Pseudoenhancement effects on iodine quantification from dual-energy spectral CT systems: A multi-vendor phantom study regarding renal lesion characterization

Diagnostic accuracy of iodine quantification and material density imaging with rapid Kilovoltage-switching DECT for small hyperattenuating renal lesions

OBJECTIVES

To assess accuracy of MDI and iodine quantification in distinguishing enhancing renal masses from hyperattenuating cysts, compared with conventional attenuation measurements, given that differentiation between these entities can influence follow-up imaging strategies and surgical decision-making, and to investigate the optimal threshold of iodine concentration using rapid kilovoltage-switching DECT (rsDECT).

MATERIALS AND METHODS

Retrospective study enrolled 126 renal lesions 1-4 cm in size with 10-70 attenuation on pre-contrast CT in patients who underwent rsDECT during the portovenous phase. Two reading sessions (true unenhanced (TUE) + post-contrast (PC) + MDI images versus MDI only images) for the visual assessment of renal mass enhancement were done (with at least 1-month time gap). Measurement of attenuation and iodine concentration within each renal lesion was recorded. Diagnostic accuracies and a threshold of each quantitative parameters were evaluated. Final diagnosis of renal lesions was based on pathological or imaging criteria.

RESULTS

Accuracy of MDI images were 90.5% with TUE + PC + MDI and 88.9% with MDI only. AUC of VUE HU, TUE HU, PC HU, PC VUE HU, PC-TUE HU, absolute and normalized iodine concentration were 0.87, 0.82, 0.96, 0.95, 0.96, 0.97 and 0.95 (all p < 0.001). The optimal absolute iodine concentration threshold was 1.6 mg I/mL, with 91% sensitivity and 92% specificity. This threshold outperformed 0.5 mg I/mL showing 100% sensitivity, 29% specificity) and 2.0 mg I/mL showing 71% sensitivity, 97% specificity.

CONCLUSION

In characterization of a small (< 4 cm) hyperattenuating renal lesion identified on abdominal CT, post processing MDI with iodine quantification has better or comparable accuracy to attenuation measurement and the specificity of iodine concentration using rsDECT improves with a threshold higher than 0.5 mg I/mL. This could enhance diagnostic workflows for renal lesion assessment using MDI and offer the potential to omit TUE scanning, thereby reducing patient radiation exposure.

Photon-counting CT for Chest Imaging-What Have We Learned So Far?

CT imaging has advanced significantly, with dual-energy CT (DECT) marking a milestone by using 2 energy spectra for enhanced tissue characterization. The latest innovation is photon-counting detectors (PCD), which offer superior spatial resolution, contrast-to-noise ratio (CNR), and potential for reduced radiation dose compared with traditional energy-integrating detectors (EID). Photon-counting CT (PCD-CT), which directly counts individual photons using semiconductors, has important implications for chest imaging, especially for complex disease processes that benefit from imaging at higher spatial resolution. PCD-CT achieves improved spatial resolution by eliminating the blurring effects associated with EID scintillators. Enhanced CNR is achieved through energy discrimination and selective use of photon energies, which also helps to minimize electronic noise. PCD-CT facilitates significant radiation dose reduction, particularly valuable for patients who receive regular follow-ups, like in lung cancer screening. In addition, PCD-CT provides spectral capabilities in every scan, unlike DECT, which requires preselecting a specific spectral scan mode. In chest imaging, PCD-CT shows promise in detecting and definitively characterizing infectious diseases, interstitial lung disease, malignancies, and vascular conditions at low radiation doses, offering higher diagnostic accuracy and patient safety. Despite these advancements, challenges remain in optimizing spectral imaging and integrating PCD-CT into routine clinical workflows, necessitating ongoing research and development.

What to Expect (and What Not) from Dual-Energy CT Imaging Now and in the Future?

Dual-energy CT (DECT) imaging has broadened the potential of CT imaging by offering multiple postprocessing datasets with a single acquisition at more than one energy level. DECT shows profound capabilities to improve diagnosis based on its superior material differentiation and its quantitative value. However, the potential of dual-energy imaging remains relatively untapped, possibly due to its intricate workflow and the intrinsic technical limitations of DECT. Knowing the clinical advantages of dual-energy imaging and recognizing its limitations and pitfalls is necessary for an appropriate clinical use. The aims of this paper are to review the physical and technical bases of DECT acquisition and analysis, to discuss the advantages and limitations of DECT in different clinical scenarios, to review the technical constraints in material labeling and quantification, and to evaluate the cutting-edge applications of DECT imaging, including artificial intelligence, qualitative and quantitative imaging biomarkers, and DECT-derived radiomics and radiogenomics.

A multienergy computed tomography method without image segmentation or prior knowledge of X-ray spectra or materials

Many methods have been proposed for multienergy computed tomography (CT) imaging based on traditional CT systems. Usually, either prior knowledge of the X-ray spectra distribution or materials or the segmentation of the projection or reconstructed image is needed. To avoid these requirements, a multienergy CT method is proposed in this paper. A CT image can be seen as a linear combination of energy-dependent components and spatially dependent components. The latter components are the base images, while the former components are the coefficients. A blind decomposition model is constructed to decompose the multivoltage projections to obtain the base images and the energies. Multienergy CT images are computationally synthesized with the base images and the energies. Multivoltage projections can be acquired based on one scan with stepped voltages. X-ray scattering is considered an important factor in imaging errors and appears as a low-frequency signal. The variance is used to describe the low-frequency features and is minimized as the optimized objective function of the decomposition model. The solution of the model uses Karush-Kuhn-Tucker (KKT) conditions. In the experiments, the images reconstructed with the proposed method exhibit weak beam-hardening artifacts. Additionally, the X-ray energies of the different materials represented have small relative errors. Therefore, the reconstructed images have narrow energy intervals. This shows the effectiveness of the proposed method.

Realistic Kidney Tissue Surrogates for Multienergy Computed Tomography-Feasibility and Estimation of Energy-Dependent Attenuation Thresholds for Renal Lesion Enhancement in Low-kV and Virtual Monoenergetic Imaging

PURPOSE

The aims of this study were to assess if kidney tissue surrogates (KTSs) are superior to distilled water-iodine solutions in the emulation of energy-dependent computed tomography (CT) attenuation characteristics of renal parenchyma and to estimate attenuation thresholds for definite lesion enhancement for low-kV single-energy and low-keV dual-energy virtual monoenergetic imaging.

METHODS

A water-filled phantom (diameter, 30 cm) with multiple vials was imaged on a dual-source dual-energy CT (DS-DE) and a single-source split-filter dual-energy CT (SF-DE), both in single-energy mode at 80, 100, 120, 140 kVp and in dual-energy mode at 80/Sn150, 90/Sn150, and 100/Sn150 kVp for DS-DE and AuSn120 kVp for SF-DE. Single-energy images, linear-blended dual-energy images, and virtual monoenergetic imaging at energy levels from 40 to 190 keV were reconstructed. First, attenuation characteristics of KTS in solid and liquid consistencies were compared. Second, solid KTSs were developed to match the CT attenuation of unenhanced renal parenchyma at 120 kVp as retrospectively measured in 100 patients. Third, CT attenuation of KTS-iodine and water-iodine solutions at 8 different iodine concentrations (0-10 mg I/mL) were compared as a function of tube voltage and of keV level using multiple linear regression models. Energy-dependent attenuation thresholds for definite lesion enhancement were calculated.

RESULTS

Unenhanced renal parenchyma at 120 kVp measured on average 30 HU on both scanners in the patient cohort. Solid KTS with a water content of 80% emulated the attenuation of unenhanced renal parenchyma (30 HU) more accurately compared with water-iodine solutions (0 HU). Attenuation difference between KTS-iodine and water-iodine solutions converged with increasing iodine concentration and decreasing x-ray energy due to beam-hardening effects. A slight attenuation difference of approximately 2 HU was found between the 2 CT scanners. Attenuation thresholds for definite lesion enhancement were dependent on tube voltage and keV level and ranged from 16.6 to 33.2 HU and 3.2 to 68.3 HU for single-energy and dual-energy CT scan modes for DS-DE and from 16.1 to 34.3 HU and 3.3 to 92.2 HU for SF-DE.

CONCLUSIONS

Kidney tissue surrogates more accurately emulate the energy-dependent CT attenuation characteristics of renal parenchyma for multienergy CT compared with conventional water-iodine approaches. Energy-dependent thresholds for definite lesion enhancement could facilitate lesion characterization when imaging at different energies than the traditional 120 kVp.

Improving radiation physics, tumor visualisation, and treatment quantification in radiotherapy with spectral or dual-energy CT

Over the past decade, spectral or dual‐energy CT has gained relevancy, especially in oncological radiology. Nonetheless, its use in the radiotherapy (RT) clinic remains limited. This review article aims to give an overview of the current state of spectral CT and to explore opportunities for applications in RT.

In this article, three groups of benefits of spectral CT over conventional CT in RT are recognized. Firstly, spectral CT provides more information of physical properties of the body, which can improve dose calculation. Furthermore, it improves the visibility of tumors, for a wide variety of malignancies as well as organs‐at‐risk OARs, which could reduce treatment uncertainty. And finally, spectral CT provides quantitative physiological information, which can be used to personalize and quantify treatment.

A Method for Reducing Variability Across Dual-Energy CT Manufacturers in Quantification of Low Iodine Content Levels

Background: Clinical use of the dual-energy CT (DECT) iodine quantification technique is hindered by between-platform (i.e., across different manufacturers) variability in iodine concentration (IC), particularly at low iodine levels. Objective: To develop in an anthropomorphic phantom a method for reducing between-platform variability in quantification of low iodine content levels using DECT and to evaluate the method's performance in patients undergoing serial clinical DECT examinations on different platforms. Methods: An anthropomorphic phantom in three body sizes, incorporating varied lesion types and scanning conditions, was imaged with three distinct DECT implementations from different manufacturers at varying radiation exposures. A cross-platform iodine quantification model for correcting between-platform variability at low iodine content was developed using the phantom data. The model was tested in a retrospective series of 30 patients (20 men, 10 women; median age, 62 years) who each underwent three serial contrast-enhanced DECT examinations of the abdomen and pelvis (90 scans total) for routine oncology surveillance, using the same three DECT platforms as in the phantom. Estimated accuracy of phantom IC values was summarized using rootmean-squared error (RMSE) relative to known IC. Between-platform variability in patients was summarized using root-mean-square-deviation (RMSD). RMSE and RMSD were compared between platform-based IC (ICPB) and cross-platform IC (ICCP). ICPB was normalized to aorta and portal vein. Results: In the phantom study, mean RMSE of ICPB across platforms and other experimental conditions was 0.65 ± 0.18 mgI/mL compared with 0.40 ± 0.075 mgI/mL for ICCP (38% decrease in mean RMSE; P<.05). Intra-patient between-platform variability across serial DECT examinations was lower for ICPB than ICCP (RMSD: 97% vs 88%; P<.001). Between-platform variability was not reduced by normalization of ICPB to aorta (RMSD: 97% vs 101%; P=.12) or portal vein (RMSD: 97% vs 97%; P=.81). Conclusion: The developed cross-platform method significantly decreased between-platform variability occurring at low iodine content with platform-based DECT iodine quantification. Clinical Impact: With further validation, the cross-platform method, which has been implemented as a webbased app, may expand clinical use of DECT iodine quantification, yielding meaningful IC values that reflect tissue biologic viability or treatment response in patients who undergo serial examinations on different platforms.

Dual-Energy CT Vital Iodine Tumor Burden for Response Assessment in Patients With Metastatic GIST Undergoing TKI Therapy: Comparison to Standard CT and FDG PET/CT Criteria

Background: CT-based criteria for assessing gastroinstestinal stromal tumor (GIST) response to tyroskine kinase inhibitor (TKI) therapy are limited partly because tumor attenuation is influenced by treatment-related changes including hemorrhage and calcification. Iodine concentration may be less impacted by such changes. Objective: To determine whether DECT vital iodine tumor burden (TB) provides improved differentiation between responders and non-responders in patients with metastatic GIST undergoing TKI therapy compared to established CT and PET/CT criteria. Methods: An anthropomorphic phantom with spherical inserts mimicking GIST lesions of varying iodine concentrations and having non-enhancing central necrotic cores underwent DECT to determine a threshold iodine concentration. Forty patients (median age 57 years; 25 women, 15 men) treated with TKI for metaststic GIST were retrospectively evaluated. Patients underwent baseline and follow-up DECT and FDG PET/CT. Response assessment was performed using RECIST 1.1, modified Choi (mChoi), vascular tumor burden (VTB), DECT vital iodine TB, and European Organization for Research and Treatment of Cancer (EORTC PET) criteria. DECT vital iodine TB used the same percentage changes as RECIST 1.1 response categories. Progression-free survival (PFS) was compared between responders and non-responders for each response criteria using Cox proportional hazard ratios and Harrell's c-indices. Results: The phantom experiment identified a 0.5 mg/mL threshold to differentiate vital from non-vital tissue. Using DECT vital iodine TB, median PFS was significantly different between non-responders and responders (587 vs 167 days, respectively; p=.02). Hazard ratio for progression for DECT vital iodine TB non-responders versus responders was 6.9, versus 7.6 for EORTC PET, 3.3 for VTB, 2.3 for RECIST 1.1, and 2.1 for mChoi. C-index was 0.74 for EORTC PET, 0.73 for DECT vital iodine TB, 0.67 for VTB, 0.61 for RECIST 1.1, and 0.58 for mChoi. C-index was significantly greater for DECT vital iodine TB than RECIST 1.1 (p=.02) and mChoi (p=.002), but not different than VTB and EORTC PET (p>.05). Conclusion: DECT vital iodine TB criteria showed comparable performance as EORTC PET and outperformed RECIST 1.1 and mChoi for response assessment of metastatic GIST under TKI therapy. Clinical Impact: DECT vital iodine TB could help guide early management decisions in patients on TKI therapy.

Spectral CT of the abdomen: Where are we now?

Spectral CT adds a new dimension to radiological evaluation, beyond assessment of anatomical abnormalities. Spectral data allows for detection of specific materials, improves image quality while at the same time reducing radiation doses and contrast media doses, and decreases the need for follow up evaluation of indeterminate lesions. We review the different acquisition techniques of spectral images, mainly dual-source, rapid kV switching and dual-layer detector, and discuss the main spectral results available. We also discuss the use of spectral imaging in abdominal pathologies, emphasizing the strengths and pitfalls of the technique and its main applications in general and in specific organs.

Evaluation of equivocal small cystic pancreatic lesions with spectral-detector computed tomography

BACKGROUND

Evaluation of small cystic lesions of the pancreas remains a challenging task, as due to their size appearance can be rather hypodense than clearly fluid-filled.

PURPOSE

To evaluate whether additional information provided by novel dual-layer spectral-detector computed tomography (SDCT) imaging can improve assessment of these lesions.

MATERIAL AND METHODS

For this retrospective study, we reviewed reports of 1192 contrast-enhanced portal-venous phase SDCT scans of the abdomen conducted between May 2017 and January 2019. On basis of the radiological report 25 small (≤1.5 cm) cystic pancreatic lesions in 22 patients were identified, in which additional short-term follow-up imaging was recommended to confirm/clarify cystic nature. Conventional images (CI) and spectral images (SI) including virtual-monoenergetic images at 40 keV (VMI), iodine-density and iodine-overlay images were reconstructed. Two readers indicated lesion conspicuity and confidence for presence of cystic nature on three-point scales. First, solely CI were evaluated, while in a second reading after a four-week interval, the combination of CI and corresponding SI were reviewed. Quantitatively, ROI-based mean attenuation was measured in CI and VMI.

RESULTS

In the subjective reading, SI significantly improved lesion conspicuity (CI 2 [1-2], SI 3 [2-3], P < 0.001) and confidence regarding presence of cystic nature (CI 2 [1-2], SI 3 [3-3], P < 0.001). Inter-observer agreement depicted by intraclass correlation coefficient improved considerably from 0.51 with only CI to 0.85 when the combination with SI was used. Further, VMI displayed significantly higher signal-to-noise (CI 1.2 ± 0.8, VMI 3.2 ± 1.8, P < 0.001) and contrast-to-noise ratios (CI 2.6 ± 0.8, VMI 4.7 ± 1.9).

CONCLUSION

Compared to CI alone, combination with SI significantly improves visualization and confidence in evaluation of small equivocal cystic pancreatic lesions.

Effects of Patient Size and Radiation Dose on Iodine Quantification in Dual-Source Dual-Energy CT

RATIONALE AND OBJECTIVES

The purpose of this study was to investigate the potential effects of patient size and radiation dose on the accuracy of iodine quantification using dual-source dual-energy computed tomography (CT).

MATERIALS AND METHODS

Three phantoms representing different patient sizes were constructed, containing iodine inserts with concentrations from 0 to 20 mg/ml. Dual-energy CT scans were performed at six dose levels from 2 to 30 mGy. Iodine concentrations were measured using a three-material-decomposition algorithm and their accuracy was assessed.

RESULTS

In a small phantom, iodine quantification was accurate and consistent at all dose levels. In a medium phantom, minor underestimations were observed, and the results were consistent except at low dose. In the large phantom, more significant underestimation of iodine concentration was observed at higher doses (≥15 mGy), which was attributed to the beam-hardening effect. At lower doses, increasing upward bias was observed in the CT number, leading to significant overestimations of both iodine concentration and fat fraction, which was attributed to the photon-starvation effect. The severity of the latter effect was determined by mA instead of mAs, suggesting that the electronic noise, rather than the quantum noise, was responsible for the bias. Using higher kVp for the low-energy tube was found to alleviate these effects.

CONCLUSION

Reliable iodine quantification can be achieved using dual-source CT, but the result can be affected by patient size and dose rate. In large patients, biases may occur due to the beam-hardening and the photon-starvation effects, in which case higher dose rate and higher kVp are recommended to minimize these effects.

Dual-Energy CT: Lower Limits of Iodine Detection and Quantification

Background Assessments of the quantitative limitations among the six commercially available dual-energy (DE) CT acquisition schemes used by major CT manufacturers could aid researchers looking to use iodine quantification as an imaging biomarker. Purpose To determine the limits of detection and quantification of DE CT in phantoms by comparing rapid peak kilovoltage switching, dual-source, split-filter, and dual-layer detector systems in six different scanners. Materials and Methods Seven 50-mL iohexol solutions were used, with concentrations of 0.03-2.0 mg iodine per milliliter. The solutions and water sample were scanned five times each in two phantoms (small, 20-cm diameter; large, 30 × 40-cm diameter) with six DE CT systems and a total of 10 peak kilovoltage settings or combinations. Iodine maps were created, and the mean iodine signal in each sample was recorded. The limit of blank (LOB) was defined as the upper limit of the 95% confidence interval of the water sample. The limit of detection (LOD) was defined as the concentration with a 95% chance of having a signal above the LOB. The limit of quantification (LOQ) was defined as the lowest concentration where the coefficient of variation was less than 20%. Results The LOD range was 0.021-0.26 mg/mL in the small phantom and 0.026-0.55 mg/mL in the large phantom. The LOQ range was 0.07-0.50 mg/mL in the small phantom and 0.20-1.0 mg/mL in the large phantom. The dual-source and rapid peak kilovoltage switching systems had the lowest LODs, and the dual-layer detector systems had the highest LODs. Conclusion The iodine limit of detection using dual-energy CT systems varied with scanner and phantom size, but all systems depicted iodine in the small and large phantoms at or below 0.3 and 0.5 mg/mL, respectively, and enabled quantification at concentrations of 0.5 and 1.0 mg/mL, respectively. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Hindman in this issue.