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Building a Better Mousetrap: The Diagnosis of Metastatic

Cervical Adenopathy
Technologic limitations are sometimes a boon. anatomic and physiological assessment, is still not fully
Whether in medicine or in other areas of science, limi- evaluated or widely available. Metabolic (functional,
tations prompt a search for new and improved solutions. physiological) imaging with fluorine-18-fluorodeoxyglu-
In surgical oncology, once techniques for removal cose positron emission tomography is new and promis-
of tumor-bearing cervical lymph nodes became part ing. The limited anatomic detail that positron emission
of standard medical practice, it was important to tomography provides will likely require correlation with
identify those nodes preoperatively. Clever minds CT or MR imaging to make it widely useful.
have devised many approaches, but the large number So where does this leave us? Radiologists who at-
of methods currently used to find cancer in lymph tempt to diagnose tumor in cervical lymph nodes and
nodes testifies eloquently to how unsatisfactory the surgeons who plan surgery with that information require
available options are. These methods can be divided more sensitive and specific information than is currently
into those that evaluate the anatomic aspects of nodes available. A new technique is needed. Add to the wish
and those that assess the physiological behavior of list a technique that simply applies existing equipment
tissue. Clinical palpation, for example, relies on ana- and technology to better advantage.
tomic features. Palpation uses no special equipment Enter dynamic contrast-enhanced MR imaging.
but does require extensive training and experience This method, evaluated in the current issue by Fisch-
and still yields a discouragingly low accuracy. bein et al, combines the best features of dynamic
CT and MR imaging have improved on that rather contrast-enhanced CT with the improved tissue con-
dismal statistic by applying a variety of anatomic cri- trast of MR imaging to open up a brave new world.
teria (size, shape, attenuation, originial intensity Dynamic contrast-enhanced MR imaging has already
number) to differentiate normal from abnormal proved its merit in evaluating primary tumors in a
nodes. The inevitable tradeoff between sensitivity and variety of locations (brain, head and neck, breast,
specificity has limited the CT and MR imaging iden- cervix, bladder, and prostate, among others) and in
tification of tumor in cervical lymph nodes. If, for cases of metastatic adenopathy.
example, the cutoff for “normal” nodes is 0.5 cm, very For reasons that are as yet incompletely under-
few tumor-bearing nodes will be missed but many stood, the current study found that tumor-bearing
normal nodes will be misidentified as abnormal. lymph nodes handled a contrast bolus differently
Therefore, most radiologists use a higher cutoff. from non-tumor-bearing nodes. The time to peak
Sonography is subject to many of the limitations that enhancement was longer for nodes that contained
plague CT and MR imaging. Color Doppler sonog- tumor, the peak was lower, and the washout of con-
raphy evaluates the “angioarchitecture” of lymph trast material was slower. These distinct differences
nodes but is not widely used in this country. separate the abnormal nodes from the normal nodes.
Sentinel node imaging provides a “road map” of Work remains to be done. The pathophysiological
the lymphatic drainage from a tumor but no informa- underpinnings of dynamic contrast-enhanced MR im-
tion regarding the presence or absence of tumor in aging are yet to be elucidated. Understanding the
those nodes. The technique entails injecting techne- physiology might lead to treatment for tumor-bearing
tium-labeled sulfur colloid particles into and around a nodes or, even better, to prevention of metastases. A
tumor. The particles migrate from the tumor into the prospective comparison of dynamic contrast-en-
draining lymphatics. Scintiphotos provide a map of hanced MR imaging and conventional MR imaging
the lymphatic drainage from the tumor, nothing should prove interesting, as will the comparison of
more. Although this may be of use in identifying dynamic MR imaging to fluorine-18-fluorodeoxyglu-
aberrant drainage pathways that would necessitate cose positron emission tomography.
modifications of a planned neck dissection, sentinel Dynamic contrast-enhanced MR imaging seems to
node imaging provides no information regarding be an important new direction that the accurate di-
where or even whether tumor is present in nodes. agnosis of head and neck metastases will take. The
Elsewhere in the body, lymphangiography and lym- article by Fischbein et al shows us that the time to
phoscintigraphy have provided a combination of ana-
start moving in that direction is now.
tomic and physiological information about lymph nodes.
Neither has proved especially useful in the neck, and JANE L. WEISSMAN, MD, FACR
both are invasive and can be technically difficult. MR Departments of Radiology and Otolaryngology
imaging performed after the administration of super- Oregon Health and Science University
paramagnetic iron oxide particles, another hybrid of Portland, OR

298 AJNR: 24, March 2003

Myelography: Still the Gold Standard

In 1986, Modic et al (1) reported that 0.6-T MR in 93% to 95% of the lateral recesses, whereas MR
imaging of the spine was equivalent to CT and my- imaging underestimated root compression in 28% to
elography in the diagnosis of lumbar canal stenosis 29% and follow-up CT underestimated root compres-
and herniated disk disease. They concluded that MR sion in 38% of the lateral recesses. Despite the short-
imaging could be viewed as an alternative to myelogra- comings of the article, we agree with the conclusion
phy. Since then, a steady decline has occurred in the presented by Bartynski and Lin that a myelographic
number of myelograms obtained throughout the coun- study is useful for cases in which a strong clinical
try. Speakers at national meetings discuss myelography suspicion of nerve root compression is present and
“for historic interest only” or in the context of “malprac- the MR images do not show the lesion or are not
tice” to discourage the practice of myelography. Institu- adequate to make this determination.
tions admitting to performing myelography are viewed The use of surgical reports to confirm lateral recess
with suspicion. This is unfortunate, because many insti- compression is problematic; surgical impressions can
tutions abandoned myelography in favor of MR imaging be both biased and unreliable. In this article, the
despite a paucity of good clinical studies comparing the surgeons reported significant compression at every
two techniques. Neuroradiology fellows are no longer lateral recess explored (58 of 58 lateral recesses). This
adequately trained in the techniques of myelography or subjective assessment may have the effect of increas-
the interpretation of myelograms. ing the apparent sensitivity and specificity of myelog-
A quality myelographic examination includes the raphy. Also, there is a high likelihood of selection
combination of fluoroscopic observation, filming, bias; patients for whom there was a strong clinical
thin-section CT, and use of contrast agent to exclude suspicion of lateral recess syndrome who had nondi-
higher lesions. Many sites drop one or multiple com- agnostic MR images were more likely to undergo
ponents, decreasing the sensitivity and specificity of myelography. Patients most likely to have lesions not
the examination and reducing the potential benefits. visible on MR images underwent myelography; most
Advances in multidector CT with capabilities to ac- patients with obvious lesions on MR images would
quire isotropic pixels and multiplanar reformats in- not have undergone myelography.
crease the resolution of the study far beyond that of Most surgeons recognize the superiority of CT my-
MR imaging and superior to that of conventional CT. elography in visualizing bony pathologic abnormality
Perhaps studies comparing myelography to MR im- in both the cervical and lumbar spine. However, MR
aging have to be repeated with the addition of this imaging is a better screening study because it is less
new technology. invasive, less expensive, and less labor intensive than
Despite advances in MR imaging of the spine, is myelography. In most cases, MR imaging ade-
pulse sequences, and coil design that have been ac- quately defines the pathologic abnormality and allows
complished during the 16 years since the article by for sound surgical decision making. Obtaining both
Modic et al was published, we have always found studies for every surgical patient is not cost-effective.
myelography (fluoroscopic observation, filming, and In clinical practice, surgeons request myelography for
thin-section CT) to be helpful in the presurgical eval- cases in which nerve root compression is strongly
uation of degenerative diseases of the cervical and clinically suspected but for which MR imaging has
lumbar spine. The MR imaging examination is some- failed to confirm the suspicion. The article by Bartyn-
times indeterminate and nondiagnostic and often ski and Lin supports the judicious use of myelography
shows many abnormalities that are difficult to corre- in such cases and emphasizes the need to train our
late with clinical data. MR myelography is disappoint- neuroradiology fellows in the proper techniques of
ing because of the lack of resolution to reliably diag- myelography and the interpretation of myelograms.
nose root compression and the inability to provide GARY M. MILLER, MD
dynamic and functional information. The myelogram Department of Radiology
best shows whether the changes seen on MR images WILLIAM E. KRAUSS, MD
result in nerve root compression or obstruction to the Department of Neurologic Surgery
flow of contrast material. Sometimes it is the fluoro- Mayo Foundation, Rochester, MN
scopic impression or plain myelographic films that are
the most diagnostic.
In this issue of the AJNR, Drs. Bartynski and Lin References
report that conventional myelography is more accu-
rate than MR imaging or follow-up CT for detecting 1. Modic MT, Masaryk T, Boumphrey F, Goormastic M, Bell G.
Lumbar herniated disk disease and canal stenosis: prospective
nerve root compression in the lateral recess. Conven- evaluation by surface coil MR, CT, and myelography. AJR Am J
tional myelography correctly predicted impingement Roentgenol 1986;147:757–765
AJNR: 24, March 2003 EDITORIALS 299

Luminal and Mural Imaging of Aneurysms

As you ramble on thru Life, Brother, more esoteric varieties take precedence. Cerebral an-
Whatever Be your Goal, eurysms in children frequently do not occur with
Keep your Eye upon the Doughnut, isolated subarachnoid hemorrhage. Asymptomatic le-
and Not upon the Hole. sions are common, and symptoms secondary to mass
—The Optimist’s Creed effect or parenchymal or subdural hemorrhage are
Aneurysms of the intracranial arteries are a signif- seen with more frequency, in our experience. The
icant source of morbidity and mortality and a signif- true nature of the source of mass effect or hemor-
icant part of the neuroradiology literature is dedi- rhage is often not readily apparent. Arteriovenous
cated to the analysis and evaluation of various fistulas, cavernous angiomas, arteriovenous malfor-
methods of diagnosing and treating cerebral aneu- mations, hemorrhagic neoplasms, and nonaccidental
rysms and their associated comorbid complications. trauma are all causes of spontaneous intracranial
Much of the advanced training in neuroradiology is hemorrhage in a child that are equally or more fre-
dedicated to acquiring the skills necessary to safely quently encountered than aneurysms. Cerebral an-
perform diagnostic and therapeutic endovascular pro- giography in children typically entails the use of gen-
cedures for the treatment of cerebral aneurysms, and eral anesthesia. For all these reasons, a greater
newer training pathways have been developed to reliance on cross-sectional imaging is justified in the
hone this therapeutic skill to a finer edge. It could be evaluation of cerebral aneurysms in children. Angio-
reasonably stated that the neuroradiologist is the ful- graphic approaches are often reserved for combined
crum of the diagnosis and management of cerebral diagnostic and therapeutic efforts.
aneurysms. In this issue, Sungarian et al present a case in a
Ever since Egas Moniz first demonstrated the in- child with intracranial hemorrhage secondary to an
tracranial arterial tree with a contrast injection in the anterior cerebral artery aneurysm. The diagnosis was
carotid artery, angiography has been the mainstay of strongly suspected after the initial nonenhanced CT
the diagnosis of cerebral aneurysms. It is often re- study, and the patient directly underwent cerebral
ferred to as the gold standard or criterion standard by angiography, which failed to show an aneurysm. An-
which any other method of diagnosis is measured. other luminal imaging study was performed, MRA,
Although it is well accepted that, like any imaging which also did not show the aneurysm, for the same
study, angiography has its share of false-negative re- reason: The lumen was no longer patent. However,
sults, its status as the ultimate diagnostic tool for the the authors were able to show the lesion by abandon-
diagnosis of cerebral aneurysms has remained essen- ing attempts to image the lumen and instead they
tially unchallenged. It should be remembered, how- concentrated on showing the aneurysm wall by ad-
ever, that it is a tool used to directly evaluate only one ministering contrast material for the MR examina-
component of the aneurysm: the lumen. tion. It is somewhat distressing that the diagnosis was
Three major modalities are used today in the im- not confirmed with follow-up luminal imaging or sur-
aging evaluation of suspected cerebral aneurysms: gery, but the fact remains that the diagnosis was made
conventional angiography, MR angiography, and CT by imaging the wall of the aneurysm and not its
angiography. All three methods rely on luminal im- contents.
aging to ascertain the correct diagnosis. In relying on The ability to demonstrate the “lay of the land”
these methods of diagnosis, the neuroradiologist tac- with MRA or CTA before embarking on a catheter-
itly assumes that the aneurysm wall is relatively im- directed diagnostic and therapeutic procedure is of
perceptible. This is a reasonable assumption in the immeasurable use to the neuroradiologist. The addi-
case of berry aneurysms, which typically have a uni- tional diagnostic and logistical hurdles inherent in the
formly thin wall that parallels the contour of the evaluation and treatment of cerebrovascular lesions
aneurysm lumen. Information regarding the thickness in children accentuate this advantage. Although
of the aneurysm wall can be obtained by using the MRA has the distinct advantage of not using ionizing
data used to generate CT angiographic (CTA) and radiation, the speed and simplicity of acquisition of
MR angiographic (MRA) images, but a separate CTA studies make it an attractive technique in the
study is required when conventional angiography is urgent evaluation of suspected cerebrovascular le-
employed to demonstrate the aneurysm. In a practical sions in children. Concerns regarding contrast agent
sense, this is not an issue, as a cross-sectional imaging volumes can be mitigated by judicious use of contrast
examination, usually CT, has invariably been per- material for both conventional angiography and CTA.
formed before cerebral angiography. At our pediatric hospital, we have long held the prac-
Berry aneurysms comprise most cerebral aneu- tice of performing a noninvasive luminal imaging
rysms in adults, but they are relatively rare in chil- study before conventional angiography whenever pos-
dren. It has been stated that atypical aneurysms pre- sible, and the addition of CTA to our diagnostic
dominate in children, but this is merely a reflection of armamentarium has greatly enhanced our ability to
the fact that in the absence of berry aneurysms, the do so. By using these modalities, previously unsus-
300 AJNR: 24, March 2003

pected causes of intracranial hemorrhage can be re- of all for us to keep our eye on the doughnut, and not
vealed. One can minimize the incidence of false- on the hole.
negative catheter angiograms and subsequently per-
form more focused and efficient catheter-directed or BLAISE V. JONES, MD
surgical therapy. It also provides the opportunity to Department of Radiology
obtain a mural imaging evaluation at the same time as Cincinnati Children’s Hospital
a luminal study, because it is sometimes to the benefit Cincinnati, OH