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Commentary |
1 Department of Radiology, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL 32224.
Received November 11, 2005; accepted after revision November 17, 2005.
Each month the American Journal of Roentgenology will republish
online one of the 100 most-cited articles from its first century. A
corresponding commentary in the print journal by a contemporary radiologist
will provide a current perspective. For a full list of these articles see page
3 of the January 2006 issue of AJR or
www.ajronline.org.
Keywords: CT • MRI • oncologic imaging
"A classic is classic not because it conforms to certain structural rules, or fits certain definitions.... It is classic because of a certain eternal and irrepressible freshness."—Ezra Pound [1]
The evolution from bone radiology to musculoskeletal imaging is a transition based on technology. It is a transition that began slowly but proceeded at warp speed after the identification of the musculoskeletal applications of the new technology known as MRI.
One of the earliest musculoskeletal applications of MRI was in the evaluation of bone and soft-tissue tumors. The editors of the American Journal of Roentgenology have identified one of these early application manuscripts as a "classic article" and have reprinted it as part of the celebration of its centennial.
Our life experience with Madison Avenue has made us skeptical when something is designated as a classic. "Classic Coke," for example, received that designation only after consumers overwhelmingly rejected the new Coke. The designation of the article by Aisen and colleagues [2] as a "classic," however, is in keeping with the traditional dictionary definition of the word as "a work of enduring excellence."
Although this article was not the first to assess the use of MRI in the evaluation of musculoskeletal tumors, it is most noteworthy for its original insightful observations, many of which were subsequently validated and have become basic tenets of tumor imaging.
Some of the many pertinent observations made that are still fundamental in tumor imaging include the importance of multiple imaging sequences and planes in tumor assessment, the usefulness of MRI in assessing the relationship of tumor to adjacent neurovascular structures, the limitations of MRI in distinguishing tumor from edema, and the value of MRI in assessing response to therapy. Although the value of MRI was embraced, it was not overstated. The authors noted accurately the diagnostic limitations of this new technique, and further, they recognized that the real value of MRI was in the assessment of the extent of disease: a principle of imaging that is just as valid today as it was then. Their observations regarding the value and limitation of CT are equally accurate.
These authors also realized the potential diagnostic value of MRI, recognizing the low signal intensity on both T1-weighted and T2-weighted images in aggressive fibromatosis, noting that such was the case when these lesions were densely collagenous and hypocellular, an observation that has also stood the test of time.
For those who were not in practice at the time of the original publication of "MRI and CT Evaluation of Primary Bone and Soft-Tissue Tumors," I recommend reading it while keeping current principles of tumor imaging in mind. For those like me, who are old enough to have been in practice 20 years ago, I think you will find it well worth rereading. I did and thoroughly enjoyed it once again.
Since this early application, cutting-edge advances in musculoskeletal imaging have mirrored those in technology. MRI software advances have allowed more rapid and higher resolution image acquisition, and hardware improvements have provided smaller (shorter), less physically constraining, and more patient-friendly scanners. Current technical innovations in musculoskeletal MRI include the use of MR spectroscopy, dynamic gadolinium-enhanced MRI, and diffusion-weighted MRI for the characterization of bone and soft-tissue tumors.
Equally exciting are the current musculoskeletal applications provided by MDCT. This technology allows isotropic data acquisition with high spatial resolution reformatted images in any plane. MDCTs also allow rapid image acquisition with high kVp settings, reducing the streak artifact associated with metallic implants and tumor prostheses and providing an effective adjunct for the evaluation of patients after reconstructive surgery.
This is an exciting time for imaging in general and for musculoskeletal imaging in particular. As I review each issue of the AJR, I keep my eye open for those reports that highlight new techniques and applications, looking for those that in 20 years from now I can say, "I knew this would be a classic." As for Aisen and colleagues, I greatly admire their ability to look above the crowd without having the shoulders of others to stand on. Kudos to them!
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