1976, British Journal of Radiology, 49, 2S1-285
MARCH 1976
Case report Radiographic and radioisotope evaluation of intra-osseous xanthoma A . Kovac, M.D.*, Y-Z Kuo, M.D.*, V. Sagar, M.D.t Radiology Service* and Nuclear Medicine Servicet Veterans Administration Center, Wilmington, Delaware 19805, U.S.A. The reports in the radiologic literature of osseous xanthomas are very rare, and only seven cases are found between 1947 and 1971. The following is an additional case with pathologic fracture of the tibia, where an intra-osseous xanthoma was diagnosed prior to occurrence of fracture. Radiographic and radioisotope studies were both instrumental in detecting the lesion six months before the fracture occurred.
CASE HISTORY
A 41-year-old, obese, black, male, steelmill worker was admitted in January 1974. Multiple, non-tender, hard, pedunculated and sessile nodules covered most of the body and extremities. He noticed the nodules first in 1954 and ever since the nodules interfered with his work, bruised easily and ulcerated. On physical examination the nodules were seen covering hands, elbows, buttocks and knees (Fig. 1). Laboratory tests revealed serum cholesterol: 300 mg, triglycerides: 710 mg, and the rest of the tests being within normal limits. The blood glucose tolerance test showed slight elevation in
FIG. 1. Both knees with nodular, tumour-like, well-outlined masses of different sizes. Note soft-tissue prominence in the areas of both tibial tuberosities. 281
VOL.
49, No. 579 Case report
the first two hours (142 mg/100 ml.) which decreased to normal limits at three hours. ECG showed findings compatible with left ventricular hypertrophy. The chest X ray showed mild enlargement of the cardiac silhouette, and radiographic bone survey showed radiolucent bone lesion at the anterior aspect of the proximal right tibia with mild irregularity of the cortex at the area of the tibial tuberosity (Fig. 2). Some changes were also seen in the opposite tibia although to a lesser degree (Fig. 3). IVP and barium-contrast studies were unremarkable. Bone scan using 99Tcm polyphosphate showed increased uptake in the above-mentioned area of the right tibia, and to a somewhat lesser degree in them corresponding left tibia (Fig. 4). Liver scan using " T c sulphur colloid showed generalized decrease of uptake in the liver. A liver biopsy showed mild to moderate fatty metamorphosis of the liver. Surgical removal of several nodules showed these to be fixed and attached to tendon sheaths. On microscopic examination "numerous foam-laden macrophages with cholesterol clefts" were seen. Serum lipid and lipoprotein determination (Seidel-Wieland test) was positive for "floating" /3-component. This was classified as Type III lipoprotein pattern with hypertriglyceridemia. In August 1974 the patient was readmitted with a painful and swollen right knee and proximal right leg. This occurred following a fall. Radiographic examination revealed a linear, radiolucent fracture line in the proximal right tibia through the abnormal area, noted on previous radiographs, confirming the diagnosis of an undisplaced pathological fracture (Fig. 5).
FIG. 2. Lateral radiograph of right knee. Intra-osseous radiolucent lesion with sclerotic margins and mild endosteal reaction is seen in the proximal right tibia opposite the tibial tuberosity.
Craig needle biopsy of the lesion in the right tibia showed accumulation of lipoid material with typical foam-laden macrophages and cholesterol clefts. This confirmed the clinical diagnosis of intra-osseous xanthoma. Follow-up film 70 days after the fracture showed healing and bony callus formation. The radiolucent lesion is still visible (Fig. 6). DISCUSSION
The radiolucent lesion described in the anterior and proximal right tibia with sclerotic margins, preserved cortex of the bone and mild endosteal changes raised the suspicion of a slow-growing tumour.
FIG. 3. Lateral radiograph of left knee which shows small area of rarefaction and radiolucency, intra-osseous in position at the level of tibial tuberosity.
282
MARCH
1976
Case report
Due to the patient's xanthomatous skin lesions and an associated radiolucent bone lesion, intraosseous xanthoma was considered first, and awareness of such a possibility may have precluded a pathological fracture. Intra-osseous xanthomas are very rare and no specific guidelines for diagnosis are available at the present time. Phenotyping of patients with primary hyperlipoproteinaemia is not within the scope of this writing and the reader is referred to works by Levy and
FIG. 4. "Tcm-polyphosphate bone scan of both lower extremities with increased uptake in proximal portions of both tibiae, more prominent on the right side.
Frederickson, 1968, Levy et ah, 1972, and Frederickson and Lees (1965) and the proceedings of the NIH conference published in Annals of Internal Medicine (Levy et ah, 1972). The main concern of this paper is to call attention to the diagnostic aspect of this rarely described entity. It is to be noted that each of the articles describing similar lesions is limited to only one case (Sneider 1963; Sorensen, 1964; Weintrob and Truswell, 1974). However, recent studies and present-day knowledge shows that a large number of the population will demonstrate high values of triglycerides and cholesterol even in the younger age group (Frederickson and Lees, 1965; Lees et al., 1972). This is considered a familial and relatively common disorder and has an ever increasing interest in atherogenesis and coronary heart disease. The second consideration is that although cutaneous manifestations are rare, deposits within the tendon sheaths are not unusual.
FIG. 5. Lateral radiograph of right knee showing linear fractures through the radiolucent lesion.
283
VOL.
49, No. 579 Case report
Description of such cases is present in the literature (Blomqvist, 1962; March, Gilbert and Kain, 1957). Blankenhorn and Meyers (1969) describe a radiographic method for evaluation of xanthomatous involvement of Achilles tendon (Blankenhorn, 1969). Thirdly, the fact that xanthomatous deposits in the tendon sheaths are not uncommon may predispose in certain cases to invasion by continuity and subsequent abnormal deposits within the bone of lipid rich material. Weintrob and Truswell (1974)
report such findings in the hand of a patient with Type III hyperlipoproteinaemia, Sneider (1963) in the calcaneus, and in our case in the tuberosity of the tibia. However, other cases described (Brusco et ah, 1966; Koch and Lewis, 1956; Layani, Durupt and Lambert, 1958; Sorensen, 1964), fail to disclose relationship of osseous lesion and tendon sheaths. Bone scanning with bone-seeking radiopharmaceuticals has improved considerably the perception of early bone lesions and, nowadays, 99Tcm labelled polyphosphate, diphosphonate and pyrophosphate are the most commonly-used agents. However, numerous conditions may show increased uptake and positive bone scan. The exact mechanism of their localization in bone is unknown, even though the uptake is influenced by the vascularity and the osteoblastic activity of the bone. In our patient with intra-osseous xanthoma, the right tibia showed a definite increase in uptake and the left tibia to a lesser degree. The amount of involvement generally correlated with the intensity of uptake and suggested an early lesion on the left side. We believe that this is the first intra-osseous xanthoma demonstrated by this method prior to pathological fracture. SUMMARY
The value of early detection of intra-osseous xanthoma by radiologic and isotopic studies is demonstrated. Although we believed that the patient had only one lesion in the right tibia, discreet findings in the bone scan and inconclusive radiographic findings raised the possibility of another lesion in the opposite (left) tibia. This will encourage close followup studies of the left tibia to preclude the occurrence of pathological fracture in the future. REFERENCES BLANKENHORN, D. H., and MEYERS, H. I., 1969. Radio-
graphic determination of Achilles tendon xanthoma size. Metabolism, 18, 882-886. BLOMQVIST, G., 1962. Xanthoma of tendo achillis. Acta Radiologica, 57, 45-47. BRUSCO, O. J., HOWARD, R. P., JARMAN, J. B., and FURMAN,
R. H., 1966. Osseous xanthomatosis and pathologic fractures in familial hyperlipemia (hyperglycidemia). American Journal of Medicine, 40, 477—484.
FREDERICKSON, D. S., and LEES, R. S., 1965. Editorial—
A system for phenotyping hyperlipoproteinemia. Circu-
lation, XXXI, 321-327.
KOCH, H. J., jun., and LEWIS, J. S., 1956. Hyperlipemic
xanthomatosis with associated osseous granuloma. New England Journal of Medicine, 255, 387-389. LAYANI, F., DURUPT, L., and LAMBERT, P., 1958. Etude
6. Lateral radiograph of right knee showing healing of fractures and bony callus formation. FIG.
critique des xanthomatoses osseuses. Semaine Hopital, Paris, 34, 3041-3053. LEVY, R. I., and FREDERICKSON, D. S., 1968. Diagnosis and
284
management of hyperlipoproteinemia. American Journal of Cardiology, 22, 576-583.
MARCH 1976
Case report LEVY, R. I., FREDERICKSON, D. S., SHULMAN, R., BILHEIMER, D. W., BRESLOW, J. L., STONE, N. J., LUX, S. E., SLOAN, H. R.( KRAUSS, R. M., and HERBERT, P. N., 1972.
SNEIDER, P., 1963. Xanthoma of the calcaneus. British Journal of Radiology, 36, 222-223. SORENSEN, E. W., 1964. A report of an unusual case comDietary and drug treatment of primary hyperlipoproteinplicated by bone lesions, macrocytic anemia and leuemia, NIH Conference. Annals of Internal Medicine, 77, kemoid bone marrow, Ada Medica Scandinavica, 175 267-294. 207-214.
MARCH, H. C , GILBERT, P. D., and KAIN, T. M., 1957.
WEINTROB, L., and TRUSWELL, A. S., 1974. A case of type
Hypercholesterolemic xanthomata of the tendons. American Journal of Roentgenology, Radium Therapy and Nuclear Medicine, 77,109-114.
III hyperliproproteinemia with xanthomata. British Journal of Radiology, 44, 215-218.
Book reviews An Atlas of Radiation Histopathology. By D. C. White, pp. iv+227, 1975 (Washington, U.S. Energy Research and Development Administration), $10-10. The U.S. Armed Forces Institute of Pathology is reputed to hold the largest collection of human histopathological material in the world, and publications emanating from the Institute reflect the outstanding provisions of their source. This inexpensive paperback by the Chief of the Institute's Division of Radiation Pathology follows that tradition. The first of the 12 chapters occupies one-third of the book, and is devoted to the effects of whole-body irradiation in relation to the kinetics of the different tissues as they affect the expression of radiation damage. This chapter draws on rare clinical material obtained from five subjects who had been accidentally exposed to whole-body doses of between 600 and 8,000 rads of radiation of mixed quality. The remaining chapters are divided by their reference to the various organs of the body; each outlines the relevant structure and function of the organ, the clinical effects of radiation damage to it, and the histological appearance of such damage. The material is drawn almost entirely from radiotherapy cases. The matter is illustrated in black and white by over 200 photomicrographs and almost 30 excellent helpful drawings. A deficiency of the full legends to the photomicrographs is that they never give the magnification and seldom indicate the time since irradiation; also, several of the low power views show too little detail to be informative, the reader having difficulty in distinguishing unstructured radiation damage from insufficient resolution. It is a considerable achievement to collect together so wide a range of material almost exclusively from clinical sources; the opportunities for obtaining specimens, especially those which illustrate sequential changes following irradiation, are inevitably restricted; as might be expected, late changes predominate in the illustrations. Thus, the atlas may be a unique work for those whose need is for reference to specifically clinical material. The student of principles will find thefirstchapter of particular value; the dependance of expression of radiation damage on tissue cell kinetics is well and fully described. The author's assurance that an index is rendered unnecessary by the systematic division of the chapters is entirely acceptable.
Tumours of the Nervous System, Edited by H. Gunter Seydel, pp. x+193,1975 (John Wiley and Sons), £10.00. This publication is an account of the proceedings of the Annual Cancer Symposium held at the Fox Chase Cancer Centre. There is a section covering the use of radionuclides in the diagnosis of tumours of the CNS. This firstly covers scanning procedures and is well illustrated in black and white. There is an interesting comparison of the accuracy of various neurodiagnostic procedures and also the success rate of brain scanning in specific tumours. There then follows an interesting section dealing with dynamic function studies using isotopes in the blood stream and also introduced into the cerebro-spinal fluid. This section then closes after considering the use of radio-isotopes in the localization of intraocular and orbital tumours. The rest of the book is concerned with the treatment of tumours in the CNS. There are papers on the surgical approach to the treatment of gliomas, the treatment of glioblastoma multiforme in different ways and combinations of surgery, radiotherapy, chemotherapy and radiation in the induced hyperthyroid state. Hyperbaric oxygen and radiation therapy for malignant gliomas is considered and the results of a pilot study reported. There is a paper considering the present state of the chemotherapy of brain tumours in childhood. The pituitary receives a good deal of attention. There is an excellent and detailed account of the treatment of pituitary tumours by radiotherapy. This is followed by a very informative account of radiation therapy in acromegaly and non-secretory chromophobe adenomas. The role of cryosurgery in the treatment of acromegaly is considered and there then follows a paper on the use of Bragg peak proton therapy to produce hypophysectomy. This is a detailed and interesting account. Finally there is a paper concerning the treatment of metastic disease of the nervous system by radiation therapy. This is a detailed analysis of what can be achieved when treating various metastases in different sites. This account of the symposium is a very worthwhile addition to the library of anyone concerned with the investigation or management of tumours of the nervous system.
H. B. HEWITT.
285
B. T. HALE.
MARCH 1976
Case report Radiographic and radioisotope evaluation of intra-osseous xanthoma A . Kovac, M.D.*, Y-Z Kuo, M.D.*, V. Sagar, M.D.t Radiology Service* and Nuclear Medicine Servicet Veterans Administration Center, Wilmington, Delaware 19805, U.S.A. The reports in the radiologic literature of osseous xanthomas are very rare, and only seven cases are found between 1947 and 1971. The following is an additional case with pathologic fracture of the tibia, where an intra-osseous xanthoma was diagnosed prior to occurrence of fracture. Radiographic and radioisotope studies were both instrumental in detecting the lesion six months before the fracture occurred.
CASE HISTORY
A 41-year-old, obese, black, male, steelmill worker was admitted in January 1974. Multiple, non-tender, hard, pedunculated and sessile nodules covered most of the body and extremities. He noticed the nodules first in 1954 and ever since the nodules interfered with his work, bruised easily and ulcerated. On physical examination the nodules were seen covering hands, elbows, buttocks and knees (Fig. 1). Laboratory tests revealed serum cholesterol: 300 mg, triglycerides: 710 mg, and the rest of the tests being within normal limits. The blood glucose tolerance test showed slight elevation in
FIG. 1. Both knees with nodular, tumour-like, well-outlined masses of different sizes. Note soft-tissue prominence in the areas of both tibial tuberosities. 281
VOL.
49, No. 579 Case report
the first two hours (142 mg/100 ml.) which decreased to normal limits at three hours. ECG showed findings compatible with left ventricular hypertrophy. The chest X ray showed mild enlargement of the cardiac silhouette, and radiographic bone survey showed radiolucent bone lesion at the anterior aspect of the proximal right tibia with mild irregularity of the cortex at the area of the tibial tuberosity (Fig. 2). Some changes were also seen in the opposite tibia although to a lesser degree (Fig. 3). IVP and barium-contrast studies were unremarkable. Bone scan using 99Tcm polyphosphate showed increased uptake in the above-mentioned area of the right tibia, and to a somewhat lesser degree in them corresponding left tibia (Fig. 4). Liver scan using " T c sulphur colloid showed generalized decrease of uptake in the liver. A liver biopsy showed mild to moderate fatty metamorphosis of the liver. Surgical removal of several nodules showed these to be fixed and attached to tendon sheaths. On microscopic examination "numerous foam-laden macrophages with cholesterol clefts" were seen. Serum lipid and lipoprotein determination (Seidel-Wieland test) was positive for "floating" /3-component. This was classified as Type III lipoprotein pattern with hypertriglyceridemia. In August 1974 the patient was readmitted with a painful and swollen right knee and proximal right leg. This occurred following a fall. Radiographic examination revealed a linear, radiolucent fracture line in the proximal right tibia through the abnormal area, noted on previous radiographs, confirming the diagnosis of an undisplaced pathological fracture (Fig. 5).
FIG. 2. Lateral radiograph of right knee. Intra-osseous radiolucent lesion with sclerotic margins and mild endosteal reaction is seen in the proximal right tibia opposite the tibial tuberosity.
Craig needle biopsy of the lesion in the right tibia showed accumulation of lipoid material with typical foam-laden macrophages and cholesterol clefts. This confirmed the clinical diagnosis of intra-osseous xanthoma. Follow-up film 70 days after the fracture showed healing and bony callus formation. The radiolucent lesion is still visible (Fig. 6). DISCUSSION
The radiolucent lesion described in the anterior and proximal right tibia with sclerotic margins, preserved cortex of the bone and mild endosteal changes raised the suspicion of a slow-growing tumour.
FIG. 3. Lateral radiograph of left knee which shows small area of rarefaction and radiolucency, intra-osseous in position at the level of tibial tuberosity.
282
MARCH
1976
Case report
Due to the patient's xanthomatous skin lesions and an associated radiolucent bone lesion, intraosseous xanthoma was considered first, and awareness of such a possibility may have precluded a pathological fracture. Intra-osseous xanthomas are very rare and no specific guidelines for diagnosis are available at the present time. Phenotyping of patients with primary hyperlipoproteinaemia is not within the scope of this writing and the reader is referred to works by Levy and
FIG. 4. "Tcm-polyphosphate bone scan of both lower extremities with increased uptake in proximal portions of both tibiae, more prominent on the right side.
Frederickson, 1968, Levy et ah, 1972, and Frederickson and Lees (1965) and the proceedings of the NIH conference published in Annals of Internal Medicine (Levy et ah, 1972). The main concern of this paper is to call attention to the diagnostic aspect of this rarely described entity. It is to be noted that each of the articles describing similar lesions is limited to only one case (Sneider 1963; Sorensen, 1964; Weintrob and Truswell, 1974). However, recent studies and present-day knowledge shows that a large number of the population will demonstrate high values of triglycerides and cholesterol even in the younger age group (Frederickson and Lees, 1965; Lees et al., 1972). This is considered a familial and relatively common disorder and has an ever increasing interest in atherogenesis and coronary heart disease. The second consideration is that although cutaneous manifestations are rare, deposits within the tendon sheaths are not unusual.
FIG. 5. Lateral radiograph of right knee showing linear fractures through the radiolucent lesion.
283
VOL.
49, No. 579 Case report
Description of such cases is present in the literature (Blomqvist, 1962; March, Gilbert and Kain, 1957). Blankenhorn and Meyers (1969) describe a radiographic method for evaluation of xanthomatous involvement of Achilles tendon (Blankenhorn, 1969). Thirdly, the fact that xanthomatous deposits in the tendon sheaths are not uncommon may predispose in certain cases to invasion by continuity and subsequent abnormal deposits within the bone of lipid rich material. Weintrob and Truswell (1974)
report such findings in the hand of a patient with Type III hyperlipoproteinaemia, Sneider (1963) in the calcaneus, and in our case in the tuberosity of the tibia. However, other cases described (Brusco et ah, 1966; Koch and Lewis, 1956; Layani, Durupt and Lambert, 1958; Sorensen, 1964), fail to disclose relationship of osseous lesion and tendon sheaths. Bone scanning with bone-seeking radiopharmaceuticals has improved considerably the perception of early bone lesions and, nowadays, 99Tcm labelled polyphosphate, diphosphonate and pyrophosphate are the most commonly-used agents. However, numerous conditions may show increased uptake and positive bone scan. The exact mechanism of their localization in bone is unknown, even though the uptake is influenced by the vascularity and the osteoblastic activity of the bone. In our patient with intra-osseous xanthoma, the right tibia showed a definite increase in uptake and the left tibia to a lesser degree. The amount of involvement generally correlated with the intensity of uptake and suggested an early lesion on the left side. We believe that this is the first intra-osseous xanthoma demonstrated by this method prior to pathological fracture. SUMMARY
The value of early detection of intra-osseous xanthoma by radiologic and isotopic studies is demonstrated. Although we believed that the patient had only one lesion in the right tibia, discreet findings in the bone scan and inconclusive radiographic findings raised the possibility of another lesion in the opposite (left) tibia. This will encourage close followup studies of the left tibia to preclude the occurrence of pathological fracture in the future. REFERENCES BLANKENHORN, D. H., and MEYERS, H. I., 1969. Radio-
graphic determination of Achilles tendon xanthoma size. Metabolism, 18, 882-886. BLOMQVIST, G., 1962. Xanthoma of tendo achillis. Acta Radiologica, 57, 45-47. BRUSCO, O. J., HOWARD, R. P., JARMAN, J. B., and FURMAN,
R. H., 1966. Osseous xanthomatosis and pathologic fractures in familial hyperlipemia (hyperglycidemia). American Journal of Medicine, 40, 477—484.
FREDERICKSON, D. S., and LEES, R. S., 1965. Editorial—
A system for phenotyping hyperlipoproteinemia. Circu-
lation, XXXI, 321-327.
KOCH, H. J., jun., and LEWIS, J. S., 1956. Hyperlipemic
xanthomatosis with associated osseous granuloma. New England Journal of Medicine, 255, 387-389. LAYANI, F., DURUPT, L., and LAMBERT, P., 1958. Etude
6. Lateral radiograph of right knee showing healing of fractures and bony callus formation. FIG.
critique des xanthomatoses osseuses. Semaine Hopital, Paris, 34, 3041-3053. LEVY, R. I., and FREDERICKSON, D. S., 1968. Diagnosis and
284
management of hyperlipoproteinemia. American Journal of Cardiology, 22, 576-583.
MARCH 1976
Case report LEVY, R. I., FREDERICKSON, D. S., SHULMAN, R., BILHEIMER, D. W., BRESLOW, J. L., STONE, N. J., LUX, S. E., SLOAN, H. R.( KRAUSS, R. M., and HERBERT, P. N., 1972.
SNEIDER, P., 1963. Xanthoma of the calcaneus. British Journal of Radiology, 36, 222-223. SORENSEN, E. W., 1964. A report of an unusual case comDietary and drug treatment of primary hyperlipoproteinplicated by bone lesions, macrocytic anemia and leuemia, NIH Conference. Annals of Internal Medicine, 77, kemoid bone marrow, Ada Medica Scandinavica, 175 267-294. 207-214.
MARCH, H. C , GILBERT, P. D., and KAIN, T. M., 1957.
WEINTROB, L., and TRUSWELL, A. S., 1974. A case of type
Hypercholesterolemic xanthomata of the tendons. American Journal of Roentgenology, Radium Therapy and Nuclear Medicine, 77,109-114.
III hyperliproproteinemia with xanthomata. British Journal of Radiology, 44, 215-218.
Book reviews An Atlas of Radiation Histopathology. By D. C. White, pp. iv+227, 1975 (Washington, U.S. Energy Research and Development Administration), $10-10. The U.S. Armed Forces Institute of Pathology is reputed to hold the largest collection of human histopathological material in the world, and publications emanating from the Institute reflect the outstanding provisions of their source. This inexpensive paperback by the Chief of the Institute's Division of Radiation Pathology follows that tradition. The first of the 12 chapters occupies one-third of the book, and is devoted to the effects of whole-body irradiation in relation to the kinetics of the different tissues as they affect the expression of radiation damage. This chapter draws on rare clinical material obtained from five subjects who had been accidentally exposed to whole-body doses of between 600 and 8,000 rads of radiation of mixed quality. The remaining chapters are divided by their reference to the various organs of the body; each outlines the relevant structure and function of the organ, the clinical effects of radiation damage to it, and the histological appearance of such damage. The material is drawn almost entirely from radiotherapy cases. The matter is illustrated in black and white by over 200 photomicrographs and almost 30 excellent helpful drawings. A deficiency of the full legends to the photomicrographs is that they never give the magnification and seldom indicate the time since irradiation; also, several of the low power views show too little detail to be informative, the reader having difficulty in distinguishing unstructured radiation damage from insufficient resolution. It is a considerable achievement to collect together so wide a range of material almost exclusively from clinical sources; the opportunities for obtaining specimens, especially those which illustrate sequential changes following irradiation, are inevitably restricted; as might be expected, late changes predominate in the illustrations. Thus, the atlas may be a unique work for those whose need is for reference to specifically clinical material. The student of principles will find thefirstchapter of particular value; the dependance of expression of radiation damage on tissue cell kinetics is well and fully described. The author's assurance that an index is rendered unnecessary by the systematic division of the chapters is entirely acceptable.
Tumours of the Nervous System, Edited by H. Gunter Seydel, pp. x+193,1975 (John Wiley and Sons), £10.00. This publication is an account of the proceedings of the Annual Cancer Symposium held at the Fox Chase Cancer Centre. There is a section covering the use of radionuclides in the diagnosis of tumours of the CNS. This firstly covers scanning procedures and is well illustrated in black and white. There is an interesting comparison of the accuracy of various neurodiagnostic procedures and also the success rate of brain scanning in specific tumours. There then follows an interesting section dealing with dynamic function studies using isotopes in the blood stream and also introduced into the cerebro-spinal fluid. This section then closes after considering the use of radio-isotopes in the localization of intraocular and orbital tumours. The rest of the book is concerned with the treatment of tumours in the CNS. There are papers on the surgical approach to the treatment of gliomas, the treatment of glioblastoma multiforme in different ways and combinations of surgery, radiotherapy, chemotherapy and radiation in the induced hyperthyroid state. Hyperbaric oxygen and radiation therapy for malignant gliomas is considered and the results of a pilot study reported. There is a paper considering the present state of the chemotherapy of brain tumours in childhood. The pituitary receives a good deal of attention. There is an excellent and detailed account of the treatment of pituitary tumours by radiotherapy. This is followed by a very informative account of radiation therapy in acromegaly and non-secretory chromophobe adenomas. The role of cryosurgery in the treatment of acromegaly is considered and there then follows a paper on the use of Bragg peak proton therapy to produce hypophysectomy. This is a detailed and interesting account. Finally there is a paper concerning the treatment of metastic disease of the nervous system by radiation therapy. This is a detailed analysis of what can be achieved when treating various metastases in different sites. This account of the symposium is a very worthwhile addition to the library of anyone concerned with the investigation or management of tumours of the nervous system.
H. B. HEWITT.
285
B. T. HALE.
