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Cho SW, Baek S, Han S, Kim CO, Kim HC, Rhee Y, Hong N. Metabolic phenotyping with computed tomography deep learning for metabolic syndrome, osteoporosis and sarcopenia predicts mortality in adults. J Cachexia Sarcopenia Muscle 2024; 15:1418-1429. [PMID: 38649795 PMCID: PMC11294037 DOI: 10.1002/jcsm.13487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 03/06/2024] [Accepted: 03/21/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Computed tomography (CT) body compositions reflect age-related metabolic derangements. We aimed to develop a multi-outcome deep learning model using CT multi-level body composition parameters to detect metabolic syndrome (MS), osteoporosis and sarcopenia by identifying metabolic clusters simultaneously. We also investigated the prognostic value of metabolic phenotyping by CT model for long-term mortality. METHODS The derivation set (n = 516; 75% train set, 25% internal test set) was constructed using age- and sex-stratified random sampling from two community-based cohorts. Data from participants in the individual health assessment programme (n = 380) were used as the external test set 1. Semi-automatic quantification of body compositions at multiple levels of abdominal CT scans was performed to train a multi-layer perceptron (MLP)-based multi-label classification model. External test set 2 to test the prognostic value of the model output for mortality was built using data from individuals who underwent abdominal CT in a tertiary-level institution (n = 10 141). RESULTS The mean ages of the derivation and external sets were 62.8 and 59.7 years, respectively, without difference in sex distribution (women 50%) or body mass index (BMI; 23.9 kg/m2). Skeletal muscle density (SMD) and bone density (BD) showed a more linear decrement across age than skeletal muscle area. Alternatively, an increase in visceral fat area (VFA) was observed in both men and women. Hierarchical clustering based on multi-level CT body composition parameters revealed three distinctive phenotype clusters: normal, MS and osteosarcopenia clusters. The L3 CT-parameter-based model, with or without clinical variables (age, sex and BMI), outperformed clinical model predictions of all outcomes (area under the receiver operating characteristic curve: MS, 0.76 vs. 0.55; osteoporosis, 0.90 vs. 0.79; sarcopenia, 0.85 vs. 0.81 in external test set 1; P < 0.05 for all). VFA contributed the most to the MS predictions, whereas SMD, BD and subcutaneous fat area were features of high importance for detecting osteoporosis and sarcopenia. In external test set 2 (mean age 63.5 years, women 79%; median follow-up 4.9 years), a total of 907 individuals (8.9%) died during follow-up. Among model-predicted metabolic phenotypes, sarcopenia alone (adjusted hazard ratio [aHR] 1.55), MS + sarcopenia (aHR 1.65), osteoporosis + sarcopenia (aHR 1.83) and all three combined (aHR 1.87) remained robust predictors of mortality after adjustment for age, sex and comorbidities. CONCLUSIONS A CT body composition-based MLP model detected MS, osteoporosis and sarcopenia simultaneously in community-dwelling and hospitalized adults. Metabolic phenotypes predicted by the CT MLP model were associated with long-term mortality, independent of covariates.
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Affiliation(s)
- Sang Wouk Cho
- Department of Internal Medicine, Endocrine Research InstituteSeverance Hospital, Yonsei University College of MedicineSeoulSouth Korea
- Institue for Innovation in Digital Healthcare (IIDH)Yonsei University Health SystemSeoulSouth Korea
| | - Seungjin Baek
- Department of Internal Medicine, Endocrine Research InstituteSeverance Hospital, Yonsei University College of MedicineSeoulSouth Korea
| | - Sookyeong Han
- Department of Internal Medicine, Endocrine Research InstituteSeverance Hospital, Yonsei University College of MedicineSeoulSouth Korea
- Institue for Innovation in Digital Healthcare (IIDH)Yonsei University Health SystemSeoulSouth Korea
| | - Chang Oh Kim
- Division of Geriatric Medicine, Department of Internal MedicineYonsei University College of MedicineSeoulSouth Korea
| | - Hyeon Chang Kim
- Institue for Innovation in Digital Healthcare (IIDH)Yonsei University Health SystemSeoulSouth Korea
- Department of Preventive MedicineYonsei University College of MedicineSeoulSouth Korea
| | - Yumie Rhee
- Department of Internal Medicine, Endocrine Research InstituteSeverance Hospital, Yonsei University College of MedicineSeoulSouth Korea
- Institue for Innovation in Digital Healthcare (IIDH)Yonsei University Health SystemSeoulSouth Korea
| | - Namki Hong
- Department of Internal Medicine, Endocrine Research InstituteSeverance Hospital, Yonsei University College of MedicineSeoulSouth Korea
- Institue for Innovation in Digital Healthcare (IIDH)Yonsei University Health SystemSeoulSouth Korea
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Kim Y, Kim C, Lee E, Lee JW. Coronal plane in opportunistic screening of osteoporosis using computed tomography: comparison with axial and sagittal planes. Skeletal Radiol 2024; 53:1103-1109. [PMID: 38055040 DOI: 10.1007/s00256-023-04525-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 12/07/2023]
Abstract
OBJECTIVE To compare the coronal plane with axial and sagittal planes in opportunistic screening of osteoporosis using computed tomography (CT). MATERIALS AND METHODS A total of 100 patients aged ≥ 50 years who underwent both lumbar spine CT and dual-energy X-ray absorptiometry within 3 months were included. Osteoporosis was diagnosed based on dual-energy X-ray absorptiometry results. The CT number was measured at the center of the vertebral body in coronal, axial, and sagittal planes. To compare the coronal plane with axial and sagittal planes in diagnosing osteoporosis, the areas under the receiver operating characteristic curve (AUC) were compared and intraclass correlation coefficient (ICC) was calculated. The optimal cutoff values were calculated using Youden's index. RESULTS The AUC of the coronal plane (0.80; 95% confidence interval [CI], 0.71-0.89) was not significantly different from that of the axial plane (0.78; 95% CI, 0.68-0.87; P = 0.39) and that of the sagittal plane (0.78; 95% CI, 0.69-0.87; P = 0.68). Excellent concordance rates were observed between coronal and axial planes with ICC of 0.95 (95% CI, 0.92-0.96) and between coronal and sagittal planes with ICC of 0.93 (95% CI, 0.85-0.96). The optimal cutoff values for the coronal, axial, and sagittal planes were 110, 112, and 112 HU, respectively. CONCLUSION The coronal plane does not significantly differ from axial and sagittal planes in opportunistic screening of osteoporosis. Thus, the coronal plane as well as axial and sagittal planes can be used interchangeably in measuring bone mineral density using CT.
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Affiliation(s)
- Youngjune Kim
- Department of Radiology, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Changhyun Kim
- Department of Radiology, Seoul National University College of Medicine, 103, Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Eugene Lee
- Department of Radiology, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Joon Woo Lee
- Department of Radiology, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea.
- Department of Radiology, Seoul National University College of Medicine, 103, Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea.
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Pan Y, Zhao F, Cheng G, Wang H, Lu X, He D, Wu Y, Ma H, PhD HL, Yu T. Automated vertebral bone mineral density measurement with phantomless internal calibration in chest LDCT scans using deep learning. Br J Radiol 2023; 96:20230047. [PMID: 37751163 PMCID: PMC10646618 DOI: 10.1259/bjr.20230047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 08/04/2023] [Accepted: 09/09/2023] [Indexed: 09/27/2023] Open
Abstract
OBJECTIVE To develop and evaluate a fully automated method based on deep learning and phantomless internal calibration for bone mineral density (BMD) measurement and opportunistic low BMD (osteopenia and osteoporosis) screening using chest low-dose CT (LDCT) scans. METHODS A total of 1175 individuals were enrolled in this study, who underwent both chest LDCT and BMD examinations with quantitative computed tomography (QCT), by two different CT scanners (Siemens and GE). Two convolutional neural network (CNN) models were employed for vertebral body segmentation and labeling, respectively. A histogram technique was applied for vertebral BMD calculation using paraspinal muscle and surrounding fat as references. 195 cases (by Siemens scanner) as fitting cohort were used to build the calibration function. 698 cases as validation cohort I (VCI, by Siemens scanner) and 282 cases as validation cohort II (VCII, by GE scanner) were performed to evaluate the performance of the proposed method, with QCT as the standard for analysis. RESULTS The average BMDs from the proposed method were strongly correlated with QCT (in VCI: r = 0.896, in VCII: r = 0.956, p < 0.001). Bland-Altman analysis showed a small mean difference of 1.1 mg/cm3, and large interindividual differences as seen by wide 95% limits of agreement (-29.9 to +32.0 mg/cm3) in VCI. The proposed method measured BMDs were higher than QCT measured BMDs in VCII (mean difference = 15.3 mg/cm3, p < 0.001). Osteoporosis and low BMD were diagnosed by proposed method with AUCs of 0.876 and 0.903 in VCI, 0.731 and 0.794 in VCII, respectively. The AUCs of the proposed method were increased to over 0.920 in both VCI and VCII after adjusting the cut-off. CONCLUSION Without manual selection of the region of interest of body tissues, the proposed method based on deep learning and phantomless internal calibration has the potential for preliminary screening of patients with low BMD using chest LDCT scans. However, the agreement between the proposed method and QCT is insufficient to allow them to be used interchangeably in BMD measurement. ADVANCES IN KNOWLEDGE This study proposed an automated vertebral BMD measurement method based on deep learning and phantomless internal calibration with paraspinal muscle and fat as reference.
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Affiliation(s)
- Yaling Pan
- Center for Rehabilitation Medicine, Department of Radiology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Fanfan Zhao
- Center for Rehabilitation Medicine, Department of Radiology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Gen Cheng
- Hangzhou Yitu Healthcare Technology Co. Ltd, Hangzhou, Zhejiang, China
| | - Huogen Wang
- College of Computer Science and Technology, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xiangjun Lu
- Center for Rehabilitation Medicine, Department of Radiology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Dong He
- Center for Rehabilitation Medicine, Department of Radiology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yinbo Wu
- Center for Rehabilitation Medicine, Department of Radiology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Hongfeng Ma
- Center for Rehabilitation Medicine, Department of Radiology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Hui Li PhD
- Hangzhou Yitu Healthcare Technology Co. Ltd, Hangzhou, Zhejiang, China
| | - Taihen Yu
- Center for Rehabilitation Medicine, Department of Radiology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
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Pickhardt PJ, Correale L, Hassan C. AI-based opportunistic CT screening of incidental cardiovascular disease, osteoporosis, and sarcopenia: cost-effectiveness analysis. Abdom Radiol (NY) 2023; 48:1181-1198. [PMID: 36670245 DOI: 10.1007/s00261-023-03800-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/02/2023] [Accepted: 01/04/2023] [Indexed: 01/22/2023]
Abstract
PURPOSE To assess the cost-effectiveness and clinical efficacy of AI-assisted abdominal CT-based opportunistic screening for atherosclerotic cardiovascular (CV) disease, osteoporosis, and sarcopenia using artificial intelligence (AI) body composition algorithms. METHODS Markov models were constructed and 10-year simulations were performed on hypothetical age- and sex-specific cohorts of 10,000 U.S. adults (base case: 55 year olds) undergoing abdominal CT. Using expected disease prevalence, transition probabilities between health states, associated healthcare costs, and treatment effectiveness related to relevant conditions (CV disease/osteoporosis/sarcopenia) were modified by three mutually exclusive screening models: (1) usual care ("treat none"; no intervention regardless of opportunistic CT findings), (2) universal statin therapy ("treat all" for CV prevention; again, no consideration of CT findings), and (3) AI-assisted abdominal CT-based opportunistic screening for CV disease, osteoporosis, and sarcopenia using automated quantitative algorithms for abdominal aortic calcification, bone mineral density, and skeletal muscle, respectively. Model validity was assessed against published clinical cohorts. RESULTS For the base-case scenarios of 55-year-old men and women modeled over 10 years, AI-assisted CT-based opportunistic screening was a cost-saving and more effective clinical strategy, unlike the "treat none" and "treat all" strategies that ignored incidental CT body composition data. Over a wide range of input assumptions beyond the base case, the CT-based opportunistic strategy was dominant over the other two scenarios, as it was both more clinically efficacious and more cost-effective. Cost savings and clinical improvement for opportunistic CT remained for AI tool costs up to $227/patient in men ($65 in women) from the $10/patient base-case scenario. CONCLUSION AI-assisted CT-based opportunistic screening appears to be a highly cost-effective and clinically efficacious strategy across a broad array of input assumptions, and was cost saving in most scenarios.
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Affiliation(s)
- Perry J Pickhardt
- Department of Radiology, University of Wisconsin School of Medicine & Public Heatlh, 600 Highland Ave, Madison, WI, 53792, USA.
| | - Loredana Correale
- Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Cesare Hassan
- Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
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Dyer DS, White C, Conley Thomson C, Gieske MR, Kanne JP, Chiles C, Parker MS, Menchaca M, Wu CC, Kazerooni EA. A Quick Reference Guide for Incidental Findings on Lung Cancer Screening CT Examinations. J Am Coll Radiol 2023; 20:162-172. [PMID: 36509659 DOI: 10.1016/j.jacr.2022.08.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE The US Preventive Services Task Force has recommended lung cancer screening (LCS) with low-dose CT (LDCT) in high-risk individuals since 2013. Because LDCT encompasses the lower neck, chest, and upper abdomen, many incidental findings (IFs) are detected. The authors created a quick reference guide to describe common IFs in LCS to assist LCS program navigators and ordering providers in managing the care continuum in LCS. METHODS The ACR IF white papers were reviewed for findings on LDCT that were age appropriate for LCS. A draft guide was created on the basis of recommendations in the IF white papers, the medical literature, and input from subspecialty content experts. The draft was piloted with LCS program navigators recruited through contacts by the ACR LCS Steering Committee. The navigators completed a survey on overall usefulness, clarity, adequacy of content, and user experience with the guide. RESULTS Seven anatomic regions including 15 discrete organs with 45 management recommendations were identified as relevant to the age of individuals eligible for LCS. The draft was piloted by 49 LCS program navigators from 32 facilities. The guide was rated as useful and clear by 95% of users. No unexpected or adverse experiences were reported in using the guide. On the basis of feedback, relevant sections were reviewed and edited. CONCLUSIONS The ACR Lung Cancer Screening CT Incidental Findings Quick Reference Guide outlines the common IFs in LCS and can serve as an easy-to-use resource for ordering providers and LCS program navigators to help guide management.
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Affiliation(s)
- Debra S Dyer
- Chair, Department of Radiology, Director, Lung Cancer Screening Program, and Director, Incidental Lung Nodule Program & Lung Nodule Registry, National Jewish Health, Denver, Colorado.
| | - Charles White
- Vice Chair, Clinical Affairs, University of Maryland School of Medicine, Baltimore, Maryland. https://twitter.com/
| | - Carey Conley Thomson
- Chair, Department of Medicine and Director, Multidisciplinary Thoracic Oncology and Lung Cancer Screening Program, Department of Medicine, Mount Auburn Hospital/Beth Israel Lahey Health, Cambridge, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Michael R Gieske
- Director, Lung Cancer Screening Physician, Director, Virtual Health Director, Primary Care East Department, Lead Provider, Ft. Mitchell St. Elizabeth Primary Care, Physician Director, Policy and Government Relations, St Elizabeth Healthcare, Edgewood, Kentucky
| | - Jeffrey P Kanne
- Chief, Thoracic Imaging and Vice Chair, Quality and Safety, Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. https://twitter.com/
| | - Caroline Chiles
- Director, Lung Cancer Screening Program, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina. https://twitter.com/
| | - Mark S Parker
- Director, Thoracic Imaging Section and Director, Thoracic Imaging Fellowship Program, Early Detection Lung Screening Program, VCU Health Systems, Richmond, Virginia
| | - Martha Menchaca
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Carol C Wu
- Deputy Chair Ad Interim, Department of Thoracic Imaging, MD Anderson Cancer Center, Houston, Texas. https://twitter.com/
| | - Ella A Kazerooni
- Associate Chief Clinical Officer for Diagnostics and Clinical Information Management, University of Michigan Medical School, Ann Arbor, Michigan. https://twitter.com/
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Pickhardt PJ, Nguyen T, Perez AA, Graffy PM, Jang S, Summers RM, Garrett JW. Improved CT-based Osteoporosis Assessment with a Fully Automated Deep Learning Tool. Radiol Artif Intell 2022; 4:e220042. [PMID: 36204542 PMCID: PMC9530763 DOI: 10.1148/ryai.220042] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 08/12/2022] [Accepted: 08/17/2022] [Indexed: 11/11/2022]
Abstract
Purpose To develop, test, and validate a deep learning (DL) tool that improves upon a previous feature-based CT image processing bone mineral density (BMD) algorithm and compare it against the manual reference standard. Materials and Methods This single-center, retrospective, Health Insurance Portability and Accountability Act-compliant study included manual L1 trabecular Hounsfield unit measurements from abdominal CT scans in 11 035 patients (mean age, 58 years ± 12 [SD]; 6311 women) as the reference standard. Automated level selection and L1 trabecular region of interest (ROI) placement were then performed in this CT cohort with both a previously validated feature-based image processing tool and a new DL tool. Overall technical success rates and agreement with the manual reference standard were assessed. Results The overall success rate of the DL tool in this heterogeneous patient cohort was significantly higher than that of the older image processing BMD algorithm (99.3% vs 89.4%, P < .001). Using this DL tool, the closest median Hounsfield unit values for single-, three-, and seven-slice vertebral ROIs were within 5% of the manual reference standard Hounsfield unit values in 35.1%, 56.9%, and 85.8% of scans; within 10% in 56.6%, 75.6%, and 92.9% of scans; and within 25% in 76.5%, 89.3%, and 97.1% of scans, respectively. Trade-offs in sensitivity and specificity for osteoporosis assessment were observed from the single-slice approach (sensitivity, 39.4%; specificity, 98.3%) to the minimum value of the multislice approach (for seven contiguous slices; sensitivity, 71.3% and specificity, 94.6%). Conclusion The new DL BMD tool demonstrated a higher success rate than the older feature-based image processing tool, and its outputs can be targeted for higher specificity or sensitivity for osteoporosis assessment.Keywords: CT, CT-Quantitative, Abdomen/GI, Skeletal-Axial, Spine, Deep Learning, Machine Learning Supplemental material is available for this article. © RSNA, 2022.
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Affiliation(s)
- Perry J. Pickhardt
- From the Department of Radiology, University of Wisconsin School of Medicine & Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252 (P.J.P., T.N., A.A.P., P.M.G., S.J., J.W.G.); and Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (R.M.S.)
| | - Thang Nguyen
- From the Department of Radiology, University of Wisconsin School of Medicine & Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252 (P.J.P., T.N., A.A.P., P.M.G., S.J., J.W.G.); and Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (R.M.S.)
| | - Alberto A. Perez
- From the Department of Radiology, University of Wisconsin School of Medicine & Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252 (P.J.P., T.N., A.A.P., P.M.G., S.J., J.W.G.); and Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (R.M.S.)
| | | | - Samuel Jang
- From the Department of Radiology, University of Wisconsin School of Medicine & Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252 (P.J.P., T.N., A.A.P., P.M.G., S.J., J.W.G.); and Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (R.M.S.)
| | - Ronald M. Summers
- From the Department of Radiology, University of Wisconsin School of Medicine & Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252 (P.J.P., T.N., A.A.P., P.M.G., S.J., J.W.G.); and Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (R.M.S.)
| | - John W. Garrett
- From the Department of Radiology, University of Wisconsin School of Medicine & Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252 (P.J.P., T.N., A.A.P., P.M.G., S.J., J.W.G.); and Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (R.M.S.)
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Pickhardt PJ. Value-added Opportunistic CT Screening: State of the Art. Radiology 2022; 303:241-254. [PMID: 35289661 PMCID: PMC9083232 DOI: 10.1148/radiol.211561] [Citation(s) in RCA: 80] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/24/2021] [Accepted: 08/27/2021] [Indexed: 12/13/2022]
Abstract
Opportunistic CT screening leverages robust imaging data embedded within abdominal and thoracic scans that are generally unrelated to the specific clinical indication and have heretofore gone largely unused. This incidental imaging information may prove beneficial to patients in terms of wellness, prevention, risk profiling, and presymptomatic detection of relevant disease. The growing interest in CT-based opportunistic screening relates to a confluence of factors: the objective and generalizable nature of CT-based body composition measures, the emergence of fully automated explainable AI solutions, the sheer volume of body CT scans performed, and the increasing emphasis on precision medicine and value-added initiatives. With a systematic approach to body composition and other useful CT markers, initial evidence suggests that their ability to help radiologists assess biologic age and predict future adverse cardiometabolic events rivals even the best available clinical reference standards. Emerging data suggest that standalone "intended" CT screening over an unorganized opportunistic approach may be justified, especially when combined with established cancer screening. This review will discuss the current status of opportunistic CT screening, including specific body composition markers and the various disease processes that may be impacted. The remaining hurdles to widespread clinical adoption include generalization to more diverse patient populations, disparate technical settings, and reimbursement.
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Affiliation(s)
- Perry J. Pickhardt
- From the Department of Radiology, The University of Wisconsin School
of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave,
Madison, WI 53792-3252
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Daniel S, Cohen-Freud Y, Shelef I, Tarasiuk A. Bone mineral density alteration in obstructive sleep apnea by derived computed tomography screening. Sci Rep 2022; 12:6462. [PMID: 35440678 PMCID: PMC9018731 DOI: 10.1038/s41598-022-10313-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 04/05/2022] [Indexed: 01/07/2023] Open
Abstract
The association between obstructive sleep apnea (OSA) and bone mineral density (BMD) is poorly elucidated and has contradictory findings. Abdominal computed tomography (CT) for other indications can provide a valuable opportunity for osteoporosis screening. Thus, we retrospectively explored the association between OSA and BMD by examining abdominal CT vertebrae images for a multitude of conditions and indications. We included 315 subjects (174 with OSA and 141 without OSA) who performed at least two CT scans (under similar settings). Both groups had a similar duration between the first and second CT scans of 3.6 years. BMD decreased in those with OSA and increased age. A multivariate linear regression indicated that OSA is associated with BMD alterations after controlling for age, gender, and cardiovascular diseases. Here, we report that OSA is associated with BMD alterations. Further studies are required to untangle the complex affect of OSA on BMD and the possible clinical implications of vertebra-depressed or femoral neck fractures.
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Affiliation(s)
- Sharon Daniel
- Sleep-Wake Disorders Unit, Soroka Medical Center, Beer-Sheva, Israel.,Department of Public Health and Pediatrics, Faculty of Health Sciences, Ben-Gurion University of the Negev and Clalit Health Services, Southern District, Beer-Sheva, Israel
| | - Yafit Cohen-Freud
- Radiology Department, Soroka University Medical Center, Beer-Sheva, Israel
| | - Ilan Shelef
- Radiology Department, Soroka University Medical Center, Beer-Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ariel Tarasiuk
- Sleep-Wake Disorders Unit, Soroka Medical Center, Beer-Sheva, Israel. .,Department of Physiology and Cell Biology, Ben-Gurion University of the Negev, Beer-Sheva, Israel. .,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel. .,Sleep-Wake Disorders Unit & Department of Physiology, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 105, 84105, Beer-Sheva, Israel.
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O’Gorman CA, Milne S, Lambe G, Sobota A, Beddy P, Gleeson N. Accuracy of Opportunistic Bone Mineral Density Assessment on Staging Computed Tomography for Gynaecological Cancers. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:1386. [PMID: 34946331 PMCID: PMC8703431 DOI: 10.3390/medicina57121386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 01/01/2023]
Abstract
Background and Objectives: Women with gynecological cancers constitute a high-risk cohort for loss of bone density. International guidance stipulates women undergoing cancer treatments associated with bone loss should have a quantitative assessment of bone density. Access to Dual-energy X-ray Absorptiometry (DXA) is limited. This study aimed to assess the accuracy of opportunistic bone density measurement on staging computed tomography (CT) scans for gynaecological malignancies, in comparison to the gold standard DXA. Materials and Methods: Women with a staging CT scan of the abdomen and pelvis for a new diagnosis of gynecological cancer were recruited. DXA was performed within 6 weeks of treatment for gynaecological cancer. Lumbar bone density was measured by CT attenuation values, in Hounsfield units (HU), of the anterior trabecular region. Correlations between CT and DXA parameters were analysed. Receiver Operating Characteristic(ROC) curves for diagnosis of low bone density and osteoporosis were analysed. Results: Final cohort included 48 of 50 women recruited. There was good diagnostic accuracy for abnormal bone density and osteoporosis, with areas under the ROC curve at L1 of 0.77 (p = 0.002) and 0.80 (p = 0.020) respectively. CT-HU of 170-190 yielded sensitivities of 87-90%, positive predictive values of 75-84% and negative predictive values of 71-75% for the diagnosis of low bone mineral density. CT-HU of 90-110 yielded specificities of 85-93% for the diagnosis of osteoporosis. Moderate correlations were found between CT-HU and both DXA T-scores and diagnostic categories. Conclusions: This is the first study to assess the opportunistic application of CT in the assessment of bone health in women with gynaecological cancer, a cohort at high-risk of osteoporosis. The correlation between bone density assessment in CT-HU and DXA, and strong AUC values for the diagnosis of low bone density (0.77) and osteoporosis (0.80) support this pragmatic solution in resolving the care-gap in cancer treatment-induced bone loss, often associated with poor access to DXA.
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Affiliation(s)
- Catherine Anne O’Gorman
- Trinity College Dublin, School of Medicine, Department of Obstetrics and Gynaecology, D02 PN40 Dublin, Ireland;
- Department of Gynaecological Oncology, St James’s Hospital, D08 NHY1 Dublin, Ireland; (S.M.); (A.S.)
| | - Sarah Milne
- Department of Gynaecological Oncology, St James’s Hospital, D08 NHY1 Dublin, Ireland; (S.M.); (A.S.)
| | - Gerard Lambe
- Department of Radiology, St James’s Hospital, D08 NHY1 Dublin, Ireland; (G.L.); (P.B.)
| | - Aleksandra Sobota
- Department of Gynaecological Oncology, St James’s Hospital, D08 NHY1 Dublin, Ireland; (S.M.); (A.S.)
| | - Peter Beddy
- Department of Radiology, St James’s Hospital, D08 NHY1 Dublin, Ireland; (G.L.); (P.B.)
| | - Noreen Gleeson
- Trinity College Dublin, School of Medicine, Department of Obstetrics and Gynaecology, D02 PN40 Dublin, Ireland;
- Department of Gynaecological Oncology, St James’s Hospital, D08 NHY1 Dublin, Ireland; (S.M.); (A.S.)
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10
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Ullrich BW, Schwarz F, McLean AL, Mendel T, Kaden I, Hein E, Lattauschke A, Beyer J, Hofmann GO, Klauke F, Schenk P. Inter-Rater Reliability of Hounsfield Units as a Measure of Bone Density: Applications in the Treatment of Thoracolumbar Fractures. World Neurosurg 2021; 158:e711-e716. [PMID: 34798342 DOI: 10.1016/j.wneu.2021.11.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The study sought to investigate the reliability of computed tomography (CT)-derived Hounsfield unit (HU) measurements and ascertain the correlation between HU with quantitative CT (qCT)-derived bone mineral density (BMD) in cases of traumatic thoracolumbar fracture, based on native CT scans. METHODS This study is a retrospective cross-sectional analysis of data sets from patients who received native CT scans and bone mineral density measurements (qCT) of the same vertebral body. Two different CT scanner models were used. The inter-rater reliability of 4 raters, which measured HU in native CT scans, was calculated using intraclass correlation coefficient for absolute agreement (ICC(3,1)). For the correlation between HU and qCT values, respectively the prediction of qCT based on HU, linear regression was used. Bland-Altman plots were used for visual comparison of predicted and measured qCT values. RESULTS In total 305 data sets were analyzed. CT scanner model was found to have no significant impact on HU (P = 0.125). The inter-rater reliability for HU measurements from native CT scans was ICC(3,1)=0.932 (95% confidence interval 0.919-0.943, P < 0.001). The linear regression showed significant correlation of HU and qCT values for each rater (P < 0.001). The equation for qCT prediction with averaged coefficient and constant is qCT = 0.8 HU + 5. In the Bland-Altman plots no bias of predicted qCT values could be found, but a trend to overestimate predicted higher qCT values and underestimate lower qCT values, respectively. CONCLUSIONS HU measurement shows very high inter-rater reliability. The HU values correlate closely with qCT BMD values. In summary, it seems that HU measurement is a suitable tool to readily and accurately assess bone quality without further scans or effort in cases of thoracolumbar spinal trauma.
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Affiliation(s)
- Bernhard Wilhelm Ullrich
- Department of Trauma and Reconstructive Surgery, BG Hospital Bergmannstrost, Halle (Saale), Germany; Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital - Friedrich Schiller University, Jena, Germany.
| | - Falko Schwarz
- Department of Neurosurgery, Jena University Hospital - Friedrich Schiller University, Jena, Germany
| | - Aaron Lawson McLean
- Department of Neurosurgery, Jena University Hospital - Friedrich Schiller University, Jena, Germany
| | - Thomas Mendel
- Department of Trauma and Reconstructive Surgery, BG Hospital Bergmannstrost, Halle (Saale), Germany; Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital - Friedrich Schiller University, Jena, Germany
| | - Ingmar Kaden
- Institution of Radiology, BG Hospital Bergmannstrost, Halle (Saale), Germany
| | - Elizabeth Hein
- Institution of Radiology, BG Hospital Bergmannstrost, Halle (Saale), Germany
| | - Anne Lattauschke
- Department of Trauma and Reconstructive Surgery, BG Hospital Bergmannstrost, Halle (Saale), Germany
| | - Julia Beyer
- Department of Trauma and Reconstructive Surgery, BG Hospital Bergmannstrost, Halle (Saale), Germany
| | - Gunther Olaf Hofmann
- Department of Trauma and Reconstructive Surgery, BG Hospital Bergmannstrost, Halle (Saale), Germany; Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital - Friedrich Schiller University, Jena, Germany
| | - Friederike Klauke
- Department of Trauma and Reconstructive Surgery, BG Hospital Bergmannstrost, Halle (Saale), Germany; Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital - Friedrich Schiller University, Jena, Germany
| | - Philipp Schenk
- Department of Research, BG Hospital Bergmannstrost, Halle (Saale), Germany
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11
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Deep learning takes the pain out of back breaking work - Automatic vertebral segmentation and attenuation measurement for osteoporosis. Clin Imaging 2021; 81:54-59. [PMID: 34598006 DOI: 10.1016/j.clinimag.2021.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/30/2021] [Accepted: 08/13/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Osteoporosis is an underdiagnosed and undertreated disease worldwide. Recent studies have highlighted the use of simple vertebral trabecular attenuation values for opportunistic osteoporosis screening. Meanwhile, machine learning has been used to accurately segment large parts of the human skeleton. PURPOSE To evaluate a fully automated deep learning-based method for lumbar vertebral segmentation and measurement of vertebral volumetric trabecular attenuation values. MATERIAL AND METHODS A deep learning-based method for automated segmentation of bones was retrospectively applied to non-contrast CT scans of 1008 patients (mean age 57 years, 472 female, 536 male). Each vertebral segmentation was automatically reduced by 7 mm in all directions in order to avoid cortical bone. The mean and median volumetric attenuation values from Th12 to L4 were obtained and plotted against patient age and sex. L1 values were further analyzed to facilitate comparison with previous studies. RESULTS The mean L1 attenuation values decreased linearly with age by -2.2 HU per year (age > 30, 95% CI: -2.4, -2.0, R2 = 0.3544). The mean L1 attenuation value of the entire population cohort was 140 HU ± 54. CONCLUSIONS With results closely matching those of previous studies, we believe that our fully automated deep learning-based method can be used to obtain lumbar volumetric trabecular attenuation values which can be used for opportunistic screening of osteoporosis in patients undergoing CT scans for other reasons.
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12
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Schulze-Hagen MF, Roderburg C, Wirtz TH, Jördens MS, Bündgens L, Abu Jhaisha S, Hohlstein P, Brozat JF, Bruners P, Loberg C, Kuhl C, Trautwein C, Tacke F, Luedde T, Loosen SH, Koch A. Decreased Bone Mineral Density Is a Predictor of Poor Survival in Critically Ill Patients. J Clin Med 2021; 10:jcm10163741. [PMID: 34442036 PMCID: PMC8397072 DOI: 10.3390/jcm10163741] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/09/2021] [Accepted: 08/17/2021] [Indexed: 11/29/2022] Open
Abstract
Alterations in bone mineral density (BMD) have been suggested as independent predictors of survival for several diseases. However, little is known about the role of BMD in the context of critical illness and intensive care medicine. We therefore evaluated the prognostic role of BMD in critically ill patients upon admission to an intensive care unit (ICU). Routine computed tomography (CT) scans of 153 patients were used to assess BMD in the first lumbar vertebra. Results were correlated with clinical data and outcomes. While median BMD was comparable between patients with and without sepsis, BMD was lower in patients with pre-existing arterial hypertension or chronic obstructive pulmonary disease. A low BMD upon ICU admission was significantly associated with impaired short-term ICU survival. Moreover, patients with baseline BMD < 122 HU had significantly impaired overall survival. The prognostic relevance of low BMD was confirmed in uni- and multivariate Cox-regression analyses including several clinicopathological parameters. In the present study, we describe a previously unrecognised association of individual BMD with short- and long-term outcomes in critically ill patients. Due to its easy accessibility in routine CT, BMD provides a novel prognostic tool to guide decision making in critically ill patients.
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Affiliation(s)
- Maximilian F. Schulze-Hagen
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (P.B.); (C.K.)
- Correspondence:
| | - Christoph Roderburg
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany; (C.R.); (M.S.J.); (S.H.L.)
| | - Theresa H. Wirtz
- Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (T.H.W.); (L.B.); (S.A.J.); (P.H.); (J.F.B.); (C.T.); (T.L.); (A.K.)
| | - Markus S. Jördens
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany; (C.R.); (M.S.J.); (S.H.L.)
| | - Lukas Bündgens
- Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (T.H.W.); (L.B.); (S.A.J.); (P.H.); (J.F.B.); (C.T.); (T.L.); (A.K.)
| | - Samira Abu Jhaisha
- Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (T.H.W.); (L.B.); (S.A.J.); (P.H.); (J.F.B.); (C.T.); (T.L.); (A.K.)
| | - Philipp Hohlstein
- Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (T.H.W.); (L.B.); (S.A.J.); (P.H.); (J.F.B.); (C.T.); (T.L.); (A.K.)
| | - Jonathan F. Brozat
- Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (T.H.W.); (L.B.); (S.A.J.); (P.H.); (J.F.B.); (C.T.); (T.L.); (A.K.)
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (P.B.); (C.K.)
| | - Christina Loberg
- Department of Diagnostic and Interventional Radiology, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany;
| | - Christiane Kuhl
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (P.B.); (C.K.)
| | - Christian Trautwein
- Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (T.H.W.); (L.B.); (S.A.J.); (P.H.); (J.F.B.); (C.T.); (T.L.); (A.K.)
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany;
| | - Tom Luedde
- Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (T.H.W.); (L.B.); (S.A.J.); (P.H.); (J.F.B.); (C.T.); (T.L.); (A.K.)
| | - Sven H. Loosen
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany; (C.R.); (M.S.J.); (S.H.L.)
| | - Alexander Koch
- Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (T.H.W.); (L.B.); (S.A.J.); (P.H.); (J.F.B.); (C.T.); (T.L.); (A.K.)
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13
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Aggarwal V, Maslen C, Abel RL, Bhattacharya P, Bromiley PA, Clark EM, Compston JE, Crabtree N, Gregory JS, Kariki EP, Harvey NC, Ward KA, Poole KES. Opportunistic diagnosis of osteoporosis, fragile bone strength and vertebral fractures from routine CT scans; a review of approved technology systems and pathways to implementation. Ther Adv Musculoskelet Dis 2021; 13:1759720X211024029. [PMID: 34290831 PMCID: PMC8274099 DOI: 10.1177/1759720x211024029] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 05/18/2021] [Indexed: 12/21/2022] Open
Abstract
Osteoporosis causes bones to become weak, porous and fracture more easily. While a vertebral fracture is the archetypal fracture of osteoporosis, it is also the most difficult to diagnose clinically. Patients often suffer further spine or other fractures, deformity, height loss and pain before diagnosis. There were an estimated 520,000 fragility fractures in the United Kingdom (UK) in 2017 (costing £4.5 billion), a figure set to increase 30% by 2030. One way to improve both vertebral fracture identification and the diagnosis of osteoporosis is to assess a patient's spine or hips during routine computed tomography (CT) scans. Patients attend routine CT for diagnosis and monitoring of various medical conditions, but the skeleton can be overlooked as radiologists concentrate on the primary reason for scanning. More than half a million CT scans done each year in the National Health Service (NHS) could potentially be screened for osteoporosis (increasing 5% annually). If CT-based screening became embedded in practice, then the technique could have a positive clinical impact in the identification of fragility fracture and/or low bone density. Several companies have developed software methods to diagnose osteoporosis/fragile bone strength and/or identify vertebral fractures in CT datasets, using various methods that include image processing, computational modelling, artificial intelligence and biomechanical engineering concepts. Technology to evaluate Hounsfield units is used to calculate bone density, but not necessarily bone strength. In this rapid evidence review, we summarise the current literature underpinning approved technologies for opportunistic screening of routine CT images to identify fractures, bone density or strength information. We highlight how other new software technologies have become embedded in NHS clinical practice (having overcome barriers to implementation) and highlight how the novel osteoporosis technologies could follow suit. We define the key unanswered questions where further research is needed to enable the adoption of these technologies for maximal patient benefit.
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Affiliation(s)
- Veena Aggarwal
- Kingston Hospital NHS Foundation Trust, Kingston Upon Thames, UK
| | | | | | | | | | | | | | - Nicola Crabtree
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
| | - Jennifer S. Gregory
- University of Aberdeen School of Medicine Medical Sciences and Nutrition, Aberdeen, UK
| | | | | | - Kate A. Ward
- University of Southampton, Southampton, Hampshire, UK
| | - Kenneth E. S. Poole
- University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital, NIHR Cambridge Biomedical Research Centre, Cambridge, CB2 0QQ, UK
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14
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Tang C, Zhang W, Li H, Li L, Li Z, Cai A, Wang L, Shi D, Yan B. CNN-based qualitative detection of bone mineral density via diagnostic CT slices for osteoporosis screening. Osteoporos Int 2021; 32:971-979. [PMID: 33165630 DOI: 10.1007/s00198-020-05673-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 10/06/2020] [Indexed: 12/15/2022]
Abstract
UNLABELLED The features extracted from diagnostic computed tomography (CT) slices were used to qualitatively detect bone mineral density (BMD) through neural network models, and the evaluation results indicated that it may be a promising approach to perform osteoporosis screening in clinical practice. INTRODUCTION The purpose of this study is to design a novelty diagnostic method for osteoporosis screening by using the convolutional neural network (CNN), which can be incorporated into the procedure of routine CT diagnostic in medical examination thereby improving the osteoporosis diagnosis and reducing the patient burden. METHODS The proposed CNN-based method mainly comprises two functional modules to perform qualitative detection of BMD by analyzing the diagnostic 2D CT slice. The first functional module aims to locate and segment the ROI of diagnostic 2D CT slice, called Mark-Segmentation-Network (MS-Net). The second functional module is used to determine the category of BMD by the features of ROI, called BMD-Classification-Network (BMDC-Net). The diagnostic 2D CT slice of pedicle level in lumbar vertebrae (L1) was selected from 3D CT image in our experiments firstly. Then, the trained MS-Net can get the mark image of input original 2D CT slice, thereby obtain the segmentation image. Finally, the trained BMDC-Net can obtain the probability value of normal bone mass, low bone mass, and osteoporosis by inputting the segmentation image. On the basis of network results, the radiologists can provide preliminary qualitative diagnosis results of BMD. RESULTS Training of the network was performed on diagnostic 2D CT slices of 150 patients. The network was tested on 63 patients. Each patient corresponds to a 2D CT slice. The proposed MS-Net has an excellent segmentation precision on the shape preservation of different lumbar vertebra. The dice index (DI), pixel accuracy (PA), and intersection over union (IOU) of segmentation results are greater than 0.8. The proposed BMDC-Net achieved an accuracy of 76.65% and an area under the receiver operating characteristic curve of 0.9167. CONCLUSIONS This study proposed a novel method for qualitative detection of BMD via diagnostic CT slices and it has great potential in clinical applications for osteoporosis screening. The method can potentially reduce the manual burden to radiologists and diagnostic cost to patients.
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Affiliation(s)
- C Tang
- PLA Strategy Support Force Information Engineering University, No.62 Science Avenue, Zhengzhou, Henan Province, China
| | - W Zhang
- PLA Strategy Support Force Information Engineering University, No.62 Science Avenue, Zhengzhou, Henan Province, China
| | - H Li
- Department of Radiology in Henan Provincial People's Hospital, Zhengzhou, Henan Province, China
| | - L Li
- PLA Strategy Support Force Information Engineering University, No.62 Science Avenue, Zhengzhou, Henan Province, China
| | - Z Li
- PLA Strategy Support Force Information Engineering University, No.62 Science Avenue, Zhengzhou, Henan Province, China
| | - A Cai
- PLA Strategy Support Force Information Engineering University, No.62 Science Avenue, Zhengzhou, Henan Province, China
| | - L Wang
- PLA Strategy Support Force Information Engineering University, No.62 Science Avenue, Zhengzhou, Henan Province, China
| | - D Shi
- Department of Radiology in Henan Provincial People's Hospital, Zhengzhou, Henan Province, China
| | - B Yan
- PLA Strategy Support Force Information Engineering University, No.62 Science Avenue, Zhengzhou, Henan Province, China.
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15
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Pickhardt PJ, Graffy PM, Perez AA, Lubner MG, Elton DC, Summers RM. Opportunistic Screening at Abdominal CT: Use of Automated Body Composition Biomarkers for Added Cardiometabolic Value. Radiographics 2021; 41:524-542. [PMID: 33646902 DOI: 10.1148/rg.2021200056] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Abdominal CT is a frequently performed imaging examination for a wide variety of clinical indications. In addition to the immediate reason for scanning, each CT examination contains robust additional data on body composition that generally go unused in routine clinical practice. There is now growing interest in harnessing this additional information. Prime examples of cardiometabolic information include measurement of bone mineral density for osteoporosis screening, quantification of aortic calcium for assessment of cardiovascular risk, quantification of visceral fat for evaluation of metabolic syndrome, assessment of muscle bulk and density for diagnosis of sarcopenia, and quantification of liver fat for assessment of hepatic steatosis. All of these relevant biometric measures can now be fully automated through the use of artificial intelligence algorithms, which provide rapid and objective assessment and allow large-scale population-based screening. Initial investigations into these measures of body composition have demonstrated promising performance for prediction of future adverse events that matches or exceeds the best available clinical prediction models, particularly when these CT-based measures are used in combination. In this review, the concept of CT-based opportunistic screening is discussed, and an overview of the various automated biomarkers that can be derived from essentially all abdominal CT examinations is provided, drawing heavily on the authors' experience. As radiology transitions from a volume-based to a value-based practice, opportunistic screening represents a promising example of adding value to services that are already provided. If the potentially high added value of these objective CT-based automated measures is ultimately confirmed in subsequent investigations, this opportunistic screening approach could be considered for intentional CT-based screening. ©RSNA, 2021.
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Affiliation(s)
- Perry J Pickhardt
- From the Department of Radiology, University of Wisconsin School of Medicine & Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252 (P.J.P., P.M.G., A.A.P., M.G.L.); and Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (D.C.E., R.M.S.)
| | - Peter M Graffy
- From the Department of Radiology, University of Wisconsin School of Medicine & Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252 (P.J.P., P.M.G., A.A.P., M.G.L.); and Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (D.C.E., R.M.S.)
| | - Alberto A Perez
- From the Department of Radiology, University of Wisconsin School of Medicine & Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252 (P.J.P., P.M.G., A.A.P., M.G.L.); and Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (D.C.E., R.M.S.)
| | - Meghan G Lubner
- From the Department of Radiology, University of Wisconsin School of Medicine & Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252 (P.J.P., P.M.G., A.A.P., M.G.L.); and Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (D.C.E., R.M.S.)
| | - Daniel C Elton
- From the Department of Radiology, University of Wisconsin School of Medicine & Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252 (P.J.P., P.M.G., A.A.P., M.G.L.); and Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (D.C.E., R.M.S.)
| | - Ronald M Summers
- From the Department of Radiology, University of Wisconsin School of Medicine & Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252 (P.J.P., P.M.G., A.A.P., M.G.L.); and Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (D.C.E., R.M.S.)
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16
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Utilizing Fully Automated Abdominal CT-Based Biomarkers for Opportunistic Screening for Metabolic Syndrome in Adults Without Symptoms. AJR Am J Roentgenol 2020; 216:85-92. [PMID: 32603223 DOI: 10.2214/ajr.20.23049] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Metabolic syndrome describes a constellation of reversible cardiometabolic abnormalities associated with cardiovascular risk and diabetes. The present study investigates the use of fully automated abdominal CT-based biometric measures for opportunistic identification of metabolic syndrome in adults without symptoms. MATERIALS AND METHODS International Diabetes Federation criteria were applied to a cohort of 9223 adults without symptoms who underwent unenhanced abdominal CT. After patients with insufficient clinical data for diagnosis were excluded, the final cohort consisted of 7785 adults (mean age, 57.0 years; 4361 women and 3424 men). Previously validated and fully automated CT-based algorithms for quantifying muscle, visceral and subcutaneous fat, liver fat, and abdominal aortic calcification were applied to this final cohort. RESULTS A total of 738 subjects (9.5% of all subjects; mean age, 56.7 years; 372 women and 366 men) met the clinical criteria for metabolic syndrome. Subsequent major cardiovascular events occurred more frequently in the cohort with metabolic syndrome (p < 0.001). Significant differences were observed between the two groups for all CT-based biomarkers (p < 0.001). Univariate L1-level total abdominal fat (area under the ROC curve [AUROC] = 0.909; odds ratio [OR] = 27.2), L3-level skeletal muscle index (AUROC = 0.776; OR = 5.8), and volumetric liver attenuation (AUROC = 0.738; OR = 5.1) performed well when compared with abdominal aortic calcification scoring (AUROC = 0.578; OR = 1.6). An L1-level total abdominal fat threshold of 460.6 cm2 was 80.1% sensitive and 85.4% specific for metabolic syndrome. For women, the AUROC was 0.930 when fat and muscle measures were combined. CONCLUSION Fully automated quantitative tissue measures of fat, muscle, and liver derived from abdominal CT scans can help identify individuals who are at risk for metabolic syndrome. These visceral measures can be opportunistically applied to CT scans obtained for other clinical indications, and they may ultimately provide a more direct and useful definition of metabolic syndrome.
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17
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Visser JJ, Goergen SK, Klein S, Noguerol TM, Pickhardt PJ, Fayad LM, Omoumi P. The Value of Quantitative Musculoskeletal Imaging. Semin Musculoskelet Radiol 2020; 24:460-474. [DOI: 10.1055/s-0040-1710356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AbstractMusculoskeletal imaging is mainly based on the subjective and qualitative analysis of imaging examinations. However, integration of quantitative assessment of imaging data could increase the value of imaging in both research and clinical practice. Some imaging modalities, such as perfusion magnetic resonance imaging (MRI), diffusion MRI, or T2 mapping, are intrinsically quantitative. But conventional morphological imaging can also be analyzed through the quantification of various parameters. The quantitative data retrieved from imaging examinations can serve as biomarkers and be used to support diagnosis, determine patient prognosis, or monitor therapy.We focus on the value, or clinical utility, of quantitative imaging in the musculoskeletal field. There is currently a trend to move from volume- to value-based payments. This review contains definitions and examines the role that quantitative imaging may play in the implementation of value-based health care. The influence of artificial intelligence on the value of quantitative musculoskeletal imaging is also discussed.
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Affiliation(s)
- Jacob J. Visser
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Stacy K. Goergen
- Department of Imaging, Monash Imaging, Clayton, Victoria, Australia
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Stefan Klein
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | | | - Perry J. Pickhardt
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Laura M. Fayad
- The Russell H. Morgan Department of Radiology & Radiological Science, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Patrick Omoumi
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Value-Added Opportunistic CT: Insights Into Osteoporosis and Sarcopenia. AJR Am J Roentgenol 2020; 215:582-594. [DOI: 10.2214/ajr.20.22874] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Leslie WD, Crandall CJ. Population-Based Osteoporosis Primary Prevention and Screening for Quality of Care in Osteoporosis, Current Osteoporosis Reports. Curr Osteoporos Rep 2019; 17:483-490. [PMID: 31673933 DOI: 10.1007/s11914-019-00542-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Despite the high prevalence and impact of osteoporosis, screening and treatment rates remain low, with few women age 65 years and older utilizing osteoporosis screening for primary prevention. RECENT FINDINGS This review examines opportunities and challenges related to primary prevention and screening for osteoporosis at the population level. Strategies on how to identify individuals at high fracture risk and target them for treatment have lagged far behind other developments in the osteoporosis field. Most osteoporosis quality improvement strategies have focused on patients with recent or prior fracture (secondary prevention), with limited attention to individuals without prior fracture. For populations without prior fracture, the only quality improvement strategy for which meta-analysis demonstrated significant improvement in osteoporosis care was patient self-scheduling of DXA plus education Much more work is needed to develop and validate effective primary screening and prevention strategies and translate these into high-quality guidelines.
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Affiliation(s)
- William D Leslie
- Departments of Medicine and Radiology, University of Manitoba, C5121 - 409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6, Canada.
| | - Carolyn J Crandall
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
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Graffy PM, Sandfort V, Summers RM, Pickhardt PJ. Automated Liver Fat Quantification at Nonenhanced Abdominal CT for Population-based Steatosis Assessment. Radiology 2019; 293:334-342. [PMID: 31526254 DOI: 10.1148/radiol.2019190512] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Nonalcoholic fatty liver disease and its consequences are a growing public health concern requiring cross-sectional imaging for noninvasive diagnosis and quantification of liver fat. Purpose To investigate a deep learning-based automated liver fat quantification tool at nonenhanced CT for establishing the prevalence of steatosis in a large screening cohort. Materials and Methods In this retrospective study, a fully automated liver segmentation algorithm was applied to noncontrast abdominal CT examinations from consecutive asymptomatic adults by using three-dimensional convolutional neural networks, including a subcohort with follow-up scans. Automated volume-based liver attenuation was analyzed, including conversion to CT fat fraction, and compared with manual measurement in a large subset of scans. Results A total of 11 669 CT scans in 9552 adults (mean age ± standard deviation, 57.2 years ± 7.9; 5314 women and 4238 men; median body mass index [BMI], 27.8 kg/m2) were evaluated, including 2117 follow-up scans in 1862 adults (mean age, 59.2 years; 971 women and 891 men; mean interval, 5.5 years). Algorithm failure occurred in seven scans. Mean CT liver attenuation was 55 HU ± 10, corresponding to CT fat fraction of 6.4% (slightly fattier in men than in women [7.4% ± 6.0 vs 5.8% ± 5.7%; P < .001]). Mean liver Hounsfield unit varied little by age (<4 HU difference among all age groups) and only weak correlation was seen with BMI (r2 = 0.14). By category, 47.9% (5584 of 11 669) had negligible or no liver fat (CT fat fraction <5%), 42.4% (4948 of 11 669) had mild steatosis (CT fat fraction of 5%-14%), 8.8% (1025 of 11 669) had moderate steatosis (CT fat fraction of 14%-28%), and 1% (112 of 11 669) had severe steatosis (CT fat fraction >28%). Excellent agreement was seen between automated and manual measurements, with a mean difference of 2.7 HU (median, 3 HU) and r2 of 0.92. Among the subcohort with longitudinal follow-up, mean change was only -3 HU ± 9, but 43.3% (806 of 1861) of patients changed steatosis category between first and last scans. Conclusion This fully automated CT-based liver fat quantification tool allows for population-based assessment of hepatic steatosis and nonalcoholic fatty liver disease, with objective data that match well with manual measurement. The prevalence of at least mild steatosis was greater than 50% in this asymptomatic screening cohort. © RSNA, 2019.
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Affiliation(s)
- Peter M Graffy
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, Wis 53792-3252 (P.M.G., P.J.P.); and Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (V.S., R.M.S.)
| | - Veit Sandfort
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, Wis 53792-3252 (P.M.G., P.J.P.); and Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (V.S., R.M.S.)
| | - Ronald M Summers
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, Wis 53792-3252 (P.M.G., P.J.P.); and Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (V.S., R.M.S.)
| | - Perry J Pickhardt
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, Wis 53792-3252 (P.M.G., P.J.P.); and Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (V.S., R.M.S.)
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Graffy PM, Liu J, O'Connor S, Summers RM, Pickhardt PJ. Automated segmentation and quantification of aortic calcification at abdominal CT: application of a deep learning-based algorithm to a longitudinal screening cohort. Abdom Radiol (NY) 2019; 44:2921-2928. [PMID: 30976827 DOI: 10.1007/s00261-019-02014-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To investigate an automated aortic calcium segmentation and scoring tool at abdominal CT in an adult screening cohort. METHODS Using instance segmentation with convolutional neural networks (Mask R-CNN), a fully automated vascular calcification algorithm was applied to a data set of 9914 non-contrast CT scans from 9032 consecutive asymptomatic adults (mean age, 57.5 ± 7.8 years; 4467 M/5447F) undergoing colonography screening. Follow-up scans were performed in a subset of 866 individuals (mean interval, 5.4 years). Automated abdominal aortic calcium volume, mass, and Agatston score were assessed. In addition, comparison was made with a separate validated semi-automated approach in a subset of 812 cases. RESULTS Mean values were significantly higher in males for Agatston score (924.2 ± 2066.2 vs. 564.2 ± 1484.2, p < 0.001), aortic calcium mass (222.2 ± 526.0 mg vs. 144.5 ± 405.4 mg, p < 0.001) and volume (699.4 ± 1552.4 ml vs. 426.9 ± 1115.5 HU, p < 0.001). Overall age-specific Agatston scores increased an average of 10%/year for the entire cohort; males had a larger Agatston score increase between the ages of 40 to 60 than females (91.2% vs. 75.1%, p < 0.001) and had significantly higher mean Agatston scores between ages 50 and 80 (p < 0.001). For the 812-scan subset with both automated and semi-automated methods, median difference in Agatston score was 66.4 with an r2 agreement value of 0.84. Among the 866-patient cohort with longitudinal follow-up, the average Agatston score change was 524.1 ± 1317.5 (median 130.9), reflecting a mean increase of 25.5% (median 73.6%). CONCLUSION This robust, fully automated abdominal aortic calcification scoring tool allows for both individualized and population-based assessment. Such data could be automatically derived at non-contrast abdominal CT, regardless of the study indication, allowing for opportunistic assessment of cardiovascular risk.
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Affiliation(s)
- Peter M Graffy
- E3/311 Clinical Science Center, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, 53792-3252, USA
| | - Jiamin Liu
- Radiology & Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Stacy O'Connor
- Department of Radiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ronald M Summers
- Radiology & Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Perry J Pickhardt
- E3/311 Clinical Science Center, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, 53792-3252, USA.
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Graffy PM, Liu J, Pickhardt PJ, Burns JE, Yao J, Summers RM. Deep learning-based muscle segmentation and quantification at abdominal CT: application to a longitudinal adult screening cohort for sarcopenia assessment. Br J Radiol 2019; 92:20190327. [PMID: 31199670 DOI: 10.1259/bjr.20190327] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To investigate a fully automated abdominal CT-based muscle tool in a large adult screening population. METHODS A fully automated validated muscle segmentation algorithm was applied to 9310 non-contrast CT scans, including a primary screening cohort of 8037 consecutive asymptomatic adults (mean age, 57.1±7.8 years; 3555M/4482F). Sequential follow-up scans were available in a subset of 1171 individuals (mean interval, 5.1 years). Muscle tissue cross-sectional area and attenuation (Hounsfield unit, HU) at the L3 level were assessed, including change over time. RESULTS Mean values were significantly higher in males for both muscle area (190.6±33.6 vs 133.3±24.1 cm2, p<0.001) and density (34.3±11.1 HU vs 27.3±11.7 HU, p<0.001). Age-related losses were observed, with mean muscle area reduction of -1.5 cm2/year and attenuation reduction of -1.5 HU/year. Overall age-related muscle density (attenuation) loss was steeper than for muscle area for both sexes up to the age of 70 years. Between ages 50 and 70, relative muscle attenuation decreased significantly more in females (-30.6% vs -18.0%, p<0.001), whereas relative rates of muscle area loss were similar (-8%). Between ages 70 and 90, males lost more density (-22.4% vs -7.5%) and area (-13.4% vs -6.9%, p<0.001). Of the 1171 patients with longitudinal follow-up, 1013 (86.5%) showed a decrease in muscle attenuation, 739 (63.1%) showed a decrease in area, and 1119 (95.6%) showed a decrease in at least one of these measures. CONCLUSION This fully automated CT muscle tool allows for both individualized and population-based assessment. Such data could be automatically derived at abdominal CT regardless of study indication, allowing for opportunistic sarcopenia detection. ADVANCES IN KNOWLEDGE This fully automated tool can be applied to routine abdominal CT scans for prospective or retrospective opportunistic sarcopenia assessment, regardless of the original clinical indication. Mean values were significantly higher in males for both muscle area and muscle density. Overall age-related muscle density (attenuation) loss was steeper than for muscle area for both sexes, and therefore may be a more valuable predictor of adverse outcomes.
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Affiliation(s)
- Peter M Graffy
- 1 University of Wisconsin School of Medicine and Public Health 600 Highland Avenue, Madison, WI 53705
| | - Jiamin Liu
- 2 Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Drive, Bethesda, MD 20892-1182
| | - Perry J Pickhardt
- 1 University of Wisconsin School of Medicine and Public Health 600 Highland Avenue, Madison, WI 53705
| | - Joseph E Burns
- 3 Department of Radiological Sciences, University of California-Irvine, Orange, CA
| | - Jianhua Yao
- 2 Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Drive, Bethesda, MD 20892-1182
| | - Ronald M Summers
- 2 Radiology and Imaging Sciences, National Institutes of Health Clinical Center, 10 Center Drive, Bethesda, MD 20892-1182
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Jang S, Graffy PM, Ziemlewicz TJ, Lee SJ, Summers RM, Pickhardt PJ. Opportunistic Osteoporosis Screening at Routine Abdominal and Thoracic CT: Normative L1 Trabecular Attenuation Values in More than 20 000 Adults. Radiology 2019; 291:360-367. [PMID: 30912719 DOI: 10.1148/radiol.2019181648] [Citation(s) in RCA: 174] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Abdominal and thoracic CT provide a valuable opportunity for osteoporosis screening regardless of the clinical indication for imaging. Purpose To establish reference normative ranges for first lumbar vertebra (L1) trabecular attenuation values across all adult ages to measure bone mineral density (BMD) at routine CT. Materials and Methods Reference data were constructed from 20 374 abdominal and/or thoracic CT examinations performed at 120 kV. Data were derived from adults (mean age, 60 years ± 12 [standard deviation]; 56.1% [11 428 of 20 374] women). CT examinations were performed with (n = 4263) or without (n = 16 111) intravenous contrast agent administration for a variety of unrelated clinical indications between 2000 and 2018. L1 Hounsfield unit measurement was obtained either with a customized automated tool (n = 11 270) or manually by individual readers (n = 9104). The effects of patient age, sex, contrast agent, and manual region-of-interest versus fully automated L1 Hounsfield unit measurement were assessed using multivariable logistic regression analysis. Results Mean L1 attenuation decreased linearly with age at a rate of 2.5 HU per year, averaging 226 HU ± 44 for patients younger than 30 years and 89 HU ± 38 for patients 90 years or older. Women had a higher mean L1 attenuation compared with men (P < .008) until menopause, after which both groups had similar values. Administration of intravenous contrast agent resulted in negligible differences in mean L1 attenuation values except in patients younger than 40 years. The fully automated method resulted in measurements that were average 21 HU higher compared with manual measurement (P < .004); at intrapatient subanalysis, this difference was related to the level of transverse measurement used (midvertebra vs off-midline level). Conclusion Normative ranges of L1 vertebra trabecular attenuation were established across all adult ages, and these can serve as a quick reference at routine CT to identify adults with low bone mineral density who are at risk for osteoporosis. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Smith in this issue.
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Affiliation(s)
- Samuel Jang
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252 (S.J., P.M.G., T.J.Z., S.J.L., P.J.P.); and Department of Diagnostic Radiology, National Institutes of Health Clinical Center, Bethesda, Md (R.M.S.)
| | - Peter M Graffy
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252 (S.J., P.M.G., T.J.Z., S.J.L., P.J.P.); and Department of Diagnostic Radiology, National Institutes of Health Clinical Center, Bethesda, Md (R.M.S.)
| | - Timothy J Ziemlewicz
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252 (S.J., P.M.G., T.J.Z., S.J.L., P.J.P.); and Department of Diagnostic Radiology, National Institutes of Health Clinical Center, Bethesda, Md (R.M.S.)
| | - Scott J Lee
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252 (S.J., P.M.G., T.J.Z., S.J.L., P.J.P.); and Department of Diagnostic Radiology, National Institutes of Health Clinical Center, Bethesda, Md (R.M.S.)
| | - Ronald M Summers
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252 (S.J., P.M.G., T.J.Z., S.J.L., P.J.P.); and Department of Diagnostic Radiology, National Institutes of Health Clinical Center, Bethesda, Md (R.M.S.)
| | - Perry J Pickhardt
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252 (S.J., P.M.G., T.J.Z., S.J.L., P.J.P.); and Department of Diagnostic Radiology, National Institutes of Health Clinical Center, Bethesda, Md (R.M.S.)
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Abstract
Fractures resulting from osteoporosis become increasingly common in women after age 55 years and men after age 65 years, resulting in substantial bone-associated morbidities, and increased mortality and health-care costs. Research advances have led to a more accurate assessment of fracture risk and have increased the range of therapeutic options available to prevent fractures. Fracture risk algorithms that combine clinical risk factors and bone mineral density are now widely used in clinical practice to target high-risk individuals for treatment. The discovery of key pathways regulating bone resorption and formation has identified new approaches to treatment with distinctive mechanisms of action. Osteoporosis is a chronic condition and long-term, sometimes lifelong, management is required. In individuals at high risk of fracture, the benefit versus risk profile is likely to be favourable for up to 10 years of treatment with bisphosphonates or denosumab. In people at a very high or imminent risk of fracture, therapy with teriparatide or abaloparatide should be considered; however, since treatment duration with these drugs is restricted to 18-24 months, treatment should be continued with an antiresorptive drug. Individuals at high risk of fractures do not receive adequate treatment and strategies to address this treatment gap-eg, widespread implementation of Fracture Liaison Services and improvement of adherence to therapy-are important challenges for the future.
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Affiliation(s)
| | - Michael R McClung
- Department of Medicine, Oregon Health and Science University, Portland, OR, USA; Mary MacKillop Institute for Health, Australian Catholic University, Melbourne, VIC, Australia
| | - William D Leslie
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
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Pickhardt PJ, Lee SJ, Liu J, Yao J, Lay N, Graffy PM, Summers RM. Population-based opportunistic osteoporosis screening: Validation of a fully automated CT tool for assessing longitudinal BMD changes. Br J Radiol 2018; 92:20180726. [PMID: 30433815 DOI: 10.1259/bjr.20180726] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
METHODS: The automated BMD tool was retrospectively applied to non-contrast abdominal CT scans in 1603 consecutive asymptomatic adults (mean age, 55.9 years; 770 M/833 F) undergoing longitudinal screening (mean interval, 5.7 years; range, 1.0-12.3 years). The spinal column was automatically segmented, with standardized L1 and L2 anterior trabecular ROI placement. Automated and manual L1 HU values were compared, as were automated supine-prone measures. L1-L2 CT attenuation values were converted to BMD values through a linear regression model. BMD values and changes were assessed according to age and gender. RESULTS: Success rate of the automated BMD tool was 99.8 % (four failed cases). Both automated supine vs prone and manual vs automated L1 attenuation measurements showed good agreement. Overall mean annual rate of bone loss was greater in females than males (-2.0% vs -1.0%), but the age-specific rate declined faster in females from age 50 (-2.1%) to age 65 (-0.3%) compared with males (-0.9% to -0.5%). Mean BMD was higher in females than males at age 50 (143.6 vs 135.1 mg cm-3), but post-menopausal bone loss in females reversed this relationship beyond age 60. By age 70, mean BMD in females and males was 100.8 and 107.7 mg cm-3 , respectively. CONCLUSION: This robust, fully automated CT BMD tool allows for both individualized and population-based assessment. Mean BMD was lower in men than women aged 50-60, but accelerated post-menopausal bone loss in women resulted in lower values beyond age 60. ADVANCES IN KNOWLEDGE: This fully automated tool can be applied to routine abdominal CT scans for prospective or retrospective opportunistic BMD assessment, including change over time. Mean BMD was lower in men compared with women aged 50-60 years, but accelerated bone loss in women during this early post-menopausal period resulted in lower BMD values for women beyond age 60.
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Affiliation(s)
- Perry J Pickhardt
- 1 Department of Radiology, University of Wisconsin School of Medicine and Public Health , Madison, WI , USA
| | - Scott J Lee
- 1 Department of Radiology, University of Wisconsin School of Medicine and Public Health , Madison, WI , USA
| | - Jiamin Liu
- 2 Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center , Bethesda, MD , USA
| | - Jianhua Yao
- 2 Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center , Bethesda, MD , USA
| | - Nathan Lay
- 2 Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center , Bethesda, MD , USA
| | - Peter M Graffy
- 1 Department of Radiology, University of Wisconsin School of Medicine and Public Health , Madison, WI , USA
| | - Ronald M Summers
- 2 Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center , Bethesda, MD , USA
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Lenchik L, Weaver AA, Ward RJ, Boone JM, Boutin RD. Opportunistic Screening for Osteoporosis Using Computed Tomography: State of the Art and Argument for Paradigm Shift. Curr Rheumatol Rep 2018; 20:74. [PMID: 30317448 DOI: 10.1007/s11926-018-0784-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Osteoporosis is disproportionately common in rheumatology patients. For the past three decades, the diagnosis of osteoporosis has benefited from well-established practice guidelines that emphasized the use of dual x-ray absorptiometry (DXA). Despite these guidelines and the wide availability of DXA, approximately two thirds of eligible patients do not undergo testing. One strategy to improve osteoporosis testing is to employ computed tomography (CT) examinations obtained as part of routine patient care to "opportunistically" screen for osteoporosis, without additional cost or radiation exposure to patients. This review examines the role of opportunistic CT in the evaluation of osteoporosis. RECENT FINDINGS Recent evidence suggests that opportunistic measurement of bone attenuation (radiodensity) using CT has sensitivity comparable to DXA. More importantly, such an approach has been shown to predict osteoporotic fractures. The paradigm shift of using CTs obtained for other reasons to opportunistically screen for osteoporosis promises to substantially improve patient care.
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Affiliation(s)
- Leon Lenchik
- Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - Ashley A Weaver
- Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Robert J Ward
- Tufts University School of Medicine, 800 Washington Street, Boston, MA, 02111, USA
| | - John M Boone
- University of California Davis Medical Center, 4860 Y Street, Suite 3100, Sacramento, CA, 95817, USA
| | - Robert D Boutin
- University of California Davis School of Medicine, 4860 Y Street, Suite 3100, Sacramento, CA, 95817, USA
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O'Connor SD, Graffy PM, Zea R, Pickhardt PJ. Does Nonenhanced CT-based Quantification of Abdominal Aortic Calcification Outperform the Framingham Risk Score in Predicting Cardiovascular Events in Asymptomatic Adults? Radiology 2018; 290:108-115. [PMID: 30277443 DOI: 10.1148/radiol.2018180562] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Purpose To determine if abdominal aortic calcification (AAC) at CT predicts cardiovascular events independent of Framingham risk score (FRS). Materials and Methods For this retrospective study, electronic health records for 829 asymptomatic patients (mean age, 57.9 years; 451 women, 378 men) who underwent nonenhanced CT colonography screening between April 2004 and March 2005 were reviewed for subsequent cardiovascular events; mean follow-up interval was 11.2 years ± 2.8 (standard deviation). Institutional review board approval was obtained. CT-based AAC was retrospectively quantified as a modified Agatston score by using a semiautomated tool. Kaplan-Meier curves and Cox proportional hazards models were used for time-to-event analysis; receiver operating characteristic curves and net reclassification improvement compared predictive abilities of AAC and FRS. Results An index cardiovascular event occurred after CT in 156 (19%) of 829 patients (6.7 years ± 3.5, including heart attack in 39 [5%] and death in 79 [10%]). AAC was higher in the cardiovascular event cohort (mean AAC, 3478 vs 664; P < .001). AAC was a strong predictor of cardiovascular events at both univariable and multivariable Cox modeling, independent of FRS (P < .001). Kaplan-Meier plots showed better separation with AAC over FRS. The area under the receiver operating characteristic curve (AUC) was higher for AAC than FRS at all evaluated time points (eg, AUC of 0.82 vs 0.64 at 2 years; P = .014). By using a cutoff point of 200, AAC improved FRS risk categorization with net reclassification improvement of 35.4%. Conclusion CT-based abdominal aortic calcification was a strong predictor of future cardiovascular events, outperforming the Framingham risk score. This finding suggests a potential opportunistic role in abdominal nonenhanced CT scans performed for other clinical indications. © RSNA, 2018.
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Affiliation(s)
- Stacy D O'Connor
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Peter M Graffy
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Ryan Zea
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Perry J Pickhardt
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis
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Tomita N, Cheung YY, Hassanpour S. Deep neural networks for automatic detection of osteoporotic vertebral fractures on CT scans. Comput Biol Med 2018; 98:8-15. [PMID: 29758455 DOI: 10.1016/j.compbiomed.2018.05.011] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/04/2018] [Accepted: 05/05/2018] [Indexed: 10/17/2022]
Abstract
Osteoporotic vertebral fractures (OVFs) are prevalent in older adults and are associated with substantial personal suffering and socio-economic burden. Early diagnosis and treatment of OVFs are critical to prevent further fractures and morbidity. However, OVFs are often under-diagnosed and under-reported in computed tomography (CT) exams as they can be asymptomatic at an early stage. In this paper, we present and evaluate an automatic system that can detect incidental OVFs in chest, abdomen, and pelvis CT examinations at the level of practicing radiologists. Our OVF detection system leverages a deep convolutional neural network (CNN) to extract radiological features from each slice in a CT scan. These extracted features are processed through a feature aggregation module to make the final diagnosis for the full CT scan. In this work, we explored different methods for this feature aggregation, including the use of a long short-term memory (LSTM) network. We trained and evaluated our system on 1432 CT scans, comprised of 10,546 two-dimensional (2D) images in sagittal view. Our system achieved an accuracy of 89.2% and an F1 score of 90.8% based on our evaluation on a held-out test set of 129 CT scans, which were established as reference standards through standard semiquantitative and quantitative methods. The results of our system matched the performance of practicing radiologists on this test set in real-world clinical circumstances. We expect the proposed system will assist and improve OVF diagnosis in clinical settings by pre-screening routine CT examinations and flagging suspicious cases prior to review by radiologists.
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Affiliation(s)
- Naofumi Tomita
- Biomedical Data Science Department, Dartmouth College, Hanover, NH 03755, USA
| | - Yvonne Y Cheung
- Radiology Department, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA
| | - Saeed Hassanpour
- Biomedical Data Science Department, Dartmouth College, Hanover, NH 03755, USA; Epidemiology Department, Dartmouth College, Hanover, NH 03755, USA; Computer Science Department, Dartmouth College, Hanover, NH 03755, USA.
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Lee SJ, Liu J, Yao J, Kanarek A, Summers RM, Pickhardt PJ. Fully automated segmentation and quantification of visceral and subcutaneous fat at abdominal CT: application to a longitudinal adult screening cohort. Br J Radiol 2018; 91:20170968. [PMID: 29557216 DOI: 10.1259/bjr.20170968] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To investigate a fully automated CT-based adiposity tool, applying it to a longitudinal adult screening cohort. METHODS A validated automated adipose tissue segmentation algorithm was applied to non-contrast abdominal CT scans in 8852 consecutive asymptomatic adults (mean age, 57.1 years; 3926 M/4926 F) undergoing colonography screening. The tool was also applied to follow-up CT scans in a subset of 1584 individuals undergoing longitudinal surveillance (mean interval, 5.6 years). Visceral and subcutaneous adipose tissue (VAT and SAT) volumes were segmented at levels T12-L5. Primary adipose results are reported herein for the L1 level as mean cross-sectional area. CT-based adipose measurements at initial CT and change over time were analyzed. RESULTS Mean VAT values were significantly higher in males (205.8 ± 107.5 vs 108.1 ± 82.4 cm2; p < 0.001), whereas mean SAT values were significantly higher in females (171.3 ± 111.3 vs 124.3 ± 79.7 cm2; p < 0.001). The VAT/SAT ratio at L1 was three times higher in males (1.8 ± 0.7 vs 0.6 ± 0.4; p < 0.001). At longitudinal follow-up CT, mean VAT/SAT ratio change was positive in males, but negative in females. Among the 502 individuals where the VAT/SAT ratio increased at follow-up CT, 333 (66.3%) were males. Half of patients (49.6%; 786/1585) showed an interval increase in both VAT and SAT at follow-up CT. CONCLUSION This robust, fully automated CT adiposity tool allows for both individualized and population-based assessment of visceral and subcutaneous abdominal fat. Such data could be automatically derived at abdominal CT regardless of the study indication, potentially allowing for opportunistic cardiovascular risk stratification. Advances in knowledge: The CT-based adiposity tool described herein allows for fully automated measurement of visceral and subcutaneous abdominal fat, which can be used for assessing cardiovascular risk, metabolic syndrome, and for change over time.
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Affiliation(s)
- Scott J Lee
- 1 Department of Radiology, University of Wisconsin School of Medicine and Public Health , Madison, WI , USA
| | - Jiamin Liu
- 2 Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, National Institutes of Health Clinical Center , Bethesda, MD , USA
| | - Jianhua Yao
- 2 Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, National Institutes of Health Clinical Center , Bethesda, MD , USA
| | - Andrew Kanarek
- 1 Department of Radiology, University of Wisconsin School of Medicine and Public Health , Madison, WI , USA
| | - Ronald M Summers
- 2 Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, National Institutes of Health Clinical Center , Bethesda, MD , USA
| | - Perry J Pickhardt
- 1 Department of Radiology, University of Wisconsin School of Medicine and Public Health , Madison, WI , USA
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