Low-dose CT: technique, reading methods and image interpretation

Exploring experiences and coping strategies of the surveillance of indeterminate pulmonary nodules: a qualitative content analysis among participants in the SCAPIS trial

OBJECTIVE

To elucidate experiences and coping strategies among adults in the surveillance of indeterminate pulmonary nodules detected with CT in the population-based Swedish CardioPulmonary bioImage Study (SCAPIS).

DESIGN

A qualitative study of conventional content analysis.

SETTINGS

The study was conducted at a university hospital in a southern region of Sweden. The SCAPIS setting is similar to the first round of a population-based lung cancer screening programme.

PARTICIPANTS

Participants in SCAPIS who had experienced psychosocial consequences of the surveillance were eligible. Participants of both genders, current, former and non-smokers and of different follow-ups in the surveillance were included. Face-to-face semi-structured interviews with 19 participants were performed using an interview guide with open-ended questions. The participants were aged 56-68 years. Nine were women, 6 and 13 were non-smokers and smokers or former smokers, respectively, and all participants had undergone at least one follow-up of the lungs in the surveillance programme.

RESULTS

The results depicted an emotional and mental journey for the participants from being distressed when informed about the need of surveillance, and realising their risks of getting sick if they did not take care of their own health, to eventually gathering the strength to cope with the situation, so the surveillance was finally valued with trust and satisfaction. The experiences and coping strategies in the surveillance programme developed a revelation of the value of health consciousness among the participants.

CONCLUSION

The study results demonstrated that a surveillance programme of pulmonary nodules might develop health consciousness among people. Still, some individuals might experience psychosocial consequences of the surveillance of indeterminate nodules. Therefore, healthcare professionals should be facilitated to perform person-centred communication to support individuals under surveillance. Preventive care to engage individuals as partners in the management of their own health should receive more attention and needs to be explored.

Impact of Simulated Reduced-Dose Chest CT on Diagnosing Pulmonary T1 Tumors and Patient Management

To determine the diagnostic performance of simulated reduced-dose chest CT scans regarding pulmonary T1 tumors and assess the potential impact on patient management, a repository of 218 patients with histologically proven pulmonary T1 tumors was used. Virtual reduced-dose images were simulated at 25%- and 5%-dose levels. Tumor size, attenuation, and localization were scored by two experienced chest radiologists. The impact on patient management was assessed by comparing hypothetical LungRADS scores. The study included 210 patients (41% females, mean age 64.5 ± 9.2 years) with 250 eligible T1 tumors. There were differences between the original and the 5%-but not the 25%-dose simulations, and LungRADS scores varied between the dose levels with no clear trend. Sensitivity of Reader 1 was significantly lower using the 5%-dose vs. 25%-dose vs. original dose for size categorization (0.80 vs. 0.85 vs. 0.84; p = 0.007) and segmental localization (0.81 vs. 0.86 vs. 0.83; p = 0.018). Sensitivities of Reader 2 were unaffected by a dose reduction. A CT dose reduction may affect the correct categorization and localization of pulmonary T1 tumors and potentially affect patient management.

Computed tomography radiomics study of invasion and instability of lung adenocarcinoma manifesting as ground glass nodule

Background

Ground-glass nodule (GGN) is the most common manifestation of lung adenocarcinoma on computed tomography (CT). Clinically, the success rate of preoperative diagnosis of GGN by puncture biopsy and other means is still low. The aim of this study is to investigate the clinical and radiomics characteristics of lung adenocarcinoma presenting as GGN on CT images using radiomics analysis methods, establish a radiomics model, and predict the classification of pathological tissue and instability of GGN type lung adenocarcinoma.

Methods

This study retrospectively collected 249 patients with 298 GGN lesions who were pathologically confirmed of having lung adenocarcinoma. The images were imported into the Siemens scientific research prototype software to outline the region of interest and extract the radiomics features. Logistic model A (a radiomics model to identify the infiltration of lung adenocarcinoma manifesting as GGNs) was established using features after the dimensionality reduction process. The receiver operating characteristic (ROC) curve of the model on training set and the verification set was drawn, and the area under the curve (AUC) was calculated. Second, a total of 112 lesions were selected from 298 lesions originating from CT images of at least two occasions, and the time between the first CT and the preoperative CT was defined as not less than 90 days. The mass doubling time (MDT) of all lesions was calculated. According to the different MDT diagnostic thresholds instability was predicted. Finally, their AUCs were calculated and compared.

Results

There were statistically significant differences in age and lesion location distribution between the "noninvasive" lesion group and the invasive lesion group (P<0.05), but there were no statistically significant differences in sex (P>0.05). Model A had an AUC of 0.89, sensitivity of 0.75, and specificity of 0.86 in the training set and an AUC of 0.87, sensitivity of 0.63, and specificity of 0.90 in the validation set. There was no significant difference statistically in MDT between "noninvasive" lesions and invasive lesions (P>0.05). The AUCs of radiomics models B1, B2 and B3 were 0.89, 0.80, and 0.81, respectively; the sensitivities were 0.71, 0.54, and 0.76, respectively; the specificities were 0.83, 0.77, and 0.60, respectively; and the accuracies were 0.78, 0.65, and 0.69, respectively.

Conclusions

There were statistically significant differences in age and location of lesions between the "noninvasive" lesion group and the invasive lesion group. The radiomics model can predict the invasiveness of lung adenocarcinoma manifesting as GGNs. There was no significant difference in MDT between "noninvasive" lesions and invasive lesions. The radiomics model can predict the instability of lung adenocarcinoma manifesting as GGN. When the threshold of MDT was set at 813 days, the model had higher specificity, accuracy, and diagnostic efficiency.

Uncertainty-aware image classification on 3D CT lung

Early detection is crucial for lung cancer to prolong the patient's survival. Existing model architectures used in such systems have shown promising results. However, they lack reliability and robustness in their predictions and the models are typically evaluated on a single dataset, making them overconfident when a new class is present. With the existence of uncertainty, uncertain images can be referred to medical experts for a second opinion. Thus, we propose an uncertainty-aware framework that includes three phases: data preprocessing and model selection and evaluation, uncertainty quantification (UQ), and uncertainty measurement and data referral for the classification of benign and malignant nodules using 3D CT images. To quantify the uncertainty, we employed three approaches; Monte Carlo Dropout (MCD), Deep Ensemble (DE), and Ensemble Monte Carlo Dropout (EMCD). We evaluated eight different deep learning models consisting of ResNet, DenseNet, and the Inception network family, all of which achieved average F1 scores above 0.832, and the highest average value of 0.845 was obtained using InceptionResNetV2. Furthermore, incorporating the UQ demonstrated significant improvement in the overall model performance. Upon evaluation of the uncertainty estimate, MCD outperforms the other UQ models except for the metric, URecall, where DE and EMCD excel, implying that they are better at identifying incorrect predictions with higher uncertainty levels, which is vital in the medical field. Finally, we show that using a threshold for data referral can greatly improve the performance further, increasing the accuracy up to 0.959.

Sparse-view synchrotron X-ray tomographic reconstruction with learning-based sinogram synthesis

Synchrotron radiation can be used as a light source in X-ray microscopy to acquire a high-resolution image of a microscale object for tomography. However, numerous projections must be captured for a high-quality tomographic image to be reconstructed; thus, image acquisition is time consuming. Such dense imaging is not only expensive and time consuming but also results in the target receiving a large dose of radiation. To resolve these problems, sparse acquisition techniques have been proposed; however, the generated images often have many artefacts and are noisy. In this study, a deep-learning-based approach is proposed for the tomographic reconstruction of sparse-view projections that are acquired with a synchrotron light source; this approach proceeds as follows. A convolutional neural network (CNN) is used to first interpolate sparse X-ray projections and then synthesize a sufficiently large set of images to produce a sinogram. After the sinogram is constructed, a second CNN is used for error correction. In experiments, this method successfully produced high-quality tomography images from sparse-view projections for two data sets comprising Drosophila and mouse tomography images. However, the initial results for the smaller mouse data set were poor; therefore, transfer learning was used to apply the Drosophila model to the mouse data set, greatly improving the quality of the reconstructed sinogram. The method could be used to achieve high-quality tomography while reducing the radiation dose to imaging subjects and the imaging time and cost.

Application value of a computer-aided diagnosis and management system for the detection of lung nodules

Background

Computer-aided diagnosis (CAD) systems can help reduce radiologists' workload. This study assessed the value of a CAD system for the detection of lung nodules on chest computed tomography (CT) images.

Methods

The study retrospectively analyzed the CT images of patients who underwent routine health checkups between August 2019 and November 2019 at 3 hospitals in China. All images were first assessed by 2 radiologists manually in a blinded manner, which was followed by assessment with the CAD system. The location and classification of the lung nodules were determined. The final diagnosis was made by a panel of experts, including 2 associate chief radiologists and 1 chief radiologist at the radiology department. The sensitivity for nodule detection and false-positive nodules per case were calculated.

Results

A total of 1,002 CT images were included in the study, and the process was completed for 999 images. The sensitivity of the CAD system and manual detection was 90.19% and 49.88% (P<0.001), respectively. Similar sensitivity was observed between manual detection and the CAD system in lung nodules >15 mm (P=0.08). The false-positive nodules per case for the CAD system were 0.30±0.84 and those for manual detection were 0.24±0.68 (P=0.12). The sensitivity of the CAD system was higher than that of the radiologists, but the increase in the false-positive rate was only slight.

Conclusions

In addition to reducing the workload for medical professionals, a CAD system developed using a deep-learning model was highly effective and accurate in detecting lung nodules and did not demonstrate a meaningfully higher the false-positive rate.

A highly accurate quantum optimization algorithm for CT image reconstruction based on sinogram patterns

Computed tomography (CT) has been developed as a nondestructive technique for observing minute internal images in samples. It has been difficult to obtain photorealistic (clean or clear) CT images due to various unwanted artifacts generated during the CT scanning process, along with the limitations of back-projection algorithms. Recently, an iterative optimization algorithm has been developed that uses an entire sinogram to reduce errors caused by artifacts. In this paper, we introduce a new quantum algorithm for reconstructing CT images. This algorithm can be used with any type of light source as long as the projection is defined. Assuming an experimental sinogram produced by a Radon transform, to find the CT image of this sinogram, we express the CT image as a combination of qubits. After acquiring the Radon transform of the undetermined CT image, we combine the actual sinogram and the optimized qubits. The global energy optimization value used here can determine the value of qubits through a gate model quantum computer or quantum annealer. In particular, the new algorithm can also be used for cone-beam CT image reconstruction and for medical imaging.

Self-adaption and texture generation: A hybrid loss function for low-dose CT denoising

BACKGROUND

Deep learning has been successfully applied to low-dose CT (LDCT) denoising. But the training of the model is very dependent on an appropriate loss function. Existing denoising models often use per-pixel loss, including mean abs error (MAE) and mean square error (MSE). This ignores the difference in denoising difficulty between different regions of the CT images and leads to the loss of large texture information in the generated image.

PURPOSE

In this paper, we propose a new hybrid loss function that adapts to the noise in different regions of CT images to balance the denoising difficulty and preserve texture details, thus acquiring CT images with high-quality diagnostic value using LDCT images, providing strong support for condition diagnosis.

METHODS

We propose a hybrid loss function consisting of weighted patch loss (WPLoss) and high-frequency information loss (HFLoss). To enhance the model's denoising ability of the local areas which are difficult to denoise, we improve the MAE to obtain WPLoss. After the generated image and the target image are divided into several patches, the loss weight of each patch is adaptively and dynamically adjusted according to its loss ratio. In addition, considering that texture details are contained in the high-frequency information of the image, we use HFLoss to calculate the difference between CT images in the high-frequency information part.

RESULTS

Our hybrid loss function improves the denoising performance of several models in the experiment, and obtains a higher peak signal-to-noise ratio (PSNR) and structural similarity index (SSIM). Moreover, through visual inspection of the generated results of the comparison experiment, the proposed hybrid function can effectively suppress noise and retain image details.

CONCLUSIONS

We propose a hybrid loss function for LDCT image denoising, which has good interpretation properties and can improve the denoising performance of existing models. And the validation results of multiple models using different datasets show that it has good generalization ability. By using this loss function, high-quality CT images with low radiation are achieved, which can avoid the hazards caused by radiation and ensure the disease diagnosis for patients.

Information needs, approaches, and case studies in human health risk communication

This article uses ten case studies to illustrate the information needs, various communication approaches, and the communicator's role in explaining environmental health risks from a variety of hazards, to a variety of audiences, over time frames from days to years, using in person consultation, lectures, zooms, and email formats. Events often had a long history before the communication began and may have had a long tail afterward. Audiences may be public officials, companies, workers, communities, or individuals. Each individual may have their own understanding or mental model regarding the hazard, exposure, and risk. The communicator's role or intention may be to reassure an audience that has unrealistic exaggerated concerns or fears or to protect a client if the fears are realistic. Or it may be altruistic to inform a complacent audience to take the risks it faces more seriously. Although risk assessment research has advanced the techniques for communicating abstruse probabilities to audiences with low numeracy, in my experience, audiences are unimpressed by precise-sounding probability numbers, and are more interested in whether exposure is occurring or may occur and how to stop it. Often audiences have reason to be outraged and may be more concerned about punishing wrong doers than about the hazard itself, particularly when the exposure is past and cannot be undone. Thus, there is a difference between discussing the riskiness of a situation (risk communication) and what you are going to do about the situation (risk management). Risk communication is successful when the audience responds as intended, calming down or taking action. These case studies are drawn from a large number of risk communication experiences that I and my Rutgers colleagues have engaged in over the past four decades. Through the 20th century, New Jersey was the most densely industrialized State in United States. New Jersey experienced growth of the chemical and petrochemical industries and the unfortunately profligate disposal of toxic wastes. Having the most Superfund sites of any state is a dubious distinction, but New Jersey also has the most experience in evaluating and responding to these hazards.

[A Review of Current Knowledge for X-ray Energy in CT: Practical Guide for CT Technologist]

In computed tomography (CT) systems, the optimal X-ray energy in imaging depends on the material composition and the subject size. Among the parameters related to the X-ray energy, we can arbitrarily change only the tube voltage. For years, the tube voltage has often been set at 120 kVp. However, since about 2000, there has been an increasing interest in reducing radiation dose, and it has led to the publication of various reports on low tube voltage. Furthermore, with the spread of dual-energy CT, virtual monochromatic X-ray images are widely used since the contrast can be adjusted by selecting the optional energy. Therefore, because of the renewed interest in X-ray energy in CT imaging, the issue of energy and imaging needs to be summarized. In this article, we describe the basics of physical characteristics of X-ray attenuation with materials and its influence on the process of CT imaging. Moreover, the relationship between X-ray energy and CT imaging is discussed for clinical applications.

Integrating Biological and Radiological Data in a Structured Repository: a Data Model Applied to the COSMOS Case Study

Integrating the information coming from biological samples with digital data, such as medical images, has gained prominence with the advent of precision medicine. Research in this field faces an ever-increasing amount of data to manage and, as a consequence, the need to structure these data in a functional and standardized fashion to promote and facilitate cooperation among institutions. Inspired by the Minimum Information About BIobank data Sharing (MIABIS), we propose an extended data model which aims to standardize data collections where both biological and digital samples are involved. In the proposed model, strong emphasis is given to the cause-effect relationships among factors as these are frequently encountered in clinical workflows. To test the data model in a realistic context, we consider the Continuous Observation of SMOking Subjects (COSMOS) dataset as case study, consisting of 10 consecutive years of lung cancer screening and follow-up on more than 5000 subjects. The structure of the COSMOS database, implemented to facilitate the process of data retrieval, is therefore presented along with a description of data that we hope to share in a public repository for lung cancer screening research.

Evaluation of Alternative Diagnostic Follow-up Intervals for Lung Reporting and Data System Criteria on the Effectiveness of Lung Cancer Screening

PURPOSE

The ACR developed the Lung CT Screening Reporting and Data System (Lung-RADS) to standardize the diagnostic follow-up of suspicious screening findings. A retrospective analysis showed that Lung-RADS would have reduced the false-positive rate in the National Lung Screening Trial, but the optimal timing of follow-up examinations has not been established. In this study, we assess the effectiveness of alternative diagnostic follow-up intervals on lung cancer screening.

METHODS

We used the Lung Cancer Outcome Simulator to estimate population-level outcomes of alternative diagnostic follow-up intervals for Lung-RADS categories 3 and 4A. The Lung Cancer Outcome Simulator is a microsimulation model developed within the Cancer Intervention and Surveillance Modeling Network Consortium to evaluate outcomes of national screening guidelines. Here, among the evaluated outcomes are percentage of mortality reduction, screens performed, lung cancer deaths averted, screen-detected cases, and average number of screens and follow-ups per death averted.

RESULTS

The recommended 3-month follow-up interval for Lung-RADS category 4A is optimal. However, for Lung-RADS category 3, a 5-month, instead of the recommended 6-month, follow-up interval yielded a higher mortality reduction (0.08% for men versus 0.05% for women), and a higher number of deaths averted (36 versus 27), a higher number of screen-detected cases (13 versus 7), and a lower number of combined low-dose CTs and diagnostic follow-ups per death avoided (8 versus 5), per one million general population. Sensitivity analysis of nodule progression threshold verifies a higher mortality reduction with a 1-month earlier follow-up for Lung-RADS 3.

CONCLUSIONS

One-month earlier diagnostic follow-ups for individuals with Lung-RADS category 3 nodules may result in a higher mortality reduction and warrants further investigation.

Lung cancer screening primer: Key information for primary care providers

OBJECTIVE

To review new evidence reported since the 2016 publication of the Canadian Task Force on Preventive Health Care recommendations and to summarize key facets of lung cancer screening to better equip primary care providers (PCPs) in anticipation of wider implementation of the recommendations.

QUALITY OF EVIDENCE

A new, large randomized controlled trial has been published since 2016, as have updates from 4 other trials. PubMed was searched for studies published between January 1, 2004, and December 31, 2020, using search words including lung cancer screening eligibility, lung cancer screening criteria, and lung cancer screening guidelines. All information from peer-reviewed articles, reference lists, books, and websites was considered.

MAIN MESSAGE

Lung cancers diagnosed at stage 4 have a 5-year survival rate of only 5% and have a disproportionate impact on those with lower socioeconomic status, rural populations, and Indigenous populations. By downstaging, or diagnosing lung cancers at an earlier and more treatable stage, lung cancer screening reduces mortality with a number needed to screen of 250 to prevent 1 death. Practical aspects of lung cancer screening are reviewed, including criteria to screen, appropriate low-dose computed tomography screening, and management of findings. Harms of screening, such as overdiagnosis and incidental findings, are discussed to allow PCPs to appropriately counsel their patients in the face of ongoing implementation of new lung cancer screening programs.

CONCLUSION

Lung cancer screening, with its embedded emphasis on smoking cessation, is an excellent addition to PCPs' preventive health care tools. The implementation of formal and pilot lung cancer screening programs across Canada means that PCPs will be increasingly required to counsel their patients around the uptake of lung cancer screening.

ABC du dépistage du cancer du poumon

Objectif

Examiner les nouvelles données probantes rapportées depuis la publication, en 2016, des recommandations du Groupe d’étude canadien sur les soins de santé préventifs et résumer les facettes clés du dépistage du cancer du poumon afin de mieux équiper les médecins de première ligne avant la mise en œuvre généralisée des recommandations.

Qualité des données

Depuis 2016, une vaste nouvelle étude randomisée et contrôlée, de même que la mise à jour de 4 autres études ont été publiées. Une recherche d’études publiées entre le 1er janvier 2004 et le 31 décembre 2020 a été effectuée dans PubMed à l’aide des mots-clés anglais lung cancer screening eligibility, lung cancer screening criteria et lung cancer screening guidelines . On a tenu compte de toute l’information trouvée dans les articles revus par les pairs, les listes de références, les manuels et les sites Web.

Message principal

Le cancer du poumon diagnostiqué au stade 4 a un taux de survie à 5 ans d’à peine 5 %, et son impact est disproportionné dans les populations à faible statut socio-économique, rurales et autochtones. En déstadifiant , c’est-à-dire en diagnostiquant le cancer du poumon à un stade plus précoce et plus facilement traitable, le dépistage du cancer du poumon réduit la mortalité, le nombre de sujets à soumettre au dépistage étant de 250 pour prévenir 1 décès. Nous examinons les aspects pratiques du dépistage du cancer du poumon, y compris les critères de dépistage, le dépistage approprié par tomodensitométrie à faible dose et la prise en charge des trouvailles. On parle des préjudices liés au dépistage, comme le surdiagnostic et les trouvailles fortuites, afin de permettre aux médecins de première ligne de bien conseiller leurs patients devant l’adoption de nouveaux programmes de dépistage du cancer du poumon.

Conclusion

Le dépistage du cancer du poumon, qui met l’accent sur l’abandon du tabac, est un excellent ajout à la boîte à outils de prévention du médecin de première ligne. La mise en œuvre de programmes formels et de programmes pilotes de dépistage du cancer du poumon partout au Canada signifie que les médecins de première ligne devront de plus en plus conseiller à leurs patients d’accepter le dépistage du cancer du poumon.

A review on Deep Learning approaches for low-dose Computed Tomography restoration

Computed Tomography (CT) is a widely use medical image modality in clinical medicine, because it produces excellent visualizations of fine structural details of the human body. In clinical procedures, it is desirable to acquire CT scans by minimizing the X-ray flux to prevent patients from being exposed to high radiation. However, these Low-Dose CT (LDCT) scanning protocols compromise the signal-to-noise ratio of the CT images because of noise and artifacts over the image space. Thus, various restoration methods have been published over the past 3 decades to produce high-quality CT images from these LDCT images. More recently, as opposed to conventional LDCT restoration methods, Deep Learning (DL)-based LDCT restoration approaches have been rather common due to their characteristics of being data-driven, high-performance, and fast execution. Thus, this study aims to elaborate on the role of DL techniques in LDCT restoration and critically review the applications of DL-based approaches for LDCT restoration. To achieve this aim, different aspects of DL-based LDCT restoration applications were analyzed. These include DL architectures, performance gains, functional requirements, and the diversity of objective functions. The outcome of the study highlights the existing limitations and future directions for DL-based LDCT restoration. To the best of our knowledge, there have been no previous reviews, which specifically address this topic.

Radiation dose reduction with the wide-volume scan mode for interstitial lung diseases

OBJECTIVES

The wide-volume mode, available on wide-area detector row CTs, has the advantage of reducing exposure time and radiation dose. It is infrequently used for lung diseases. The purpose of this study is to compare image quality and radiation dose of wide-volume chest CT to those of standard helical CT in the setting of interstitial lung diseases.

METHODS

Retrospective monocentric study including 50 consecutive patients referred for follow-up or screening of interstitial lung diseases, requiring prone scan, acquired with the wide-volume mode, in addition to the routine supine scan, acquired with the helical mode. The optimal collimation in wide-volume mode (320 × 0.5mm or 240 × 0.5mm) was chosen according to the length of the thorax. Wide-volume acquisitions were compared to helical acquisitions for radiation dose (CTDI_vol, DLP) and image quality, including analysis of normal structures, lesions, overall image quality, and artifacts (Wilcoxon signed-rank test).

RESULTS

Median CTDI_vol and DLP with wide volumes (3.1 mGy and 94.6 mGy·cm) were significantly reduced (p < 0.0001) as compared to helical mode (3.7mGy and 122.1 mGy·cm), leading to a median 21% and 32% relative reduction of CTDI_vol and DLP, respectively. Image noise and quality were not significantly different between the two modes. Misalignment artifact at the junction of two volumes was occasionally seen in the wide-volume scans and, when present, did not impair the diagnostic quality in the majority of cases.

CONCLUSIONS

Wide-volume mode allows 32% radiation dose reduction compared to the standard helical mode and could be used routinely for diagnosis and follow-up of interstitial lung diseases.

KEY POINTS

• Retrospective monocentric study showed that wide-volume scan mode reduces radiation dose by 32% in comparison to helical mode for chest CT in the setting of interstitial lung diseases. • Mild misalignment may be observed at the junction between volumes with the wide-volume mode, without decrease of image quality in the majority of cases and without impairing diagnostic quality. • Wide-volume mode could be used routinely for the diagnosis and follow-up of interstitial lung diseases.

Diagnostic accuracy of low-dose and ultra-low-dose CT in detection of chest pathology: a systematic review

PURPOSE

Studies have evaluated imaging modalities with a lower radiation dose than standard-dose CT (SD-CT) for chest examination. This systematic review aimed to summarize evidence on diagnostic accuracy of these modalities - low-dose and ultra-low-dose CT (LD- and ULD-CT) - for chest pathology.

METHOD

Ovid-MEDLINE, Ovid-EMBASE and the Cochrane Library were systematically searched April 29th-30th, 2019 and screened by two reviewers. Studies on diagnostic accuracy were included if they defined their index tests as 'LD-CT', 'Reduced-dose CT' or 'ULD-CT' and had SD-CT as reference standard. Risk of bias was evaluated on study level using the Quality Assessment of Diagnostic Accuracy Studies-2. A narrative synthesis was conducted to compare the diagnostic accuracy measurements.

RESULTS

Of the 4257 studies identified, 18 were eligible for inclusion. SD-CT (3.17 ± 1.47 mSv) was used as reference standard in all studies to evaluate diagnostic accuracy of LD- (1.22 ± 0.34 mSv) and ULD-CT (0.22 ± 0.05 mSv), respectively. LD-CT had high sensitivities for detection of bronchiectasis (82-96%), honeycomb (75-100%), and varying sensitivities for nodules (63-99%) and ground glass opacities (GGO) (77-91%). ULD-CT had high sensitivities for GGO (93-100%), pneumothorax (100%), consolidations (90-100%), and varying sensitivities for nodules (60-100%) and emphysema (65-90%).

CONCLUSION

The included studies found LD-CT to have high diagnostic accuracy in detection of honeycombing and bronchiectasis and ULD-CT to have high diagnostic accuracy for pneumothorax, consolidations and GGO. Summarizing evidence on diagnostic accuracy of LD- and ULD-CT for other chest pathology was not possible due to varying outcome measures, lack of precision estimates and heterogeneous study design and methodology.

Region-Based Segmentation and Wiener Pilot-Based Novel Amoeba Denoising Scheme for CT Imaging

Computed tomography (CT) is one of the most common and beneficial medical imaging schemes, but the associated high radiation dose injurious to the patient is always a concern. Therefore, postprocessing-based enhancement of a CT reconstructed image acquired using a reduced dose is an active research area. Amoeba- (or spatially variant kernel-) based filtering is a strong candidate scheme for postprocessing of the CT image, which adapts its shape according to the image contents. In the reported research work, the amoeba filtering is customized for postprocessing of CT images acquired at a reduced X-ray dose. The proposed scheme modifies both the pilot image formation and amoeba shaping mechanism of the conventional amoeba implementation. The proposed scheme uses a Wiener filter-based pilot image, while region-based segmentation is used for amoeba shaping instead of the conventional amoeba distance-based approach. The merits of the proposed scheme include being more suitable for CT images because of the similar region-based and symmetric nature of the human body anatomy, image smoothing without compromising on the edge details, and being adaptive in nature and more robust to noise. The performance of the proposed amoeba scheme is compared to the traditional amoeba kernel in the image denoising application for CT images using filtered back projection (FBP) on sparse-view projections. The scheme is supported by computer simulations using fan-beam projections of clinically reconstructed and simulated head CT phantoms. The scheme is tested using multiple image quality matrices, in the presence of additive projection noise. The scheme implementation significantly improves the image quality visually and statistically, providing better contrast and image smoothing without compromising on edge details. Promising results indicate the efficacy of the proposed scheme.

A CT-based radiomics model to detect prostate cancer lymph node metastases in PSMA radioguided surgery patients

PURPOSE

In recurrent prostate carcinoma, determination of the site of recurrence is crucial to guide personalized therapy. In contrast to prostate-specific membrane antigen (PSMA)-positron emission tomography (PET) imaging, computed tomography (CT) has only limited capacity to detect lymph node metastases (LNM). We sought to develop a CT-based radiomic model to predict LNM status using a PSMA radioguided surgery (RGS) cohort with histological confirmation of all suspected lymph nodes (LNs).

METHODS

Eighty patients that received RGS for resection of PSMA PET/CT-positive LNMs were analyzed. Forty-seven patients (87 LNs) that received inhouse imaging were used as training cohort. Thirty-three patients (62 LNs) that received external imaging were used as testing cohort. As gold standard, histological confirmation was available for all LNs. After preprocessing, 156 radiomic features analyzing texture, shape, intensity, and local binary patterns (LBP) were extracted. The least absolute shrinkage and selection operator (radiomic models) and logistic regression (conventional parameters) were used for modeling.

RESULTS

Texture and shape features were largely correlated to LN volume. A combined radiomic model achieved the best predictive performance with a testing-AUC of 0.95. LBP features showed the highest contribution to model performance. This model significantly outperformed all conventional CT parameters including LN short diameter (AUC 0.84), LN volume (AUC 0.80), and an expert rating (AUC 0.67). In lymph node-specific decision curve analysis, there was a clinical net benefit above LN short diameter.

CONCLUSION

The best radiomic model outperformed conventional measures for detection of LNM demonstrating an incremental value of radiomic features.

Imaging patterns of early stage lung cancer for the thoracic surgeon

In the modern era, thoracic surgeons are experiencing an increase interest in imaging patterns of early stage lung cancer due to the introduction of the ground glass opacity in clinical practice, and for the necessity to an accurate cancer localization to perform the appropriate type of resection. In this brief review we analyze the latest news regarding imaging patterns of early pulmonary nodules with special emphasis to ground glass opacity.

Low-dose chest CT and the impact on nodule visibility

INTRODUCTION

The need to continually optimise CT protocols is essential to ensure the lowest possible radiation dose for the clinical task and individual patient. The aim of this study was to explore the effect of reducing effective mAs on nodule detection and radiation dose across six scanners.

METHODS

An anthropomorphic chest phantom was scanned using a low-dose chest CT protocol, with the effective mAs lowered to the lowest permissible level. All other acquisition parameters remained consistent. Images were evaluated by five radiologists to determine their sensitivity in detecting six simulated nodules within the phantom. Image noise was calculated together with DLP.

RESULTS

The lowest possible mAs achievable ranged from 7 to 19 mAs. The two highest mAs setting (17 mAs + 19 mAs) had kV modulation enabled (100 kV instead of 120 kV) which consequently resulted in a higher nodule detection rate. Overall nodule detection averaged at 91% (range 80-97%). Out of a possible 180 nodules, 16 were missed, with 12 of those 16 being the same nodule. Noise was double for the Somatom Sensation scanner when compared to the others; however, this scanner did not have iterative reconstruction and it was installed over 10 years ago. There was a strong correlation between image noise and scanner age.

CONCLUSION

This study highlighted that nodules can be detected at very low effective mAs (<20 mAs) but only when other acquisition parameters are optimised i.e. iterative reconstruction and kV modulation. Nodule detection rates were affected by nodule location and image noise.

IMPLICATIONS FOR PRACTICE

This study consolidates previous findings on how to successfully optimise low-dose chest CT. It also highlights the difficulty with standardisation owing to factors such as scanner age and different vendor attributes.

Effect of iterative reconstruction techniques on image quality in low radiation dose chest CT: a phantom study

PURPOSE

We aimed to evaluate the quality of chest computed tomography (CT) images obtained with low-dose CT using three iterative reconstruction (IR) algorithms.

METHODS

Two 64-detector spiral CT scanners (HDCT and iCT) were used to scan a chest phantom containing 6 ground-glass nodules (GGNs) at 11 radiation dose levels. CT images were reconstructed by filtered back projection or three IR algorithms. Reconstructed images were analyzed for CT values, average noise, contrast-to-noise ratio (CNR) values, subjective image noise, and diagnostic acceptability of the GGNs. Repeated-measures analysis of variance was used for statistical analyses.

RESULTS

Average noise decreased and CNR increased with increasing radiation dose when the same reconstruction algorithm was applied. Average image noise was significantly lower when reconstructed with MBIR than with iDOSE4 at the same low radiation doses. The two radiologists showed good interobserver consistency in image quality with kappa 0.83. A significant relationship was found between image noise and diagnostic acceptability of the GGNs.

CONCLUSION

Three IR algorithms are able to reduce the image noise and improve the image quality of low-dose CT. In the same radiation dose, the low-dose CT image quality reconstructed with MBIR algorithms is better than that of other IR algorithms.

Lung Cancer Surveillance After Definitive Curative-Intent Therapy: ASCO Guideline

PURPOSE

To provide evidence-based recommendations to practicing clinicians on radiographic imaging and biomarker surveillance strategies after definitive curative-intent therapy in patients with stage I-III non-small-cell lung cancer (NSCLC) and SCLC.

METHODS

ASCO convened an Expert Panel of medical oncology, thoracic surgery, radiation oncology, pulmonary, radiology, primary care, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 2000 through 2019. Outcomes of interest included survival, disease-free or recurrence-free survival, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations.

RESULTS

The literature search identified 14 relevant studies to inform the evidence base for this guideline.

RECOMMENDATIONS

Patients should undergo surveillance imaging for recurrence every 6 months for 2 years and then annually for detection of new primary lung cancers. Chest computed tomography imaging is the optimal imaging modality for surveillance. Fluorodeoxyglucose positron emission tomography/computed tomography imaging should not be used as a surveillance tool. Surveillance imaging may not be offered to patients who are clinically unsuitable for or unwilling to accept further treatment. Age should not preclude surveillance imaging. Circulating biomarkers should not be used as a surveillance strategy for detection of recurrence. Brain magnetic resonance imaging should not be used for routine surveillance in stage I-III NSCLC but may be used every 3 months for the first year and every 6 months for the second year in patients with stage I-III small-cell lung cancer who have undergone curative-intent treatment.

Lung Cancer Screening, Version 3.2018, NCCN Clinical Practice Guidelines in Oncology

Lung cancer is the leading cause of cancer-related mortality in the United States and worldwide. Early detection of lung cancer is an important opportunity for decreasing mortality. Data support using low-dose computed tomography (LDCT) of the chest to screen select patients who are at high risk for lung cancer. Lung screening is covered under the Affordable Care Act for individuals with high-risk factors. The Centers for Medicare & Medicaid Services (CMS) covers annual screening LDCT for appropriate Medicare beneficiaries at high risk for lung cancer if they also receive counseling and participate in shared decision-making before screening. The complete version of the NCCN Guidelines for Lung Cancer Screening provides recommendations for initial and subsequent LDCT screening and provides more detail about LDCT screening. This manuscript focuses on identifying patients at high risk for lung cancer who are candidates for LDCT of the chest and on evaluating initial screening findings.

Implementation of lung cancer screening at the national level: Polish example

In Poland the national demonstration lung cancer screening program is about to be started in 2019. We share our concerns and discussing most important topics to be resolved while preparing such a program. The decisions made are virtually based on available scientific data and the results of two randomized controlled trials but also on the personal experience gained during the lung cancer screening studies performed in Poland. The most important and comprehensive guidelines and statements, both European and American, have been searched to find an optimal solution adjusted to the Polish national circumstances-as we assume that should be done in each country implementing such a program.

Imaging Cancer Metabolism

It is widely accepted that altered metabolism contributes to cancer growth and has been described as a hallmark of cancer. Our view and understanding of cancer metabolism has expanded at a rapid pace, however, there remains a need to study metabolic dependencies of human cancer in vivo. Recent studies have sought to utilize multi-modality imaging (MMI) techniques in order to build a more detailed and comprehensive understanding of cancer metabolism. MMI combines several in vivo techniques that can provide complementary information related to cancer metabolism. We describe several non-invasive imaging techniques that provide both anatomical and functional information related to tumor metabolism. These imaging modalities include: positron emission tomography (PET), computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance spectroscopy (MRS) that uses hyperpolarized probes and optical imaging utilizing bioluminescence and quantification of light emitted. We describe how these imaging modalities can be combined with mass spectrometry and quantitative immunochemistry to obtain more complete picture of cancer metabolism. In vivo studies of tumor metabolism are emerging in the field and represent an important component to our understanding of how metabolism shapes and defines cancer initiation, progression and response to treatment. In this review we describe in vivo based studies of cancer metabolism that have taken advantage of MMI in both pre-clinical and clinical studies. MMI promises to advance our understanding of cancer metabolism in both basic research and clinical settings with the ultimate goal of improving detection, diagnosis and treatment of cancer patients.

[Growth Evaluation of Pulmonary Nodules on Chest CT]

对肺结节行计算机断层扫描（computed tomography, CT）随访并确定结节生长特性是临床针对不定性肺结节常采用的策略。依据肿瘤生长指数模型，常采用体积或质量倍增时间量化结节的生长速率。本文拟对肺癌的指数生长模型、肺结节生长量化评价的方法学、不同类型肺结节的生长特性进行综述。

An aggressive non-small cell lung cancer in nonsmokers: A case report of an unusual presentation of micropapillary lung adenocarcinoma

We describe a case of an unusual fast growing lung micropapillary-predominant adenocarcinoma in a nonsmoker male patient without pre-existing lung disease. Adenocarcinomas have been described to be slow growing tumors, however our patient presented a fast-growing rate over a period of 21 days. When the patient failed broad spectrum antibiotic coverage, malignancy became part of the differential diagnosis. Once malignancy was detected, prompt identification and treatment was started in order to improve prognosis of the patients.

Spectrum of early lung cancer presentation in low-dose screening CT: a pictorial review

The typical presentation of early stage lung cancers on low-dose CT screening are non-calcified pulmonary nodules. However, there is a wide spectrum of unusual focal abnormalities that can be early presentations of lung cancer. These abnormalities include, for example, cancers associated with 'cystic airspaces' or scar-like cancers. The detection of lung cancer with low-dose CT can be affected by the absence of intravenous contrast medium. As a consequence, endobronchial and central lesions can be difficult to recognize, raising the potential for missed cancers. Focal lesions arising within pre-existing lung disease, such as lung fibrosis or apical scars, can also be early lung cancer manifestations and deserve particular consideration as recognition of these lesions may be hindered by the underlying disease. Furthermore, the unpredictable growth rate of lung cancer, which ranges from indolent to aggressive cancers, necessitates attention to the wide spectrum of progression in lung cancer appearance on serial low-dose CT scans. In this pictorial review we discuss the spectrum of early lung cancer presentation in low-dose CT screening, highlighting typical as well as unusual radiological features and the varied growth rates of early lung cancer. Teaching Points • There is a wide spectrum of early presentations of lung cancer on LDCT. • Low radiation dose and the absence of contrast medium injection can affect lung cancer detection. • Lung cancer growth shows various behaviours, ranging from indolent to aggressive cancers. • Familiarity with LDCT technique can improve CT screening effectiveness and avoid missed diagnosis.

Lung cancer screening: Computed tomography or chest radiographs?

Worldwide, lung cancer is the leading cause of mortality due to malignancy. The vast majority of cases of lung cancer are smoking related and the most effective way of reducing lung cancer incidence and mortality is by smoking cessation. In the Western world, smoking cessation policies have met with limited success. The other major means of reducing lung cancer deaths is to diagnose cases at an earlier more treatable stage employing screening programmes using chest radiographs or low dose computed tomography. In many countries smoking is still on the increase, and the sheer scale of the problem limits the affordability of such screening programmes. This short review article will evaluate the current evidence and potential areas of research which may benefit policy making across the world.

Role of imaging in diagnosis, staging and follow-up of lung cancer

PURPOSE OF REVIEW

Primary lung cancer is still the number one cause of cancer death worldwide. Screening, detection and staging of lung cancer are important because the only potentially curative therapy today is surgical resection of early-stage lung cancer.

RECENT FINDINGS

Different imaging techniques can be used in these different processes. Recent advances in computed tomography (CT) technology have allowed investigation of novel methods for the evaluation of lung cancer. Recent advances in magnetic resonance technology and administration of contrast media have further improved the image quality and diagnostic capability of magnetic resonance. Positron emission tomography (PET)/CT has been shown to be superior to stand-alone PET or CT in the evaluation of lymph nodes and in the detection of distant metastases.

SUMMARY

The current recommended imaging required for lung cancer staging is CT of the thorax and PET/CT from skull base to mid-thigh. However, with the recent developments in the armamentarium of imaging techniques, the choice of one of these techniques can be directed by the presence of a technique in a local hospital and/or by the presence of an experienced person at that time.

Image reconstruction for sparse-view CT and interior CT-introduction to compressed sensing and differentiated backprojection

New designs of future computed tomography (CT) scanners called sparse-view CT and interior CT have been considered in the CT community. Since these CTs measure only incomplete projection data, a key to put these CT scanners to practical use is a development of advanced image reconstruction methods. After 2000, there was a large progress in this research area briefly summarized as follows. In the sparse-view CT, various image reconstruction methods using the compressed sensing (CS) framework have been developed towards reconstructing clinically feasible images from a reduced number of projection data. In the interior CT, several novel theoretical results on solution uniqueness and solution stability have been obtained thanks to the discovery of a new class of reconstruction methods called differentiated backprojection (DBP). In this paper, we mainly review this progress including mathematical principles of the CS image reconstruction and the DBP image reconstruction for readers unfamiliar with this area. We also show some experimental results from our past research to demonstrate that this progress is not only theoretically elegant but also works in practical imaging situations.