Staging of breast cancer in the breast and regional lymph nodes using contrast-enhanced photon-counting detector CT: accuracy and potential impact on patient management.

OBJECTIVES: To describe the feasibility and evaluate the performance of multiphasic photon-counting detector (PCD) CT for detecting breast cancer and nodal metastases with correlative dynamic breast MRI and digital mammography as the reference standard. METHODS: Adult females with biopsy-proven breast cancer undergoing staging breast MRI were prospectively recruited to undergo a multiphasic PCD-CT using a 3-phase protocol: a non-contrast ultra-high-resolution (UHR) scan and 2 intravenous contrast-enhanced scans with 50 and 180 s delay. Three breast radiologists compared CT characteristics of the index malignancy, regional lymphadenopathy, and extramammary findings to MRI. RESULTS: Thirteen patients underwent both an MRI and PCD-CT (mean age: 53 years, range: 36-75 years). Eleven of thirteen cases demonstrated suspicious mass or non-mass enhancement on PCD-CT when compared to MRI. All cases with metastatic lymphadenopathy (3/3 cases) demonstrated early avid enhancement similar to the index malignancy. All cases with multifocal or multicentric disease on MRI were also identified on PCD-CT (3/3 cases), including a 4 mm suspicious satellite lesion. Four of five patients with residual suspicious post-biopsy calcifications on mammograms were detected on the UHR PCD-CT scan. Owing to increased field-of-view at PCD-CT, a 5 mm thoracic vertebral metastasis was identified at PCD-CT and not with the breast MRI. CONCLUSIONS: A 3-phase PCD-CT scan protocol shows initial promising results in characterizing breast cancer and regional lymphadenopathy similar to MRI and detects microcalcifications in 80% of cases. ADVANCES IN KNOWLEDGE: UHR and spectral capabilities of PCD-CT may allow for comprehensive characterization of breast cancer and may represent an alternative to breast MRI in select cases.

Back to the Future: Dynamic Contrast-Enhanced Photon-Counting Detector CT for the Detection of Pituitary Adenoma in Cushing Disease.

Historically, MR imaging has been unable to detect a pituitary adenoma in up to one-half of patients with Cushing disease. This issue is problematic because the standard-of-care treatment is surgical resection, and its success is correlated with finding the tumor on imaging. Photon-counting detector CT is a recent advancement that has multiple benefits over conventional energy-integrating detector CT. We present the use of dynamic contrast-enhanced imaging using photon-counting detector CT for the detection of pituitary adenomas in patients with Cushing disease.

Coronary artery stenosis quantification in patients with dense calcifications using ultra-high-resolution photon-counting-detector computed tomography.

BACKGROUND: To quantify differences in coronary artery stenosis severity in patients with calcified lesions between conventional energy-integrating detector (EID) CT and ultra-high-resolution (UHR) photon-counting-detector (PCD) CT. METHODS: Patients undergoing clinically indicated coronary CT angiography were prospectively recruited and scanned first on an EID-CT (SOMATOM Force, Siemens Healthineers) and then a PCD-CT (NAEOTOM Alpha, Siemens Healthineers) on the same day. EID-CT was performed with standard mode (192 â€‹× â€‹0.6 â€‹mm detector collimation) following our clinical protocol. PCD-CT scans were performed under UHR mode (120 â€‹× â€‹0.2 â€‹mm detector collimation). For each patient, left main, left anterior descending, right coronary artery, and circumflex were reviewed and the most severe stenosis from dense calcification for each coronary was quantified using commercial software. Additionally, each measured stenosis was assigned a severity category based on percent diameter stenosis, and changes in severity category across EID-CT and PCD-CT were assessed. RESULTS: A total of 23 patients were enrolled, with 34 coronary artery stenoses analyzed. Stenosis was significantly reduced in PCD-CT compared to EID-CT (p â€‹< â€‹0.001), resulting in an average of 11% (SD â€‹= â€‹11%) reduction in percent diameter stenosis. Among the 34 lesions, 15 changed in stenosis severity category: 3 went from moderate to minimal, 1 from moderate to mild, 9 from mild to minimal, and 2 from minimal to mild with the use of PCD-CT compared to EID-CT. CONCLUSION: Use of UHR PCD-CT decreased percent diameter stenosis by an average of 11% relative to EID-CT, resulting in 13 of 34 stenoses being downgraded in stenosis severity category, potentially sparing patients from unnecessary intervention.

Bilateral lunotriquetral coalition: a dynamic four-dimensional computed tomography technical case report.

Lunotriquetral coalitions are the most common form of carpal coalition wherein the cartilage between the lunate and triquetrum ossification centers failed to undergo apoptosis. This technical case report examines the arthrokinematics of bilateral lunotriquetral coalitions with dissimilar Minnaar types in one participant with one asymptomatic wrist and one wrist with suspected distal radioulnar joint injury. Static and dynamic (four-dimensional) CT images during pronosupination were captured using a photon-counting detector CT scanner. Interosseous proximity distributions were calculated between the lunotriquetral coalition and adjacent bones in both wrists to quantify arthrokinematics. Interosseous proximity distributions at joints adjacent to the lunotriquetral coalition demonstrate differences in median and minimum interosseous proximities between the asymptomatic and injured wrists during resisted pronosupination. Altered kinematics from lunotriquetral coalitions may be a source of ulnar-sided wrist pain and discomfort, limiting the functional range of motion. This case report highlights potential alterations to wrist arthrokinematics in the setting of lunotriquetral coalitions and possible associations with ulnar-sided wrist pain, highlighting anatomy to examine in radiographic follow-up. Furthermore, this case report demonstrates the technical feasibility of four-dimensional CT using photon-counting detector technology in assessing arthrokinematics in the setting of variant wrist anatomy.

Diagnostic Performance of Decubitus Photon-Counting Detector CT Myelography for the Detection of CSF-Venous Fistulas.

BACKGROUND AND PURPOSE: CSF-venous fistulas are a common cause of spontaneous intracranial hypotension. Lateral decubitus digital subtraction myelography and CT myelography are the diagnostic imaging standards to identify these fistulas. Photon-counting CT myelography has technological advantages that might improve CSF-venous fistula detection, though no large studies have yet assessed its diagnostic performance. We sought to determine the diagnostic yield of photon-counting detector CT myelography for detection of CSF-venous fistulas in patients with spontaneous intracranial hypotension. MATERIALS AND METHODS: We retrospectively searched our database for all decubitus photon-counting detector CT myelograms performed at our institution since the introduction of the technique in our practice. Per our institutional workflow, all patients had prior contrast-enhanced brain MR imaging and spine MR imaging showing no extradural CSF. Two neuroradiologists reviewed preprocedural brain MRIs, assessing previously described findings of intracranial hypotension (Bern score). Additionally, 2 different neuroradiologists assessed each myelogram for a definitive or equivocal CSF-venous fistula. The yield of photon-counting detector CT myelography was calculated and stratified by the Bern score using low-, intermediate-, and high-probability tiers. RESULTS: Fifty-seven consecutive photon-counting detector CT myelograms in 57 patients were included. A single CSF-venous fistula was definitively present in 38/57 patients. After we stratified by the Bern score, a definitive fistula was seen in 56.0%, 73.3%, and 76.5% of patients with low-, intermediate-, and high-probability brain MR imaging, respectively. CONCLUSIONS: Decubitus photon-counting detector CT myelography has an excellent diagnostic performance for the detection of CSF-venous fistulas. The yield for patients with intermediate- and high-probability Bern scores is at least as high as previously reported yields of decubitus digital subtraction myelography and CT myelography using energy-integrating detector scanners. The yield for patients with low-probability Bern scores appears to be greater compared with other modalities. Due to the retrospective nature of this study, future prospective work will be needed to compare the sensitivity of photon-counting detector CT myelography with other modalities.

Potential benefits of photon counting detector computed tomography in pediatric imaging.

Photon counting detector (PCD) CT represents the newest advance in CT technology, with improved radiation dose efficiency, increased spatial resolution, inherent spectral imaging capabilities, and the ability to eliminate electronic noise. Its design fundamentally differs from conventional energy integrating detector CT because photons are directly converted to electrical signal in a single step. Rather than converting X-rays to visible light and having an output signal that is a summation of energies, PCD directly counts each photon and records its individual energy information. The current commercially available PCD-CT utilizes a dual-source CT geometry, which allows 66 ms cardiac temporal resolution and high-pitch (up to 3.2) scanning. This can greatly benefit pediatric patients by facilitating high quality fast scanning to allow sedation-free imaging. The energy-resolving nature of the utilized PCDs allows "always-on" dual-energy imaging capabilities, such as the creation of virtual monoenergetic, virtual non-contrast, virtual non-calcium, and other material-specific images. These features may be combined with high-resolution imaging, made possible by the decreased size of individual detector elements and the absence of interelement septa. This work reviews the foundational concepts associated with PCD-CT and presents examples to highlight the benefits of PCD-CT in the pediatric population.

Classification of high-risk coronary plaques using radiomic analysis of multi-energy photon-counting-detector computed tomography (PCD-CT) images.

Coronary plaque risk classification in images acquired with photon-counting-detector (PCD) CT was performed using a radiomics-based machine learning (ML) model. With IRB approval, 19 coronary CTA patients were scanned on a PCD-CT (NAEOTOM Alpha, Siemens Healthineers) with median CTDIvol of 8.02 mGy. Five types of images: virtual monoenergetic images (VMIs) at 50-keV, 70-keV, and 100-keV, iodine maps, and virtual non-contrast (VNC) images were reconstructed using an iterative reconstruction algorithm (QIR), a quantitative kernel (Qr40) and 0.6-mm/0.3-mm slice thickness/increment. Atherosclerotic plaques were segmented using semi-automatic software (Research Frontier, Siemens). Segmentation confirmation and risk stratification (low- vs high-risk) were performed by a board-certified cardiac radiologist. A total of 93 radiomic features were extracted from each image using PyRadiomics (v2.2.0b1). For each feature, a t-test was performed between low- and high-risk plaques (p<0.05 considered significant). Two significant and non-redundant features were input into a support vector machine (SVM). A leave-one-out cross-validation strategy was adopted and the classification accuracy was computed. Fifteen low-risk and ten high-risk plaques were identified by the radiologist. A total of 18, 32, 43, 16, and 55 out of 93 features in 50-keV, 70-keV, 100-keV, iodine map, and VNC images were statistically significant. A total of 17, 19, 22, 20, and 22 out of 25 plaques were classified correctly in 50-keV, 70-keV, 100-keV, iodine map, and VNC images, respectively. A ML model using 100-keV VMIs and VNC images derived from coronary PCD-CTA best automatically differentiated low- and high-risk coronary plaques.

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.

Diagnostic Performance in Low- and High-Contrast Tasks of an Image-Based Denoising Algorithm Applied to Radiation Dose-Reduced Multiphase Abdominal CT Examinations.

BACKGROUND. Anatomic redundancy between phases can be used to achieve denoising of multiphase CT examinations. A limitation of iterative reconstruction (IR) techniques is that they generally require use of CT projection data. A frequency-split multi-band-filtration algorithm applies denoising to the multiphase CT images themselves. This method does not require knowledge of the acquisition process or integration into the reconstruction system of the scanner, and it can be implemented as a supplement to commercially available IR algorithms. OBJECTIVE. The purpose of the present study is to compare radiologists' performance for low-contrast and high-contrast diagnostic tasks (i.e., tasks for which differences in CT attenuation between the imaging target and its anatomic background are subtle or large, respectively) evaluated on multiphase abdominal CT between routine-dose images and radiation dose-reduced images processed by a frequency-split multiband-filtration denoising algorithm. METHODS. This retrospective single-center study included 47 patients who underwent multiphase contrast-enhanced CT for known or suspected liver metastases (a low-contrast task) and 45 patients who underwent multiphase contrast-enhanced CT for pancreatic cancer staging (a high-contrast task). Radiation dose-reduced images corresponding to dose reduction of 50% or more were created using a validated noise insertion technique and then underwent denoising using the frequency-split multi-band-filtration algorithm. Images were independently evaluated in multiple sessions by different groups of abdominal radiologists for each task (three readers in the low-contrast arm and four readers in the high-contrast arm). The noninferiority of denoised radiation dose-reduced images to routine-dose images was assessed using the jackknife alternative free-response ROC (JAFROC) figure-of-merit (FOM; limit of noninferiority, -0.10) for liver metastases detection and using the Cohen kappa statistic and reader confidence scores (100-point scale) for pancreatic cancer vascular invasion. RESULTS. For liver metastases detection, the JAFROC FOM for denoised radiation dose-reduced images was 0.644 (95% CI, 0.510-0.778), and that for routine-dose images was 0.668 (95% CI, 0.543-0.792; estimated difference, -0.024 [95% CI, -0.084 to 0.037]). Intraobserver agreement for pancreatic cancer vascular invasion was substantial to near perfect when the two image sets were compared (κ = 0.53-1.00); the 95% CIs of all differences in confidence scores between image sets contained zero. CONCLUSION. Multiphase contrast-enhanced abdominal CT images with a radiation dose reduction of 50% or greater that undergo denoising by a frequency-split multiband-filtration algorithm yield performance similar to that of routine-dose images for detection of liver metastases and vascular staging of pancreatic cancer. CLINICAL IMPACT. The image-based denoising algorithm facilitates radiation dose reduction of multiphase examinations for both low- and high-contrast diagnostic tasks without requiring manufacturer-specific hardware or software.

The feasibility of low iodine dynamic CT angiography with test bolus for evaluation of lower extremity peripheral artery disease.

OBJECTIVE: This study aims to determine if low iodine dynamic computed tomography angiography performed after a fixed delay or test bolus acquisition demonstrates high concordance with clinical computed tomography angiography (using a routine amount of iodinated contrast) to display lower extremity peripheral arterial disease. METHODS: After informed consent, low iodine dynamic computed tomography angiography examination (using either a fixed delay or test bolus) using 50 ml of iodine contrast media was performed. A subsequent clinical computed tomography angiography using standard iodine dose (115 or 145 ml) served as the reference standard. A vascular radiologist reviewed dynamic and clinical computed tomography angiography images to categorize the lumen into "not opacified", "<50% stenosis", " 50 ̶70% stenosis", ">70% stenosis", and "occluded" for seven arterial segments in each lower extremity. Concordance between low iodine dynamic computed tomography angiography and the routine iodine reference standard was calculated. The clinical utility of 4D volume-rendered images was also evaluated. RESULTS: Sixty-eight patients (average age 66.1 ± 12.3 years, male; female = 49: 19) were enrolled, with 34 patients each undergoing low iodine dynamic computed tomography angiography using fixed delay and test bolus techniques, respectively. One patient assigned to the test bolus group did not undergo low iodine computed tomography angiography due to unavailable delayed time. The fixed delay was 13 s, with test bolus acquisition resulting in a mean variable delay prior to image acquisition of 19.5 s (range; 8-32 s). Run-off to the ankle was observed using low iodine dynamic computed tomography angiography following fixed delay and test bolus acquisition in 76.4% (26/34) and 100% (33/33) of patients, respectively (p = 0.005). Considering extremities with run-off to the ankle and without severe artifact, the concordance rate between low iodine dynamic computed tomography angiography and the routine iodine reference standard was 86.8% (310/357) using fixed delay and 97.9% (425/434) using test bolus (p < 0.001). 4D volume-rendered images using fixed delay and test bolus demonstrated asymmetric flow in 57.7% (15/26) and 58.1% (18/31) (p = 0.978) of patients, and collateral blood flow in 11.5% (3/26) and 22.6% (7/31) of patients (p = 0.319), respectively. CONCLUSION: Low iodine dynamic computed tomography angiography with test bolus acquisition has a high concordance with routine peripheral computed tomography angiography performed with standard iodine dose, resulting in improved run-off to the ankle compared to dynamic computed tomography angiography performed after a fixed delay. This method is useful for minimizing iodine dose in patients at risk for contrast-induced nephropathy. 4D volume-rendered computed tomography angiography images provide useful dynamic information.

Dynamic computed tomographic assessment of the mitral annulus in patients with and without mitral prolapse.

OBJECTIVES: To obtain 3D CT measurements of mitral annulus throughout cardiac cycle using prototype mitral modeling software, assess interobserver agreement, and compare among patients with mitral prolapse (MP) and control group. BACKGROUND: Pre-procedural imaging is critical for planning of transcatheter mitral valve (MV) replacement. However, there is limited data regarding reliable CT-based measurements to accurately characterize the dynamic geometry of the mitral annulus in patients with MV disease. METHODS: Patients with MP and control subjects without any MV disease who underwent ECG-gated cardiac CT were retrospectively identified. Multiphasic CT data was loaded into a prototype mitral modeling software. Multiple anatomical parameters in 3D space were recorded throughout the cardiac cycle (0-95%): annular circumference, planar-surface-area (PSA), anterior-posterior (A-P) distance, and anterolateral-posteromedial (AL-PM) distance. Comparisons were made among the two groups, with p < 0.05 considered statistically significant. Interobserver agreement was assessed on ten patients using intraclass correlation coefficient (ICC) among 4 experienced readers. RESULTS: A total of 100 subjects were included: 50 with MP and 50 control. Annular dimensions were significantly higher in the MP group than control group, with circumference (144 ± 11 vs. 117±8 mm), PSA (1533 ± 247 vs. 1005 ± 142 mm2), A-P distance (38 ± 4 vs. 32±2 mm), and AL-PM distance (47 ± 4 vs. 39±3 mm) (all p < 0.001). Substantial size changes were observed throughout the cardiac cycle, but with maximal and minimal sizes at different cardiac phases for the two groups. The interobserver agreement was excellent (ICC≥0.75) for annular circumference, PSA, A-P- and AL-PM distance. CONCLUSION: A significant variation in the mitral annular measures between different cardiac phases and two groups was observed with excellent interobserver agreement.

Image quality in abdominal CT using an iodine contrast reduction algorithm employing patient size and weight and low kV CT technique.

BACKGROUND: Low tube potential-high tube current computed tomography (CT) imaging allows reduction in iodine-based contrast dose and may extend the benefit of routine contrast-enhanced CT exams to patients at risk of nephrotoxicity. PURPOSE: To determine the ability of an iodine contrast reduction algorithm to maintain diagnostic image quality for contrast-enhanced abdominal CT. MATERIAL AND METHODS: CT exams with iodine contrast reduction were prescribed for patients at risk for renal dysfunction. The iodine contrast reduction algorithm combines weight-based contrast volume reduction with patient width-based low tube potential selection and bolus-tracking. Control exams with routine iodine dose were selected based on weight, width, and scan protocol. Three radiologists evaluated image quality and diagnostic confidence using a 4-point scale (<2 acceptable). Another radiologist assessed contrast reduction indications and measured portal vein and liver contrast-to-noise ratios. RESULTS: Forty-six contrast reduction algorithm and control exams were compared (mean creatinine 1.6 vs. 1.2 mg/dL, P ≤ 0.0001). Thirty-nine contrast reduction patients had an eGFR <60 mL/min/1.73m2 and 15 had single or transplanted kidney. Mean iodine contrast dose was lower in the contrast reduction group (20.9 vs. 39.4 g/mL, P < 0.0001). Diagnostic confidence was rated as acceptable in 95% (131/138) of contrast reduction and 100% of control exams (1.18-1.28 vs. 1.02-1.13, respectively; P > 0.06). Liver attenuation and contrast-to-noise ratio (CNR) were similar (P = 0.08), but portal vein attenuation and CNR were lower with contrast-reduction (mean 176 vs. 198 HU, P = 0.02; 13 vs. 16, P = 0.0002). CONCLUSION: This size-based contrast reduction algorithm using low kV and bolus tracking reduced iodine contrast dose by 50%, while achieving acceptable image quality in 95% of exams.

Individualized Delay for Abdominal Computed Tomography Angiography Bolus-Tracking Based on Sequential Monitoring: Increased Aortic Contrast Permits Decreased Injection Rate and Lower Iodine Dose.

OBJECTIVE: The aim of this study was to determine if computed tomography (CT) angiography using an individualized transition delay (CTA-ID) would facilitate reductions in injection rate and iodine dose. METHODS: The CTA-ID was performed in 20 patients with routine injection rate and iodine dose; 20 patients with injection rate lowered by 1 mL/s; and 40 patients with injection rate lowered by 1 mL/s with 29% less iodine. Routine CTAs in the same or size-matched patients served as controls. Diagnostic image quality and intra-arterial CT numbers were assessed. RESULTS: The median transition delay between aortic threshold and CTA-ID image acquisition was significantly longer than with conventional bolus tracking (mean increase, 13.3 seconds; P < 0.0001), with image quality being the same or better. Intra-arterial CT numbers were 200 Hounsfield units or greater for 80 of 80 CTA-ID, but not for 6 of 49 (12%) internal control or for 11 of 80 (14%) size-matched control patients. CONCLUSION: The CTA-ID bolus-tracking software alters transition delays to permit diagnostic CTA examinations despite slower injection rate and less iodine.

Breathe New Life Into Your Chest CT Exams: Using Advanced Acquisition and Postprocessing Techniques.

OBJECTIVE: Chest computed tomography (CT) imaging enables detailed visualization of the pulmonary structures and diseases. This article reviews how continued innovation and improvements in modern CT system hardware and software now facilitate a wider range of image acquisition options and generate unique qualitative and quantitative information that can benefit patients RESULTS: Dual energy imaging utilizes two x-ray energies to highlight differences in tissue properties and increase iodine signal to improve diagnosis or reduce metal artifacts. Ultra-low dose imaging can be performed by using additional x-ray beam filtration, such as a tin filter, combined with iterative reconstruction algorithms to benefit lung cancer screening or pediatric imaging. Ultra-fast pitch spiral acquisition improves temporal resolution and reduces motion artifacts. Higher spatial resolution acquisition and reconstruction methods permit improved visualization of small structures. Radiomic analysis of chest CT image features permits risk stratification of pulmonary nodules and masses and reliable measures of change in pulmonary architecture and disease. CONCLUSIONS: Multiple new CT acquisition and reconstruction techniques, along with advanced post processing methods permit detailed analysis of changes in pulmonary architecture and function, and an expanded ability to adapt chest CT to the unique needs of different patients.