Letter from the Editor

Article Outline

• Copyright

It was during my residency in 1973 that a junior member of the Cincinnati radiology faculty placed an ultrasound transducer on the flank of a prone patient and pointed out the kidney to me. To Michael Grossman, it was obvious, “The kidney is that oval thing with echoes in the middle,” but for me it required a leap of imagination. After all, he was showing me a bistable image on a very early piece of equipment. All I saw was a bunch of dots, and I scoffed quietly. In just less than a few years, however, improvements in image quality had made such an impact that we were actually able to put together an issue of this journal entitled, “The Kidney” (March 1981, Volume 2, Number 1). This really was an ultrasound issue (Seminars was then an ultrasound journal). The only other test that had any major value then was the iconic intravenous urogram (IVU). This test had long been the gold standard for urological imaging, and intravenous pyelograms (IVPs as they were popularly known then) were almost as ubiquitous as upper GIs and barium enemas. CT and MRI were still coming attractions in 1980. Who could have imagined then just how much of an impact these modalities would have throughout radiology. Ultrasound would still have its place especially after the development of Doppler techniques, and an occasional IVU would be done after protest, but as one can glean from looking at the Table of Contents of this issue, CT and MRI now dominate this field. Reflecting on the explosion of information in renal imaging, this is a rather large issue with an expanded binder.

The issue begins with an article on multidectector CT urogram (CTU). This is the test that mostly replaced the IVU even with its tomography. If you were going to subject your patients to IV contrast and radiation, you may as well obtain as much information about the urinary tract as possible, and a huge amount of information is available. Drs. Washburn and Dillman and associates discuss CT urography in detail, including practical considerations of technique and radiation exposure. The article continues with a discussion of the CTU appearances of urological abnormalities.

What about the promise of MR urography? Drs. Leyendecker and Clingan confront this question. No one can deny the advantages of MR in avoidance of radiation and iodinated contrast, and no one can deny that MR has well-known technical disadvantages. However, in certain situations, such as in pregnant women, children who need repeated scans, and others, MR is the way to go. MR may also be useful in working out complex urological anatomy and pathology and down the road may become an accepted means of evaluating hematuria.

The subject of imaging adult patients with painless hematuria is the next article in this issue. Dr. O'Regan and associates discuss the value of our various modalities in the investigation of this sign that can range in importance from transient unexplained hematuria to signaling an underlying urinary tract malignancy. As expected, their algorithm recommendations are more in keeping with the prevailing European opinions that give greater roles to IVU and ultrasound in low-risk patients.

There is a wide range of vascular conditions that may affect the kidneys. In their very comprehensive article, Drs. Sidhu and Lockhart review the various vascular lesions of the kidney that can range from often asymptomatic anomalies to potentially catastrophic conditions of renal artery dissection and renal vein thrombosis. Each section of this article deals with the available imaging options of ultrasound, CT, MR, and nuclear medicine.

The sonographic appearance of the kidney in patients with AIDS was described as far back as 1984. Improved treatments for HIV-infected patients have resulted in prolonged survival but increased morbidity. The kidneys are commonly affected. In their article on the imaging features of renal pathology in HIV-infected patients, Drs. Symeonidou, Hammedunin, and Malhotra review the subtle ultrasound and CT findings of early HIVAN (HIV-associated nephropathy). The article continues with discussions of renal infections and tumors in HIV-infected patients and finally a discussion of renal pathology related to HAART (highly active antiretroviral therapy).

The March 1981 issue contained an article on the ultrasound of renal transplants and one is included in this issue by Dr. Irshad and his colleagues. What a difference! Not only have the grayscale images improved dramatically, but now with Doppler and the occasional use CT and MR and nuclear medicine, imaging is much more effective and elegant for the wide variety of complications that may occur.

The final three articles focus on renal masses. First, Dr. Choudhary and associates provide an in-depth discussion of renal cell carcinoma and its histologic subtypes—clear cell and papillary carcinoma. Next is an article by Drs. Sun and Pedrosa on MR of renal masses. As mentioned in the article, MR with its superior soft-tissue contrast, multiplanar, and subtraction capabilities is especially well-positioned for evaluation of renal masses. Once masses are found and characterized, how are they treated? The options for dealing with a subset of renal masses, those that are considered small and often incidentally found, are discussed in the next article by Dr. Kunkle and associates. Although previously the vast majority of renal masses were surgically treated, minimally invasive ablative techniques have shown great promise. There are even patient populations where active surveillance has shown survival rates comparable to surgery and ablation.

If the cancer is detected late or if the various therapies fail to contain the disease, metastatic disease may threaten survival. As discussed by Dr. Griffin and associates, detection of metastatic disease may be critical because of recent improvements in chemotherapy that may significantly improve survival. Their modality of choice is CT.

I could not be happier at how this issue turned out. All the articles in the issue are of uniformly high quality. I want to thank all the authors of all the articles for their fine work. It was truly an honor and a pleasure to have served as Editor for this issue.

The year in which I saw my first renal ultrasound, 1973, was the same year in which my editorial assistant, Dana Roth (née Raymond) was born. I would like to take this opportunity to thank her for helping me keep this journal together. Without her help this issue would not have been possible.