Contrast-enhanced dual-energy CT of gastrointestinal stromal tumors: is iodine-related attenuation a potential indicator of tumor response?

White Paper of the Society of Computed Body Tomography and Magnetic Resonance on Dual-Energy CT, Part 4: Abdominal and Pelvic Applications

This is the fourth of a series of 4 white papers that represent expert consensus documents developed by the Society of Computed Body Tomography and Magnetic Resonance through its task force on dual-energy computed tomography. This article, part 4, discusses DECT for abdominal and pelvic applications and, at the end of each, will offer our consensus opinions on the current clinical utility of the application and opportunities for further research.

Feasibility and accuracy of dual-layer spectral detector computed tomography for quantification of gadolinium: a phantom study

Objectives

The aim of this study was to evaluate the feasibility and accuracy of dual-layer spectral detector CT (SDCT) for the quantification of clinically encountered gadolinium concentrations.

Methods

The cardiac chamber of an anthropomorphic thoracic phantom was equipped with 14 tubular inserts containing different gadolinium concentrations, ranging from 0 to 26.3 mg/mL (0.0, 0.1, 0.2, 0.4, 0.5, 1.0, 2.0, 3.0, 4.0, 5.1, 10.6, 15.7, 20.7 and 26.3 mg/mL). Images were acquired using a novel 64-detector row SDCT system at 120 and 140 kVp. Acquisitions were repeated five times to assess reproducibility. Regions of interest (ROIs) were drawn on three slices per insert. A spectral plot was extracted for every ROI and mean attenuation profiles were fitted to known attenuation profiles of water and pure gadolinium using in-house-developed software to calculate gadolinium concentrations.

Results

At both 120 and 140 kVp, excellent correlations between scan repetitions and true and measured gadolinium concentrations were found (R > 0.99, P < 0.001; ICCs > 0.99, CI 0.99–1.00). Relative mean measurement errors stayed below 10% down to 2.0 mg/mL true gadolinium concentration at 120 kVp and below 5% down to 1.0 mg/mL true gadolinium concentration at 140 kVp.

Conclusion

SDCT allows for accurate quantification of gadolinium at both 120 and 140 kVp. Lowest measurement errors were found for 140 kVp acquisitions.

Key Points

• Gadolinium quantification may be useful in patients with contraindication to iodine.

• Dual-layer spectral detector CT allows for overall accurate quantification of gadolinium.

• Interscan variability of gadolinium quantification using SDCT material decomposition is excellent.

Assessing tumor vascularization as a potential biomarker of imatinib resistance in gastrointestinal stromal tumors by dynamic contrast-enhanced magnetic resonance imaging

BACKGROUND

Most metastatic gastrointestinal stromal tumors (GISTs) develop resistance to the first-line imatinib treatment. Recently, increased vessel density and angiogenic markers were reported in GISTs with a poor prognosis, suggesting that angiogenesis is implicated in GIST tumor progression and resistance. The purpose of this study was to investigate the relationship between tumor vasculature and imatinib resistance in different GIST mouse models using a noninvasive magnetic resonance imaging (MRI) functional approach.

METHODS

Immunodeficient mice (n = 8 for each cell line) were grafted with imatinib-sensitive (GIST882 and GIST-T1) and imatinib-resistant (GIST430) human cell lines. Dynamic contrast-enhanced MRI (DCE-MRI) was performed on GIST xenografts to quantify tumor vessel permeability (K ^trans) and vascular volume fraction (v _p). Microvessel density (MVD), permeability (mean dextran density, MDD), and angiogenic markers were evaluated by immunofluorescence and western blot assays.

RESULTS

Dynamic contrast-enhanced magnetic resonance imaging showed significantly increased vessel density (P < 0.0001) and permeability (P = 0.0002) in imatinib-resistant tumors compared to imatinib-sensitive ones. Strong positive correlations were observed between MRI estimates, K ^trans and v _p, and their related ex vivo values, MVD (r = 0.78 for K ^trans and r = 0.82 for v _p) and MDD (r = 0.77 for K ^trans and r = 0.94 for v _p). In addition, higher expression of vascular endothelial growth factor receptors (VEGFR2 and VEFGR3) was seen in GIST430.

CONCLUSIONS

Dynamic contrast-enhanced magnetic resonance imaging highlighted marked differences in tumor vasculature and microenvironment properties between imatinib-resistant and imatinib-sensitive GISTs, as also confirmed by ex vivo assays. These results provide new insights into the role that DCE-MRI could play in GIST characterization and response to GIST treatment. Validation studies are needed to confirm these findings.

Dual energy CT allows for improved characterization of response to antiangiogenic treatment in patients with metastatic renal cell cancer

OBJECTIVES

To evaluate the potential role of dual energy CT (DECT) to visualize antiangiogenic treatment effects in patients with metastatic renal cell cancer (mRCC) while treated with tyrosine-kinase inhibitors (TKI).

METHODS

26 patients with mRCC underwent baseline and follow-up single-phase abdominal contrast enhanced DECT scans. Scans were performed immediately before and 10 weeks after start of treatment with TKI. Virtual non-enhanced (VNE) and colour coded iodine images were generated. 44 metastases were measured at the two time points. Hounsfield unit (HU) values for VNE and iodine density (ID) as well as iodine content (IC) in mg/ml of tissue were derived. These values were compared to the venous phase DECT density (CTD) of the lesions. Values before and after treatment were compared using a paired Student's t test.

RESULTS

Between baseline and follow up, mean CTD and DECT-derived ID both showed a significant reduction (p < 0.005). The relative reduction measured in percent was significantly greater for ID than for CTD (49.8 ± 36,3 % vs. 29.5 ± 20.8 %, p < 0.005). IC was also significantly reduced under antiangiogenic treatment (p < 0.0001).

CONCLUSIONS

Dual energy CT-based quantification of iodine content of mRCC metastases allows for significantly more sensitive and reproducible detection of antiangiogenic treatment effects.

KEY POINTS

• A sign of tumour response to antiangiogenic treatment is reduced tumour perfusion. • DECT allows visualizing iodine uptake, which serves as a marker for vascularization. • More sensitive detection of antiangiogenic treatment effects in mRCC is possible.

Treatment response after radioembolisation in patients with hepatocellular carcinoma-An evaluation with dual energy computed-tomography

PURPOSE

The aim of this prospective study was to examine the diagnostic value of dual-energy CT (DECT) in the assessment of response of HCC after radioembolisation (RE).

MATERIAL AND METHODS

40 HCC patients with 82 measurable target lesions were included in this study. At baseline and follow-up examination target lesions were evaluated with (IU), AASLD and Choi measurement criteria. Disease control was defined as the sum of complete response (CR), partial response (PR), progression disease (PD) and stable disease (SD).

RESULTS

With Choi and IU more patients were considered than PR and less than PD and SD. According to AASLD more patients were measured as SD and PD than PR. 26/40 patients were classified as PR with IU. In contrast measurements with AASLD in only 8/26 patients were also classified as PR. 6/12 SD patients measured with IU were measured as PD with AASLD. 4/26 patients classified with IU as PR were described as SD with CHOI, 10/14 SD patients measured with CHOI were SD according to IU, the other 4 patients were PR with IU. 2/4 PD patients according to CHOI were SD with IU.

CONCLUSION

More patients by IU were classified as SD versus PD and PR versus SD. We attribute this to the more detailed consideration of the HU differences between the virtual native and contrast-enhanced series generated by DECT. Iodine uptake (IU) in HCC measured and visualized with DECT is a promising imaging method for the assessment of treatment response after radioembolisations.

KEY POINTS

-dual energy CT of hypervascular tumors such as HCC allows to quantify contrast enhancement without native imaging. -this can be used to evaluate the therapy response after Radioembolization.

A primer on the use of dual-energy CT in the evaluation of commonly encountered neoplasms

Technical improvements in the acquisition and display of dual-energy computed tomography (DECT) have made this technique increasingly applicable to clinical practice, particularly in the setting of oncologic imaging. DECT allows for qualitative and quantitative analysis of tissue composition beyond the standard anatomical evaluation possible with single-energy computed tomography. For example, DECT can be used to interrogate iodine and calcium concentrations and to increase iodine signal, which makes many pathologic processes more conspicuous and provides improved understanding of internal structure within mass lesions. A working understanding of common postprocessing DECT displays will allow radiologists to maximize the additional diagnostic information available in DECT examinations. In this article, we describe common strategies for DECT interrogation by organ system, which may improve the conspicuity and understanding of suspected malignancies.

Small Bowel Imaging: an Update

Bowel imaging had experienced relevant technical advances during the last decade. The developments in the field of cross-sectional imaging had a particular impact on the assessment of Crohn's disease. The purpose of this manuscript is to provide a review of the main progress of cross-sectional imaging in the assessment of Crohn's disease and other small bowel diseases with relevance in clinical practice and in research. Also, we outline the technical advances, trends, and potential contributions of new technological cross-sectional imaging improvements that may have potential impact and contribution in the near future.

Iodine quantification to characterize primary lesions, metastatic and non-metastatic lymph nodes in lung cancers by dual energy computed tomography: An initial experience

PURPOSE

To investigate whether dual energy computed tomography (CT) with iodine quantification can characterize primary lesions and metastatic lymph nodes from non-metastatic ones in non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

Sixty-one patients with NSCLC confirmed by pathology underwent chest contrast CT scan with dual energy computed tomography before surgery. The Iodine concentration (IC) and normalized iodine concentration (NIC) values of the primary lesions, 20 metastatic and 20 non-metastatic lymph nodes were measured, respectively. The differences between the primary lesions, metastatic and non-metastatic lymph nodes were statistically analyzed.

RESULTS

For the IC and NIC values of the primary lesions and their metastatic lymph nodes, there were no significant differences between lung squamous cell carcinomas and adenocarcinomas, respectively (P>0.05), while significant differences existed between metastatic and non-metastatic lymph nodes, respectively (P<0.05). The IC of 29.32 100μg/cm(3) and NIC value of 0.4328 of a lymph node represented the optimal threshold to discriminate metastatic from non-metastatic lymph nodes and yielded the following: sensitivity, 80% and 75%; specificity, 65% and 75%; PPV, 70% and 75%; NPV, 76% and 75%; accuracy, 73% and 75%, respectively.

CONCLUSION

Although its value in distinguishing primary lesions and their metastatic lymph nodes in NSCLC needs to be verified in further studies, dual energy CT with iodine quantification may be used to differentiate metastatic from non-metastatic lymph nodes in NSCLC.

Assessment of Vascularity in Hepatic Alveolar Echinococcosis: Comparison of Quantified Dual-Energy CT with Histopathologic Parameters

Purpose

To investigate whether dual-energy computer tomography(DECT) could determine the angiographic vascularity of alveolar echinococcosis lesions by comparing the quantitative iodine concentration (IC) with the microvascular density (MVD).

Material and Methods

Twenty-five patients (16 men, 9 women; mean age, 40.9 ± 13.8 years) with confirmed hepatic alveolar echinococcosis (HAE) underwent DECT of the abdomen, consisting of arterial phase (AP), portal venous phase (PVP), and delayed phase (DP) scanning, in dual-source mode (100 kV/140 kV). Image data were processed with a DECT software algorithm that was designed for the evaluation of iodine distribution in the different layers (marginal zone, solid and cystic) of the lesions. The CT patterns of HAE lesions were classified into three types: solid type, pseudocystic type and ‘geographic map’ (mixed) type. The IC measurements in different layers and different types of lesions were statistically compared. MVD was examined using CD34 immunohistochemical staining of the resected HAE tissue and scored based on the percentage of positively stained cells and their intensity. Pearson’s correlation analysis was used to evaluate the potential correlation between DECT parameters and MVD.

Results

A total of 27 HAE lesions were evaluated, of which 9 were solid type, 3 were pseudocystic type and 15 were mixed type. The mean lesion size was 100.7 ± 47.3 mm. There was a significant difference in the IC measurements between different layers of HAE lesions during each scan phase (p < 0.001). The IC in the marginal zone was significantly higher than in the solid and cystic components in AP (2.15 mg/mL vs. 0.17 or 0.01 mg/mL), PVP (3.08 mg/mL vs. 0.1 or 0.02 mg/mL), and DP (2.93 mg/mL vs. 0.04 or 0.02 mg/mL). No significant difference was found among the different CT patterns of HAE lesions. Positive expression of CD34 in the marginal zones surrounding HAE lesions was found in 92.5% (25/27) of lesions, of which 18.5% (5/27) were strongly positive, 62.7% (17/27) were moderately positive, and 11.1% (3/27) were weakly positive. In contrast, 7.4% (2/27) of the lesions were negative for CD34. There was a positive correlation between IC measurements and MVD in the marginal zone of HAE lesions (r = 0.73, p < 0.05).

Conclusions

The DECT quantitative iodine concentration was significantly correlated with MVD in the marginal zones surrounding HAE lesions. Dual-energy CT using a quantitative analytic methodology can be used to evaluate the vascularity of AE.

Inflammatory bowel disease imaging: Current practice and future directions

The purpose of this paper is to evaluate the role of imaging in inflammatory bowel disease (IBD), including detection of extraluminal complications and extraintestinal manifestations of IBD, assessment of disease activity and treatment response, and discrimination of inflammatory from fibrotic strictures. IBD is a chronic idiopathic disease affecting the gastrointestinal tract that is comprised of two separate, but related intestinal disorders; Crohn’s disease and ulcerative colitis. The paper discusses, in detail the pros and cons of the different IBD imaging modalities that need to be considered in order to optimize the imaging and clinical evaluation of patients with IBD. Historically, IBD evaluation of the bowel has included imaging to assess the portions of the small bowel that are inaccessible to optical endoscopic visualization. This traditionally was performed using barium fluoroscopic techniques; however, cross-sectional imaging techniques (computed tomography and magnetic resonance imaging) are being increasingly utilized for IBD evaluation because they can simultaneously assess mural and extramural IBD manifestations. Recent advances in imaging technology, that continue to improve the ability of imaging to noninvasively follow disease activity and treatment response, are also discussed. This review article summarizes the current imaging approach in inflammatory bowel disease as well as the role of emerging imaging modalities.

Iodine concentration as a perfusion surrogate marker in oncology: Further elucidation of the underlying mechanisms using Volume Perfusion CT with 80 kVp

OBJECTIVES

To assess the value of iodine concentration (IC) in computed tomography data acquired with 80 kVp, as a surrogate for perfusion imaging in hepatocellular carcinoma (HCC) and lymphoma by comparing iodine related attenuation (IRA) with quantitative Volume Perfusion CT (VPCT)-parameters.

METHODS

VPCT-parameters were compared with intra-tumoral IC at 5 time points after the aortic peak enhancement (APE) with a temporal resolution of 3.5 sec in untreated 30 HCC and 30 lymphoma patients.

RESULTS

Intra-tumoral perfusion parameters for HCC showed a blood flow (BF) of 52.7 ± 17.0 mL/100 mL/min, blood volume (BV) 12.6 ± 4.3 mL/100 mL, arterial liver perfusion (ALP) 44.4 ± 12.8 mL/100 mL/min. Lesion IC 7 sec after APE was 133.4 ± 57.3 mg/100 mL. Lymphoma showed a BF of 36.8 ± 13.4 mL/100 mL/min, BV of 8.8 ± 2.8 mL/100 mL and IC of 118.2 ± 64.5 mg/100 mL 3.5 sec after APE. Strongest correlations exist for VPCT-derived BF and ALP with IC in HCC 7 sec after APE (r = 0.71 and r = 0.84) and 3.5 sec after APE in lymphoma lesions (r = 0.77). Significant correlations are also present for BV (r = 0.60 and r = 0.65 for HCC and lymphoma, respectively).

CONCLUSIONS

We identified a good, time-dependent agreement between VPCT-derived flow values and IC in HCC and lymphoma. Thus, CT-derived ICs 7 sec after APE in HCC and 3.5 sec in lymphoma may be used as surrogate imaging biomarkers for tumor perfusion with 80 kVp.

KEY POINTS

• Iodine concentration derived from low kVp CT is regarded as perfusion surrogate • Correlation with Perfusion CT was performed to elucidate timing and histology dependencies • Highest correlation was present 7 sec after aortic peak enhancement in hepatocellular carcinoma • In lymphoma, highest correlation was calculated 3.5 sec after aortic peak enhancement • With these results, further optimization of Dual energy CT protocols is possible.

A pilot study using low-dose Spectral CT and ASIR (Adaptive Statistical Iterative Reconstruction) algorithm to diagnose solitary pulmonary nodules

BACKGROUND

Lung cancer is the most common cancer which has the highest mortality rate. With the development of computed tomography (CT) techniques, the case detection rates of solitary pulmonary nodules (SPN) has constantly increased and the diagnosis accuracy of SPN has remained a hot topic in clinical and imaging diagnosis. The aim of this study was to evaluate the combination of low-dose spectral CT and ASIR (Adaptive Statistical Iterative Reconstruction) algorithm in the diagnosis of solitary pulmonary nodules (SPN).

METHODS

62 patients with SPN (42 cases of benign SPN and 20 cases of malignant SPN, pathology confirmed) were scanned by spectral CT with a dual-phase contrast-enhanced method. The iodine and water concentration (IC and WC) of the lesion and the artery in the image that had the same density were measured by the GSI (Gemstone Spectral Imaging) software. The normalized iodine and water concentration (NIC and NWC) of the lesion and the normalized iodine and water concentration difference (ICD and WCD) between the arterial and venous phases (AP and VP) were also calculated. The spectral HU (Hounsfield Unit ) curve was divided into 3 sections based on the energy (40-70, 70-100 and 100-140 keV) and the slopes (λHU) in both phases were calculated. The ICAP, ICVP, WCAP and WCVP, NIC and NWC, and the λHU in benign and malignant SPN were compared by independent sample t-test.

RESULTS

The iodine related parameters (ICAP, ICVP, NICAP, NICVP, and the ICD) of malignant SPN were significantly higher than that of benign SPN (t = 3.310, 1.330, 2.388, 1.669 and 3.251, respectively, P <0.05). The 3 λHU values of venous phase in malignant SPN were higher than that of benign SPN (t = 3.803, 2.846 and 3.205, P <0.05). The difference of water related parameters (WCAP, WCVP, NWCAP, NWCVP and WCD) between malignant and benign SPN were not significant (t = 0.666, 0.257, 0.104, 0.550 and 0.585, P > 0.05).

CONCLUSIONS

The iodine related parameters and the slope of spectral curve are useful markers to distinguish the benign from the malignant lung diseases, and its application is extremely feasible in clinical applications.

Impact of dual-energy CT prior to radioembolization (RE)

BACKGROUND

Depiction of the exact arterial liver anatomy as well as identifying potential extrahepatic non-target vessels is crucial for a successful preparation of radioembolization (RE).

PURPOSE

To compare the diagnostic impact of dual-energy computed tomography (DECT) to digital subtraction angiography prior to RE.

MATERIAL AND METHODS

DECT was applied in 46 patients with hepatocellular carcinoma (HCC) prior to RE. Eighty kV DE as well as reconstructed 120 kV equivalent DE datasets were evaluated in comparison to correlating digital subtraction angiography (DSA) datasets. Two radiologists evaluated in consensus the delineation of liver arteries and extrahepatic non-target vessels utilizing a 4-point scale (4 = excellent delineation; 1 = non-diagnostic). In addition, the arterial vascularization of liver segment IV was evaluated and classified: signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR; liver arteries to adjacent liver tissue) were obtained via ROI analysis.

RESULTS

Both imaging techniques (DECT, DSA) enabled high-quality assessment of all analyzed liver arteries. Out of the two CT datasets, 80 kVp-DE datasets offered superior delineation of the right gastric artery (3.5 ± 0.7 vs. 2.5 ± 0.5), the vascularization of segment IV (3.9 ± 0.2 vs. 3.3 ± 0.5) as well as potential extrahepatic non-target vessels (3.9 ± 0.1 vs. 3.3 ± 0.5). In accordance to the results of the qualitative analysis, 80 kVp-DE datasets also yielded higher SNR (34.84 vs. 29.31) and CNR (28.29 vs. 21.8) values in comparison to the 120 kVp datasets.

CONCLUSION

Eighty kVp DECT enables a significantly better assessment of the arteries of the upper abdomen for therapy planning in comparison to correlating 120 kVp datasets. This may allow for identification of potential extrahepatic non-target vessels and assessment of target volume for therapy planning prior to DSA.

Histogram analysis of iodine maps from dual energy computed tomography for monitoring targeted therapy of melanoma patients

AIM

Iodine quantification with dual energy computed tomography (DECT) enables quantitative assessment of contrast medium uptake. Our purpose was to investigate patterns of enhancement under BRAF inhibitor therapy by performing histogram analyses (HAs) of iodine maps.

MATERIALS & METHODS

A total of 11 stage IV melanoma patients (32 metastases) underwent DECT at baseline and at least one follow up. Iodine uptake and HAs including maximum HU value (MAX), mean HU value (MEAN) and standard deviation (STD) was calculated.

RESULTS

For BRAF-responders MEAN, MAX and STD decreased significantly (p < 0.05). Nonresponder showed increasing MAX and STD for six out of seven lesions, while MEAN and Iodine uptake decreased (four) and increased (three).

CONCLUSION

HA based on DECT enables a quantitative and functional criterion and contributes to accurate response assessment for promising targeted therapies.

Evaluating the response of gastric carcinomas to neoadjuvant chemotherapy using iodine concentration on spectral CT: a comparison with pathological regression

AIM

To investigate the potential of iodine concentration (IC) determined using virtual monochromatic spectral computed tomography (CT) to predict the response of gastric carcinomas to preoperative neoadjuvant chemotherapy (NC).

MATERIALS AND METHODS

A total of 20 patients were enrolled who underwent two spectral CT examinations (1 week before and two cycles after NC). The percentage change in tumour thickness (%ΔCWT) and in IC on the arterial phase (%ΔIC-a) and venous phase (%ΔIC-v) after NC were calculated and compared for different histopathological regression grades and response groups. The diagnostic efficacies to discriminate good response (GR) and poor response (PR) of the above three parameters were evaluated using receiver operating characteristic (ROC) curves.

RESULTS

The decrease rate of %ΔIC-a for the GR group was higher than that for the PR group (-0.59 [-0.76, -0.20] versus -0.11 [-0.75, 0.92], p=0.012). There was no significant difference in the %ΔIC-v and %ΔCWT values between the GR and PR groups (p=0.076 and p=0.779, respectively). The areas under the ROC curve (AUC) values were 0.857, 0.762, and 0.542 for %ΔIC-a, %ΔIC-v, and %ΔCWT, respectively, in the response prediction. The cut-off value for identifying PR was a decrease rate of <52.9% for %ΔIC-a, and the sensitivity and specificity values were 0.857 and 0.833.

CONCLUSION

Changes in the IC for gastric carcinomas following NC were detected using spectral CT and correlated with histopathological regression. The prediction efficacy for IC was better than that for tumour thickness, with IC on the arterial phase being a better predictor than IC on the venous phase.

Dual-energy CT of the abdomen

Although conceived of in the 1970s, practical use of dual-energy CT in the clinical setting did not come to fruition until 2006, and since that time an ever expanding exploration of the technology has been underway. This article will discuss technical aspects of the two commercially available CT scanners, review the recent literature, and provide an organ-based description of abdominal dual-energy CT applications for the practicing radiologist.

Oncologic applications of dual-energy CT in the abdomen

Dual-energy computed tomographic (DECT) technology offers enhanced capabilities that may benefit oncologic imaging in the abdomen. By using two different energies, dual-energy CT allows material decomposition on the basis of energy-dependent attenuation profiles of specific materials. Although image acquisition with dual-energy CT is similar to that with single-energy CT, comprehensive postprocessing is able to generate not only images that are similar to single-energy CT (SECT) images, but a variety of other images, such as virtual unenhanced (VUE), virtual monochromatic (VMC), and material-specific iodine images. An increase in the conspicuity of iodine on low-energy VMC images and material-specific iodine images may aid detection and characterization of tumors. Use of VMC images of a desired energy level (40-140 keV) improves lesion-to-background contrast and the quality of vascular imaging for preoperative planning. Material-specific iodine images enable differentiation of hypoattenuating tumors from hypo- or hyperattenuating cysts and facilitate detection of isoattenuating tumors, such as pancreatic masses and peritoneal disease, thereby defining tumor targets for imaging-guided therapy. Moreover, quantitative iodine mapping may serve as a surrogate biomarker for monitoring effects of the treatment. Dual-energy CT is an innovative imaging technique that enhances the capabilities of CT in evaluating oncology patients.

Oncological applications of dual-energy computed tomography imaging

Dual-energy computed tomography (DECT) imaging is a promising method used in oncology for accurate detection/diagnosis of malignant and benign lesions. Use of dual-energy spectral, weighted average, color-coded map, and virtual unenhanced images provides increased visual detection and easy lesion delineation. Lesion detectability, sensitivity, and conspicuity are significantly improved using DECT. Material characterization and decomposition are promising using DECT. Both anatomical and functional information related to oncology can be provided by DECT using single contrast-enhanced CT.

Interdependencies of acquisition, detection, and reconstruction techniques on the accuracy of iodine quantification in varying patient sizes employing dual-energy CT

PURPOSE

To assess the impact of patient habitus, acquisition parameters, detector efficiencies, and reconstruction techniques on the accuracy of iodine quantification using dual-source dual-energy CT (DECT).

MATERIALS AND METHODS

Two phantoms simulating small and large patients contained 20 iodine solutions mimicking vascular and parenchymal enhancement from saline isodensity to 400 HU and 30 iodine solutions simulating enhancement of the urinary collecting system from 400 to 2,000 HU. DECT acquisition (80/140 kVp and 100/140 kVp) was performed using two DECT systems equipped with standard and integrated electronics detector technologies. DECT raw datasets were reconstructed using filtered backprojection (FBP), and iterative reconstruction (SAFIRE I/V).

RESULTS

Accuracy for iodine quantification was significantly higher for the small compared to the large phantoms (9.2 % ± 7.5 vs. 24.3 % ± 26.1, P = 0.0001), the integrated compared to the conventional detectors (14.8 % ± 20.6 vs. 18.8 % ± 20.4, respectively; P = 0.006), and SAFIRE V compared to SAFIRE I and FBP reconstructions (15.2 % ± 18.1 vs. 16.1 % ± 17.6 and 18.9 % ± 20.4, respectively; P ≤ 0.003). A significant synergism was observed when the most effective detector and reconstruction techniques were combined with habitus-adapted dual-energy pairs.

CONCLUSION

In a second-generation dual-source DECT system, the accuracy of iodine quantification can be substantially improved by an optimal choice and combination of acquisition parameters, detector, and reconstruction techniques.

Accuracy of contrast-enhanced dual-energy MDCT for the assessment of iodine uptake in renal lesions

OBJECTIVE

The objective of our study was to assess the accuracy of iodine-related attenuation and iodine quantification as imaging biomarkers of iodine uptake in renal lesions on a single-phase nephrographic image with dual-energy MDCT.

MATERIALS AND METHODS

Fifty-nine patients (41 men, 18 women; age range, 28-84 years) with 80 renal lesions underwent contrast-enhanced dual-energy CT during the nephrographic phase of enhancement. Renal lesions were characterized as enhancing or nonenhancing on color-coded iodine overlay maps using iodine-related attenuation (in Hounsfield units) and iodine quantification (in milligrams per milliliter). For iodine-related attenuation the iodine uptake thresholds of 15 and 20 HU were tested; a threshold of 0.5 mg/mL was used for iodine quantification. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of iodine-related attenuation and iodine quantification were calculated from chi-square tests of contingency with histopathology or imaging follow-up as the reference standard. The 95% CIs were calculated from binomial expression. Differences in sensitivity and specificity were assessed by means of McNemar analysis.

RESULTS

A significant difference in sensitivity and specificity was found between iodine-related attenuation with the thresholds of 15 HU (sensitivity, 91.4%; specificity, 93.3%; PPV, 91.4%; NPV, 93.3%) and 20 HU (sensitivity, 77.1%; specificity, 100%; PPV, 100%; NPV, 84.9%) (p = 0.008) and between iodine quantification (sensitivity, 100%; specificity, 97.7%; PPV, 97.2%; NPV, 100%) and iodine-related attenuation with a threshold of 20 HU (p = 0.004). No significant difference in sensitivity and specificity was found between iodine quantification and iodine-related attenuation with a threshold of 15 HU.

CONCLUSION

Contrast-enhanced dual-energy MDCT with iodine-related attenuation and iodine quantification allows accurate evaluation of iodine uptake in renal lesions on a single-phase nephrographic image.

Dual-energy computed tomography for the assessment of early treatment effects of regorafenib in a preclinical tumor model: comparison with dynamic contrast-enhanced CT and conventional contrast-enhanced single-energy CT

OBJECTIVES

The potential diagnostic value of dual-energy computed tomography (DE-CT) compared to dynamic contrast-enhanced CT (DCE-CT) and conventional contrast-enhanced CT (CE-CT) in the assessment of early regorafenib treatment effects was evaluated in a preclinical setting.

METHODS

A rat GS9L glioma model was examined with contrast-enhanced dynamic DE-CT measurements (80 kV/140 kV) for 4 min before and on days 1 and 4 after the start of daily regorafenib or placebo treatment. Tumour time-density curves (0-240 s, 80 kV), DE-CT (60 s) derived iodine maps and the DCE-CT (0-30 s, 80 kV) based parameters blood flow (BF), blood volume (BV) and permeability (PMB) were calculated and compared to conventional CE-CT (60 s, 80 kV).

RESULTS

The regorafenib group showed a marked decrease in the tumour time-density curve, a significantly lower iodine concentration and a significantly lower PMB on day 1 and 4 compared to baseline, which was not observed for the placebo group. CE-CT showed a significant decrease in tumour density on day 4 but not on day 1. The DE-CT-derived iodine concentrations correlated with PMB and BV but not with BF.

CONCLUSIONS

DE-CT allows early treatment monitoring, which correlates with DCE-CT. Superior performance was observed compared to single-energy CE-CT.

KEY POINTS

• Regorafenib treatment response was evaluated by CT in a rat tumour model. • Dual-energy contrast-enhanced CT allows early treatment monitoring of targeted anti-tumour therapies. • Dual-energy CT showed higher diagnostic potential than conventional contrast enhanced single-energy CT. • Dual-energy CT showed diagnostic potential comparable to dynamic contrast-enhanced CT. • Dual-energy CT is a promising method for efficient clinical treatment response evaluation.

Objective and subjective image quality of liver parenchyma and hepatic metastases with virtual monoenergetic dual-source dual-energy CT reconstructions: an analysis in patients with gastrointestinal stromal tumor

RATIONALE AND OBJECTIVES

To compare in dual-energy CT (DECT) conventionally reconstructed polyenergetic images (PEI) at 120 kVp to virtual monoenergetic images (MEI) at different kiloelectron volt (keV) levels for evaluation of liver and gastrointestinal stromal tumor (GIST) hepatic metastases with regard to objective (IQob) and subjective image quality (IQsub) assessed by two readers of varying experience. Image quality was correlated to patient size and compared between PEI and MEI.

MATERIALS AND METHODS

From 50 examinations of 17 GIST patients (12 with hepatic metastases) undergoing abdominal dual-source DECT for staging, therapy monitoring or follow-up, PEI and nine MEI in 10-keV intervals from 40 to 120 keV were reconstructed. Liver contrast-to-noise ratios (CNR) and metastasis-to-liver ratios were calculated. MEI reconstructions with the highest IQob were compared to PEI for IQsub by one experienced reader (ER) and one inexperienced reader (IR). Patients' diameters were correlated to IQob and IQsub ratings.

RESULTS

MEI at 70 keV had the highest IQob with equal liver CNR and metastasis-to-liver ratio compared to PEI. The ER rated 70-keV MEI and PEI equally high (median 4), whereas the IR rated IQsub best in 70-keV MEI (median 5). Unlike in PEI, IQsub ratings in 70-keV MEI were not correlated to patient size.

CONCLUSIONS

MEI at 70 keV provided an IQob equivalent to PEI. Regarding the IR, IQsub was improved in 70-keV MEI compared to PEI and less dependent on patient size. Therefore, IRs might improve their diagnostic confidence in the assessment of hepatic GIST metastases by evaluating MEI reconstructions at 70 keV.

Iodine quantification with dual-energy CT: phantom study and preliminary experience with VX2 residual tumour in rabbits after radiofrequency ablation

OBJECTIVE

The purpose of our study was to validate iodine quantification in a phantom study with dual-source dual-energy CT (DECT) and to apply this technique to differentiate benign periablational reactive tissue from residual tumour in VX2 carcinoma in rabbits after radiofrequency ablation (RFA).

METHODS

We applied iodine quantification with DECT in a phantom and in VX2 carcinoma in rabbits after incomplete RFA to differentiate benign periablational reactive tissue from residual tumour and evaluated its efficacy in demonstrating response to therapeutic RFA. A series of tubes containing solutions of varying iodine concentration were scanned with DECT. The iodine concentration was calculated and compared with known true iodine concentration. Triple-phase contrast-enhanced DECT data on 24 rabbits with VX2 carcinoma were then assessed at Day 3 (n=6), 1 week (n=6), 2 weeks (n=6) and 3 weeks (n=6) after incomplete RFA independently by 2 readers. Dual-energy postprocessing was used to produce iodine-only images. Regions of interest were positioned on the iodine image over the lesion and, as a reference, over the aorta, to record iodine concentration in the lesion and in the aorta. The pathological specimens were sectioned in the same plane as DECT imaging, and the lesion iodine concentration and lesion-to-aorta iodine ratio of residual tumour and benign periablational reactive tissue were assessed.

RESULTS

There was excellent correlation between calculated and true iodine concentration (r=0.999, p<0.0001) in the phantom study. The lesion iodine concentration and lesion-to-aorta iodine ratio in residual tumour were significantly higher than in benign periablational reactive tissue in the 2-week group during the arterial phase (AP) (p<0.01) and in the 3-week group during both the AP (p<0.05) and the portal venous phase (p<0.05). There was no significant difference between them with respect to the lesion iodine concentration or lesion-to-aorta iodine ratio in the 3-day and 1-week groups.

CONCLUSION

Iodine quantification with DECT is accurate in a phantom study and can be used to differentiate benign periablational reactive tissue from residual tumour in VX2 carcinoma in rabbits after RFA.

ADVANCES IN KNOWLEDGE

Iodine quantification with DECT may help in differentiating benign periablational reactive tissue from residual tumour in VX2 carcinoma in rabbits after RFA.

Monitoring targeted therapy using dual-energy CT: semi-automatic RECIST plus supplementary functional information by quantifying iodine uptake of melanoma metastases

AIM

Supplementary functional information can contribute to assess response in targeted therapies. The aim of this study was to evaluate semi-automatic RECIST plus iodine uptake (IU) determination in melanoma metastases under BRAF inhibitor (vemurafenib) therapy using dual-energy computed tomography (DECT).

METHODS

Nine patients with stage IV melanoma treated with a BRAF inhibitor were included. Contrast-enhanced DECT was performed before and twice after treatment onset. Changes in tumor size were assessed according to RECIST. Quantification of IU (absolute value for total IU (mg) and volume-normalized IU (mg/ml)) was based on semi-automatic tumor volume segmentation. The decrease compared with baseline was calculated.

RESULTS

The mean change of RECIST diameter sum per patient was -47% at the first follow-up (FU), -56% at the second FU (P < 0.01). The mean normalized IU per patient was -21% at the first FU (P < 0.2) and -45% at the second FU (P < 0.01). Total IU per patient, combining both normalized IU and volume, showed the most pronounced decrease: -89% at the first FU and -90% at the second FU (P < 0.01).

CONCLUSION

Semi-automatic RECIST plus IU quantification in DECT enables objective, easy and fast parameterization of tumor size and contrast medium uptake, thus providing 2 complementary pieces of information for response monitoring applicable in daily routine.

Additional value of dual-energy CT to differentiate between benign and malignant mediastinal tumors: an initial experience

OBJECTIVES

To investigate the feasibility of dual-energy computed tomography (DECT) in differentiating malignant from benign mediastinal tumors.

MATERIALS AND METHODS

We prospectively enrolled 25 patients (14 males; mean age: 56.7 years) who had suspected mediastinal tumors on chest radiography or non-contrast chest computed tomography (CT). All patients underwent a two-phase DECT using gemstone spectral imaging (GSI) mode (GE HD750). For the quantitative analysis, two investigators measured the following parameters of the tumors in the early and the delayed phases: CT attenuation value in Hounsfield units (HU) and iodine concentration (mg/ml). Pathological results were used for a final diagnosis. Statistical analyses were performed using the Fisher's exact test and the Mann-Whitney t-test.

RESULTS

10 patients (40%) had benign pathology, while 15 (60%) had malignant pathology. The iodine concentration measurements were significantly different between benign and malignant tumors both in the early phase (1.38 mg/ml vs. 2.41 mg/ml, p=0.001) and in the delayed phase (1.52 mg/ml vs. 2.84 mg/ml, p=0.001), while mean attenuation values were not significantly different in both phases (57.8 HU vs. 69.1 HU, p=0.067 and 67.4 HU vs. 78.4 HU, p=0.086, respectively).

CONCLUSIONS

Dual-energy CT using a quantitative analytic methodology can be used to differentiate between benign and malignant mediastinal tumors.

Correlation analysis of dual-energy CT iodine maps with quantitative pulmonary perfusion MRI

AIM: To correlate dual-energy computed tomography (DECT) pulmonary angiography derived iodine maps with parameter maps of quantitative pulmonary perfusion magnetic resonance imaging (MRI).

METHODS: Eighteen patients with pulmonary perfusion defects detected on DECT derived iodine maps were included in this prospective study and additionally underwent time-resolved contrast-enhanced pulmonary MRI [dynamic contrast enhanced (DCE)-MRI]. DCE-MRI data were quantitatively analyzed using a pixel-by-pixel deconvolution analysis calculating regional pulmonary blood flow (PBF), pulmonary blood volume (PBV) and mean transit time (MTT) in visually normal lung parenchyma and perfusion defects. Perfusion parameters were correlated to mean attenuation values of normal lung and perfusion defects on DECT iodine maps. Two readers rated the concordance of perfusion defects in a visual analysis using a 5-point Likert-scale (1 = no correlation, 5 = excellent correlation).

RESULTS: In visually normal pulmonary tissue mean DECT and MRI values were: 22.6 ± 8.3 Hounsfield units (HU); PBF: 58.8 ± 36.0 mL/100 mL per minute; PBV: 16.6 ± 8.5 mL; MTT: 17.1 ± 10.3 s. In areas with restricted perfusion mean DECT and MRI values were: 4.0 ± 3.9 HU; PBF: 10.3 ± 5.5 mL/100 mL per minute, PBV: 5 ± 4 mL, MTT: 21.6 ± 14.0 s. The differences between visually normal parenchyma and areas of restricted perfusion were statistically significant for PBF, PBV and DECT (P < 0.0001). No linear correlation was found between MRI perfusion parameters and attenuation values of DECT iodine maps (PBF: r = 0.35, P = 0.15; PBV: r = 0.34, P = 0.16; MTT: r = 0.41, P = 0.08). Visual analysis revealed a moderate correlation between perfusion defects on DECT iodine maps and the parameter maps of DCE-MRI (mean score 3.6, κ 0.45).

CONCLUSION: There is a moderate visual but not statistically significant correlation between DECT iodine maps and perfusion parameter maps of DCE-MRI.

Dual-energy micro-computed tomography imaging of radiation-induced vascular changes in primary mouse sarcomas

PURPOSE

To evaluate the effects of radiation therapy on primary tumor vasculature using dual-energy (DE) micro-computed tomography (micro-CT).

METHODS AND MATERIALS

Primary sarcomas were generated with mutant Kras and p53. Unirradiated tumors were compared with tumors irradiated with 20 Gy. A liposomal-iodinated contrast agent was administered 1 day after treatment, and mice were imaged immediately after injection (day 1) and 3 days later (day 4) with DE micro-CT. CT-derived tumor sizes were used to assess tumor growth. After DE decomposition, iodine maps were used to assess tumor fractional blood volume (FBV) at day 1 and tumor vascular permeability at day 4. For comparison, tumor vascularity and vascular permeability were also evaluated histologically by use of CD31 immunofluorescence and fluorescently-labeled dextrans.

RESULTS

Radiation treatment significantly decreased tumor growth from day 1 to day 4 (P<.05). There was a positive correlation between CT measurement of tumor FBV on day 1 and extravasated iodine on day 4 with microvascular density (MVD) on day 4 (R(2)=0.53) and dextran accumulation (R(2)=0.63) on day 4, respectively. Despite no change in MVD measured by histology, tumor FBV significantly increased after irradiation as measured by DE micro-CT (0.070 vs 0.091, P<.05). Both dextran and liposomal-iodine accumulation in tumors increased significantly after irradiation, with dextran fractional area increasing 5.2-fold and liposomal-iodine concentration increasing 4.0-fold.

CONCLUSIONS

DE micro-CT is an effective tool for noninvasive assessment of vascular changes in primary tumors. Tumor blood volume and vascular permeability increased after a single therapeutic dose of radiation treatment.

Functional imaging of the liver

Anatomical-based imaging is used widely for the evaluation of diffuse and focal liver, including detection, characterization, and therapy response assessment. However, a limitation of anatomical-based imaging is that structural changes may occur relatively late in a disease process. By applying conventional anatomical-imaging methods in a more functional manner, specific pathophysiologic alterations of the liver may be assessed and quantified. There has been an increasing interest in both the clinical and research settings, with the expectation that functional-imaging techniques may help solve common diagnostic dilemmas that conventional imaging alone cannot. This review considers the most common functional magnetic resonance imaging, computed tomography, and ultrasound imaging techniques that may be applied to the liver.

Dual-energy CT: radiation dose aspects

OBJECTIVE

Various applications for dual-energy CT (DECT) have been investigated and have shown substantial clinical benefits. However, only limited data are available regarding the radiation dose associated with DECT imaging. The purpose of this article is to review the available literature regarding the radiation dose associated with DECT imaging applications in comparison with conventional single-energy CT techniques.

CONCLUSION

The rediscovery of DECT and the increasing availability of this technique on clinical CT systems have opened new dimensions for CT. The advanced spectral differentiation of materials within the human body as well as the selective visualization or subtraction of iodinated contrast material or xenon provides both advanced visualization of disease-specific molecular substrates as well as additional functional information within a single scan.

Quantitative therapy response assessment by volumetric iodine-uptake measurement: initial experience in patients with advanced hepatocellular carcinoma treated with sorafenib

OBJECTIVES

To investigate the volumetric iodine-uptake (VIU) changes by dual-energy CT (DECT) in assessing the response to sorafenib treated hepatocellular carcinoma (HCC) patients, compared with AASLD (American Association for the Study of Liver Diseases) and Choi criteria.

MATERIALS AND METHODS

Fifteen patients with HCC receiving sorafenib, monitored with contrast-enhanced DECT scans at baseline and a minimum of one follow-up (8-12 weeks) were retrospectively evaluated. 30 target lesions in total were analyzed for tumor response according to VIU and adapted Choi criteria and compared with the standard AASLD.

RESULTS

According to AASLD criteria, 67% target lesions showed disease control: partial response (PR) in 3% and stable disease (SD) in 63%. 33% lesions progressed (PD). Disease control rate presented by VIU (60%) was similar to AASLD (67%) and Choi (63%) (P>0.05). For disease control group, change in mean VIU was from 149.5 ± 338.3mg to 108.5 ± 284.1mg (decreased 19.1 ± 42.9%); and for progressive disease group, change in mean VIU was from 163.7 ± 346.7 mg to 263.9 ± 537.2 mg (increased 230.5 ± 253.1%). Compared to AASLD (PR, 3%), VIU and Choi presented more PR (33% and 30%, respectively) in disease control group (P<0.05). VIU has moderate consistency with both AASLD (kappa=0.714; P<0.005) and Choi (kappa=0.648; P<0.005), while VIU showed a better consistency and correlation with AASLD (kappa=0.714; P<0.005; r=0.666, P<0.005) than Choi with AASLD (kappa=0.634, P<0.005; r=0.102, P=0.296).

CONCLUSION

VIU measurements by DECT can evaluate the disease control consistent with the current standard AASLD. Measurements are semi-automatic and therefore easy and robust to apply. As VIU reflects vital tumor burden in HCC, it is likely to be an optimal tumor response biomarker in HCC.

[Dual-energy computed tomography: what is it useful for?]

Dual-energy CT is one of the newest and most attractive fields in radiology today. New generation scanners can acquire datasets with different X-ray spectra, which facilitates the characterization of certain chemical elements, making it possible to detect functional alterations in the absence of morphologic or densitometric anomalies. The capability of characterizing these elements is enabling new applications to be developed for clinical practice and changing the way we work. The aim of this article is to explain what dual-energy CT studies are, the techniques available for performing them, the advantages and disadvantages of these studies, and what we might expect from this field in the future.