Photon-counting Detector CT with Deep Learning Noise Reduction to Detect Multiple Myeloma.

Background Photon-counting detector (PCD) CT and deep learning noise reduction may improve spatial resolution at lower radiation doses compared with energy-integrating detector (EID) CT. Purpose To demonstrate the diagnostic impact of improved spatial resolution in whole-body low-dose CT scans for viewing multiple myeloma by using PCD CT with deep learning denoising compared with conventional EID CT. Materials and Methods Between April and July 2021, adult participants who underwent a whole-body EID CT scan were prospectively enrolled and scanned with a PCD CT system in ultra-high-resolution mode at matched radiation dose (8 mSv for an average adult) at an academic medical center. EID CT and PCD CT images were reconstructed with Br44 and Br64 kernels at 2-mm section thickness. PCD CT images were also reconstructed with Br44 and Br76 kernels at 0.6-mm section thickness. The thinner PCD CT images were denoised by using a convolutional neural network. Image quality was objectively quantified in two phantoms and a randomly selected subset of participants (10 participants; median age, 63.5 years; five men). Two radiologists scored PCD CT images relative to EID CT by using a five-point Likert scale to detect findings reflecting multiple myeloma. The scoring for the matched reconstruction series was blinded to scanner type. Reader-averaged scores were tested with the null hypothesis of equivalent visualization between EID and PCD. Results Twenty-seven participants (median age, 68 years; IQR, 61-72 years; 16 men) were included. The blinded assessment of 2-mm images demonstrated improvement in viewing lytic lesions, intramedullary lesions, fatty metamorphosis, and pathologic fractures for PCD CT versus EID CT (P < .05 for all comparisons). The 0.6-mm PCD CT images with convolutional neural network denoising also demonstrated improvement in viewing all four pathologic abnormalities and detected one or more lytic lesions in 21 of 27 participants compared with the 2-mm EID CT images (P < .001). Conclusion Ultra-high-resolution photon-counting detector CT improved the visibility of multiple myeloma lesions relative to energy-integrating detector CT. © RSNA, 2022 Online supplemental material is available for this article.

Clinical applications of photon counting detector CT.

The X-ray detector is a fundamental component of a CT system that determines the image quality and dose efficiency. Until the approval of the first clinical photon-counting-detector (PCD) system in 2021, all clinical CT scanners used scintillating detectors, which do not capture information about individual photons in the two-step detection process. In contrast, PCDs use a one-step process whereby X-ray energy is converted directly into an electrical signal. This preserves information about individual photons such that the numbers of X-ray in different energy ranges can be counted. Primary advantages of PCDs include the absence of electronic noise, improved radiation dose efficiency, increased iodine signal and the ability to use lower doses of iodinated contrast material, and better spatial resolution. PCDs with more than one energy threshold can sort the detected photons into two or more energy bins, making energy-resolved information available for all acquisitions. This allows for material classification or quantitation tasks to be performed in conjunction with high spatial resolution, and in the case of dual-source CT, high pitch, or high temporal resolution acquisitions. Some of the most promising applications of PCD-CT involve imaging of anatomy where exquisite spatial resolution adds clinical value. These include imaging of the inner ear, bones, small blood vessels, heart, and lung. This review describes the clinical benefits observed to date and future directions for this technical advance in CT imaging. KEY POINTS: • Beneficial characteristics of photon-counting detectors include the absence of electronic noise, increased iodine signal-to-noise ratio, improved spatial resolution, and full-time multi-energy imaging. • Promising applications of PCD-CT involve imaging of anatomy where exquisite spatial resolution adds clinical value and applications requiring multi-energy data simultaneous with high spatial and/or temporal resolution. • Future applications of PCD-CT technology may include extremely high spatial resolution tasks, such as the detection of breast micro-calcifications, and quantitative imaging of native tissue types and novel contrast agents.

Photon-Counting Detector CT for Musculoskeletal Imaging: A Clinical Perspective.

Photon-counting detector (PCD) CT has emerged as a novel imaging modality that represents a fundamental shift in the way that CT systems detect x-rays. After pre-clinical and clinical investigations showed benefits of PCD CT for a range of imaging tasks, the U.S. FDA in 2021 approved the first commercial PCD CT system for clinical use. The technologic features of PCD CT are particularly well suited for musculo-skeletal imaging applications. Advantages of PCD CT compared with conventional energy-integrating detector (EID) CT include smaller detector pixels and excellent geometric dose efficiency that enable imaging of large joints and central skeletal anatomy at ultrahigh spatial resolution; advanced multienergy spectral postprocessing that allows quantification of gout deposits and generation of virtual noncalcium images for visualization of bone edema; improved metal artifact reduction for imaging of orthopedic implants; and higher CNR and suppression of electronic noise. Given substantially improved cortical and trabecular detail, PCD CT images more clearly depict skeletal abnormalities, including fractures, lytic lesions, and mineralized tumor matrix. The purpose of this article is to review, by use of clinical examples comparing EID CT and PCD CT, the technical features of PCD CT and their associated impact on musculoskeletal imaging applications.

Seeing More with Less: Clinical Benefits of Photon-counting Detector CT.

Photon-counting detector (PCD) CT is an emerging technology that has led to continued innovation and progress in diagnostic imaging after it was approved by the U.S. Food and Drug Administration for clinical use in September 2021. Conventional energy-integrating detector (EID) CT measures the total energy of x-rays by converting photons to visible light and subsequently using photodiodes to convert visible light to digital signals. In comparison, PCD CT directly records x-ray photons as electric signals, without intermediate conversion to visible light. The benefits of PCD CT systems include improved spatial resolution due to smaller detector pixels, higher iodine image contrast, increased geometric dose efficiency to allow high-resolution imaging, reduced radiation dose for all body parts, multienergy imaging capabilities, and reduced artifacts. To recognize these benefits, diagnostic applications of PCD CT in musculoskeletal, thoracic, neuroradiologic, cardiovascular, and abdominal imaging must be optimized and adapted for specific diagnostic tasks. The diagnostic benefits and clinical applications resulting from PCD CT in early studies have allowed improved visualization of key anatomic structures and radiologist confidence for some diagnostic tasks, which will continue as PCD CT evolves and clinical use and applications grow. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material. See the invited commentary by Ananthakrishnan in this issue.

Multimodality evaluation of transfascial muscle and other soft tissue herniations of the extremities.

This review illustrates the multimodality assessment of transfascial muscle and other soft tissue herniations of the extremities. Transfascial herniations of the extremities can develop from congenital or acquired disruptions of the deep fascia, resulting in herniation of the underlying muscle, nerve, or soft tissue tumor into the subcutaneous tissues. While most patients present with a painless subcutaneous nodule that may change in size with muscle activation, some may experience focal or diffuse extremity symptoms such as pain and paresthesias. Although the diagnosis may be clinically suspected, radiologic evaluation is useful for definitive diagnosis and characterization. Ultrasound is the preferred modality for initial workup through a focused and dynamic examination. Magnetic resonance imaging can be utilized for equivocal, complicated, and preoperative cases. Computed tomography is less useful in the evaluation of transfascial herniations in the extremities due to similarities in the attenuation between muscle and fascia, which can decrease the conspicuity of small defects.

Improved visualization of the wrist at lower radiation dose with photon-counting-detector CT.

OBJECTIVE: To compare the image quality of ultra-high-resolution wrist CTs acquired on photon-counting detector CT versus conventional energy-integrating-detector CT systems. MATERIALS AND METHODS: Participants were scanned on a photon-counting-detector CT system after clinical energy-integrating detector CTs. Energy-integrating-detector CT scan parameters: comb filter-based ultra-high-resolution mode, 120 kV, 250 mAs, Ur70 or Ur73 kernel, 0.4- or 0.6-mm section thickness. Photon-counting-detector CT scan parameters: non-comb-based ultra-high-resolution mode, 120 kV, 120 mAs, Br84 kernel, 0.4-mm section thickness. Two musculoskeletal radiologists blinded to CT system, scored specific osseous structures using a 5-point Likert scale (1 to 5). The Wilcoxon rank-sum test was used for statistical analysis of reader scores. Paired t-test was used to compare volume CT dose index, bone CT number, and image noise between CT systems. P-value < 0.05 was considered statistically significant. RESULTS: Twelve wrists (mean participant age 55.3 ± 17.8, 6 females, 6 males) were included. The mean volume CT dose index was lower for photon-counting detector CT (9.6 ± 0.1 mGy versus 19.0 ± 6.7 mGy, p < .001). Photon-counting-detector CT images had higher Likert scores for visualization of osseous structures (median score = 4, p < 0.001). The mean bone CT number was higher in photon-counting-detector CT images (1946 ± 77 HU versus 1727 ± 49 HU, p < 0.001). Conversely, there was no difference in the mean image noise of the two CT systems (63 ± 6 HU versus 61 ± 6 HU, p = 0.13). CONCLUSION: Ultra-high-resolution imaging with photon-counting-detector CT depicted wrist structures more clearly than conventional energy-integrating-detector CT despite a 49% radiation dose reduction.

Node Positivity Among Sonographically Suspicious but FNA-Negative Axillary Nodes.

BACKGROUND: Fine needle aspiration (FNA) of sonographically suspicious axillary lymph nodes is helpful to clinically stage patients and guide consideration of neoadjuvant therapy in breast cancer. However, data are limited for suspicious nodes that are FNA negative. Our goal is to compare the frequency of node positivity between patients with negative axillary ultrasound (AUSneg) versus suspicious AUS with negative FNA (FNAneg). METHODS: With IRB approval, we identified all clinically node-negative (cN0) patients with invasive breast cancer treated with upfront surgery at our tertiary care center between 2016 and 2021. AUS is routinely performed with FNA of suspicious lymph node(s). We compared clinicopathologic characteristics and nodal positivity rates between AUSneg and FNAneg groups. RESULTS: A total of 1580 cN0 patients with invasive breast cancer were analyzed, including 1240 AUSneg and 340 FNAneg patients. The FNAneg group was younger (median age 59.7 years versus 63.5 years, p < 0.001) and had higher clinical T (cT) category (29.1% versus 21.7% with cT2-cT4 disease, p = 0.005). Final axillary pathologic node positivity did not differ significantly between the AUSneg and FNAneg groups (16.5% versus 19.1%, p = 0.25). Among FNAneg patients, 58/340 (17.1%) had a clip placed, with retrieval confirmed in 28/58 (48.3%). Of the 28 retrieved clipped nodes, 27 were sentinel nodes. Final pathologic nodal status (pN+%) did not differ between patients in whom retrieval of the clipped node was confirmed versus not confirmed (28.6% versus 16.7%, p = 0.28). CONCLUSIONS: Both patients with sonographically suspicious node(s) and negative FNA and patients with negative AUS have a similarly low chance of positive nodes. Additionally, routine targeted excision of FNA-negative clipped nodes is not warranted.

Ultra-high-resolution imaging of the shoulder and pelvis using photon-counting-detector CT: a feasibility study in patients.

OBJECTIVE: To evaluate ultra-high-resolution (UHR) imaging of large joints using an investigational photon-counting detector (PCD) CT. MATERIALS AND METHODS: Patients undergoing clinical shoulder or pelvis energy-integrating-detector (EID) CT exam were scanned using the UHR mode of the PCD-CT system. Axial EID-CT images (1-mm sections) and PCD-CT images (0.6-mm sections) were reconstructed using Br62/Br64 and Br76 kernels, respectively. Two musculoskeletal radiologists rated visualization of anatomic structures using a 5-point Likert scale. Wilcoxon rank-sum test was used for statistical analysis of reader scores, and paired t-test was used for comparing bone CT numbers and image noise from PCD-CT and EID-CT. RESULTS: Thirty-two patients (17 shoulders and 15 pelvis) were prospectively recruited for this feasibility study. Mean age for shoulder exams was 67.3 ± 15.5 years (11 females) and 47.2 ± 15.8 years (11 females) for pelvis exams. The mean volume CT dose index was lower on PCD-CT compared to that on EID-CT (shoulders: 18 mGy vs. 34 mGy, pelvis: 11.6 mGy vs. 16.7 mGy). PCD-CT was rated significantly better than EID-CT (p < 0.001) for anatomic-structure visualization. Trabecular delineation in shoulders (mean score = 4.24 ± 0.73) and femoroacetabular joint visualization in the pelvis (mean score = 3.67 ± 1.03) received the highest scores. PCD-CT demonstrated significant increase in bone CT number (p < 0.001) relative to EID-CT; no significant difference in image noise was found between PCD-CT and EID-CT. CONCLUSION: The evaluated PCD-CT system provided improved visualization of osseous structures in the shoulders and pelvises at a 31-47% lower radiation dose compared to EID-CT. KEY POINTS: • A full field-of-view PCD-CT with 0.151 mm × 0.176 mm detector pixel size (isocenter) facilitates bilateral, high-resolution imaging of shoulders and pelvis. • The evaluated investigational PCD-CT system was rated superior by two musculoskeletal radiologists for anatomic structure visualization in shoulders and pelvises despite a 31-47% lower radiation dose compared to EID-CT. • PCD-CT demonstrated significantly higher bone CT number compared to EID-CT, while no significant difference in image noise was observed between PCD-CT and EID-CT despite a 31-47% dose reduction on PCD-CT.

Evolving Role of Dual-Energy CT in the Clinical Workup of Gout: A Retrospective Study.

BACKGROUND. Dual-energy CT (DECT) allows noninvasive detection of monosodium urate (MSU) crystal deposits and has become incorporated into the routine clinical evaluation for gout at many institutions over the past decade. OBJECTIVE. The purpose of this study was to compare two time periods over the past decade in terms of radiologists' interpretations of DECT examinations performed for the evaluation of gout and subsequent clinical actions. METHODS. This retrospective study included 100 consecutive adult patients who underwent DECT to evaluate for gout in each of two periods (one beginning in March 2013 and one beginning in September 2019). Examinations performed in 2013 were conducted using a second-generation DECT scanner (80 kV [tube A] and 140 kV [tube B] with a 0.4-mm tin filter), and those performed in 2019 were conducted using a third-generation DECT scanner (80 kV [tube A] and 150 kV [tube B] with a 0.6-mm tin filter) that provides improved spectral separation. Original DECT reports were classified as positive, negative, or equivocal for MSU crystals indicative of gout. Joint aspirations occurring after the DECT examinations were recorded on the basis of findings from medical record review. A single radiologist performed a post hoc retrospective blinded image review, classifying examinations as positive, negative, or equivocal. RESULTS. In 2013, 44.0% of DECT examinations were interpreted as positive, 23.0% as negative, and 33.0% as equivocal; in 2019, 37.0% were interpreted as positive, 47.0% as negative, and 16.0% as equivocal (p < .001). The frequency of joint aspiration after DECT was 14.0% in 2013 versus 2.0% in 2019 (p = .002), and that after DECT examinations with negative interpretations was 17.4% in 2013 versus 2.1% in 2019 (p = .02). In post hoc assessment by a single radiologist, the distribution of interpretations in 2013 was positive in 49.0%, negative in 22.0%, and equivocal in 29.0%, and in 2019 it was positive in 39.0%, negative in 50.0%, and equivocal in 11.0% (p < .001). CONCLUSION. When DECT examinations performed for gout in 2013 and 2019 were compared, the frequency of equivocal interpretations was significantly lower in 2019, possibly in relation to interval technologic improvements. Negative examinations were less frequently followed by joint aspirations in 2019, possibly reflecting increasing clinical acceptance of the DECT results. CLINICAL IMPACT. The findings indicate an evolving role for DECT in the evaluation of gout after an institution's routine adoption of the technology for this purpose.

Preoperative ultrasound accurately characterizes surgically confirmed extracranial spinal accessory nerve injuries.

OBJECTIVE: To determine the accuracy of preoperative ultrasound and MRI in surgically confirmed spinal accessory nerve injuries and present the benefits of a multimodality image review. MATERIALS AND METHODS: A retrospective review of 38 consecutive patients referred to a peripheral nerve surgical practice at an academic teaching hospital with surgically confirmed spinal accessory nerve injuries. All cases were reviewed for patient demographics, date and cause of injury, preoperative EMG, and surgical diagnosis and management. Additionally, prospective interpretation of preoperative ultrasound and MRI reports were reviewed for concordance or discordance with the surgical diagnosis. RESULTS: Iatrogenic injury was present in 37 (97%) cases and most commonly a result of an excisional lymph node biopsy (68%). Surgically confirmed spinal accessory nerve injury diagnoses consisted of 25 (66%) stump neuromas and 13 (34%) incomplete nerve injuries. Nine months was the average time from injury to surgery. Twenty-nine patients underwent preoperative ultrasound and/or MRI evaluation: 12 ultrasound only, 10 MRI only, and seven with both ultrasound and MRI. Eighteen (95%) preoperative ultrasound reports compared to four (24%) preoperative MRI reports were concordant with the surgical diagnosis. In the seven cases with both preoperative ultrasound and MRI, six had discordant ultrasound and MRI imaging diagnoses for which the ultrasound was concordant with the surgical diagnoses in all cases. CONCLUSION: Preoperative ultrasound more accurately characterizes spinal accessory nerve injuries compared to MRI and should serve as the modality of choice when a spinal accessory nerve injury is suspected.

Clinical evaluation of a phantom-based deep convolutional neural network for whole-body-low-dose and ultra-low-dose CT skeletal surveys.

OBJECTIVE: This study evaluated the clinical utility of a phantom-based convolutional neural network noise reduction framework for whole-body-low-dose CT skeletal surveys. MATERIALS AND METHODS: The CT exams of ten patients with multiple myeloma were retrospectively analyzed. Exams were acquired with routine whole-body-low-dose CT protocol and projection noise insertion was used to simulate 25% dose exams. Images were reconstructed with either iterative reconstruction or filtered back projection with convolutional neural network post-processing. Diagnostic quality and structure visualization were blindly rated (subjective scale ranging from 0 [poor] to 100 [excellent]) by three musculoskeletal radiologists for iterative reconstruction and convolutional neural network images at routine whole-body-low-dose and 25% dose CT. RESULTS: For the diagnostic quality rating, the convolutional neural network outscored iterative reconstruction at routine whole-body-low-dose CT (convolutional neural network: 95 ± 5, iterative reconstruction: 85 ± 8) and at the 25% dose level (convolutional neural network: 79 ± 10, iterative reconstruction: 22 ± 13). Convolutional neural network applied to 25% dose was rated inferior to iterative reconstruction applied to routine dose. Similar trends were observed in rating experiments focusing on structure visualization. CONCLUSION: Results indicate that the phantom-based convolutional neural network noise reduction framework can improve visualization of critical structures within CT skeletal surveys. At matched dose level, the convolutional neural network outscored iterative reconstruction for all conditions studied. The image quality improvement of convolutional neural network applied to 25% dose indicates a potential for dose reduction; however, the 75% dose reduction condition studied is not currently recommended for clinical implementation.

Role of ultrasound-guided perineural injection of the posterior antebrachial cutaneous nerve for diagnosis and potential treatment of chronic lateral elbow pain.

OBJECTIVE: To examine diagnostic and therapeutic utility of novel ultrasound-guided perineural injection of posterior antebrachial cutaneous nerve in chronic lateral elbow pain. MATERIALS AND METHODS: We performed a retrospective analysis of ultrasound-guided perineural injection of the posterior antebrachial cutaneous nerve with local anesthetic with or without corticosteroid in patients with chronic lateral elbow pain. Data variables collected included patient demographics, illness course, diagnostic ultrasound findings, immediate pre- and post-injection pain using numeric rating pain scale between 0 and 10, injection complications, and post-injection outcomes. RESULTS: Fifteen patients (9 females and 6 males) with average age 46.9 (range 16-69 years) underwent 20 perineural injections between 2009 and 2019. Patients had on average 84% reduction in pain immediately after the injection (median pre- and post-procedure numeric rating pain scale of 6 and 0, respectively, p < 0.001). Patients had pain relief for an average of 15 h (range 2-48 h) when only local anesthetic was injected, compared with average pain relief of 26.5 days (range 2 h-43 days) when local anesthetic was combined with corticosteroid, p = 0.01. CONCLUSION: Novel ultrasound-guided perineural anesthetic injections around the posterior antebrachial cutaneous nerve can be performed safely and have diagnostic and potentially therapeutic utility in select patients with chronic refractory lateral elbow pain.

BRAF inhibitor-induced panniculitis in patients treated for stage IV metastatic melanoma: a case series.

BRAF and MEK inhibitor combination therapy is the standard treatment for patients with BRAF V600E mutant metastatic melanoma. Neutrophilic panniculitis is a known rare complication of BRAF inhibitor therapy and can act as a potential mimic of melanoma metastases on 18F-FDG PET/CT. In this case series, we present three cases of BRAF inhibitor-induced panniculitis in patients being treated for BRAF-mutant metastatic melanoma and emphasize the use of ultrasound to differentiate between panniculitis lesions, which are typically ill-defined echogenic masses and subcutaneous soft tissue melanoma metastases, which present as hypoechoic vascular masses.

Preoperative sonographic ulnar nerve mapping in the postoperative elbow.

OBJECTIVE: To describe the technique of sonographic ulnar nerve mapping in the postoperative elbow for surgical planning. MATERIALS AND METHODS: A retrospective review of a surgical databank identified 24 patients, all aged 18 years and older with a history of orthopedic elbow surgery, who were referred for preoperative sonographic mapping of the ulnar nerve prior to subsequent surgery. All cases were reviewed for patient demographics, clinical presentation, prior surgical interventions, and ultrasound technique. Charts were reviewed for intraoperative and postoperative outcomes, including nerve injury. RESULTS: The cohort included 12 males and 12 females with a mean age of 51 years (range 22-68 years) and a mean BMI of 29 (range 20-48). Preoperative sonographic ulnar nerve mapping occurred following various elbow surgeries including ulnar nerve transposition to assess nerve location prior to subsequent elbow surgery. Of the 24 patients with preoperative sonographic ulnar nerve mapping, subsequent surgery was performed arthroscopically in 14 and open in 10 cases. In 11 of the 24 cases, there was specific mention of a modified approach to joint access which was guided by the ulnar nerve map. There were no perioperative ulnar nerve-related complications, such as nerve transection. CONCLUSION: Preoperative mapping can facilitate planning of surgical access and ulnar nerve dissection. Sonographic mapping of the ulnar nerve reduces the potential uncertainty of nerve palpation in a complex postoperative elbow following ulnar nerve transposition. This technique may mitigate the risk of ulnar nerve injury.

Benefits of iterative metal artifact reduction and dual-energy CT towards mitigating artifact in the setting of total shoulder prostheses.

OBJECTIVE: To determine the utility of iterative metal artifact reduction and 130 keV dual-energy virtual monoenergetic images to improve bone and soft tissue visualization in CT scans affected by metal artifacts. MATERIAL AND METHODS: Thirteen females and 6 males with a history of total shoulder prosthesis who underwent dual-energy shoulder CT were included. Four sets of images were reconstructed for each patient: (1) original polychromatic kV images reconstructed with weighted filtered back projection; (2) polychromatic kV images with iterative metal artifact reduction; (3) 130 keV dual-energy virtual monoenergetic; (4) combined iterative metal artifact reduction and 130 keV dual-energy virtual monoenergetic. Three readers blindly reviewed all image sets and graded the extent of artifact and image quality. RESULTS: Mean artifact score and median overall image quality score were better in 130 keV dual-energy virtual monoenergetic with iterative metal artifact reduction compared with those in original polychromatic kV images (3.02 vs 4.28, P < 0.001 and 3.00 vs 4.33, P < 0.001, respectively). The median difference in CT numbers between regions affected by artifacts and normal regions was lowest in 130 keV dual-energy virtual monoenergetic with iterative metal artifact reduction compared with that in original polychromatic kV images (72.28 vs 252.08, P < 0.001 for bony regions and 15.09 vs 324.38, P < 0.001 for soft tissue). CONCLUSION: In patients with metal artifacts due to shoulder replacement surgery, the use of dual-energy monoenergetic images and iterative metal artifact reduction reconstruction significantly improves both subjective and objective indicators of image quality.

Clinical evaluation of a new adaptive iterative metal artifact reduction method in whole-body low-dose CT skeletal survey examinations.

OBJECTIVE: To evaluate a new adaptive iterative metal artifact reduction algorithm (AiMAR) in whole-body low-dose CT (WBLDCT) skeletal survey examinations. METHODS: Projection data were retrospectively obtained from 25 clinical WBLDCT skeletal survey patients, each with two types of metal implants. Images were reconstructed with bone and soft tissue kernels using four settings-original and AiMAR with strengths of 2, 4, and 5. All images were anonymized and randomized for a reader study, where three musculoskeletal radiologists independently determined the overall ranking of all series based on diagnostic quality, and local scoring of metal artifact and anatomy visualization for each implant. Quantitative image noise analysis was performed in areas close to the implants. Intraclass correlation coefficients (ICC) and Krippendorff's alpha were computed for inter-rater reliability. RESULTS: AiMAR 4 was ranked the highest for 64.3% of the series across eight types of implants. For local scoring task, AiMAR 4 showed better metal artifact and anatomy visualization than the original and AiMAR 2. AiMAR 4 was comparable in anatomy visualization but inferior to AiMAR 5 in metal artifact scores. AiMAR 4 led to 56.3% noise reduction around the implant areas compared with the original images, and AiMAR 5 68.1% but also resulted in anatomy blurring in 40% of the implants. ICC and Krippendorff's alpha revealed at least substantial reliability in the local scores among the readers. CONCLUSIONS: AiMAR was evaluated in WBLDCT skeletal surveys. AiMAR 4 demonstrated the highest overall quality ranking and improved local scores with noise reduction around implant areas.

Role of imaging in multiple myeloma.

With rapid advancements in the diagnosis and treatment of multiple myeloma (MM), imaging has become instrumental in detection of intramedullary and extramedullary disease, providing prognostic information, and assessing therapeutic efficacy. Whole-body low dose computed tomography (WBLDCT) has emerged as the study of choice to detect osteolytic bone disease. Positron emission tomography/computed tomography (PET/CT) combines functional and morphologic information to identify MM disease activity and assess treatment response. Magnetic resonance imaging (MRI) has excellent soft-tissue contrast and is the modality of choice for bone marrow evaluation. This review focuses on the imaging modalities available for MM patient management, highlighting advantages, disadvantages, and applications of each.

Imaging Features and Treatment Options for Breast Pseudoaneurysms After Biopsy: A Case-Based Pictorial Review.

Pseudoaneurysm (PSA) formation is a potential complication of breast biopsies. Ultrasound is the most common imaging modality used for evaluation and treatment of a PSA. Color Doppler images show a cystic structure with swirling flow inside in a "to-and-fro" pattern. Treatment options for PSA include observation, ultrasound-guided focused compression, thrombin injection, open surgical repair, and percutaneous embolization. The risks and benefits of these treatment options will be discussed in the following cases.

Ability of Dual-Energy CT to Detect Silicone Gel Breast Implant Rupture and Nodal Silicone Spread.

OBJECTIVE: The purpose of this study is to compare the performance of dual-energy CT (DECT) with that of breast MRI for detection of silicone gel breast implant rupture and nodal spread of silicone. SUBJECTS AND METHODS: This prospective study enrolled consecutive patients with current or prior silicone gel implants and clinical suspicion of implant rupture or extra-capsular silicone. All patients underwent MRI followed by unenhanced DECT. A breast radiologist not participating in image evaluation established reference standards for implant rupture (intra- or extracapsular) and regional nodal silicone spread (to axillary nodes and internal mammary [IM] and mediastinal nodes) using MRI, surgical findings, and medical records. After undergoing reader training, two radiologists who were blinded to all medical records interpreted randomized images in two sessions, indicating confidence in diagnosis using a 100-point visual scale. RESULTS: A total of 46 patients who had a subpectoral silicone gel implant (n = 31), a subglandular silicone gel implant (n = 14), or a silicone gel implant that was removed (n = 1) underwent MRI and DECT (mean [± SD] volume CT dose index, 8.2 ± 2.0 mGy). Nineteen patients had implant rupture, and 13 of these patients had silicone within the IM or axillary nodes. Pooled data showed no significant difference between MRI and DECT interpretation of intra- or extracapsular rupture of implants (AUC value for intracapsular rupture, 0.958 [for MRI] vs 0.989 [for DECT]; p = 0.28; AUC value for extracapsular rupture, 0.864 [for MRI] vs 0.878 [for DECT]; p = 0.78). No difference was noted in the AUC value for silicone spread to regional lymph nodes: 0.823-0.866 [for MRI] vs 0.892-0.906 [for DECT]; p = 0.34-0.54). CONCLUSION: DECT performs similar to MRI for the detection of silicone gel implant rupture and the presence of silicone in regional lymph nodes, and it may be an alternative for patients who are unable or unwilling to undergo MRI.

Clinical utility of virtual noncalcium dual-energy CT in imaging of the pelvis and hip.

Dual-energy virtual noncalcium images are increasingly used to identify marrow edema which accompanies bony pelvic injuries and marrow pathology obscured by cancellous bone. We present a clinical perspective of our experience using virtual noncalcium images in the work up of pelvic osseous pathology.