J. Jones,
Richard
The
E
MD
Role
Marrow
of the bone marrow for determining
VALUATION
fundamental
treatment
ofBone
and
prognosis
is the
of patients
involvement and the elofibrosis or
by neoplastic development (3), which
associated
with
diseases
in patients
about has
(1,2)
bone
of
found
fling
with
marrow disorders, have important prognostic implications. Bone marrow aspiration and/or biopsy (usually of the posterior iliac crest) remains the primary means of examining the bone marrow. Bone marrow biopsy is required for evaluating infiltration of the bone marrow by a tumor or fibrosis.
marrow
scan-
tween
myebofibrosis
(6).
radionucbide
scanning
of the
marrow
architecture
and
resonance (MR) imaging is technique for imaging and appears to be the most
sensitive method of detecting avascular necrosis (7,8). Multiple groups (4,5,9-15) have reported on the use of MR imaging in comprehensive evaluation of the
ability
to characterize
bone
mar-
row composition, in addition to being able to allow estimation of bone marrow
biopsy of the iliac crest may not be representative of changes in the rest of the bone marrow. Imaging studies offer the potential of assessing the entire marrow compartment and therefore overcoming sampling errors associated with aspiration and biopsy. Detection of lesions associated with disorders of the bone marrow by means of conventional radiography or computed tomography usually re-
evaluation of neoplastic infiltrations of the bone marrow or in assessing bone marrow fibrosis. However, the role of MR imaging in the clinical assessment
quires
that
there
be
destruction
of tra-
becular or cortical bone (4,5). Radionucide scanning of the bone marrow with radioactive colboid or radiolabeled iron has been used to estimate the pattern of distribution of bone marrow in various disorders. Symmetrical expansion of cellular bone marrow into normally inactive areas such as the long bones has
tissues
of bone studies
pact
of bone
studies scriptive.
bone
Bone marrow,
MR, 40.1214
Radiology
MR imaging;
have
with
clinical
parameters
of both
associated
lactate
the
with
as determined
From The Johns
Rm 2-127,
Received 17. Address RSNA,
600 N Wolfe
February reprint 1992
See also the article 334)
in this
Hopkins
issue.
Oncology
St, Baltimore,
14, 1992; accepted requests
to the
by Kaplan
Center, MD
21205.
February author.
et al (pp 329-
dein
at
by Kap-
In
MR imaging Although dress
more
dehydrogenase
the
severe
disof serum
and
cholesterol
follow-up examidemonstrated according to both
and laboratory parameters. this report begins to adclinical
relevance
row MR imaging findings, problems in interpreting portance
capital
trochanters
by means
remain.
No
of bone
mar-
a number of their true im-
correlation
be-
values of clinical myebofibrosis.
What
non-
the femoral
greater
Compari-
may
not be the best
mdi-
severity in patients Comparison of the
should
be the
role
of MR
imag-
use
with either polycythemia vera or myebofibrosis, the authors found that expansion of cellular marrow into the normal and
(10,11).
At present, I think the clinical role of MR imaging in the evaluation of bone marrow disorders is limited. Lack of specificity or information regarding
lan et al (16) in this issue of Radiology. a retrospective review of 14 patients
marrow
marrow
ing in the care of patients with bone marrow disorders and how can we best
to correlate findings with
is reported
cellular
son of the clinical importance of the TIweighted images with that of chemical shift images would have been useful. Serum lactate dehydrogenase and cho-
most
causes of marrow similar changes
values. Furthermore, nations of two patients progression of disease I
been
and
im-
have been MR findings
generally
most producing
were in
MR imaging findings with other important clinical variables such as anemia, thrombocytopenia, need for treatment, and ultimately survival is crucial.
in the
certain. Few the clinical
MR imaging (4,5,14). One of the first attempts bone marrow MR imaging
was
183:321-322
important
marrow
marrow
The
different
of this procedure Moreover, the
specific, infiltration
ease, 1992;
skeleton.
marrow is not have evaluated
epiphyses
Editorials
the
for distinguishing is particularly
fatty
Index terms:
within
potential
find-
authors.
Only Ti- and T2-weighted images correlated with clinical parameters,
lesterol
distribution
histologic
by the
ings in the femurs, the MR imaging patterns could have been validated by the results of iliac crest biopsy, since the specimens varied from normal to markedly cellular in the patients studied.
cators with
However, involvement of the bone marrow may not be homogeneous; owing to sampling error, results of nonguided
and
performed
spite of the fact that chemical shift imaging has been reported to be the best means of discriminating between fatty
bone marrow, and MR imaging appears to be the most useful way to image bone marrow. Because it can distinguish fat from other tissues, MR imaging has a unique
was
Although this obviously would have been difficult to do in regard to the find-
specificity.
Magnetic an important bone lesions
MR imaging
ings
has never gained wide it yields limited information
bone low
isotopic with
bone marrow use because
and extent of mycan be idiopathic a variety
been
However,
with disorders that affect the lymphohematopoietic system. These disorders include anemias, leukemias, lymphomas, metastatic tumors, certain infections, and marrow failure states, including myebofibrosis. Bone marrow
Imaging’
this
technology
to our
advantage?
clinical importance in particular disorders makes it difficult to base clinical decisions on bone marrow MR imaging findings. Therefore, without evidence
demonstrating clinical relevance, bone marrow imaging should not be used as routine screening in disorders that can involve the bone marrow. However, one current application of MR imaging is in
the
workup
of patients
with
focal
symptomatic areas of suspected neoplastic bone marrow involvement. MR imaging has been found to reveal mar-
row involvement that was not seen on radionucide bone scans or in blind postenor iliac crest marrow biopsy specimens (4). Consequently, may be the procedure
MR imaging of choice for the
evaluation of focal bone pain in patients with known neoplastic disease. MR imaging should be particularly helpful if the pain involves the vertebrae, as MR also provides an excellent way to assess epidural masses. Although the clinical utility may be 321
currently
limited,
bone
marrow
with MR deserves further of the potential advantages. studies
should
the clinical MR imaging
focus
on
importance findings
imaging
study because Future better
of bone marrow and improving
of bone
can be detected at biopsy, would
marrow,
at MR have
and
which
imaging the same
but not effect
on prognosis as diffuse involvement that could be detected with bone marrow biopsy. The importance of focal neoplastic
detected
involvement
of bone
at MR imaging
but
to discriminate
MR imaging suited
The ability
would
for bone
1.
to monitor
marrow compartment bone marrow sampling difficulties in accessing areas associated with opsy.
appear
marrow cmistudof
Furthermore,
imaging
#{149} RadioloQv
has
been
limited.
9.
RI, DeVita
BL, Simon for advanced diffuse histiocytic lymphoma following treatment with combination chemotherapy. Am J Med 1977; 63:177-182. Conlan MG, Bast M, Armitage JO, Weisenburger DD. Bone marrow involvement by non-Hodgkin’s lymphoma: the clinical sig-
RC.
VTJr,Johnson
Prognostic
3.
4.
bone
the
Clough V. Geary CC, Hashuci brosis in chronic granulocytic J Haematol 1978; 42:515-526. Porter BA, Shields AF, Olson
11.
12.
13.
14.
15.
6.
269-289. Vogler JB III, Murphy imaging. Radiology Datz FL, Taylor A.
dionuclide bone marrow imaging. Nucl Med 1985; 15:239-259.
7.
Semin
1986; 10:634-636. Kushner
bone marrow
DC,
et ab.
disorders:
RJ, Schapiro
RU.
MRI in the de-
of malignant AJR 1986;
16.
Kaplan
KR, Mitchell
17.
Polycythemia vera and myelofibrosis: correlation of MR imaging, clinical, and laboratory findings. Radiology 1992; 183:329334. Irving MC, Brooks WM, Brereton IM, et al. Use of high resolution in vivo volume selected ‘H-magnetic resonance spectroscopy to investigate leukemia in humans. Cancer Res 1987; 47:3901-3906.
Mag-
WA. Bone marrow 1988; 168:679-693. The clinical use of ra-
DM,
tection marrow.
netic resonance imaging of bone marrow disorders. Radiol Clin North Am 1986; 24: 5.
Assist Tomogr
BR, Fleming
quantitative chemical shift MR imaging. Radiology 1988; 169:799-804. Cuckel F, Brix C, Semmler W, et al. Systemic bone marrow disorders: characterization with proton chemical shift imaging. Comput Assist Tomogr 1990; 14:633-642. Steiner RM, Mitchell DC, Rao VM, et al. Magnetic resonance imaging of bone marrow: diagnostic value in diffuse hematologic disorders. Magn Reson Q 1990; 6:1734. Shields AF, Porter BA, Churchley 5, Olson DA, Appelbaum FR, Thomas ED. The detection of bone marrow involvement by lymphoma using magnetic resonance imaging. J Clin Oncol 1987; 5:225-230. Smith SR. Williams CE, Davies JM, Edwards RHT. Bone marrow disorders: characterization with quantitative MR imaging. Radiology 1989; 172:805-810. Daffner RH, Lupetin AR, Dash N, Deeb ZL,
Sefczek
K. Myelofileukemia. Br DO.
Rosen
Hematologic
factors
the
netic resonance imaging of osteonecrosis. Radiob Clin North Am 1986; 24:193-208. Lanir A, Aghai E, Simon JS, Lee RCL, Clouse ME. MR imaging in myelofibrosis.
J Comput 10.
Careful
of morphologic discordance belymph node and bone marrow. Clin Oncol 1990; 8:1163-1172.
8.
322
Fisher
tween
to be ide-
has
cell
nificance
overcomes the errors and the some marrow bone marrow biMR
2.
imaging.
the entire
its use
R, Young
between
marrow
different
References
different marrow disorders are also needed. In particular, MR spectroscopy may provide an important means for distinguishing different types of marrow infiltrations (17). ally
possibly
clinical studies are needed to define the potential roles of MR imaging in the evaluation of disorders that affect the bone marrow. The clinical impact of this procedure probably has yet to be fully realized. U
not at bi-
opsy can be determined only with cal studies. Precinical and clinical ies into ways to improve the ability MR imaging
spectroscopy)
to distinguish dif(with the use of MR
types from one another. In clinical practice, however, bone marrow imaging with MR has proved rather nonspecific
defining
the specificity of these findings. To achieve this goal, careful prospective clinical studies with correlative pathologic follow-up are needed. For example, it is unknown if focal neoplastic
involvement
potential capacity ferent tissues and
infiltration 146:353-358.
DC, Steiner
of bone
RM, et al.
Mitchell MD, Kundel HL, Steinberg ME, Kressel HY, Alavi A, Axel U. Avascular necrosis of the hip: comparison of MR. CT, and scintigraphy. AJR 1986; 147:67-71. Gillespy T, Genant HK, Helms CA. Mag-
May
1992
Richard
The
E
MD
Role
Marrow
of the bone marrow for determining
VALUATION
fundamental
treatment
ofBone
and
prognosis
is the
of patients
involvement and the elofibrosis or
by neoplastic development (3), which
associated
with
diseases
in patients
about has
(1,2)
bone
of
found
fling
with
marrow disorders, have important prognostic implications. Bone marrow aspiration and/or biopsy (usually of the posterior iliac crest) remains the primary means of examining the bone marrow. Bone marrow biopsy is required for evaluating infiltration of the bone marrow by a tumor or fibrosis.
marrow
scan-
tween
myebofibrosis
(6).
radionucbide
scanning
of the
marrow
architecture
and
resonance (MR) imaging is technique for imaging and appears to be the most
sensitive method of detecting avascular necrosis (7,8). Multiple groups (4,5,9-15) have reported on the use of MR imaging in comprehensive evaluation of the
ability
to characterize
bone
mar-
row composition, in addition to being able to allow estimation of bone marrow
biopsy of the iliac crest may not be representative of changes in the rest of the bone marrow. Imaging studies offer the potential of assessing the entire marrow compartment and therefore overcoming sampling errors associated with aspiration and biopsy. Detection of lesions associated with disorders of the bone marrow by means of conventional radiography or computed tomography usually re-
evaluation of neoplastic infiltrations of the bone marrow or in assessing bone marrow fibrosis. However, the role of MR imaging in the clinical assessment
quires
that
there
be
destruction
of tra-
becular or cortical bone (4,5). Radionucide scanning of the bone marrow with radioactive colboid or radiolabeled iron has been used to estimate the pattern of distribution of bone marrow in various disorders. Symmetrical expansion of cellular bone marrow into normally inactive areas such as the long bones has
tissues
of bone studies
pact
of bone
studies scriptive.
bone
Bone marrow,
MR, 40.1214
Radiology
MR imaging;
have
with
clinical
parameters
of both
associated
lactate
the
with
as determined
From The Johns
Rm 2-127,
Received 17. Address RSNA,
600 N Wolfe
February reprint 1992
See also the article 334)
in this
Hopkins
issue.
Oncology
St, Baltimore,
14, 1992; accepted requests
to the
by Kaplan
Center, MD
21205.
February author.
et al (pp 329-
dein
at
by Kap-
In
MR imaging Although dress
more
dehydrogenase
the
severe
disof serum
and
cholesterol
follow-up examidemonstrated according to both
and laboratory parameters. this report begins to adclinical
relevance
row MR imaging findings, problems in interpreting portance
capital
trochanters
by means
remain.
No
of bone
mar-
a number of their true im-
correlation
be-
values of clinical myebofibrosis.
What
non-
the femoral
greater
Compari-
may
not be the best
mdi-
severity in patients Comparison of the
should
be the
role
of MR
imag-
use
with either polycythemia vera or myebofibrosis, the authors found that expansion of cellular marrow into the normal and
(10,11).
At present, I think the clinical role of MR imaging in the evaluation of bone marrow disorders is limited. Lack of specificity or information regarding
lan et al (16) in this issue of Radiology. a retrospective review of 14 patients
marrow
marrow
ing in the care of patients with bone marrow disorders and how can we best
to correlate findings with
is reported
cellular
son of the clinical importance of the TIweighted images with that of chemical shift images would have been useful. Serum lactate dehydrogenase and cho-
most
causes of marrow similar changes
values. Furthermore, nations of two patients progression of disease I
been
and
im-
have been MR findings
generally
most producing
were in
MR imaging findings with other important clinical variables such as anemia, thrombocytopenia, need for treatment, and ultimately survival is crucial.
in the
certain. Few the clinical
MR imaging (4,5,14). One of the first attempts bone marrow MR imaging
was
183:321-322
important
marrow
marrow
The
different
of this procedure Moreover, the
specific, infiltration
ease, 1992;
skeleton.
marrow is not have evaluated
epiphyses
Editorials
the
for distinguishing is particularly
fatty
Index terms:
within
potential
find-
authors.
Only Ti- and T2-weighted images correlated with clinical parameters,
lesterol
distribution
histologic
by the
ings in the femurs, the MR imaging patterns could have been validated by the results of iliac crest biopsy, since the specimens varied from normal to markedly cellular in the patients studied.
cators with
However, involvement of the bone marrow may not be homogeneous; owing to sampling error, results of nonguided
and
performed
spite of the fact that chemical shift imaging has been reported to be the best means of discriminating between fatty
bone marrow, and MR imaging appears to be the most useful way to image bone marrow. Because it can distinguish fat from other tissues, MR imaging has a unique
was
Although this obviously would have been difficult to do in regard to the find-
specificity.
Magnetic an important bone lesions
MR imaging
ings
has never gained wide it yields limited information
bone low
isotopic with
bone marrow use because
and extent of mycan be idiopathic a variety
been
However,
with disorders that affect the lymphohematopoietic system. These disorders include anemias, leukemias, lymphomas, metastatic tumors, certain infections, and marrow failure states, including myebofibrosis. Bone marrow
Imaging’
this
technology
to our
advantage?
clinical importance in particular disorders makes it difficult to base clinical decisions on bone marrow MR imaging findings. Therefore, without evidence
demonstrating clinical relevance, bone marrow imaging should not be used as routine screening in disorders that can involve the bone marrow. However, one current application of MR imaging is in
the
workup
of patients
with
focal
symptomatic areas of suspected neoplastic bone marrow involvement. MR imaging has been found to reveal mar-
row involvement that was not seen on radionucide bone scans or in blind postenor iliac crest marrow biopsy specimens (4). Consequently, may be the procedure
MR imaging of choice for the
evaluation of focal bone pain in patients with known neoplastic disease. MR imaging should be particularly helpful if the pain involves the vertebrae, as MR also provides an excellent way to assess epidural masses. Although the clinical utility may be 321
currently
limited,
bone
marrow
with MR deserves further of the potential advantages. studies
should
the clinical MR imaging
focus
on
importance findings
imaging
study because Future better
of bone marrow and improving
of bone
can be detected at biopsy, would
marrow,
at MR have
and
which
imaging the same
but not effect
on prognosis as diffuse involvement that could be detected with bone marrow biopsy. The importance of focal neoplastic
detected
involvement
of bone
at MR imaging
but
to discriminate
MR imaging suited
The ability
would
for bone
1.
to monitor
marrow compartment bone marrow sampling difficulties in accessing areas associated with opsy.
appear
marrow cmistudof
Furthermore,
imaging
#{149} RadioloQv
has
been
limited.
9.
RI, DeVita
BL, Simon for advanced diffuse histiocytic lymphoma following treatment with combination chemotherapy. Am J Med 1977; 63:177-182. Conlan MG, Bast M, Armitage JO, Weisenburger DD. Bone marrow involvement by non-Hodgkin’s lymphoma: the clinical sig-
RC.
VTJr,Johnson
Prognostic
3.
4.
bone
the
Clough V. Geary CC, Hashuci brosis in chronic granulocytic J Haematol 1978; 42:515-526. Porter BA, Shields AF, Olson
11.
12.
13.
14.
15.
6.
269-289. Vogler JB III, Murphy imaging. Radiology Datz FL, Taylor A.
dionuclide bone marrow imaging. Nucl Med 1985; 15:239-259.
7.
Semin
1986; 10:634-636. Kushner
bone marrow
DC,
et ab.
disorders:
RJ, Schapiro
RU.
MRI in the de-
of malignant AJR 1986;
16.
Kaplan
KR, Mitchell
17.
Polycythemia vera and myelofibrosis: correlation of MR imaging, clinical, and laboratory findings. Radiology 1992; 183:329334. Irving MC, Brooks WM, Brereton IM, et al. Use of high resolution in vivo volume selected ‘H-magnetic resonance spectroscopy to investigate leukemia in humans. Cancer Res 1987; 47:3901-3906.
Mag-
WA. Bone marrow 1988; 168:679-693. The clinical use of ra-
DM,
tection marrow.
netic resonance imaging of bone marrow disorders. Radiol Clin North Am 1986; 24: 5.
Assist Tomogr
BR, Fleming
quantitative chemical shift MR imaging. Radiology 1988; 169:799-804. Cuckel F, Brix C, Semmler W, et al. Systemic bone marrow disorders: characterization with proton chemical shift imaging. Comput Assist Tomogr 1990; 14:633-642. Steiner RM, Mitchell DC, Rao VM, et al. Magnetic resonance imaging of bone marrow: diagnostic value in diffuse hematologic disorders. Magn Reson Q 1990; 6:1734. Shields AF, Porter BA, Churchley 5, Olson DA, Appelbaum FR, Thomas ED. The detection of bone marrow involvement by lymphoma using magnetic resonance imaging. J Clin Oncol 1987; 5:225-230. Smith SR. Williams CE, Davies JM, Edwards RHT. Bone marrow disorders: characterization with quantitative MR imaging. Radiology 1989; 172:805-810. Daffner RH, Lupetin AR, Dash N, Deeb ZL,
Sefczek
K. Myelofileukemia. Br DO.
Rosen
Hematologic
factors
the
netic resonance imaging of osteonecrosis. Radiob Clin North Am 1986; 24:193-208. Lanir A, Aghai E, Simon JS, Lee RCL, Clouse ME. MR imaging in myelofibrosis.
J Comput 10.
Careful
of morphologic discordance belymph node and bone marrow. Clin Oncol 1990; 8:1163-1172.
8.
322
Fisher
tween
to be ide-
has
cell
nificance
overcomes the errors and the some marrow bone marrow biMR
2.
imaging.
the entire
its use
R, Young
between
marrow
different
References
different marrow disorders are also needed. In particular, MR spectroscopy may provide an important means for distinguishing different types of marrow infiltrations (17). ally
possibly
clinical studies are needed to define the potential roles of MR imaging in the evaluation of disorders that affect the bone marrow. The clinical impact of this procedure probably has yet to be fully realized. U
not at bi-
opsy can be determined only with cal studies. Precinical and clinical ies into ways to improve the ability MR imaging
spectroscopy)
to distinguish dif(with the use of MR
types from one another. In clinical practice, however, bone marrow imaging with MR has proved rather nonspecific
defining
the specificity of these findings. To achieve this goal, careful prospective clinical studies with correlative pathologic follow-up are needed. For example, it is unknown if focal neoplastic
involvement
potential capacity ferent tissues and
infiltration 146:353-358.
DC, Steiner
of bone
RM, et al.
Mitchell MD, Kundel HL, Steinberg ME, Kressel HY, Alavi A, Axel U. Avascular necrosis of the hip: comparison of MR. CT, and scintigraphy. AJR 1986; 147:67-71. Gillespy T, Genant HK, Helms CA. Mag-
May
1992
