ICRP PUBLICATION 120: Radiological protection in cardiology.

Cardiac nuclear medicine, cardiac computed tomography (CT), interventional cardiology procedures, and electrophysiology procedures are increasing in number and account for an important share of patient radiation exposure in medicine. Complex percutaneous coronary interventions and cardiac electrophysiology procedures are associated with high radiation doses. These procedures can result in patient skin doses that are high enough to cause radiation injury and an increased risk of cancer. Treatment of congenital heart disease in children is of particular concern. Additionally, staff(1) in cardiac catheterisation laboratories may receive high doses of radiation if radiological protection tools are not used properly. The Commission provided recommendations for radiological protection during fluoroscopically guided interventions in Publication 85, for radiological protection in CT in Publications 87 and 102, and for training in radiological protection in Publication 113 (ICRP, 2000b,c, 2007a, 2009). This report is focused specifically on cardiology, and brings together information relevant to cardiology from the Commission's published documents. There is emphasis on those imaging procedures and interventions specific to cardiology. The material and recommendations in the current document have been updated to reflect the most recent recommendations of the Commission. This report provides guidance to assist the cardiologist with justification procedures and optimisation of protection in cardiac CT studies, cardiac nuclear medicine studies, and fluoroscopically guided cardiac interventions. It includes discussions of the biological effects of radiation, principles of radiological protection, protection of staff during fluoroscopically guided interventions, radiological protection training, and establishment of a quality assurance programme for cardiac imaging and intervention. As tissue injury, principally skin injury, is a risk for fluoroscopically guided interventions, particular attention is devoted to clinical examples of radiation-related skin injuries from cardiac interventions, methods to reduce patient radiation dose, training recommendations, and quality assurance programmes for interventional fluoroscopy.

Acid/pepsin promotion of carcinogenesis in the hamster cheek pouch.

OBJECTIVE: While clinical observation has suggested an association between gastroesophageal reflux and laryngeal carcinoma, the nature of this relationship has yet to be defined. The purpose of this study is to determine the carcinogenic potential of acid and pepsin mixtures in the hamster cheek pouch animal model. DESIGN: A blinded intervention study. SUBJECTS: One hundred male Syrian hamsters aged approximately 5 weeks. INTERVENTIONS: A control group of 20 hamsters received application of the carcinogen 9,10-dimethyl-1,2-henzanthracene (DMBA) to their cheek pouch mucosa. One experimental group (n = 20) received applications of DMBA plus hydrochloric acid, and another (n = 20) received DMBA plus an acid and pepsin solution. Latency to squamous cell tumor production, size of tumors, and numbers of tumors were compared among groups. RESULTS: Latency to tumor production and size of tumor were similar among groups, with both experimental and control groups developing tumors of comparable size after 12 weeks of chemical application. However, the number of tumors produced was significantly higher in the DMBA/acid and DMBA/acid/ pepsin groups than in the DMBA only group at 18 weeks, with 23, 27, and 10 tumors in these groups, respectively (P<.02). Likewise, a cumulative dysplasia score was different among groups at 18 weeks with the DMBA/acid and DMBA/acid/pepsin groups scoring higher degrees of dysplasia than the DMBA only group. CONCLUSION: These results suggest that application of acid and acid/pepsin mixtures may promote experimental carcinogenesis in the hamster cheek pouch.

Diagnosis: atypical fibroxanthoma or not? Evaluating spindle cell malignancies on sun damaged skin: a practical approach.

Poorly differentiated spindle cell malignancies on sun damaged skin frequently pose a diagnostic challenge for dermatopathologists. The vast majority of these neoplasms ultimately are diagnosed as either atypical fibroxanthoma (AFX), spindle cell squamous cell carcinoma (SCSCC), or spindle cell melanoma (SCM), and rarely leiomyosarcoma or angiosarcoma. Light microscopic clues may suggest one of these neoplasms, but subtle and overlapping characteristics often render precise diagnosis impossible based on morphological features alone. Immunohistochemistry therefore is necessary to firmly and accurately diagnose the majority of spindle cell malignancies on sun damaged skin. We summarize typical clinical and histological findings associated with this group of malignancies and offer a practical immunohistochemical approach to use in their diagnosis.

Cutaneous malignant epithelioid neoplasms.

In summary, cutaneous malignancies with an epithelioid appearance form a diverse group of neoplasms that may be difficult to diagnose by utilizing routine microscopy alone. Cutaneous malignancies, including malignant melanoma and metastatic carcinoma, certain benign neoplasms such as mixed tumor of the skin and angiolymphoid hyperplasia with eosinophils (epithelioid hemangioma), and infectious conditions such as bacillary (epithelioid) angiomatosis can be considered in this differential. However, through recognition of the characteristic histologic, immunocytochemical, and ultrastructural findings outlined above, definitive diagnosis of these challenging neoplasms is usually possible.

Submandibular gland carcinoma ex pleomorphic adenoma. Report of a case with cytologic features and diagnostic pitfalls.

BACKGROUND: Carcinoma ex pleomorphic adenoma is a rare neoplasm of the salivary gland. This lesion, also known as malignant mixed tumor, occurs when a malignant tumor arises in the epithelial component of a pleomorphic adenoma. Reports of fine needle aspiration biopsy (FNAB) diagnosis of malignant mixed tumors are rare and have been limited to cases arising in the parotid. Cytologic features and diagnostic pitfalls of this uncommon neoplasm are presented. CASE: A 75-year-old male presented with a nontender submandibular mass. The lesion had been present 12 months, with a recent increase in size. FNAB was performed, and the smears revealed a mixture of benign and malignant areas. The benign portion of the smears showed findings typical of pleomorphic adenoma. The malignant area showed large cells occurring singly and in groups. The malignant cells contained pleomorphic nuclei with irregular nuclear membranes and prominent macronucleoli; cytologically, they resembled cells from a poorly differentiated adenocarcinoma. CONCLUSION: We present the first case of carcinoma ex pleomorphic adenoma of the submandibular gland correctly diagnosed by FNAB. This rare salivary gland malignancy can be accurately diagnosed on FNAB if strict criteria are applied.

Expression pattern of the bullous pemphigoid-180 antigen in normal and neoplastic epithelia.

BP180 is a 180kDa hemidesmosomal protein recognized by bullous pemphigoid (BP) and pemphigoid gestationis (PG) autoantibodies. Recent cloning and sequence analysis performed by our laboratory have revealed that BP180 is a transmembrane protein with a long extracellular collagen-like region. A rabbit polyclonal antibody has been generated against a recombinant protein, designated GST-N delta 1, containing a segment of the BP180 ectodomain. The resulting antiserum, RN delta 1A, was shown to specifically react with BP180 on immunoblot, and labelled the extracellular region of the epidermal hemidesmosome on immunoelectron microscopy. A panel of normal and neoplastic human tissues were analysed by indirect immunofluorescence (IF) and RN delta 1A, to determine the distribution of BP180. A total of nine basal cell carcinomas (BCCs) and four squamous cell carcinomas (SCCs) of the skin were also studied. Intense IF staining was seen along the basement membrane zone (BMZ) of the epidermis, hair follicles, and the periphery of sebaceous gland lobules. The sebaceous lobules showed more intense staining in areas close to the duct. The epithelial BMZ of the following tissues also reacted with RN delta 1A: cornea, ocular conjunctiva, buccal mucosa, upper oesophagus, placenta (amnion placentum), umbilical cord and transitional epithelium of the bladder. The epithelium of the jejunum and ovary failed to react with RN delta 1A. Staining of the BCCs and SCCs was variable. Five of six nodular BCCs showed some anti-BP180 staining at the tumour-stromal interface, although the level of staining was less intense than that observed in the overlying normal epidermis. All three morphoeic BCCs analysed in this investigation did not show any staining with RN delta 1A. Three of four SCCs showed weak staining at the tumour-stromal interface. Thus, the tissue distribution of BP180 paralleled that of hemidesmosomes, and expression of this protein was found to be decreased or absent in cutaneous neoplasms.

Reevaluation of the superiority of polyethylene glycol-modified interleukin-2 over regular recombinant interleukin-2.

Other groups have reported a superior antitumor efficacy of polyethylene glycol-modified interleukin-2 (PEG-IL-2) compared with regular recombinant interleukin-2 (rIL-2). However, detailed comparison of the antitumor efficacies of locally applied PEG-IL-2 and rIL-2 in the well-established DBA/2-SL2 model shows a higher antitumor efficacy of PEG-IL-2 only at doses < 800 micrograms IL-2 protein/kg body weight. At doses > 800 micrograms IL-2 protein/kg body weight, rIL-2 has better therapeutic efficacy. The superiority of rIL-2 at doses > 800 micrograms IL-2 protein/kg body weight is a result of the toxicity of PEG-IL-2 at these doses. With either IL-2 preparation, cure rates of approximately 90% can be obtained at nontoxic doses. We conclude that PEG-IL-2 does not have superior antitumor efficacy to rIL-2. The main advantage of PEG-IL-2 is that for optimal therapeutic efficacy a daily injection schedule is not required as seems to be the case for rIL-2.

[Diagnosis of carotid body tumor by imaging procedures]. / Die Diagnostik des Glomus-caroticum-Tumors durch bildgebende Verfahren.

The imaging techniques available for the diagnosis of tumors of the glomus caroticum are discussed with reference to four cases (three patients, one with tumor bilaterally). Taking into consideration the practicability and invasiveness of the investigations as well as the risks and costs involved, we propose that the procedures be performed in the following sequence: ultrasonography, Doppler ultrasonography, computed tomography (CT) or (even better) magnetic resonance imaging (MRI), and selective angiography. In most cases where there is a non-inflammatory mass in the neck, ultrasonography and Doppler ultrasonography may be adequate to establish the diagnosis of a glomus caroticum tumor. B-scan ultrasonography reveals an inhomogeneous mass that pushes the carotid arteries apart and an arteriovenous shunt may be seen using the Doppler technique. CT and MRI show the full extent of the tumor and provide information about infiltration of adjacent structures. Selective intra-arterial angiography confirms the diagnosis, demonstrating a profound vascularized tumor in the carotid bifurcation. If angiography leads to identification of an afferent vessel, selective embolization of the tumor may be performed, thus enabling a much safer operation with less blood loss.

Pelvic hemangiopericytomas: a report of five cases and literature review.

Five cases of pelvic hemangiopericytomas are reported. One of these tumors arose from the uterus, and four patients had extrauterine, pelvic hemangiopericytomas. The patient with a primary uterine hemangiopericytomas had only simple excision, and, after 6 years, is alive and free of disease. All four patients with extrauterine, pelvic hemangiopericytomas had incomplete resection of their tumors because of hemorrhage. However, pelvic radiation therapy was then employed in these patients and produced a complete regression in one patient and partial regression in two patients with minimal shrinkage in another patient. The latter patients were reexplored after pelvic radiation and underwent complete resection of their disease. Two patients developed pelvic recurrences at 2 and 9 years, respectively, and these were effectively resected. All four patients are all alive and free of disease 5 to 18 years later. If this lesion is unexpectedly discovered at laparotomy, our experience suggests that the resection should be discontinued and that they should be treated with pelvic radiation and delayed resection of persistent and recurrent pelvic tumors.

Positron emission tomography in neuropsychiatric lupus erythematosus.

We performed positron emission tomography (PET) using 18F-labeled 2-F-2-deoxyglucose in 13 patients with systemic lupus erythematosus (SLE). Ten of them had clinical signs of central nervous system involvement (NP-SLE). All patients with neurologic symptoms showed pathologic changes on PET, always in accordance with the clinical state. Three patients without neuropsychiatric manifestations had normal PETs. Computed tomography of the brain and magnetic resonance imaging proved to be less sensitive to both presence and localization of CNS lesions. We conclude that the combination of PET and MRI constitutes the most useful diagnostic procedure for NP-SLE.

Neuropathological studies in a mutant hamster model of paroxysmal dystonia.

Dystonic movements in a mutation of the Syrian golden hamster, named dtsz, have several features in common with clinically observed paroxysmal dystonic choreoathetosis. In this study the CNS of the mutant hamsters and age-matched nondystonic controls was examined for morphological alterations at the age of 30 days, i.e., when the severity of the dystonic syndrome is fully developed. Particular interest was directed to those brain regions (caudate nucleus, putamen, globus pallidus, ventrolateral thalamus) that are presumably involved in symptomatic dystonia of humans, as well as to regions (e.g., spinal cord, dorsal root ganglia, nucleus ruber) for which neuropathologically detectable lesions have been found previously in the dystonia musculorum mouse. The neuropathological investigation was carried out on routine paraffin histology on step sections of the whole brain and spinal cord. In addition, a silver impregnation method was used for detection of pre- and/or postsynaptic degeneration. Light microscopic examination, including morphometry, of the nervous tissue failed to reveal any morphological or morphometric differences between control and dystonic hamsters. The only abnormality that was found in several control and dystonic hamsters was hydrocephalus. Breeding studies using magnetic resonance imaging for detection of hydrocephalus showed that hydrocephalus was hereditary but not related to dystonia. Virus infections as a cause of hydrocephalus or dystonia could be excluded by serological analysis with determinations of various virus antibodies in hamster sera. The lack of neuropathological alterations related to dystonic movements in the present study in dtsz hamsters is comparable to most cases of human hereditary or idiopathic dystonia, which show dystonic movements in the absence of morphological alterations.

[Imaging diagnosis of central nervous system involvement in panarteritis nodosa]. / Bildgebende Diagnostik der zentralnervösen Beteiligung bei der Panarteriitis nodosa.

Central nervous system involvement of periarteritis nodosa is a rare complication of this disease. The diagnosis of CNS manifestation in vasculitis has been improved by using imaging techniques (i.e., magnetic resonance tomography, computed tomography, positron emission tomography). A case of polyarteritis nodosa with CNS involvement is presented; the diagnostic value of magnetic resonance imaging and positron emission tomography is discussed.

Reactive fibromatosis in pustulotic arthro-osteitis.

Sterno-costo-hyperostosis is an inflammatory rheumatic disease which is associated to pustulosis palmaris et plantaris. The origin of this disorder is unknown. We described the appearance as a "reactive" fibromatosis in connection with a hyperostosis of a clavicle, which could be demonstrated in a biopsy-probe and by NMR-technique.

[Differentiation of focal liver lesions using contrast-enhanced MRT]. / Differenzierung fokaler Leberläsionen mit der kontrastmittelunterstützten KST.

47 patients with liver tumours (haemangioma, focal nodular hyperplasia, hepatocellular carcinoma) underwent MRI of the liver before and after i.v. injection of 0.2 ml./kg. gadolinium-DTPA in addition to other imaging methods. The demarcation of focal nodular hyperplasia is not influenced by use of the contrast agent as it almost behaves like surrounding normal liver tissue, thus only indirectly facilitating its identification. With regard to liver haemangiomas that show the most intensive uptake of gadolinium-DTPA, the contrast enhanced image does not reach the contrast and sensitivity of a native T2-weighted SE image, especially in cases of small haemangiomas. The contrast agent is helpful, however, in the recognition of large cavernous haemangiomas that are partially fibrotic or thrombotic. Emphasis is given to the contrast agent in hepatomas: gadolinium-DTPA presents a pattern of uptake and distribution frequently found in hepatocellular carcinoma providing additional information on the delineation of internal tumour details.

PET and MR imaging in a neuro-Behçet syndrome.

Positron emission tomography (PET) and magnetic resonance imaging (MRI) studies were performed on a case of neuro-Behçet's syndrome. In accordance with the clinical signs, FDG PET (using 18F-labeled 2-F-2'-desoxyglucose) revealed disseminated storage defects in the cerebrum and cerebellum. Focal regions of enhanced signal intensity were demonstrated in the parietal white matter of the cerebrum in T2-weighted images and in the brain stem by MRI.