Figure 6. The first carcinoma of the kidney diagnosed by CT at
NYU Medical Center (1977).
These great advances in imaging have resulted in improved detection, diagnosis, and treatment of diseases throughout the body, and, as we have described, in renal cancer as well. We now detect many more cancers of the kidney before they have metastasized, thereby increasing the cure rate of this disease. These advances in imaging have helped enable the treatment of renal cancer to progress from “exploratory surgery” to radical nephrectomy and then to nephron-sparing partial nephrectomy. Laparoscopic nephrectomy and laparoscopic partial nephrectomy have been developed and are increasingly being performed, and the techniques of percutaneous radiofrequency and cryoablation are being used in appropriate cases.
This review of the progression of imaging in the specialty of radiology, and specifically in the diagnosis of renal cancer, over the past 50 years is my own personal perspective and others might view certain aspects somewhat differently (Goldman and Sandler 2000). I have been fortunate to have practiced radiology during the introduction and development of all of these techniques — from nephrotomography (Bosniak and Faegenburg 1964) to renal arteriography (Bosniak 1964; Bosniak et al 1968;Evans and Bosniak 1971) to computed tomography (Bosniak 1986; Bosniak 1991) and MRI (Israel and Bosniak 2004). It is important for us to remember that while the technology available to us is continually improving, we must be certain that we do not rely solely on technology to do the job for us, but that we take the time and make the effort to perform the highest-quality examinations possible with the equipment available. We owe this to those who developed these modalities, to the specialty of radiology, to our clinical colleagues, and most of all, to our patients.
Acknowledgement: I would like to thank Drs. Alec Megibow and Chris Marshall for their input into some of the technical aspects of these recollections and reflections. I would also like to thank Martha Helmers for her photography work.
1 For information about uroradiology in the first half of the twentieth century, the articles by Elkin (1990) and Pollack (1996) are of interest.
2 The diatriozate compounds introduced in 1955, led by diatriozate sodium (Hypaque), were much better tolerated by patients compared to the previously used acetriozate sodium (Urokon). In fact, nephrotomography was originally performed with 90% Hypaque, which had to be warmed to lessen its viscosity, so that it could be injected rapidly.
3 Intravenous aortography was performed in the 1950s in some medical centers. The study was performed by a rapid intravenous injection by hand of 100 cc of concentrated contrast media through a large-bore needle (usually 50cc in each arm simultaneously), with filming performed 1–2 seconds after a predetermined circulation time. The results were variable (somewhat better for the thoracic aorta), but often diagnostic of gross disease conditions (Bosniak and Byck 1960). However, the technique was soon abandoned when catheter aortography was introduced.
4 It was a common sight in the radiology department to see a group of radiologists standing in the hall outside the fluoroscopic rooms wearing red goggles and heavy, bulky lead aprons becoming “dark adapted” so that they could do their barium studies in the darkened fluoroscopic rooms (a sight that might now look like it was part of a “sci-fi” movie).
5 The ability to perform selective arteriography in the radiology department transformed the specialty of radiology, in my opinion. It was a great advance for the specialty because radiologists gained added respect from their clinical colleagues, who became more dependent on them. It also stimulated top-rated medical students to enter the specialty and led to the field of cardiovascular radiology and subsequently to interventional radiology as we know it today.
6 Renal angiography using epinephrine to help better visualize “tumor vessels” in questionable cases was used with some success (FIGURE 4).
7 Sonography with cyst puncture was frequently used by some radiologists to diagnose renal cysts. Cyst puncture, however, as well as nephrotomography, quickly became obsolete as CT equipment became available. However, tomography remains an essential part of the urogram (Goldman and Sandler 2000).
8 With the introduction of CT and its continued development, the role of intravenous urography, which had been the principal examination initially to evaluate the urinary tract, has continually lessened. Conventional intravenous urography is now rarely used as an independent examination but has been incorporated into CT urography which has become even more feasible with the introduction of MDCT. (MR urography can also be performed.)
9 The Nobel Prize in Medicine in 2003 was presented to Paul C. Lauterbur and Peter Mansfield for their part in the development of magnetic resonance imaging (Partain 2004).
References
Bosniak MA “A collateral pathway through the vertebral arteries associated with obstruction of the innominate and proximal subclavian arteries.” Radiology (1963) 81:89–95.
Bosniak MA “Radiographic manifestations of massive arteriovenous fistula in renal cancer.” Radiology (1965) 85:454–459.
Bosniak MA “The current radiological approach to renal cysts.” Radiology (1986) 158:1–10.
Bosniak MA “The small (< 3.0 cm) renal parenchymal tumor: detection, diagnosis and controversies.” Radiology (1991) 179:307–317.
Bosniak MA, Byck W. “Wandering spleen diagnosed preoperatively by intravenous aortography.” Am J Roentgen (1960) 84: 898–901.
Bosniak MA, O’Connor JF, Caplan LH “Renal arteriography in patients with metastatic renal cell carcinoma. Its use as a substitute for histopathologic biopsy.” JAMA (1968) 203:249–254.
Bosniak MA, Faegenburg D “The thick-wall sign: an important finding in nephrotomography.” Radiology (1965) 84:692–697.
Elkin M “Stages in the growth of uroradiology.” Radiology (1990) 175:297–306.
Evans JA, Bosniak MA Atlas of Tumor Radiology: The Kidney. (1971) Chicago: Yearbook Medical Publishers.
Evans JA, Dubilier, W, Montrith JC “Nephrotomography: a preliminary report.” AJR Am J Roentgen (1954) 71:213–223.
Goldman SM, Sandler CM “Genitourinary imaging: the past 40 years.” Radiology (2000) 215:313–324.
Hounsfield GN “Computed medical imaging.” Nobel lecture, Dec. 8,1979. J Comput Assist Tomogr (1980) 4:665–674.
Isherwood I “Sir Godfrey Hounsfield. In Memoriam.” Radiology (2005) 234:975–976.
Israel GM, Bosniak MA “MR imaging of cystic renal masses.” Magn Reson Imaging Clin N Am (2004) 12:403–412.
Partain CL “The 2003 Nobel prize for MRI: significance and impact.” J Magn Resonan Imaging (2004) 20:173–174.
Pollack HM “Uroradiology.” In McClennan BL ed. Reston, VA: Radiology Centennial, Inc. (1996) 195–253.
Seldinger SI “Catheter replacement of the needle in percutaneous arteriography. A new technique.” Acta Radiol (1953) 39:368–376.
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