA, M, - A 15, A 20 SHINOHARA, S. - A 42, A 180 WHITEHOUSE, W.M. - A 85 SIMON, G.T. - A 60 WILLIAMSON, B.D.P. - A 5 SINGH, A.D. - A 60 WILKIE, R.C. - A 75 SINGH, J. - A 148 WOLFE, R.D. - A 84, A 107 SINGH, N. - A 113 WONG, W.L. - A 12 SINGH, P. - A 35 SISPRIJA, Vo - A 77 SMITH, M.M. - A 95 SOESILO, R.M. - A 65 YAMADA, A. - A 43, A 162 SOMBU PILLAY, S. - A 154 YAMAGISHI, Y. - A 161 SORBY, W.A. - A 74 YAMASHITA, H. - A 36, A 41, A 69, SPRAGUE, P.L. - A 26 A 183 SRIDBAR, C.B. - A 82 YASUKOCHI, H. - A 98, A 102, A 142 STANFORD, R.W. - A 6 YONG, N. K. - A 148 STEINER, R.E. - A 18 YOSHIDA, R. - A 94 STEVENS, D.J. - A 1 YU, C. - A 10 SUBBARAO, K. - A 128 YUI, N. - A 176 SUDARSANAM, D.T. - A 163 SUKEHOMYA, C. - A 169 SUNAYASHIKI, T. - A 119 SUNDBCM, L. - A 2, A 158 SURYAWIDJAYA, M.D. - A 65 SUZUKI, T. - A 98, A 105 SYED, I.B. - A 175 SYME, J. - A 104, A 147

TAKAHARA, H. - A 121 TAKESHITA, K. - A 119 TAKETA, C. - A 58 TALWATTE, S.N.B. - A 13 TAMAKAWA, Y. - A 46 TAH, B.C. - A 64 TANAKA, Y. - A 138, A 186 TARUSAWA, T. - A 111 TATSUNO, I. - A 57 TAYLOR, R.G.S. - A 91 THIAGARAJAH, R.S. - A 20 THOMAS, V.H. - A 127 TOD, P.A. - A 166 TSUBOGO, Y. - A 30 TSUKAMOTO, K. - A 58 TdUNEMQTO, H. - A 118 TUCKER, W.G.S. - A 71

UCHIYAMA, G. - A 176 UMEGAKI, Y. - A 58, A 118 UMENO, K. - A 94

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