A Single Enhanced Dual-Energy CT Scan May Distinguish Lung Squamous Cell Carcinoma From Adenocarcinoma During the Venous phase

Differentiating invasive thymic epithelial tumors from mediastinal lung cancer using spectral CT parameters

PURPOSE

The purpose of the study was to explore the importance of quantitative characteristics of spectral CT between invasive thymic epithelial tumors (TETs) and mediastinal lung cancer.

METHODS

We analyzed 54 patients (28 with invasive TETs and 26 with mediastinal lung cancer) who underwent spectral CT. During the arterial and venous phase, we measured the CT70keV, effective atomic number (Zeff), iodine concentration (IC), and water concentration (WC) and calculated the slope of the spectral curve (K100keV). We compared the clinical findings and spectral CT parameters of both groups and performed receiver operating characteristic analysis to evaluate the diagnostic efficacy and the optimal cutoff values of the spectral CT parameters.

RESULTS

During the AP and VP, the CT70keV, Zeff, IC, and K100keV were significantly higher in patients with invasive TETs than those in patients with mediastinal lung cancer (p < 0.05). WC was not statistically significantly different between the two groups (p > 0.05). ROC curve analysis revealed that all quantitative parameters combined in the AP and VP provided the best diagnostic performance in identifying invasive TETs from mediastinal lung cancer (AUC = 0.88, p = 0.002, sensitivity = 0.89 and specificity = 0.77). The cutoff values in the AP for CT70keV, IC, Zeff, and K100keV to differentiate invasive TETs from mediastinal lung cancer were 75.55, 15.86, 8.45, and 1.71, respectively. The cutoff values in the VP for CT70keV, IC, Zeff, and K100keV to differentiate them were 67.06, 15.74, 8.50, and 1.81, respectively.

CONCLUSIONS

Spectral CT imaging has potential value in the differential diagnosis of invasive TETs and mediastinal lung cancer.

Spectral CT - a new supplementary method for preoperative assessment of pathological grades of esophageal squamous cell carcinoma

BACKGROUND

Spectral CT imaging parameters have been reported to be useful in the differentiation of pathological grades in different malignancies. This study aims to investigate the value of spectral CT in the quantitative assessment of esophageal squamous cell carcinoma (ESCC) with different degrees of differentiation.

METHODS

There were 191 patients with proven ESCC who underwent enhanced spectral CT from June 2018 to March 2020 retrospectively enrolled. These patients were divided into three groups based on pathological results: well differentiated ESCC, moderately differentiated ESCC, and poorly differentiated ESCC. Virtual monoenergetic 40 keV-equivalent image (VMI40keV), iodine concentration (IC), water concentration (WC), effective atomic number (Eff-Z), and the slope of the spectral curve(λHU) of the arterial phase (AP) and venous phase (VP) were measured or calculated. The quantitative parameters of the three groups were compared by using one-way ANOVA and pairwise comparisons were performed with LSD. Receiver operating characteristic (ROC) analysis was used to evaluate the diagnostic performance of these parameters in poorly differentiated groups and non-poorly differentiated groups.

RESULTS

There were significant differences in VMI40keV, IC, Eff-Z, and λHU in AP and VP among the three groups (all p < 0.05) except for WC (p > 0.05). The VMI40keV, IC, Eff-Z, and λHU in the poorly differentiated group were significantly higher than those in the other groups both in AP and VP (all p < 0.05). In the ROC analysis, IC performed the best in the identification of the poorly differentiated group and non-poorly differentiated group in VP (AUC = 0.729, Sensitivity = 0.829, and Specificity = 0.569 under the threshold of 21.08 mg/ml).

CONCLUSIONS

Quantitative parameters of spectral CT could offer supplemental information for the preoperative differential diagnosis of ESCC with different degrees of differentiation.

Dual-energy CT-based radiomics for predicting invasiveness of lung adenocarcinoma appearing as ground-glass nodules

Objectives

To explore the value of radiomics based on Dual-energy CT (DECT) for discriminating preinvasive or MIA from IA appearing as GGNs before surgery.

Methods

The retrospective study included 92 patients with lung adenocarcinoma comprising 30 IA and 62 preinvasive-MIA, which were further divided into a training (n=64) and a test set (n=28). Clinical and radiographic features along with quantitative parameters were recorded. Radiomics features were derived from virtual monoenergetic images (VMI), including 50kev and 150kev images. Intraclass correlation coefficients (ICCs), Pearson's correlation analysis and least absolute shrinkage and selection operator (LASSO) penalized logistic regression were conducted to eliminate unstable and redundant features. The performance of the models was evaluated by area under the curve (AUC) and the clinical utility was assessed using decision curve analysis (DCA).

Results

The DECT-based radiomics model performed well with an AUC of 0.957 and 0.865 in the training and test set. The clinical-DECT model, comprising sex, age, tumor size, density, smoking, alcohol, effective atomic number, and normalized iodine concentration, had an AUC of 0.929 in the training and 0.719 in the test set. In addition, the radiomics model revealed a higher AUC value and a greater net benefit to patients than the clinical-DECT model.

Conclusion

DECT-based radiomics features were valuable in predicting the invasiveness of GGNs, yielding a better predictive performance than the clinical-DECT model.

Dual-energy computed tomography as a lower radiation dose alternative to perfusion computed tomography in tumor viability assessment

To present the utility of dual-energy computed tomography (DECT) in the assessment of angiogenesis of focal lesions as an example of a solitary pulmonary nodule (SPN). This prospective study comprised 28 patients with SPN who underwent DECT and perfusion computed tomography (CTP), according to a proprietary protocol. Two radiologists independently analyzed four perfusion parameters, namely blood flow (BF), blood volume (BV), the time to maximum of the tissue residue function (Tmax), permeability surface area product (PS) from CTP, in addition to the iodine concentration (IC) and normalized iodine concentration (NIC) of the SPN from DECT. We used the Pearson R correlation and interclass correlation coefficients (ICC_s). Statistical significance was assumed at p < 0.05. The mean tumor size was 23.5 ± 6.5 mm. We observed good correlations between IC and BF (r = 0.78, p < 0.000) and NIC and BF (r = 0.71, p < 0.000) as well as between IC and BV (r = 0.73, p < 0.000) and NIC and BV (r = 0.73, p < 0.000) and poor correlation between IC and PS (r = 0.38, p = 0.044).There was no correlation between NIC and PS (r = 0.35, p = 0.064), IC content and Tmax (r = - 0.28, p = 0.147) and NIC and Tmax (r = - 0.21, p = 0.266). Inter-reader agreement on quantitative parameters at CTP (ICC_PS = 0.97, ICC_Tmax = 0.96, ICC_BV = 0.98, and ICC_BF = 0.99) and DECT (ICC_IC = 0.98) were excellent. The radiation dose was significantly lower in DECT than that in CTP (4.84 mSv vs. 9.07 mSv, respectively). DECT is useful for the functional assessment of oncological lesions with less exposure to radiation compared to perfusion computed tomography.

Development and validation of a radiomic nomogram based on pretherapy dual-energy CT for distinguishing adenocarcinoma from squamous cell carcinoma of the lung

Objective

Based on pretherapy dual-energy computed tomography (DECT) images, we developed and validated a nomogram combined with clinical parameters and radiomic features to predict the pathologic subtypes of non-small cell lung cancer (NSCLC) - adenocarcinoma (ADC) and squamous cell carcinoma (SCC).

Methods

A total of 129 pathologically confirmed NSCLC patients treated at the Second Affiliated Hospital of Nanchang University from October 2017 to October 2021 were retrospectively analyzed. Patients were randomly divided in a ratio of 7:3 (n=90) into training and validation cohorts (n=39). Patients' pretherapy clinical parameters were recorded. Radiomics features of the primary lesion were extracted from two sets of monoenergetic images (40 keV and 100 keV) in arterial phases (AP) and venous phases (VP). Features were selected successively through the intra-class correlation coefficient (ICC) and the least absolute shrinkage and selection operator (LASSO). Multivariate logistic regression analysis was then performed to establish predictive models. The prediction performance between models was evaluated and compared using the receiver operating characteristic (ROC) curve, DeLong test, and Akaike information criterion (AIC). A nomogram was developed based on the model with the best predictive performance to evaluate its calibration and clinical utility.

Results

A total of 87 ADC and 42 SCC patients were enrolled in this study. Among the five constructed models, the integrative model (AUC: Model 4 = 0.92, Model 5 = 0.93) combining clinical parameters and radiomic features had a higher AUC than the individual clinical models or radiomic models (AUC: Model 1 = 0.84, Model 2 = 0.79, Model 3 = 0.84). The combined clinical-venous phase radiomics model had the best predictive performance, goodness of fit, and parsimony; the area under the ROC curve (AUC) of the training and validation cohorts was 0.93 and 0.90, respectively, and the AIC value was 60.16. Then, this model was visualized as a nomogram. The calibration curves demonstrated it's good calibration, and decision curve analysis (DCA) proved its clinical utility.

Conclusion

The combined clinical-radiomics model based on pretherapy DECT showed good performance in distinguishing ADC and SCC of the lung. The nomogram constructed based on the best-performing combined clinical-venous phase radiomics model provides a relatively accurate, convenient and noninvasive method for predicting the pathological subtypes of ADC and SCC in NSCLC.

Quantitative parameters of enhanced dual-energy computed tomography for differentiating lung cancers from benign lesions in solid pulmonary nodules

Objectives

This study aimed to investigate the ability of quantitative parameters of dual-energy computed tomography (DECT) and nodule size for differentiation between lung cancers and benign lesions in solid pulmonary nodules.

Materials and Methods

A total of 151 pathologically confirmed solid pulmonary nodules including 78 lung cancers and 73 benign lesions from 147 patients were consecutively and retrospectively enrolled who underwent dual-phase contrast-enhanced DECT. The following features were analyzed: diameter, volume, Lung CT Screening Reporting and Data System (Lung-RADS) categorization, and DECT-derived quantitative parameters including effective atomic number (Zeff), iodine concentration (IC), and normalized iodine concentration (NIC) in arterial and venous phases. Multivariable logistic regression analysis was used to build a combined model. The diagnostic performance was assessed by area under curve (AUC) of receiver operating characteristic curve, sensitivity, and specificity.

Results

The independent factors for differentiating lung cancers from benign solid pulmonary nodules included diameter, Lung-RADS categorization of diameter, volume, Zeff in arterial phase (Zeff_A), IC in arterial phase (IC_A), NIC in arterial phase (NIC_A), Zeff in venous phase (Zeff_V), IC in venous phase (IC_V), and NIC in venous phase (NIC_V) (all P &lt; 0.05). The IC_V, NIC_V, and combined model consisting of diameter and NIC_V showed good diagnostic performance with AUCs of 0.891, 0.888, and 0.893, which were superior to the diameter, Lung-RADS categorization of diameter, volume, Zeff_A, and Zeff_V (all P &lt; 0.001). The sensitivities of IC_V, NIC_V, and combined model were higher than those of IC_A and NIC_A (all P &lt; 0.001). The combined model did not increase the AUCs compared with IC_V (P = 0.869) or NIC_V (P = 0.633).

Conclusion

The DECT-derived IC_V and NIC_V may be useful in differentiating lung cancers from benign lesions in solid pulmonary nodules.

Application of dual-energy computed tomography in preoperative evaluation of Ki-67 expression levels in solid non-small cell lung cancer

To investigate whether there were significant differences in dual-energy CT (DECT) in reflecting different quantitative parameters among different levels of Ki-67 expression in patients with solid non-small cell lung cancer (NSCLC). The diagnosis performance of DECT in patients with solid lung adenocarcinoma (LAC) among NSCLC was further discusses. Two hundred fifteen patients confirmed with solid NSCLC were enrolled and analyzed retrospectively in this study. 148 patients were confirmed with LAC among all patients. Three expression levels of Ki-67 were determined by the percentage of Ki-67 positive cancer cells with immunohistochemistry: high-level group (>30%), middle-level group (10%-30%), and low-level group (≤10%). And the latter two levels also known as non-high-level group. The quantitative parameters of enhanced chest DECT (venous phase, VP), including iodine concentration (IC), water concentration (WC), CT value at 40 keV (CT40keV), the slope of energy spectral attenuation curve (λHU) and normalized iodine concentration (NIC) were measured and calculated by gemstone spectral imaging Viewer software. One-way ANOVA was used for the comparison of normal distribution DECT parameters between three levels for patients with NSCLC and patients with LAC. Non-normal distribution data were tested by non-parametric test. In addition, the receiver operating characteristic curve of statistically significant DECT parameters was drawn to distinguish the non-high-level and the high-level of Ki-67. Area under the curve (AUC), sensitivity, specificity was calculated to measure the diagnostic performance of parameter. Both in solid NSCLC and LAC, the IC, NIC, WC, λHU and CT40keV at VP in the high-level group were significantly lower than those in the middle- and low-level group respectively, and the WC at VP in the high-level group was significantly higher than that in the middle- and low-level group respectively (all P < .05). Receiver operating characteristic analysis showed that IC and λHU at VP performed better in distinguishing the high-level and the non-high-level of Ki-67 (NSCLC: AUC = 0.713 and 0.714 respectively; LAC: AUC = 0.705 and 0.706 respectively). Quantitative parameters of DECT provide a new non-invasive method for evaluating the proliferation of cancer cells in solid NSCLC and LAC.

Analysis of the value of enhanced CT combined with texture analysis in the differential diagnosis of pulmonary sclerosing pneumocytoma and atypical peripheral lung cancer: a feasibility study

BACKGROUND

As a rare benign lung tumour, pulmonary sclerosing pneumocytoma (PSP) is often misdiagnosed as atypical peripheral lung cancer (APLC) on routine imaging examinations. This study explored the value of enhanced CT combined with texture analysis to differentiate between PSP and APLC.

METHODS

Forty-eight patients with PSP and fifty patients with APLC were retrospectively enrolled. The CT image features of the two groups of lesions were analysed, and MaZda software was used to evaluate the texture of CT venous phase thin-layer images. Independent sample t-test, Mann-Whitney U tests or χ² tests were used to compare between groups. The intra-class correlation coefficient (ICC) was used to analyse the consistency of the selected texture parameters. Spearman correlation analysis was used to evaluate the differences in texture parameters between the two groups. Based on the statistically significant CT image features and CT texture parameters, the independent influencing factors between PSP and APLC were analysed by multivariate logistic regression. Extremely randomized trees (ERT) was used as the classifier to build models, and the models were evaluated by the five-fold cross-validation method.

RESULTS

Logistic regression analysis based on CT image features showed that calcification and arterial phase CT values were independent factors for distinguishing PSP from APLC. The results of logistic regression analysis based on CT texture parameters showed that WavEnHL_s-1 and Perc.01% were independent influencing factors to distinguish the two. Compared with the single-factor model (models A and B), the classification accuracy of the model based on image features combined with texture parameters was 0.84 ± 0.04, the AUC was 0.84 ± 0.03, and the sensitivity and specificity were 0.82 ± 0.13 and 0.87 ± 0.12, respectively.

CONCLUSION

Enhanced CT combined with texture analysis showed good diagnostic value for distinguishing PSP and APLC, which may contribute to clinical decision-making and prognosis evaluation.

Comparison of Spectral and Perfusion Computed Tomography Imaging in the Differential Diagnosis of Peripheral Lung Cancer and Focal Organizing Pneumonia

Objective

To investigate the spectral and perfusion computed tomography (CT) findings of peripheral lung cancer (PLC) and focal organizing pneumonia (FOP) and to compare the accuracy of spectral and perfusion CT imaging in distinguishing PLC from FOP.

Materials and Methods

Patients who were suspected of having lung tumor and underwent “one-stop” chest spectral and perfusion CT, with their diagnosis confirmed pathologically, were prospectively enrolled from September 2020 to March 2021. Patients who were suspected of having lung tumor and underwent “one-stop” chest spectral and perfusion CT, with their diagnosis confirmed pathologically, were prospectively enrolled from September 2020 to March 2021. A total of 57 and 35 patients with PLC and FOP were included, respectively. Spectral parameters (CT_40keV, CT_70keV, CT_100keV, iodine concentration [IC], water concentration [WC], and effective atomic number [Zeff]) of the lesions in the arterial and venous phases were measured in both groups. The slope of the spectral curve (K_70keV) was calculated. The perfusion parameters, including blood volume (BV), blood flow (BF), mean transit time (MTT), and permeability surface (PS), were measured simultaneously in both groups. The differences in the spectral and perfusion parameters between the groups were examined. Receiver operating characteristic (ROC) curves were generated to calculate and compare the area under the curve (AUC), sensitivity, specificity, and accuracy of both sets of parameters in both groups.

Results

The patients’ demographic and clinical characteristics were similar in both groups (P > 0.05). In the arterial and venous phases, the values of spectral parameters (CT_40keV, CT_70keV, spectral curve K_70keV, IC, and Zeff) were greater in the FOP group than in the PLC group (P < 0.05). In contrast, the values of the perfusion parameters (BV, BF, MTT, and PS) were smaller in the FOP group than in the PLC group (P < 0.05). The AUC of the combination of the spectral parameters was larger than that of the perfusion parameters. For the former imaging method, the AUC, sensitivity, and specificity were 0.89 (95% confidence interval [CI]: 0.82–0.96), 0.86, and 0.83, respectively. For the latter imaging method, the AUC, sensitivity, and specificity were 0.80 (95% CI: 0.70–0.90), 0.71, and 0.83, respectively. There was no significant difference in AUC between the two imaging methods (P > 0.05).

Conclusion

Spectral and perfusion CT both has the capability to differentiate PLC and FOP. However, compared to perfusion CT imaging, spectral CT imaging has higher diagnostic efficiency in distinguishing them.

Comparison of Radiation Dose and Image Quality Between Split-Filter Twin Beam Dual-Energy Images and Single-Energy Images in Single-Source Contrast-Enhanced Chest Computed Tomography

OBJECTIVE

To compare image quality and radiation dose of split-filter TwinBeam dual-energy (SF-TBDE) with those of single-energy images (SECT) in the contrast-enhanced chest computed tomography (CT).

METHODS

Two hundred patients who underwent SF-TBDE (n = 100) and SECT (n = 100) contrast-enhanced chest scanning were retrospectively analyzed. The contrast-to-noise ratio (CNR) and figure of merit (FOM)-CNR of 5 structures (lung, aorta, pulmonary artery, thyroid, and erector spinae) were calculated and subjectively evaluated by 2 independent radiologists. Radiation dose was compared using volume CT dose index and size-specific dose estimate.

RESULTS

The CNR and FOM-CNR of lung and erector spinae in SF-TBDE were higher than those of SECT (P < 0.001). The differences in the subjective image quality between the 2 groups were not significant (P = 0.244). Volume CT dose index and size-specific dose estimate of SF-TBDE were lower than those of SECT (6.60 ± 1.56 vs 7.81 ± 3.02 mGy, P = 0.001; 9.25 ± 1.60 vs. 10.55 ± 3.54; P = 0.001).

CONCLUSIONS

The SF-TBDE CT can provide similar image quality at a lower radiation dose compared with SECT.

Dual-Energy Computed Tomography for the Diagnosis of Mediastinal Lymph Node Metastasis in Lung Cancer Patients: A Preliminary Study

OBJECTIVE

This study explored the feasibility of dual-energy computed tomography (DECT) for the diagnosis of mediastinal lymph node (LN) metastasis in patients with lung cancer.

METHODS

Forty-two consecutive patients with lung cancer, who underwent DECT, were included in this retrospective study. The attenuation value (Hounsfield unit) in virtual monochromatic images and the iodine concentration in the iodine map were measured at mediastinal LNs. The slope of the spectral attenuation curve (K) and normalized iodine concentration (in thoracic aorta) were calculated. The measurement results were statistically compared using 2 independent samples t test. Receiver operating characteristic curve analysis, net reclassification improvement, and integrated discrimination improvement were used to evaluate the diagnostic performance of DECT for mediastinal LN metastasis.

RESULTS

A total of 74 mediastinal LNs were obtained, including 33 metastatic LNs and 41 nonmetastatic LNs. The attenuation value at the lower energy levels of virtual monochromatic images (40-90 keV), K, and normalized iodine concentration demonstrated a significant difference between metastatic LNs and nonmetastatic LNs. The attenuation value at 40 keV was the most favorable biomarker for the diagnosis of mediastinal LN metastasis (area under curve, 0.91; sensitivity, 0.94; specificity, 0.81), which showed a much better performance than the LN diameter-based evaluation method (area under curve, 0.72; sensitivity, 0.66; specificity, 0.82; net reclassification improvement, 0.359; integrated discrimination improvement, 0.330).

CONCLUSIONS

Dual-energy computed tomography is a promising diagnostic approach for the diagnosis of mediastinal LN metastasis in patients with lung cancer, which may help clinicians implement personalized treatment strategies.

A New Outlook on the Ability to Accumulate an Iodine Contrast Agent in Solid Lung Tumors Based on Virtual Monochromatic Images in Dual Energy Computed Tomography (DECT): Analysis in Two Phases of Contrast Enhancement

For some time, dual energy computed tomography (DECT) has been an established method used in a vast array of clinical applications, including lung nodule assessment. The aim of this study was to analyze (using monochromatic DECT images) how the X-ray absorption of solitary pulmonary nodules (SPNs) depends on the iodine contrast agent and when X-ray absorption is no longer dependent on the accumulated contrast agent. Sixty-six patients with diagnosed solid lung tumors underwent DECT scans in the late arterial phase (AP) and venous phase (VP) between January 2017 and June 2018. Statistically significant correlations (p ≤ 0.001) of the iodine contrast concentration were found in the energy range of 40–90 keV in the AP phase and in the range of 40–80 keV in the VP phase. The strongest correlation was found between the concentrations of the contrast agent and the scanning energy of 40 keV. At the higher scanning energy, no significant correlations were found. We concluded that it is most useful to evaluate lung lesions in DECT virtual monochromatic images (VMIs) in the energy range of 40–80 keV. We recommend assessing SPNs in only one phase of contrast enhancement to reduce the absorbed radiation dose.

The application of dual-layer spectral detector computed tomography in solitary pulmonary nodule identification

Background

Differentiating between malignant solitary pulmonary nodules (SPNs) and other lung diseases remains a substantial challenge. The latest generation of dual-energy computed tomography (CT), which realizes dual-energy technology at the detector level, has clinical potential for distinguishing lung cancer from other benign SPNs. This study aimed to evaluate the performance of dual-layer spectral detector CT (SDCT) for the differentiation of SPNs.

Methods

Spectral images of 135 SPNs confirmed by pathology were retrospectively analyzed in both the arterial phase (AP) and the venous phase (VP). Patients were classified into two groups [the malignant group (n=93) and the benign group (n=42)], with the malignant group further divided into small cell lung cancer (SCLC, n=30) and non-small cell lung cancer (NSCLC, n=63) subtypes. The slope of the spectral Hounsfield Unit (HU) curve (λ_HU), normalized iodine concentration (NIC), CT values of 40 keV monochromatic images (CT_40keV), and normalized arterial enhancement fraction (NAEF) in contrast-enhanced images were calculated and compared between the benign and malignant groups, as well as between the SCLC and NSCLC subgroups. ROC curve analysis was performed to assess the diagnostic performance of the above parameters. Seventy cases were randomly selected and independently measured by two radiologists, and intraclass correlation coefficient (ICC) and Bland-Altman analyses were performed to calculate the reliability of the measurements.

Results

Except for NAEF (P=0.23), the values of the parameters were higher in the malignant group than in the benign group (all P<0.05). NIC, λ_HU, and CT_40keV performed better in the VP (NIC_VP, λ_VPHU, and CT_VP40keV) (P<0.001), with an area under the ROC curve (AUC) of 0.93, 0.89, and 0.89 respectively. With respective cutoffs of 0.31, 1.83, and 141.00 HU, the accuracy of NIC_VP, λ_VPHU, and CT_VP40keV was 91.11%, 85.19%, and 88.15%, respectively. In the subgroup differentiating NSCLC and SCLC, the diagnostic performances of NIC_AP (AUC =0.89) were greater than other parameters. NIC_AP had an accuracy of 86.02% when the cutoff was 0.14. ICC and Bland-Altman analyses indicated that the measurement of SDCT has great reproducibility.

Conclusions

Quantitative measures from SDCT can help to differentiate benign from malignant SPNs and may help with the further subclassification of malignant cancer into SCLC and NSCLC.