Murray L. Janower

LYMPHANGITIC SPREAD OF METASTATIC CANCER TO THE LUNG. A RADIOLOGIC-PATHOLOGIC CLASSIFICATION

Autopsy diagnosis of pulmonary lymphangitic carcinomatosis was made in 23 cases in which recent chest radiographs were available. Three radiologic groups were evident: Group I—5 cases with both parenchymal nodules and an interstitial linear pattern; Group II—10 cases with an interstitial linear pattern only; Group III—8 cases in which the lungs appeared normal. The radiologic-pathologic correlation was excellent. Lymph nodes contained metastatic tumor in 11 cases while arterial tumor emboli were identified in 20 of the 23 cases. The pathogenic mechanism of such tumor spread may be primarily vascular embolization rather than retrograde spread from central lymphnode involvement.

Effects of Long-Term Thorotrast Exposure

Abstract The authors evaluated radiation-related morbidity in a follow-up study involving 724 patients who received Thorotrast for cerebral angiography and 315 control patients who underwent similar diagnostic examinations with use of nonradioactive media. Intensive clinical and laboratory examinations were conducted on 42 of the Thorotrast patients and 29 of the controls. In the Thorotrast series there were 2 cases of thorotrastoma, abnormalities in Brom-sulphalein and serum alkaline phosphatase values, a high frequency of chromosome aberrations, and 1 instance each of liver neoplasm, granulocytic leukemia, and nonalcoholic hepatic cirrhosis. Anemia, elevated white cell counts, and disturbances in red cell morphology were not found.

Fatal Complications of Percutaneous Lung Biopsy

Abstract A case is reported of mortality probably secondary to tracheal aspiration of blood following performance of percutaneous needle biopsy under fluoroscopic guidance. Radiologists should be aware of this potential complication.

Site-specific cancer incidence and mortality after cerebral angiography with radioactive thorotrast.

Abstract Travis, L. B., Hauptmann, M., Gaul, L. K., Storm, H. H., Goldman, M. B., Nyberg, U., Berger, E., Janower, M. L., Hall, P., Monson, R. R., Holm, L-E., Land, C. E., Schottenfeld, D., Boice, J. D., Jr. and Andersson, M. Site-Specific Cancer Incidence and Mortality after Cerebral Angiography with Radioactive Thorotrast. Radiat. Res. 160, 691–706 (2003). Few opportunities exist to evaluate the carcinogenic effects of long-term internal exposure to α-particle-emitting radionuclides. Patients injected with Thorotrast (thorium-232) during radiographic procedures, beginning in the 1930s, provide one such valuable opportunity. We evaluated site-specific cancer incidence and mortality among an international cohort of 3,042 patients injected during cerebral angiography with either Thorotrast (n = 1,650) or a nonradioactive agent (n = 1,392) and who survived 2 or more years. Standardized incidence ratios (SIR) for Thorotrast and comparison patients (Denmark and Sweden) were estimated and relative risks (RR), adjusted for population, age and sex, were generated with multivariate statistical modeling. For U.S. patients, comparable procedures were used to estimate standardized mortality ratios (SMR) and RR, representing the first evaluation of long-term, site-specific cancer mortality in this group. Compared with nonexposed patients, significantly increased risks in Thorotrast patients were observed for all incident cancers combined (RR = 3.4, 95% CI 2.9–4.1, n = 480, Denmark and Sweden) and for cancer mortality (RR = 4.0, 95% CI 2.5–6.7, n = 114, U.S.). Approximately 335 incident cancers were above expectation, with large excesses seen for cancers of the liver, bile ducts and gallbladder (55% or 185 excess cancers) and leukemias other than CLL (8% or 26 excess cancers). The RR of all incident cancers increased with time since angiography (P < 0.001) and was threefold at 40 or more years; significant excesses (SIR = 4.0) persisted for 50 years. Increasing cumulative dose of radiation was associated with an increasing risk of all incident cancers taken together and with cancers of the liver, gallbladder, and peritoneum and other digestive sites; similar findings were observed for U.S. cancer mortality. A marginally significant dose response was observed for the incidence of pancreas cancer (P = 0.05) but not for lung cancer. Our study confirms the relationship between Thorotrast and increased cancer incidence at sites of Thorotrast deposition and suggests a possible association with pancreas cancer. After injection with >20 ml Thorotrast, the cumulative excess risk of cancer incidence remained elevated for up to 50 years and approached 97%. Caution is needed in interpreting the excess risks observed for site-specific cancers, however, because of the potential bias associated with the selection of cohort participants, noncomparability with respect to the internal or external comparison groups, and confounding by indication. Nonetheless, the substantial risks associated with liver cancer and leukemia indicate that unique and prolonged exposure to α-particle-emitting Thorotrast increased carcinogenic risks.

Multiple metaplastic (hyperplastic) polyposis of the colon.

Multiple metaplastic (hyperplastic) polyposis of the entire colon is an unusual entity which presents with a radiologic pattern resembling familial polyposis. It is important that the radiologist be aware of this entity and distinguish between these 2 conditions. The radiologic, pathologic, and clinical features of this condition are reviewed and an illustrative case is presented.

A case of Buerger's disease causing ischemic colitis with perforation in a young male.

A case of Buegers disease causing ischemic colitis with perforation in a 32-year-old male is presented. Abdominal angiography demonstrated occlusion of the vasculature supplying the involved transverse colon. The association of Buergers disease with ischemic colitis is emphasized.

Too Many Radiologists

Many radiologists in community practice believe that the planned increases in numbers of radiologists and residents in training represent an over-reaction of planners of training programs to past manpower shortages. With the current plethora of radiologists, however, the quality and quantity of resident applications have improved dramatically, and radiology is much stronger as a profession than in the past. Perhaps the major problem is not numbers of radiologists in practice but their poor distribution in the country.

LATE CLINICAL AND LABORATORY MANIFESTATIONS OF THOROTRAST ADMINISTRATION IN CEREBRAL ARTERIOGRAPHY: A FOLLOW-UP STUDY OF THIRTY PATIENTS.

Abstract Thirty patients who received thorotrast for cerebral arteriography from 1948 to 1952 were studied to determine the delayed effects of chronic low-dose internal-emitter radiation. The whole...

Mortality after Cerebral Angiography with or without Radioactive Thorotrast: An International Cohort of 3,143 Two-Year Survivors

Abstract Travis, L. B., Land, C. E., Andersson, M., Nyberg, U., Goldman, M. B., Knudson Gaul, L., Berger, E., Storm, H. H., Hall, P., Auvinen, A., Janower, M. L., Holm, L-E., Monson, R. R., Schottenfeld D. and Boice, J. D., Jr. Mortality after Cerebral Angiography with or without Radioactive Thorotrast: An International Cohort of 3,143 Two-Year Survivors. Radiat. Res. 156, 136–150 (2001). There are few studies on the long-term sequelae of radionuclides ingested or injected into the human body. Patients exposed to radioactive Thorotrast in the 1930s through the early 1950s provide a singular opportunity, since the administration of this radiographic contrast agent resulted in continuous exposure to α particles throughout life at a low dose rate. We evaluated cause-specific mortality among an international cohort of 3,143 patients injected during cerebral angiography with either Thorotrast (n = 1,736) or a similar but nonradioactive agent (n = 1,407) and who survived 2 or more years. Standardized mortality ratios (SMRs) for Thorotrast and comparison patients were calculated, and relative risks (RR), adjusted for population, age and sex, were obtained by multivariate statistical modeling. Most patients were followed until death, with only 94 (5.4%) of the Thorotrast patients known to be alive at the closure of the study. All-cause mortality (n = 1,599 deaths) was significantly elevated among Thorotrast subjects [RR 1.7; 95% confidence interval (CI) 1.5–1.8]. Significantly increased relative risks were found for several categories, including cancer (RR 2.8), benign and unspecified tumors (RR 1.5), benign blood diseases (RR 7.1), and benign liver disorders (RR 6.5). Nonsignificant increases were seen for respiratory disease (RR 1.4) and other types of digestive disease (RR 1.6). The relative risk due to all causes increased steadily after angiography to reach a threefold RR at 40 or more years (P < 0.001). Excess cancer deaths were observed for each decade after Thorotrast injection, even after 50 years (SMR 8.6; P < 0.05). Increasing cumulative dose of radiation was directly associated with death due to all causes combined, cancer, respiratory disease, benign liver disease, and other types of digestive disease. Our study confirms the relationship between Thorotrast and increased mortality due to cancer, benign liver disease, and benign hematological disease, and suggests a possible relationship with respiratory disorders and other types of digestive disease. The cumulative excess risk of cancer death remained high up to 50 years after injection with >20 ml Thorotrast and approached 50%.

Radiological features of the most common autosomal disorders: Trisomy 21–22 (Mongolism or Down's syndrome), trisomy 18, trisomy 13–15, and the cri du chat syndrome

Four autosomal disorders are described; trisomy 21 (mongolism or Downs syndrome), trisomy 18, trisomy 13–15 and ‘cri du chat’ syndrome. These disorders are associated with patterns of clinical and radiographic abnormalities that are characteristic. The typical karyotypes, clinical manifestations, radiographic findings, and differential features are presented.