7
NEPHROCALCINOSIS WITH SPECIAL REFERENCE TO ITS OCCURRENCE IN RENAL TUBULAR ACIDOSIS R. E. RICHARDSON, M.R.C.P., D.M.R.D. * From the Diagnostic X-ray Department, Bristol Royal Infirmary, Bristol NEPHROCALCINOSIS is a radiological diagnosis, whilst the elucidation of its aetiology is a clinical, biochemical and radiological problem. It is the purpose of this paper to discuss the scope for radiology both in unveiling the cause of the calcinosis and also in observing its natural history. DEFINITION Nephroealcinosis has been defined as " renal calcinosis marked by the precipitation of calcium phosphate in the kidney tubules " (Blakistone). Sometimes it is used as a term synonymous with parenchymal calcification. There would, however, appear to be considerable justification for reserving the term for a radiological appearance. This appearance may consist of the typical striated appearance where one can be certain that not only is the calcification parenchymal but also tubular. Frequently, however, such a characteristic pattern is absent and one sees mottled areas of calcinosis with no obviously striated arrangement. In these cases it is difficult to be certain of the exact anatomical site of the calcium deposition which may either be within the minor calyces or the pyramids. However, in both these instances, it would appear justifiable for the following reasons, to use the term nephrocalcinosis :-- 4. Cortisone therapy (a) It is the radiologist who first recognises the 5. Sarcoidosis condition. (b) Histological evidence is inevitably often only of academic consequence and when available, a precise anatomical localisation of the calcium is to 7. Carcinomatosis be preferred to the use of the term nephrocalcinosis. (c) In the absence of a spiculated appearance typical of tubular calcification, the calcification may be within the lesser calyces, the pyramids, or a combination of both. However, in each of these instances, a full investigation for an underlying metabolic disorder is warranted. (d) To use the term to signify parenchymal calcification would require the inclusion of tuber- culous, neoplastic and other rare forms of calci- fication, as aetiological factors. These usually give rise to a different pattern of calcification. In this Group C Idiopathic cases paper, therefore, unless otherwise stated, the term * Now at The Middlesex Hospital, London, W.1 224 nephrocalcinosis will be used for a radiological appearance. PATHOGENESIS Nephrocalcinosis may arise in two different ways: (a) In disorders associated with hypercalciuria and/or hypercalcaemia (see Table 1). (b) In conditions where the biochemical or physical conditions favour the deposition of calcium and where hypercalcaemia does not necessarily co-exist. Sometimes however, both factors may operate and sometimes no cause may be found for the disorder. This grouping is of radiological signi- ficance for it follows that since 99 per cent of the TABLE 1 DISORDERS GIVING ~EPHROCALCINOSIS Radiological Features Group A 1. Hyperparathyroidism 2. Renal tubular acidosis 3. Cushing's syndrome 6. Multiple myelomatosis 8. Idiopathic hypercalcuria 9. Hypervitaminosis D Group B 1. Necrotising papillitis 2. Medullary sponge kidney 3. Drugs--sulphonamides 4. Alkalis Osteoporosis; cysts; sub- periosteal resorption;" rugby jersey " vertebrae Osteomalacia or rachitic changes Osteoporosis; rib fractures with hypertrophic callus formation Osteoporosis Pulmonary and osseous changes Osteoporosis; destructive changes Evidence of primary lesion; osteoporosis; other evidence of metastases Osteomalacia Osteoporotic bone

Nephrocalcinosis with special reference to its occurrence in renal tubular acidosis

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Page 1: Nephrocalcinosis with special reference to its occurrence in renal tubular acidosis

N E P H R O C A L C I N O S I S W I T H S P E C I A L R E F E R E N C E T O I T S O C C U R R E N C E I N R E N A L T U B U L A R A C I D O S I S

R. E. RICHARDSON, M.R.C.P., D.M.R.D. *

From the Diagnostic X-ray Department, Bristol Royal Infirmary, Bristol

NEPHROCALCINOSIS is a radiological diagnosis, whilst the elucidation of its aetiology is a clinical, biochemical and radiological problem. It is the purpose of this paper to discuss the scope for radiology both in unveiling the cause of the calcinosis and also in observing its natural history.

DEFINITION Nephroealcinosis has been defined as " renal

calcinosis marked by the precipitation of calcium phosphate in the kidney tubules " (Blakistone). Sometimes it is used as a term synonymous with parenchymal calcification. There would, however, appear to be considerable justification for reserving the term for a radiological appearance.

This appearance may consist of the typical striated appearance where one can be certain that not only is the calcification parenchymal but also tubular. Frequently, however, such a characteristic pattern is absent and one sees mottled areas of calcinosis with no obviously striated arrangement. In these cases it is difficult to be certain of the exact anatomical site of the calcium deposition which may either be within the minor calyces or the pyramids. However, in both these instances, it would appear justifiable for the following reasons, to use the term nephrocalcinosis : - - 4. Cortisone therapy

(a) It is the radiologist who first recognises the 5. Sarcoidosis condition.

(b) Histological evidence is inevitably often only of academic consequence and when available, a precise anatomical localisation of the calcium is to 7. Carcinomatosis be preferred to the use of the term nephrocalcinosis.

(c) In the absence of a spiculated appearance typical of tubular calcification, the calcification may be within the lesser calyces, the pyramids, or a combination of both. However, in each of these instances, a full investigation for an underlying metabolic disorder is warranted.

(d) To use the term to signify parenchymal calcification would require the inclusion of tuber- culous, neoplastic and other rare forms of calci- fication, as aetiological factors. These usually give rise to a different pattern of calcification. In this Group C

Idiopathic cases paper, therefore, unless otherwise stated, the term

* N o w at The Middlesex Hospi ta l , London , W.1

224

nephrocalcinosis will be used for a radiological appearance.

PATHOGENESIS Nephrocalcinosis may arise in two different ways: (a) In disorders associated with hypercalciuria

and/or hypercalcaemia (see Table 1). (b) In conditions where the biochemical or

physical conditions favour the deposition of calcium and where hypercalcaemia does not necessarily co-exist.

Sometimes however, both factors may operate and sometimes no cause may be found for the disorder. This grouping is of radiological signi- ficance for it follows that since 99 per cent of the

TABLE 1

DISORDERS GIVING ~EPHROCALCINOSIS

Radiological Features

Group A

1. Hyperparathyroidism

2. Renal tubular acidosis

3. Cushing's syndrome

6. Multiple myelomatosis

8. Idiopathic hypercalcuria

9. Hypervitaminosis D

Group B

1. Necrotising papillitis

2. Medullary sponge kidney

3. Drugs- -su lphonamides

4. Alkalis

Osteoporosis; cysts; sub- periosteal resorpt ion;" rugby jersey " vertebrae

Osteomalacia or rachitic changes

Osteoporosis; rib fractures with hypertrophic callus formation

Osteoporosis

Pulmonary and osseous changes

Osteoporosis; destructive changes

Evidence of primary lesion; osteoporosis; other evidence of metastases

Osteomalacia

Osteoporotic bone

Page 2: Nephrocalcinosis with special reference to its occurrence in renal tubular acidosis

N E P H R O C A L C I N O S I S ; I T S O C C U R R E N C E I N R E N A L T U B U L A R A C I D O S I S

body calcium is contained within bone, metabolic diseases resulting in calcium loss may produce osseous changes. If these changes are apparent on radiographs and if the pattern is specific, then the radiologist is able to determine the cause of the nephrocalcinosis; whilst if the changes are simply a loss in bone density he can infer that the condition is likely to be caused by one of those disorders in Group A. Thus, in Group A, radiological diagnosis is achieved by detecting changes which occur out- side the urinary tract. In contra distinction in Group B, a radiological diagnosis can only be reached by noting the presence of renal changes, other than the calcinosis. For instance, excretion urography may reveal the dilated tubules in the region of the papillae which suggests the diagnosis o f a " sponge kidney." It does not, however, follow that where bone changes are absent, the condition belongs to Group B, for loss of bone density does not become apparent until 50 per cent of the calcium has been lost from the skeleton (Babaintz 1948). Many cases in the first group will therefore show no skeletal change and the determination of their cause is then a clinical and biochemical problem (Table 1).

TABLE 2

GROUPING OF CASES OF NEPHROCALCINOSIS

Group A (10 cases)

4 cases rena l tubula r acidosis

1 case sarcoidosis

3 cases p r ima ry hyperpa ra thyro id i sm

2 cases id iopa th ic hyperca lcur ia

Group B

1 case medu l l a ry sponge k idney

Group C

2 id iopa th ic cases

R A D I O G R A P H Y

The radiographs required will be mainly those of the urinary tract and skeletal system. In addition, the chest and hands should be routinely x-rayed and the lumbar spine studied for osteoporosis. In doubtful cases further views of the long bones and a lateral view of the lumbar spine may help to decide whether any loss of bone density is present. Finally, excretion urography will often be necessary to detect any other renal changes which may co- exist with the calcinosis, and sometimes retrograde pyelography will be of help.

CASE M A T E R I A L

In all, thirteen cases are described and of these ten fell into Group A, one into Group B, and there were two cases in Group C (Table 2).

(a) Renal tubular acidosis.--Many aetiological factors are responsible for this condition but the essential biochemical features by which it is recog- nised are a systemic acidosis in conjunction with an alkaline urine. Additional features often present are hypophosphataemia and hypokalaemia. It is, however, the acidosis which, by creating a demand for base, results in the withdrawal of calcium and other basic ions from the body with their elimin- ation through the kidneys. The alkaline reaction of

225

the tubular contents reduces the solubility of the calcium which, as it is present in excessive amounts, is readily precipitated. Hence both the nephro- calcinosis and the osteomalacia--a combination which, when radiologically manifest, is of consider- able diagnostic value.

CASE HISTORIES

All four cases in this section showed the diagnostic features of raised plasma chlorides, lowered bicarbonate reserve and an alkaline urine; they were all treated by means of alkalis. In the first three cases renal infection has been a marked feature but, so far, it has been absent in Case 4.

Case 1.--Female patient who, in 1948 at the age of twenty- eight, passed a renal calculus per urethram and was found to have calcinosis in both kidneys. Subsequently, she had recurrent episodes of urinary infection, ultimately dying in 1959 from uraemia and chronic pyelonephritis. Radiological features--In 1948 the patient had nephrocalcinosis together with a large calculus in each renal pelvis. By 1959 the calcinosis was no longer apparent although the staghorn calculi had increased in size. Radiographs of her hands showed subperiosteal bone resorption. The post mortem findings revealed (a) bilateral pyelonephritis with a right- sided pyonephrosis, (b) large bilateral staghorn calculi but no parenchymal calcification, (c) markedly hyperplastic parathyroids weighing 119.8 gm.

Case 2.--Radiological features--A female patient who, in 1941 at the age of seven, was noted to have rachitic changes. In 1950 bilateral striated renal calcification was first noted and by 1952 this was becoming confluent. Further films in 1957 showed remarkable resolution in the calcinosis although calculi were present on the left side. The most recent films show that the calculi have increased in size whilst the calcinosis has disappeared (Figs. 1 and 2).

Case 3.--Radiological features--Female patient who, in 1946 at the age of eighteen, was found to have bilateral nephrocalcinosis with a right renal calculus. Rachitic changes were also present in the epiphyses of the long bones and there were pseudo-fractures in the femora. The most recent film of 1959 shows remarkable resolution of the calcinosis although there is a large right-sided staghorn

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226 CLINICAL RADIOLOGY

Fro. 1 FIG. 2 The pictures show coalescence of the areas of calcinosis giving rise to renal calculi. These changes occurred between 1950 and

1959 during which time the nephrocalcinosis has disappeared.

FIG. 3 F~o. 4 Case 3--The pictures show disappearance in the calcinosis between 1946 and 1959. The right renal calculus has increased in size.

calculus together with two smaller ones on the left (Figs. 3 to 6).

Case 4.--(Brother of Case 3 discovered on routine examination of the family.) Radiological features--The first film in 1952 at the age of fourteen showed bilateral nephrocalcinosis. The most recent picture shows that by now confluence has started to occur giving rise, in some areas, to the picture of moderately large calculi. The bone age in this patient was slightly retarded, but there was no detectable alteration in bone density (Figs. 7 and 8).

(b) Sarcoidosis.--The n e p h r o c a l c i n o s i s in these pa t i en t s arises f r o m the h y p e r c a l c a e m i a wh ich is p r e s en t in 20 to 45 p e r cen t o f al l cases ( S n a p p e r 1957). T h e h igh b l o o d c a l c i u m is p r o b a b l y the resul t o f excess ive ca l c ium a b s o r p t i o n due, as A l b r i g h t suggests, to the f o r m a t i o n o f a v i t a m i n D-

l ike subs tance . Th i s c o n t e n t i o n is s u p p o r t e d b o t h b y ca l c ium ba l ance s tudies and by the sensi t iv i ty such pa t i en t s s h o w to ca lc i ferol .

Case 5.--History Female patient who, in 1945 at the age of twenty-five, developed parotitis, iritis and a 7th nerve lesion together with cervical and axillary glandular enlarge- ment. The diagnosis was histologically confirmed after biopsy of a gland. In 1950, the patient was treated with calciferol and showed a marked increase in the serum calcium, and in 1955, following an attack of haematuria, she was found to have nephrocalcinosis. She died of renal failure in 1958. Radiological features--When .first investi- g~tted, radiographs showed hilar glandular enlargement and in 1955 nephrocalcinosis was found. There were no bone changes (Figs. 9 and 10).

(c) Primary hyperparathyroidism.--There were two cases o f h y p e r p a r a t h y r o i d i s m whi le a th i rd

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N E P H R O C A L C I N O S I S " ITS O C C U R R E N C E IN R E N A L T U B U L A R A C I D O S I S 227

patient is under observation with a biochemistry suggestive of the disorder. Of the first two cases, one was found to have an adenoma at operation and the other had well-marked subperiosteal bone

resorption together with biochemical changes which were consistent with hyperparathyroidism. The latter patient gave a history of recurrent calculi for twenty-two years for which twelve years previously,

Fro. 5 FIG. 6 Case 3--Showing rachitic changes in the wrist and a pseudo-fracture in the femur.

FIG. 7 FIG. 8

Case 4--Fusion is seen to be developing in the areas of calcinosis between 1952 and 1959.

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228 CLINICAL RADIOLOGY

FIG. 10

a left nephrectomy had been performed. In 1957, when first seen at the Bristol Royal Infirmary, the remaining kidney showed nephrocalcinosis.

(d) Idiopathic hypercalciuria.--This condition, which was first described by Albright (Albright and Reifenstein 1948), differs biochemically from primary hyperparathyroidism only in the absence ofhypercalcaemia. In thepresent series, there were two cases. Neither of these patients showed the osteomalacia which may sometimes be present owing to the hyperealciuria. The nephrocalcinosis showed no characteristic features and was bilateral in both cases.

(e) Medullary sponge kidney.--This condition, which is of congenital origin, is due to a disordered arrangement of the tubules in the region of the pyramids (McKenna and Kampmeier 1934); here the tubules become dilated or even cystic and calcium deposition readily and often occurs. The calcinosis may, on occasion, be unilateral. Amongst the present series there was one case in which the diagnosis of a medullary sponge kidney seemed probable.

Case history.--Male patient of forty-four years who gave a seven-year history of recurrent renal colic. The bio- chemical investigations were normal and there was no evidence of renal tuberculosis. Radiological features-- X-rays of the renal area showed unilateral calcinosis which, on pyelography, appeared to be within the pyramidal region.

( f ) Idiopathic cases.--There were two idiopathic cases. Both of these had metabolic disturbances not normally associated with nepbrocalcinosis. One patient had myxoedema together with an un- explained abnormality in the liver function and the other patient had Addison's disease, although there was nothing to suggest that the patient had at any time had renal tuberculosis.

DISCUSSION It is of interest that, in the thirteen cases ofnephro-

calcinosis here described, a definite or presumptive diagnosis was obtained in eleven cases. In five of these cases the diagnosis could have been reached or suspected soMy on radiological grounds. Thesecases included the two proven instances ofhyperparathy- roidism, the case of sarcoidosis, one case of renal acidosis and the naedullary sponge kidney. In the latter instance, the diagnosis, although unproven, has been reached solely on radiological grounds; indeed the condition is one in which radiology offers the only prospect of a " clinical" diagnosis. In this condition the diagnosis is most secure when, in addition to the calcinosis, excretion urography reveals dilatation or cystic changes within the tubules before compression has been applied. In the absence of these changes, it is essential to show that the caMnosis is within the pyramidal region.

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N E P H R O C A L C I N O S I S : ITS O C C U R R E N C E IN R E N A L T U B U L A R A C I D O S I S 229

Where, however, the calcinosis can be shown to be present in the pyramidal region and where it is grouped in clusters and the kidneys are enlarged, it has been claimed that the diagnosis can be made without recourse to pyelography (Nils Lindvall 1958). Nonetheless, in such cases a biochemical investigation is justifiable to exclude the presence of any underlying metabolic disorder which would enhance the formation of calculi. For instance, both the cases of idiopathic hypercalcuria have features suggestive o f " sponge kidneys" and may possibly have a dual pathology. Finally it is worth noting that this is the only condition in which accurate anatomical localisation of the calcium is diagnostic- ally important and to this end oblique views are often of considerable help.

The case of sarcoidosis illustrates the importance of a chest radiograph. The earlier description of the pathogenesis of the nephrocalcinosis explains the mechanism of the hypercalciuria. It also explains whY the bone changes of sarcoid and the hyper- calcaemia and hence the renal calcification, are unrelated. It therefore follows that since the osseous changes in sarcoid have no relationship to the nephrocalcinosis and since bone changes are uncommon, a chest x-ray is more likely to be of help in establishing a diagnosis. For this reason a chest x-ray should be routinely taken in an investi- gation of nephrocaMnosis.

The two cases ofhyperparathyroidism showed no unusual features. The detection of subperiosteal bone resorption is of the greatest value diagnostic- ally, and it was marked in the only case in which radiographs of the hands were taken. In the other case osteoporotic bone changes were present and there was a fracture through the clavicle which had been caused by only minor trauma. Hellstrum(1955) in a review of seventy cases of primary hyper- parathyroidism, showed that 80 per cent had renal calcification due either to calculi or histo- logical calcinosis. He also contended that tubular calcification was an essential prerequisite to the formation of calculi believing that the latter rose from extruded tubular calcified debris. This view further supports the belief that a sharp anatomical definition of nephrocalcinosis is unwarranted and often arbitrary.

In the four cases of renal acidosis, the natural history of the nephrocalcinosis is of considerable interest. The first three showed a remarkable resolution of the areas of calcinosis; indeed, in Case 1 at autopsy, there was no evidence of any parenchymal calcification and only large staghorn calculi were present. This resolution can take place very rapidly after alkali treatment has started and

in Case 3 considerable radiological resolution had occurred within ten months. An apparently paradoxical feature in the first three cases was that each of them had staghorn calculi which increased in size at a time when the calcinosis was resolving. It is unlikely that this was due to the hypercalcaemia as under these circumstances the calcinosis would be expected to increase; again, although infection was present in three cases, it has been absent in Case 4. What does appear likely is that there is a tendency for the areas of calcinosis to fuse, the process being similar to the microscopic fusion of calcified foci described by Anderson (1946). Cases 2 and 3 both showed this change whilst in Case 4 picked up on routine examination, fusion has been seen occurring at a stage before recognisable calculi have developed. In Case 1 at autopsy, only large staghorn calculi were present in spite of the earlier finding of nephrocalcinosis. This tendency to coalescence is of some importance (i) because the apparent resolution of areas of calcinosis may, in part, be illusory. Reference to earlier films may show that such areas have simply fused to form large pelvic calculi. (ii) Because such a patient will be exposed to the hazards of renal calculi. However, until calculus formation has occurred, there is a possibility that the nephrocalcinosis may resolve.

Ths other changes present in these patients were in the skeleton. Cases 2 and 3 showed either osteo- malacia or rachitic changes while Case 1 showed the changes of secondary hyperparathyroidism. The finding of manifest hyperparathyroidism is an unusual feature in most case reports. The para- thyroid hyperplasia almost certainly arises as a response to the hyperphosphataemia which in its turn results from the pyelonephritis and renal failure. It is in these cases that the radiological detection of subperiosteal bone resorption is of considerable value for the biochemical assessment is complicated by the disturbance in calcium and phospherous metabolism due to the primary renal defect. Routine radiographs of the hands would almost certainly bring to light more cases of secondary hyperparathyroidism in these patients.

Two cases showed the changes of '° adolescent rickets " and in one of them pseudo-fractures were present. The combination of these changes with nephrocalcinosis is highly suggestive of renal acidosis. Cushing's syndrome with multiple rib

• fractures might give rise to confusion as the latter may sometimes resemble pseudo-fractures. The clinical features will, however, make the distinction easy and in any case the presence of nephro- calcinosis is rare in this condition.

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230 C L I N I C A L RADIOLOGY

S U M M A R Y

T h i r t e e n cases o f n e p h r o c a l c i n o s i s a re d e s c r i b e d . I n e l e v e n o f t h e s e a d i a g n o s i s w a s m a d e u s i n g c l in ica l , b i o c h e m i c a l a n d r a d i o l o g i c a l m e t h o d s o f i n v e s t i g a t i o n . I n five, a d i a g n o s i s c o u l d h a v e b e e n r e a c h e d o n r a d i o l o g i c a l g r o u n d s , T h e r a d i o l o g i s t c a n t h e r e f o r e p l a y a v a l u a b l e p a r t i n d e t e r m i n i n g t h e a e t i o l o g y o f n e p h r o c a l c i n o s i s .

I t is a l so s u g g e s t e d t h a t t h e t e r m n e p h r o c a l c i n o s i s m i g h t b e r e s e r v e d f o r a f a m i l i a r b u t u n c o m m o n r a d i o l o g i c a l p a t t e r n .

Acknowledgements.--My thanks are due to Prof. J. H. Middlemiss for his help in the preparation of this paper and

to Prof. R. Steiner of the Post-Graduate Hospital, Hammer- smith, for permission to reproduce Case 5.

REFERENCES ALBRIGHT, F. & REIEENSTEIN, A. B. (1948). Parathyroid

Glands and Metabolic Bone Disease. 260. ANDERSON, L. (1946). Sarg. Gynec. Obstet. 32, 275. BABAINTZ, L. (1948). J. Radiol. l~lectrol. 29, 333. BLAKISTONE. New Gould Medical Dictionary, 2nd ed. : 784. HELLSTRUM, J. (1955). Brit. J. Urol. 27, 387. LINDVALL, NILS (1958). Acta Radiol. (Stockh.), 51, 193. MCKENNA, C. M., & KAMPMEIER, O. F. (1934). J. Urol.

32, 37. SNAPPER, I. (1957). Bone Disease in Medical Practice, 101.

B O O K R E V I E W S

Les Cancers du Massif Maxillalre Sup6rieur. By P. C. HUET and S. STEEANL Pp. 260, 57 illus. 1960. Paris: Masson et Cie. Price, N.F. 50.

Tins book is the joint work of a surgeon and a radiotherapist, and it is based on a clinical material of 248 cases of cancer of the antrum, the ethmoids or the nasal fossa seen from 1922 to 1955 at the Institut Gustave-Roussy in Paris. The introductory chapters illustrate the classification according to site of origin and to extent of the primary turnout, and after an analysis of the cases according to age and sex the clinical signs, natural evolution and diagnosis of the condition are described.

Of the 222 cases of carcinoma, 68 per cent were squamous celled and there was a five year survival rate of 24 per cent in that group. Twenty per cent were adeno-carcinomas (19 per cent five year survival rate) and 12 per cent oftumours were undifferentiated (7 per cent five year survival rate). Most squamous cell tumours were situated in the antrum whereas the adeno-carcinomas were more common in the ethmoid region. Lymph node metastases occurred in 25 per cent of all cases. A review of 122 treated cases, observed for at least five years, showed that 42 per cent had died within the first year, 62 per cent were dead at the end of the second year and 77 per cent at the end of the fifth year (23 per cent five year survival rate). Analysis of the treatment failures showed that 77 per cent of these had uncontrolled local disease and 20 per cent had distant metastases. The rest had died in consequence of surgical or radiation treatment. Metastases were usually situated in lungs, mediastinum or bones and their incidence was highest in the failures of the undifferentiated carcinoma group (50 per cent).

The authors give a full review of radiotherapeutic techniques with special reference to the problem of protecting the eyes and the brain. Their presently adopted treatment scheme employs irradiation for all undifferentiated tumours, gives preference to surgery for adeno-carcinoma, and chooses a combination of both methods in the treatment of most squamous cell lesions. Limited tumours without marked bone invoNement are excised with or without additional irradiation, but intra-cavitary radium is the method of choice in carcinoma of the nasal fossa. Extensive tumours with marked bone involvement but without invasion of tissues outside the bony cage are treated by external irradiation (cobalt) if they originate in the upper part of the

antrum with lateral spread, or in the mid antrum with anterior spread. Tumours of the antro-ethmoid region or of the posterior wall of the antrum with spread towards the pterygo-maxillary fossa are treated by excision followed by intra-cavitary irradiation. Inferior antral carcinoma is resected and treated afterwards by external irradiation. Extensive lesions with spread beyond the bony cage are given surgical drainage before radical irradiation with tele- cobalt (6,000 r in six to seven weeks). This is followed by electro-coagulation of any tumour residue and by orbital exenteration--if indicated. In cases of squamous or undifferentiated carcinoma of the lower or lateral part of the antrum prophylactic irradiation is given to the sub- mandibular and upper cervical lymph nodes. Twelve cases of reticulo- and lympho-sarcoma were seen (9 per cent of all cases) only two out of five surviving for five years. No long survivors were seen amongst seven patients with fibro- sarcoma and two patients with osteogenic sarcoma. Five cases of malignant melanoma are fully reported together with a review of 259 cases from the literature. The prognosis is very grave and the authors advocate radical surgical treatment with lymph node dissection. One case of a tumour metastasis in the paranasal sinuses is described and the literature is reviewed. In eighty-one cases of this nature the primary tumour was most commonly situated in the kidney, thyroid or lung. The end of the book contains a comprehensive bibliography of several hundred references.

This is a very clearly written, informative and comprehensive work and it should be of great interest to radiotherapists and E,N.T. surgeons alike. M. HULBERT

Radiographic Anatomy of the Human Skeleton. By W. H. JOHNSON, E.S.R., and J. A. KENNEDY, M.B., M.R.C.S., D.M.R., D.M.R.D. Pp. 280, Figs. 233. 1961. Edinburgh: E. & S. Livingstone. £2 10s.

THIS book is written for radiographers and combines full descriptions of osseous anatomy with the radiographic appearances in routine projections.

The book is well produced. The illustrations, both radio- graphs and anatomical drawings, are clear and of excellent quality. It is a very useful addition to the literature and should prove most helpful to radiographers both student and qualified. S. LEAc~