Using CT-Based Pelvimetry and Visceral Obesity Measurements to Predict Total Mesorectal Excision Quality for Patients Undergoing Rectal Cancer Surgery.

BACKGROUND: A complete total mesorectal excision is the criterion standard in curative rectal cancer surgery. Ensuring quality is challenging in a narrow pelvis, and obesity amplifies technical difficulties. Pelvimetry is the measurement of pelvic dimensions, but its role in gauging preoperatively the difficulty of proctectomy is largely unexplored. OBJECTIVE: To determine pelvic structural factors associated with incomplete total mesorectal excision after curative proctectomy and build a predictive model for total mesorectal excision quality. DESIGN: Retrospective cohort study. SETTING: A quaternary referral center database of patients diagnosed with rectal adenocarcinoma (2009-2017). PATIENTS: Curative-intent proctectomy for rectal adenocarcinoma. INTERVENTIONS: All radiological measurements were obtained from preoperative CT images using validated imaging processing software tools. Completeness of total mesorectal excision was obtained from histology reports. MAIN OUTCOME MEASURES: Ability of radiological pelvimetry and obesity measurements to predict total mesorectal excision quality. RESULTS: Of the 410 cases meeting inclusion criteria, 362 underwent a complete total mesorectal excision (88%). Multivariable regression identified a deeper sacral curve (per 100 mm 2 [OR: 1.14; 95% CI, 1.06-1.23; p < 0.001]) and a greater transverse distance of the pelvic outlet (per 10 mm [OR:1.41, 95% CI, 1.08-1.84; p = 0.012]) to be independently associated with incomplete total mesorectal excision. An increased area of the pelvic inlet (per 10 cm 2 [OR: 0.85; 95% CI, 0.75-0.97; p = 0.02) was associated with a higher rate of complete mesorectal excision. No difference in visceral obesity ratio and visceral obesity (ratio >0.4 vs <0.4) between BMI (<30 vs ≥30) and sex was identified. A model was built to predict mesorectal quality using the following variables: depth of sacral curve, area of pelvic inlet, and transverse distance of the pelvic outlet. LIMITATIONS: Retrospective analysis is not controlled for the choice of surgical approach. CONCLUSIONS: Pelvimetry predicts total mesorectal excision quality in rectal cancer surgery and can alert surgeons preoperatively to cases of unusual difficulty. This predictive model may contribute to treatment strategy and aid in the comparison of outcomes between traditional and novel techniques of total mesorectal excision. See Video Abstract . USO DE MEDICIONES DE PELVIMETRA Y OBESIDAD VISCERAL BASADAS EN TC PARA PREDECIR LA CALIDAD DE TME EN PACIENTES SOMETIDOS A CIRUGA DE CNCER DE RECTO: ANTECEDENTES:Una escisión mesorrectal total y completa es el estándar de oro en la cirugía curativa del cáncer de recto. Garantizar la calidad es un desafío en una pelvis estrecha y la obesidad amplifica las dificultades técnicas. La pelvimetría es la medición de las dimensiones pélvicas, pero su papel para medir la dificultad preoperatoria de la proctectomía está en gran medida inexplorado.OBJETIVO:Determinar los factores estructurales pélvicos asociados con la escisión mesorrectal total incompleta después de una proctectomía curativa y construir un modelo predictivo para la calidad de la escisión mesorrectal total.DISEÑO:Estudio de cohorte retrospectivo.ÁMBITO:Base de datos de un centro de referencia cuaternario de pacientes diagnosticados con adenocarcinoma de recto (2009-2017).PACIENTES:Proctectomía con intención curativa para adenocarcinoma de recto.INTERVENCIONES:Todas las mediciones radiológicas se obtuvieron a partir de imágenes de TC preoperatorias utilizando herramientas de software de procesamiento de imágenes validadas. La integridad de la escisión mesorrectal total se obtuvo a partir de informes histológicos.PRINCIPALES MEDIDAS DE VALORACIÓN:Capacidad de la pelvimetría radiológica y las mediciones de obesidad para predecir la calidad total de la escisión mesorrectal.RESULTADOS:De los 410 casos que cumplieron los criterios de inclusión, 362 tuvieron una escisión mesorrectal total completa (88%). Una regresión multivariable identificó una curva sacra más profunda (por 100 mm2); OR:1,14,[IC95%:1,06-1,23,p<0,001], y mayor distancia transversal de salida pélvica (por 10mm); OR:1,41, [IC 95%:1,08-1,84,p=0,012] como asociación independiente con escisión mesorrectal total incompleta. Un área aumentada de entrada pélvica (por 10 cm2); OR:0,85, [IC95%:0,75-0,97,p=0,02] se asoció con una mayor tasa de escisión mesorrectal completa. No se identificaron diferencias en la proporción de obesidad visceral y la obesidad visceral (proporción>0,4 vs.<0,4) entre el índice de masa corporal (<30 vs.>=30) o el sexo. Se construyó un modelo para predecir la calidad mesorrectal utilizando variables: profundidad de la curva sacra, área de la entrada pélvica y distancia transversal de la salida pélvica.LIMITACIONES:Análisis retrospectivo no controlado por la elección del abordaje quirúrgico.CONCLUSIONES:La pelvimetría predice la calidad de la escisión mesorrectal total en la cirugía del cáncer de recto y puede alertar a los cirujanos preoperatoriamente sobre casos de dificultad inusual. Este modelo predictivo puede contribuir a la estrategia de tratamiento y ayudar en la comparación de resultados entre técnicas tradicionales y novedosas de escisión mesorrectal total. (Traducción- Dr. Ingrid Melo).

Visceral adipose tissue volume effect in Crohn's disease using reduced exposure CT enterography.

PURPOSE: The purpose of this investigation was to assess the effect of visceral adipose tissue volume (VA) on reader efficacy in diagnosing and characterizing small bowel Crohn's disease using lower exposure CT enterography (CTE). Secondarily, we investigated the effect of lower exposure and VA on reader diagnostic confidence. METHODS: Prospective paired investigation of 256 CTE, 129 with Crohn's disease, were reconstructed at 100% and simulated 50% and 30% exposure. The senior author provided the disease classification for the 129 patients with Crohn's disease. Patient VA was measured, and exams were evaluated by six readers for presence or absence of Crohn's disease and phenotype using a 0-10-point scale. Logistic regression models assessed the effect of VA on sensitivity and specificity. RESULTS: The effect of VA on sensitivity was significantly reduced at 30% exposure (odds radio [OR]: 1.00) compared to 100% exposure (OR: 1.12) (p = 0.048). There was no statistically significant difference among the exposures with respect to the effect of visceral fat on specificity (p = 0.159). The study readers' probability of agreement with the senior author on disease classification was 60%, 56%, and 53% at 100%, 50%, and 30% exposure, respectively (p = 0.004). When detecting low severity Crohn's disease, readers' mean sensitivity was 83%, 75%, and 74% at 100%, 50%, and 30% exposure, respectively (p = 0.002). In low severity disease, sensitivity also tended to increase as visceral fat increased (ORs per 1000 cm3 increase in visceral fat: 1.32, 1.31, and 1.18, p = 0.010, 0.016, and 0.100, at 100%, 50%, and 30% exposure). CONCLUSIONS: While the interaction is complex, VA plays a role in detecting and characterizing small bowel Crohn's disease when exposure is altered, particularly in low severity disease.

Factors predicting the active treatment of renal angiomyolipoma: 30 years of experience in two tertiary referral centers.

Introduction and objective: This study aimed to identify clinical features representing predictive factors of active treatment (AT) compared to active surveillance (AS) for renal angiomyolipoma (AML). Patients and methods: From 1990 to 2020, patients referred to two institutions for a renal mass and diagnosed with an AML based on typical features on CT were included in the analysis. The study population was divided into two groups based on the treatment received: active surveillance (AS) or active treatment (AT). Age, gender, tuberous sclerosis syndrome, tumor size, contralateral kidney disease, renal function, year of diagnosis, and symptoms at presentation were assessed as potential predictive factors of active treatment using a logistic regression model in univariate and multivariate analyses. Results: In total, 253 patients (mean age 52.3 ± 15.7 years; 70% women; 70.9% incidentally diagnosed) were included in the analysis. One hundred and nine (43%) received AS, whereas 144 (57%) were actively treated. For univariate analysis, age, tuberous sclerosis complex syndrome, tumor size, symptoms at presentation, and contralateral kidney disease were found to be predictors of AT. Only tumor size (p < 0.001) and the year of diagnosis (p < 0.001) remained significant for multivariable analyses. The likelihood of being managed with AS evolved over the study period and was 50% and 75% when diagnosed before and after 2010, respectively. With respect to size, 4-cm and 6-cm tumors had a probability of 50% and 75% of being treated with AS, respectively. Conclusion: The present analysis from a high-volume institution provides evidence that the management of renal masses with typical radiological features of AML has markedly changed over the last three decades with a trend toward AS over AT. Tumor size and the year of diagnosis were significant factors for the treatment strategies.

Effect of obesity on ability to lower exposure for detection of low-attenuation liver lesions.

PURPOSE: The purpose of this study was to assess the effect of obesity and iterative reconstruction on the ability to reduce exposure by studying the accuracy for detection of low-contrast low-attenuation (LCLA) liver lesions on computed tomography (CT) using a phantom model. METHODS: A phantom with four unique LCLA liver lesions (5- to 15-mm spheres, -24 to -6 HU relative to 90-HU background) was scanned without ("thin" phantom) and with ("obese" phantom) a 5-cm thick fat-attenuation ring at 150 mAs (thin phantom) and 450 mAs (obese phantom) standard exposures and at 33% and 67% exposure reductions. Images were reconstructed using standard filtered back projection (FBP) and with iterative reconstruction (Adaptive Model-Based Iterative Reconstruction strength 3, ADMIRE). A noninferiority analysis of lesion detection was performed. RESULTS: Mean area under the curve (AUC) values for lesion detection were significantly higher for the thin phantom than for the obese phantom regardless of exposure level (P < 0.05) for both FBP and ADMIRE. At 33% exposure reduction, AUC was noninferior for both FBP and ADMIRE strength 3 (P < 0.0001). At 67% exposure reduction, AUC remained noninferior for the thin phantom (P < 0.0035), but was no longer noninferior for the obese phantom (P ≥ 0.7353). There were no statistically significant differences in AUC between FBP and ADMIRE at any exposure level for either phantom. CONCLUSIONS: Accuracy for lesion detection was not only significantly lower in the obese phantom at all relative exposures, but detection accuracy decreased sooner while reducing the exposure in the obese phantom. There was no significant difference in lesion detection between FBP and ADMIRE at equivalent exposure levels for either phantom.

How We Do It: Creating Consistent Structure and Content in Abdominal Radiology Report Templates.

OBJECTIVE: The purposes of this article are to describe the creation of template report formats and content for a variety of abdominal and pelvic CT and MRI examinations and discuss a review-of-systems approach to text and avoidance of pitfalls of report templates. CONCLUSION: Organ system-specific report templates for CT and MRI incorporate radiologist preferences. Disease-specific report templates are created from these reports to provide a consistent radiologist and referring physician experience across the report templates.

Navigating Uncertainty in the Management of Incidental Findings.

The lack of prospective outcomes studies for many types of incidental findings limits our understanding of both their natural history and the potential efficacy of treatment. To support decision making for the management of incidental findings, major sources of uncertainty in management pathways can be mapped and analyzed using mathematical models. This process yields important insights into how uncertainty influences the best treatment decision. Here, we consider a classification scheme, grounded in decision science, which exposes various levels and types of uncertainty in the management of incidental findings and addresses (1) disease-related risks, which are considered in context of a patient's competing causes of mortality; (2) potential degrees of intervention; (3) strength of evidence; and (4) patients' treatment-related preferences. Herein we describe how categorizing uncertainty by the sources, issues, and locus can build a framework from which to improve the management of incidental findings. Accurate and comprehensive handling of uncertainty will improve the quality of related decision making and will help guide future research priorities.

Imaging Follow-up of Low-Risk Incidental Pancreas and Kidney Findings: Effects of Patient Age and Comorbidity on Projected Life Expectancy.

Purpose To determine the effects of patient age and comorbidity level on life expectancy (LE) benefits associated with imaging follow-up of Bosniak IIF renal cysts and pancreatic side-branch (SB) intraductal papillary mucinous neoplasms (IPMNs). Materials and Methods A decision-analytic Markov model to evaluate LE benefits was developed. Hypothetical cohorts with varied age (60-80 years) and comorbidities (none, mild, moderate, or severe) were evaluated. For each finding, LE projections from two strategies were compared: imaging follow-up and no imaging follow-up. Under follow-up, it was assumed that cancers associated with the incidental finding were successfully treated before they spread. For patients without follow-up, mortality risks from Bosniak IIF cysts (renal cell carcinoma) and SBIPMNs (pancreatic ductal adenocarcinoma) were incorporated. Model assumptions and parameter uncertainty were evaluated in sensitivity analysis. Results In the youngest, healthiest cohorts (age, 60 years; no comorbidities), projected LE benefits from follow-up were as follows: Bosniak IIF cyst, 6.5 months (women) and 5.8 months (men); SBIPMN, 6.4 months (women) and 5.3 months (men). Follow-up of Bosniak IIF cysts in 60-year-old women with severe comorbidities yielded a LE benefit of 3.9 months; in 80-year-old women with no comorbidities, the benefit was 2.8 months, and with severe comorbidities the benefit was 1.5 months. Similar trends were observed in men and for SBIPMN. Results were sensitive to the performance of follow-up for cancer detection; malignancy risks; and stage at presentation of malignant, unfollowed Bosniak IIF cysts. Conclusion With progression of age and comorbidity level, follow-up of low-risk incidental findings yields increasingly limited benefits for patients. © RSNA, 2018 Online supplemental material is available for this article.

Dose Reduction With Dedicated CT Metal Artifact Reduction Algorithm: CT Phantom Study.

OBJECTIVE: The objective of this study was to compare reader accuracy detecting lesions near hardware in a CT phantom model at different radiation exposures using an advanced metal artifact reduction (MAR) algorithm and standard filtered back projection (FBP) techniques and to determine if radiation exposure could be decreased using MAR without compromising lesion detectability. MATERIALS AND METHODS: A CT phantom manufactured with spherical lesions of various sizes (10-20 mm) and attenuations (20-50 HU) embedded around cobalt-chromium spheres attached to titanium rods, simulating an arthroplasty, was scanned on a single CT scanner (FLASH, Siemens Healthcare) at 140 kVp and 0.6-mm collimation using clinical-dose (300 Quality Reference mAs [Siemens Healthcare]), low-dose (150 Quality Reference mAs), and high-dose (600 Quality Reference mAs) protocols. Images reconstructed with iterative MAR, advanced modeled iterative reconstruction (ADMIRE), and FBP with identical parameters were anonymized and independently reviewed by three radiologists. Accuracies for detecting lesions, measured as AUC, sensitivity, and specificity, were compared. RESULTS: Accuracy using MAR was significantly higher than that using FBP at all exposures (p values ranged from < 0.001 to 0.021). Sensitivity was also higher for MAR than for FBP at all exposures. Specificity was very high for both reconstruction techniques at all exposures with no significant differences. Accuracy of low-dose MAR was higher than and not inferior to standard-dose and high-dose FBP. MAR was significantly more sensitive than FBP in detecting smaller lesions (p = 0.021) and lesions near high streak artifact (p < 0.001). CONCLUSION: MAR improves reader accuracy to detect lesions near hardware and allows significant reductions in radiation exposure without compromising accuracy compared with FBP in a CT phantom model.

Management of the Incidental Renal Mass on CT: A White Paper of the ACR Incidental Findings Committee.

The ACR Incidental Findings Committee (IFC) presents recommendations for renal masses that are incidentally detected on CT. These recommendations represent an update from the renal component of the JACR 2010 white paper on managing incidental findings in the adrenal glands, kidneys, liver, and pancreas. The Renal Subcommittee, consisting of six abdominal radiologists and one urologist, developed this algorithm. The recommendations draw from published evidence and expert opinion and were finalized by informal iterative consensus. Each flowchart within the algorithm describes imaging features that identify when there is a need for additional imaging, surveillance, or referral for management. Our goal is to improve quality of care by providing guidance for managing incidentally detected renal masses.

Accuracy and Interobserver Agreement for Prostate Imaging Reporting and Data System, Version 2, for the Characterization of Lesions Identified on Multiparametric MRI of the Prostate.

OBJECTIVE: The objective of this study was to measure the accuracy and interobserver agreement of the Prostate Imaging Reporting and Data System, version 2 (PI-RADSv2), for the characterization of prostate lesions on multiparametric MRI. MATERIALS AND METHODS: This retrospective study included 170 men examined at a single institution between August 2014 and February 2015 on a 3-T MRI scanner. Study patients were found to have lesions concerning for prostate cancer that were targeted for MRI/transrectal ultrasound fusion biopsy. Two experienced readers independently assigned a PI-RADSv2 assessment category to the dominant lesion in each patient. The AUC was calculated to determine reader accuracy for the detection of clinically significant prostate cancer (Gleason score ≥ 3 + 4). The Cohen kappa statistic was used to quantify interobserver agreement. RESULTS: The prevalence of clinically significant prostate cancer was 0.36 (61/170 patients). The AUCs for readers 1 and 2 were 0.871 and 0.882, respectively. The AUCs were greater for peripheral zone lesions than for transition zone lesions. When a PI-RADSv2 assessment category ≥ 3 was considered positive, the agreement between readers was good overall (κ = 0.63) and was fair for transition zone lesions (κ = 0.53). When a PI-RADSv2 assessment category ≥ 4 was considered positive, the agreement was excellent overall (κ = 0.91) and was excellent for both peripheral zone lesions (κ = 0.91) and transition zone lesions (κ = 0.87). CONCLUSION: Two experienced readers were able to accurately identify patients with clinically significant prostate cancer using PI-RADSv2 with good interobserver agreement overall.

Imaging Manifestations of Hematologic Diseases with Renal and Perinephric Involvement.

The kidneys and perinephric tissues can be affected by a variety of hematologic disorders, which usually occur in the setting of multisystem involvement. In many of these disorders, imaging is used to evaluate the extent of disease, guide biopsy, and/or monitor disease activity and patient response to therapy. Lymphoma, leukemia, and multiple myeloma commonly manifest as multiple parenchymal or perinephric lesions. Erdheim-Chester disease and Rosai-Dorfman disease, rare forms of multisystemic histiocytosis, are often identified as perinephric and periureteral masses. Renal abnormalities depicted at imaging in patients with sickle cell disease include renal enlargement, papillary necrosis, and renal medullary carcinoma. Sickle cell disease, along with other causes of intravascular hemolysis, can also lead to hemosiderosis of the renal cortex. Thrombosis of renal veins is sometimes seen in patients with coagulation disorders but more often occurs in association with certain malignancies and nephrotic syndrome. Immunoglobulin G4-related sclerosing disease is another multisystem process that often produces focal renal lesions, seen along with involvement of more characteristic organs such as the pancreas. Perinephric lesions with calcifications should raise the possibility of secondary amyloidosis, especially in patients with a history of lymphoma and multiple myeloma. Although the imaging patterns of renal and perinephric involvement are usually not specific for a single entity, and the same entity can manifest with different or overlapping patterns, familiarity with these patterns and key clinical and histopathologic features may help to narrow the differential diagnosis and determine the next step of care. (©)RSNA, 2016.

Rethinking Normal: Benefits and Risks of Not Reporting Harmless Incidental Findings.

The authors explore the benefits and risks of not reporting imaging findings that do not have clinical relevance, with the goal of developing recommendations to reduce their reporting. The authors review the example of incidentally detected, simple renal cysts (Bosniak category I), including medicolegal conditions required for such a shift in reporting practices to be acceptable. The authors propose four potential criteria for not reporting clinically unimportant findings and recommend that these criteria be debated in other contexts, so that they can be refined and implemented.

Imaging of Arthroplasties: Improved Image Quality and Lesion Detection With Iterative Metal Artifact Reduction, a New CT Metal Artifact Reduction Technique.

OBJECTIVE: The purpose of this study was to compare iterative metal artifact reduction (iMAR), a new single-energy metal artifact reduction technique, with filtered back projection (FBP) in terms of attenuation values, qualitative image quality, and streak artifacts near shoulder and hip arthroplasties and observer ability with these techniques to detect pathologic lesions near an arthroplasty in a phantom model. MATERIALS AND METHODS: Preoperative and postoperative CT scans of 40 shoulder and 21 hip arthroplasties were reviewed. All postoperative scans were obtained using the same technique (140 kVp, 300 quality reference mAs, 128 × 0.6 mm detector collimation) on one of three CT scanners and reconstructed with FBP and iMAR. The attenuation differences in bones and soft tissues between preoperative and postoperative scans at the same location were compared; image quality and streak artifact for both reconstructions were qualitatively graded by two blinded readers. Observer ability and confidence to detect lesions near an arthroplasty in a phantom model were graded. RESULTS: For both readers, iMAR had more accurate attenuation values (p < 0.001), qualitatively better image quality (p < 0.001), and less streak artifact (p < 0.001) in all locations near arthroplasties compared with FBP. Both readers detected more lesions (p ≤ 0.04) with higher confidence (p ≤ 0.01) with iMAR than with FBP in the phantom model. CONCLUSION: The iMAR technique provided more accurate attenuation values, better image quality, and less streak artifact near hip and shoulder arthroplasties than FBP; iMAR also increased observer ability and confidence to detect pathologic lesions near arthroplasties in a phantom model.

Diagnostic Accuracy of CT Enterography for Active Inflammatory Terminal Ileal Crohn Disease: Comparison of Full-Dose and Half-Dose Images Reconstructed with FBP and Half-Dose Images with SAFIRE.

Purpose To compare the diagnostic accuracy and image quality of computed tomographic (CT) enterographic images obtained at half dose and reconstructed with filtered back projection (FBP) and sinogram-affirmed iterative reconstruction (SAFIRE) with those of full-dose CT enterographic images reconstructed with FBP for active inflammatory terminal or neoterminal ileal Crohn disease. Materials and Methods This retrospective study was compliant with HIPAA and approved by the institutional review board. The requirement to obtain informed consent was waived. Ninety subjects (45 with active terminal ileal Crohn disease and 45 without Crohn disease) underwent CT enterography with a dual-source CT unit. The reference standard for confirmation of active Crohn disease was active terminal ileal Crohn disease based on ileocolonoscopy or established Crohn disease and imaging features of active terminal ileal Crohn disease. Data from both tubes were reconstructed with FBP (100% exposure); data from the primary tube (50% exposure) were reconstructed with FBP and SAFIRE strengths 3 and 4, yielding four datasets per CT enterographic examination. The mean volume CT dose index (CTDIvol) and size-specific dose estimate (SSDE) at full dose were 13.1 mGy (median, 7.36 mGy) and 15.9 mGy (median, 13.06 mGy), respectively, and those at half dose were 6.55 mGy (median, 3.68 mGy) and 7.95 mGy (median, 6.5 mGy). Images were subjectively evaluated by eight radiologists for quality and diagnostic confidence for Crohn disease. Areas under the receiver operating characteristic curves (AUCs) were estimated, and the multireader, multicase analysis of variance method was used to compare reconstruction methods on the basis of a noninferiority margin of 0.05. Results The mean AUCs with half-dose scans (FBP, 0.908; SAFIRE 3, 0.935; SAFIRE 4, 0.924) were noninferior to the mean AUC with full-dose FBP scans (0.908; P < .003). The proportion of images with inferior quality was significantly higher with all half-dose reconstructions than with full-dose FBP (mean proportion: 0.117 for half-dose FBP, 0.054 for half-dose SAFIRE 3, 0.054 for half-dose SAFIRE 4, and 0.017 for full-dose FBP; P < .001). Conclusion The diagnostic accuracy of half-dose CT enterography with FBP and SAFIRE is statistically noninferior to that of full-dose CT enterography for active inflammatory terminal ileal Crohn disease, despite an inferior subjective image quality. (©) RSNA, 2016 Online supplemental material is available for this article.

Image Noise, CNR, and Detectability of Low-Contrast, Low-Attenuation Liver Lesions in a Phantom: Effects of Radiation Exposure, Phantom Size, Integrated Circuit Detector, and Iterative Reconstruction.

Purpose To assess image noise, contrast-to-noise ratio (CNR) and detectability of low-contrast, low-attenuation liver lesions in a semianthropomorphic phantom by using either a discrete circuit (DC) detector and filtered back projection (FBP) or an integrated circuit (IC) detector and iterative reconstruction (IR) with changes in radiation exposure and phantom size. Materials and Methods An anthropomorphic phantom without or with a 5-cm-thick fat-mimicking ring (widths, 30 and 40 cm) containing liver inserts with four spherical lesions was scanned with five exposure settings on each of two computed tomography scanners, one equipped with a DC detector and the other with an IC detector. Images from the DC and IC detector scanners were reconstructed with FBP and IR, respectively. Image noise and lesion CNR were measured. Four radiologists evaluated lesion presence on a five-point diagnostic confidence scale. Data analyses included receiver operating characteristic (ROC) curve analysis and noninferiority analysis. Results The combination of IC and IR significantly reduced image noise (P < .001) (with the greatest reduction in the 40-cm phantom and at lower exposures) and improved lesion CNR (P < .001). There was no significant difference in area under the ROC curve between detector-reconstruction combinations at fixed exposure for either phantom. Reader accuracy with IC-IR was noninferior at 50% (100 mAs [effective]) and 25% (300 mAs [effective]) exposure reduction for the 30- and 40-cm phantoms, respectively (adjusted P < .001 and .04 respectively). IC-IR improved readers' confidence in the presence of a lesion (P = .029) independent of phantom size or exposure level. Conclusion IC-IR improved objective image quality and lesion detection confidence but did not result in superior diagnostic accuracy when compared with DC-FBP. Moderate exposure reductions maintained comparable diagnostic accuracy for both detector-reconstruction combinations. Lesion detection in the 40-cm phantom was inferior at smaller exposure reduction than in the 30-cm phantom. (©) RSNA, 2016 Online supplemental material is available for this article.

Estimated Patient Dose Indexes in Adult and Pediatric MDCT: Comparison of Automatic Tube Voltage Selection With Fixed Tube Current, Fixed Tube Voltage, and Weight-Based Protocols.

OBJECTIVE: The purposes of this study were to determine the differences in estimated volumetric CT dose index (CTDIvol) obtained from the topogram before abdominal and pelvic MDCT in adult and pediatric patients using a scan type-based algorithm for selecting kilovoltage (CARE kV) and a fixed and a weight-based Quality Reference mAs for selecting tube (gmAs) current-exposure time product, in comparison with standard protocols, and to determine the bias and variability of estimated CTDIvol vis-à-vis actual CTDIvol using the standard protocols. MATERIALS AND METHODS: During a 14-month period, 312 adult and pediatric patients referred for abdominal and pelvic MDCT were included in the study. For all patients, the estimated CTDIvol based on the topogram was recorded: protocol A, CARE kV on and 210 gmAs; protocol B, CARE kV on and 1 gmAs times patient weight (in pounds); and protocol C (standard protocol), CARE kV off, 120 kVp, and 1 gmAs times patient weight (in pounds). For the pediatric patients, estimated CTDIvol for the standard protocol D was calculated with 120 kVp and 150 gmAs. All patients were scanned with the standard protocols, and the actual CTDIvol was recorded. Linear regression models compared the CTDIvol of the three protocols in adults and the fourth for children. The estimated and actual CTDIvol were compared using a t test. RESULTS: Protocol B yielded the lowest estimated CTDIvol (mean, 13.2 mGy for adults and 3.5 mGy for pediatric patients). The estimated CTDIvol overestimated the actual CTDIvol by, on average, 1.07 mGy for adults and 0.3 mGy for children. CONCLUSION: CARE kV appears to reduce estimated CTDIvol vis-à-vis standard protocols only when a weight-based gmAs is used. Prescan estimated CTDIvol calculations appear to generally overestimate actual CTDIvol.