Clinical Case Collection TwinBeam Dual Energy

Clinical Case Collection TwinBeam Dual Energy whitepaper

Clinical Case Collection TwinBeam Dual Energy SIEMENS Healthineers Contents 2 Reprint of SOMATOM Sessions · News & Stories · Contents 04 17 25 Cardiovascular Oncology 04 Renal artery aneurysm 08 Differentiation of liver metastases from benign cysts Gastroenterology 10 Metastatic pulmonary hepatoid carcinoma with vascular complications and transplanted kidney 06 Follow up evaluation on Crohn disease 16 A large mesenteric pleomorphic sarcoma - where to target a biopsy? 18 An incidental find of hepatocellular carcinoma 20 Metastatic clear cell renal cell carcinoma and complicated renal cyst 22 An incidental renal mass Orthopedics 24 Gouty tophi and haglund's deformity in the right foot Reprint of SOMATOM Sessions · News & Stories · 3 Clinical results · Cardiovascular History Comments A 69-year-old female patient A renal artery aneurysm (RAA) is well as its relation to the nearby suffering from nausea and weight defined as a dilated segment of the organs. Increasingly higher speed loss of 5 kg within the past 2 months renal artery that exceeds twice the and improved spatial resolution was referred for a CT examination. diameter of a normal renal artery.[1] make CT a first-line imaging modality. TwinBeam Dual Energy (TBDE) CT It is usually asymptomatic but can be Three-dimensional image recon- was performed to rule out any complicated by conditions such as structions demonstrate the aneurysm abdominal disorders. rupture, thrombosis, distal embolism, in an illustrative way and provide us obstructive uropathy, hypertension with its detailed anatomy. This is Diagnosis of renovascular etiology, and arterio- of particular value when planning venous communications.[2] Treat- surgery. In this case, an innovative CT images showed a saccular, wide- ment of an RAA depends upon the Dual Energy approach, TBDE, was necked, contrast-filled outpouching size and location of the aneurysm, performed. It allows simultaneous arising from the bifurcation of the and also whether it is symptomatic acquisition of high and low kV data- right renal artery, suggesting an or not. Prior to surgical repair or sets in a single scan. The datasets extra-parenchymal aneurysm. The endovascular interventions, CT or are processed in syngo.CT DE Direct maximum diameter was 2.8 cm. MR examinations are usually required Angio, which accurately highlights Kidney perfusion and excretion to evaluate the exact location, size, bone structures and removes them appeared to be symmetrical. Calcified and structure of the aneurysm as in an automated workflow. plaques were seen at the origin of the celiac artery and of the left renal artery as well as in the abdominal aorta and bilateral iliac arteries, all causing no significant stenosis. 1a 1b 1 Cinematic rendering images show a saccular aneurysm arising from JA the bifurcation of the right renal artery. 4 Reprint of SOMATOM Sessions 37 · Cardiovascular · Clinical results 2a 2b 2 Cinematic rendering images, using different presets, show the anterior (Figs. 2a and 2b) and posterior (Figs. 2c and 2d) views of the abdominal aorta and its branches, before (Fig. 2a) and after (Figs. 2b-2d) bone removal using syngo.CT DE Direct Angio. Kidney perfusion appears symmetrical. A A 2c 2d References [1] Coleman DM, Stanley JC. Renal artery aneurysms. J Vasc Surg. 2015 Sep. 62 (3):779-85. [2] I. Anastasiou, I. Katafigiotis, C. Pournaras, E. Fragkiadis, I. Leotsakos, and D. Mitropoulos, “A cough deteriorat- ing gross hematuria: a clinical sign of a forthcoming life-threatening rupture of an intraparenchymal aneurysm of renal artery (Wunderlich’s Syndrome),” Case Reports in Vascular Medicine, vol. 2013, Article ID 452317, 3 pages, 2013 Examination Protocol Scanner SOMATOM Definition Edge Scan area Abdomen Rotation time 0.33 s Scan mode TwinBeam Dual Energy Pitch 0.45 Scan length 406 mm Slice collimation 64 × 0.6 mm Scan direction Caudo-cranial Slice width 0.75 mm Scan time 7.7 s Reconstruction increment 0.5 mm Tube voltage AuSn 120 kV Reconstruction kernel Q30f Effective mAs 365 mAs Dose modulation CARE Dose4D Contrast 400 mg / mL CTDIvol 7.83 mGy Volume 120 mL + 40 mL saline DLP 332 mGy*cm Flow rate 4 mL / s Effective dose 4.98 mSv Start delay Bolus tracking Reprint of SOMATOM Sessions 37 · 5 Clinical results · Gastroenterology Follow up evaluation on Crohn disease Professor Alec J. Megibow, MD Department of Radiology, NYU-Langone Medical Center, NY, USA History Comments A 22-year-old female patient, CT and MR enterography are the can be significantly enhanced at suffering from symptomatic Crohn procedures of choice for evaluating lower energy levels, such as in this disease (CD), was sent for an patient with CD. CT may potentially case – comparing conventional imaging follow up evaluation. help the physicians to distinguish acquisition (Figs. 1a and 2a) with TwinBeam Dual Energy (TBDE) CT between major phenotypes of the Monoenergetic Plus images at was performed. disease (active, penetrating, 50 keV setting (Figs. 1b and 2b), the stricturing, quiescent) and depict increased conspicuity of regions of Diagnosis extra-intestinal complications higher iodine content as well as the (fistulae, abscess, obstruction, joint fistulous tracts between the large TBDE images revealed a complex, involvement). TBDE allows simul- and small bowel can be immediately active, penetrating right lower taneous acquisition of high and depicted, facilitating recognition quadrant CD affecting the distal low kV datasets in a single scan as of the presence of the disease. The small bowel and the proximal large well as data processing in syngo.CT image quality remains high despite bowel. DE Monoenergetic Plus to display the 4.18 mSv effective dose, an images at energy levels between important consideration in younger 40 and 190 keV. The image contrast patients. Examination Protocol Scanner SOMATOM Definition Edge Scan area Abdomen / Pelvis Rotation time 0.33 s Scan mode TwinBeam Dual Energy Pitch 0.3 Scan length 433 mm Slice collimation 64 × 0.6 mm Scan direction Caudal-cranial Slice width 0.75 mm Scan time 12.3 s Reconstruction increment 0.5 mm Tube voltage AuSn 120 kV Reconstruction kernel Q40 Effective mAs 288 mAs Dose modulation CARE Dose4D Contrast 300 mg / mL CTDIvol 6.16 mGy Volume 85 mL DLP 278.6 mGy*cm Flow rate 2.5 mL / s Effective dose 4.18 mSv Start delay 60s 6 Reprint of News & Stories · Gastroenterology · Clinical results 1a 1b 2a 2b 1-2 DE CT enterography conventional (Fig. a) and monoenergetic Plus 50 keV (Fig. b). Images in coronal (Fig. 1) and axial views (Fig. 2) show a complex, active, penetrating right lower quadrant CD affecting the distal small bowel and the proximal large bowel. Image contrast is significantly enhanced at 50 keV setting. Reprint of News & Stories · 7 Clinical results · Oncology Differentation of liver metastases from benign cysts Anushri Parakh, MD; Sebastian Schindera, MD Department of Radiology and Nuclear Medicine, University Hospital Basel, Switzerland History Diagnosis Examination Protocol An 54-year-old female patient with Composed TBCT images (Figs. 1a breast cancer, post-lumpectomy and 1b) revealed multiple liver Scanner SOMATOM status, underwent thoracoabdominal lesions in both lobes. Some of these Definition Edge CT for the assessment of metastatic lesions could be clearly diagnosed Scan area TAP disease. A contrast-enhanced as simple hepatic cysts, as the TwinBeam Dual Energy CT (TBCT) measured values were below 10 HU. Scan length 650 mm was performed. However, some lesions showed Scan direction Cranio-caudal Scan time 18 s 1a 2a Tube voltage AuSn 120 kV Tube current 355 mAs Dose CARE Dose4D modulation CTDIvol 7.6 mGy DLP 508 mGy*cm Effective dose 7.6 mSv Rotation time 0.33 s Pitch 0.3 1b 2b Slice collimation 64 × 0.6 mm Slice width 1.5 mm 200 HU] Reconstruction 1.2 mm increment Reconstruction Q30f kernel (ADMIRE 3) Contrast 370 mg /mL Volume 90 mL Flow rate 2 mL /s Start delay 70 s References [1] De Cecco CN, Darnell A, Rengo M, et al. Dual-energy CT: oncologic applications. AJR Am J Roentgenol 2012; 199:S98- S105 [2] Agrawal MD, Pinho DF, Kulkarni NM, 1 Axial (Fig. 1a) and coronal (Fig. 1b) 2 Fused VNC/iodine maps demonstrate Hahn PF, Guimaraes AR, Sahani DV. views of the mixed AuSn 120 kV the increased conspicuity of liver Oncologic applications of dual-energy CT dataset (blending of 0.8) show lesions in axial (Fig. 2a) and coronal in the abdomen. Radiographics 2014; multiple lesions in both liver lobes. (Fig. 2b) sections. 34:589-612 8 Reprint of SOMATOM Sessions 35 · Oncology · Clinical results 3 200 [HU] 4a DO HUT Norm ROI CT App: Au 120/ Sn120 Mean: 171.5/ 127 9 HU Contrast Enhancement: 159.3 HU 4b [13] CT App: VNC/ CM/ Mixed 0.8 [12] CT Mean:. 1.3/.18,8/.20.3.HU App: VNC/ CM/ Mixed 0.8 Area: 8.6 mm2 Mean: -- 5-7/-8-8/3.0-HU Area: 0.2 cm2 lodine Density, 3.4 mg/ml / 39.6 % lodine Density: 0.2 mg/ml / 2.8 % [HUT 3 The evaluated iodine concentration in suspicious liver lesions shows a significant 4 VNC images generated from the post- difference in the liver metastasis (ROI#13) and in the benign simple cyst (ROI#12). contrast dual energy dataset show ROIs were also placed in the aorta (blue) forormalization. the same axial (Fig. 4a) and coronal (Fig. 4b) section. higher CT values of up to 32 HU. Comments The radiologists were unable to definitely classify these lesions as Dual Energy CT plays a pertinent projections is available for both spectra. hepatic metastases since hepatic role in oncological imaging by virtue The simultaneously acquired low- and cysts can sometimes rupture of its ability to assess the amount high-energy data can be reconstructed resulting in higher CT attenuation of iodine uptake in suspicious separately to provide a high- and low- values. Since the examination was lesions. This could be associated with energy image series or composed to acquired using dual energy, the tumor vascularity and could become give a single energy image dataset. iodine maps (Fig. 2 and Fig. 3) were useful in therapy monitoring.[1] The full field-of-view of 50 cm as well calculated, enabling iodine uptake Because of a series of virtual unen- as advanced dose reduction evaluation in the hepatic lesions. hanced images, can be extracted techniques, such as advanced modeled The significant differences in the from the contrast-enhanced images, iterative reconstruction (ADMIRE) and iodine concentration evaluated there is an opportunity to reduce real-time anatomic exposure control in the lesions helped to differentiate radiation dose by avoiding having (CARE Dose4D), are all available. between the simple benign hepatic to perform a second CT study.[2] TwinBeam CT is capable of providing cysts and the metastatic lesions TwinBeam Dual Energy is a new morphological and functional (Fig. 3). Figure 4 demonstrates technology that creates two X-ray information in oncological exami- the virtual unenhanced images spectra simultaneously from a nations and has tremendous potential (VNC) generated from the contrast- single X-ray tube. The X-ray beam in replacing the routine use of single- enhanced TBCT dataset, which can is pre-filtered using two different energy scans in the future. This is be used for analyzing CT attenuation materials: gold (Au) and tin (Sn). accompanied by the advantage values of organs (e.g. liver, adrenal As a result, the 120 kV X-ray beam is of providing a dose-neutral dual gland) in the absence of a true split into a high-(Sn) and low-energy energy imaging approach compared unenhanced image. (Au) X-ray spectrum before reaching with a standard 120 kV single-energy the patient. The full number of study. Reprint of SOMATOM Sessions 35 · 9 Clinical results · Oncology Metastatic pulmonary hepatoid carcinoma with vascular compli- cations and transplanted kidney Matthias Stefan May, MD Department of Radiology, University Hospital Erlangen, Germany History Diagnosis Comments A 74-year-old male patient came CT images revealed two consolida- Hepatoid carcinoma is a rare extra- to the hospital complaining of tions in the upper left lobe in seg- hepatic tumor with histomorpho- increasing shortness of breath. ments 2 and 3, with thickening of logical features similar to hepato- A chest radiograph showed a the surrounding septa, obstruction cellular carcinoma. Pulmonary triangular opacity in the periphery of the segmental bronchus 2, and hepatoid carcinoma is extremely of the left lung, possibly indicating enlargement of the lymphatic nodes rare and, once detected, requires a pulmonary embolism (PE). An in the left hilum. These findings differential diagnosis from meta- abdominal ultrasound examination suggested a bronchial carcinoma static hepatocellular carcinoma. revealed a possible abdominal aortic with perifocal lymphangitic In this case, one of the challenges aneurysm (AAA). The patient had carcinomatosis and ipsilateral for the radiologist was to complete a history of right hip replacement lymphatic metastases. No signs of a workup of several clinical tasks and chronic claudication with right PE were present. Histopathological with a single injection of contrast lower limb pain. A decade ago, he workup via endobronchial biopsy agent: Rule out a PE, evaluate underwent kidney transplantation, resulted in a final diagnosis of lung perfusion, assess staging of and currently had an estimated pulmonary hepatoid carcinoma (G3). bronchial carcinoma, differentiate glomerular filtration rate (GFR) of A solitary lytic bone metastasis in lesion characters in the adrenal 70.3 mL/min/1.73 m². TwinBeam the left fifth rib was visualized. The gland, evaluate an AAA as well as Dual Energy (TBDE) CT imaging was left adrenal gland was enlarged, the left iliac kidney transplant, and performed to rule out PE and to hyperdense and contrast enhanced, determine grading of peripheral investigate the systemic arterial suggesting a metastasis. The arterial disease with visualization circulation, using only a single bolus infrarenal abdominal aorta was for clinical presentation. TBDE allows injection and thereby keeping the enlarged and partially thrombotic, the simultaneous acquisition of iodine charge as low as possible. measuring 4.8 × 4.5 cm in size, high and low energy spectra in a confirming an AAA. A moderate single scan. The dataset can then stenosis of the proximal celiac artery be processed using various DE appli- and a severe stenosis of the left cations. DSA-like CT angiographic external iliac artery, right below the images can be easily reformatted, well-perfused transplanted kidney using syngo.CT DE Direct Angio, to in the left iliac fossa, were seen. remove the bony structures. Virtual The right superficial femoral artery noncontrast (VNC) images and was occluded in the adductor canal iodine maps can be created using over a length of 5 cm, causing a syngo.CT DE Virtual Unenhanced to delay in the blood flow of the present and quantify the iodine popliteal artery via collaterals. A uptake. The image contrast can be right prosthetic component was significantly enhanced using correctly positioned with no signs syngo.CT DE Monoenergetic Plus of fracture or dislocation. (Mono+) at lower keV settings. 10 Reprint of SOMATOM Sessions 38 · Oncology · Clinical results 1a 1b R4 R6 R6 R7 RB R9 RIO R11 R12 1c 1d 1 Axial (Fig. 1a) and coronal (Fig. 1c) views show two consolidations in the upper left lobe in segments 2 and 3 (arrows), thickening of the surround- ing septa, obstruction of the segmen- tal bronchus 2, and enlarged lym- phatic nodes in the left hilum. Lung PBV image (Fig. 1d) shows areas with defects in PBV corresponding to em- physema and distal to the obstruction of the bronchus. A rib unfolding image (Fig. 1b) easily reveals a solitary lytic bone metastasis in the left fifth rib (arrow, ribs #1–3 were incompletely covered in the scan range). Examination Protocol Scanner SOMATOM go.Top Scan area Whole body Pitch 0.3 Scan mode TwinBeam Dual Energy Slice collimation 64 × 0.6 mm Scan length 1,563.8 mm Slice width 0.8 mm Scan direction Cranio-caudal Reconstruction increment 0.6 mm Scan time 44.7 s Reconstruction kernel Qr40, Bv36 and Br56 Tube voltage AuSn120 kV (each with ADMIRE 3) Effective mAs 238 mAs Contrast 350 mg / mL Dose modulation CARE Dose4D Volume 100 mL + 30 mL saline CTDIvol 6.6 mGy Flow rate 5 mL / s DLP 1,064 mGy*cm Start delay Aortic bolus tracking Rotation time 0.33 s with 100 HU + 10s Reprint of SOMATOM Sessions 38 · 11 Clinical results · Oncology 2a 2b 2c 2 A cinematic VRT image (Fig. 2a) shows an AAA (dotted arrow), a moderate stenosis of the proximal celiac artery (arrow), and the well-perfused transplanted kidney. MIP images (Figs. 2b and Fig. 2c) show that a severe stenosis of the left external iliac artery, right below the renal artery of the transplanted kidney that cannot be visualized in standard reconstructions due to severe calcifications (Fig. 2b), is clearly depicted after calcium removal (Fig. 2c, arrow). The perfused blood volume (PBV) 3 200 [HU] of the lungs can also be evaluated using syngo.CT DE Lung PBV. Additionally, the syngo CT Vascular [8] CT App: VNC/ CM/ Mixed 0.8/ Au120/ Sn120 application allows the generation Mean: 39.5/ 35,5/ 76.1/ 79.1/ 64.3 HU Stddev: 8.0/ 12.8/ 13.9/ 15.3/ 18.0 HU of a curved MPR along the center- Area: 0.6 cm2 lodine Density: 2.1 mg/ml / 64.9 % line of the abdominal aorta for an accurate measurement of its size and removal of the calcified plaques for clear visualization of the true vessel lumen as well as the severity of the stenosis. The metal artifacts caused by the hip prosthesis, which impact the view of the surrounding ana- R tomical structures, can be signifi- cantly reduced by iterative Metal Artifact Reduction (iMAR). All these applications help the physicians make a confident diagnosis and plan further treatment. Norm. ROICT App: Au120/ Sn120 Mean: 145.1/ 122.2 HU 3 An axial iodine map shows an Contrast Enhancement: 68.4 HU enlarged and enhanced left adrenal gland, measuring 39.5 HU in density on VNC and 76.1 HU in the portal venous phase, with an iodine uptake of 2.1 mg/mL, suggesting a [nH] o metastasis. 12 Reprint of SOMATOM Sessions 38 · Oncology · Clinical results 4a 4b 5a 5b 4 A MIP image acquired at 120 kV after bone removal (Fig. 4a) shows extensive calcified plaques in the whole body CTA. Image contrast is significantly enhanced using Mono+ at 45 keV, and the vessel lumen is clearly depicted after calcium removal (Fig. 4b). The right superficial femoral artery is occluded over a length of 5 cm (Fig. 4b, arrow), causing a delay in the blood flow in the popliteal artery via collaterals. Both images are displayed with the same window levels. 5 Axial images show that severe metal artifacts (Fig. 5a), affecting the visualization of the hip, pelvis, and the iliac arteries, are widely removed by iMAR application (Fig. 5b). Reprint of SOMATOM Sessions 38 · 13 Clinical results · Oncology Hepatocellular carcinoma recurrence in a patient with impaired renal function Rika Iwamasa, MD1; Kenji Shinozaki, MD1; Tetsuya Minamide2 1 Department of Diagnostic Imaging and Nuclear Medicine, National Hospital Organization Kyushu Cancer Center Fukuoka, Japan 2 Department of Radiology, National Hospital Organization Kyushu Cancer Center Fukuoka, Japan History Comments Examination Protocol A 97-year-old male patient suffering HCC is one of the most common Scanner SOMATOM from hepatocellular carcinoma hypervascular lesions found in Definition Edge (HCC) underwent multiple sessions the liver. CT assessment of an HCC recurrence requires a higher Scan area Abdomen of transcatheter arterial chemo- embolization (TACE) within the past contrast-to-noise ratio (CNR) and Scan mode TwinBeam seven years. He was referred for an therefore an adequate amount of Dual Energy assessment of an HCC recurrence contrast medium administration to Scan length 274 mm due to an elevated alphafetoprotein obtain the necessary tissue enhance- (AFP) serum level. Regularly, it would ment for differential diagnosis. Scan direction Cranio-caudal require 600 mgL/kg for the diagnosis However, the reduction of contrast Scan time 7.64 s of HCC in our institution. Taking into medium for patients with impaired Tube voltage AuSn 120 kV consideration his impaired kidney renal function must also be con- function (eGFR 32 mL/min/1.73 m2), sidered to avoid potential contrast- Effective mAs 559 mAs only 300 mgL/kg was administered. induced nephrotoxicity (CIN). Dose CARE Dose4D A TwinBeam Dual Energy (TBDE) CT To help manage such a conflict, modulation scan was performed. advanced CT techniques have been developed, such as TBDE and CTDIvol 11.97 mGy Diagnosis syngo.CT DE Monoenergetic Plus. DLP 350.3 mGy*cm TBDE CT enables the simultaneous Rotation time 0.33 s TBDE CT images revealed multiple image acquisition at two different hypervascular lesions in both liver energy levels. Images acquired Pitch 0.3 lobes. The lesions were significantly can be displayed at energy levels Slice collimation 64 × 0.6 mm enhanced and better seen in the between 40 and 190 keV using DE images displayed at 45 keV using Monoenergetic Plus. Image contrast Slice width 1.5 mm DE Monoenergetic Plus than in the can be significantly enhanced at Reconstruction 1.0 mm mixed images acquired at AuSn lower energy levels and presented increment 120 kV (Fig. 1). The characteristics graphically. In this case, although Reconstruction of the lesions suggested an HCC only 300 mgL/kg was administrated, Q30f kernel recurrence. In the subsequent angio- the achieved lesion-to-background (SAFIRE 2) graphy, all lesions were confirmed contrast was almost quadrupled Contrast 300 mg/mL and another session of TACE treat- (Fig. 2). This helps the physicians ment was accordingly scheduled. to reach a confident diagnosis Volume 50 mL and plan an adequate treatment Flow rate 2 mL/s strategy. Start delay 30 s 14 Reprint of SOMATOM Sessions 38 · Oncology · Clinical results 1a 1b 1 Axial images (5 mm) show multiple hypervascular lesions (arrows) in both liver lobes. The lesions are significantly enhanced and better seen in the images displayed at 45 keV (Figs. 1b and 1d) using DE Monoenergetic Plus than in the mixed images acquired at AuSn 120 kV (Figs. 1a and 1c). All images are displayed at window width of 350 and window center of 35. 1c 1d 2 2 Graphical presentation shows Showing last 5 findings CT attenuation in accordance with 800 - CT Value [HU] Finding PI energy (keV) levels. Comparing 40 keV with 70 keV (equivalent to 750 120 kV acquisition), the CT value of the aorta has more than doubled 700 - and the lesion-to-background (normal liver tissue) contrast has 650 almost quadrupled. 600 550 - Aorta O 500 - 450 - 400 - 350 - 300 - 250 - 200 - 150 - Lesion O 3 100 - 5 Su O Normal liver Energy IkeVI 4 U O 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 Reprint of SOMATOM Sessions 38 · 15 Clinical results · Oncology A large mesenteric pleomorphic sarcoma - where to target a biopsy? Professor Arvind K Chaturvedi, MD; Ankush Jajodia, MD Department of Radiology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India History Comments Examination Protocol A 58-year-old male patient, who Pleomorphic sarcoma of the mes- Scanner SOMATOM has been suffering from chronic liver entery is a rare tumor entity, and the Definition AS+ disease with portal hypertension for management of this is significantly the past 12 years, presented to the different from that of a hepato- Scan area Abdomen/pelvis hospital due to abdominal distension cellular carcinoma. Although tests Scan mode TwinBeam for the past month. Hepatocellular of AFP and immunohistochemistry Dual Energy carcinoma was suspected, and a could be helpful for differential Scan length 473 mm TwinBeam Dual Energy (TBDE) CT diagnosis, identification of a target scan was ordered for assessment. area for biopsy in such a large Scan direction Cranio-caudal tumor remains challenging. TBDE Scan time 13 s Diagnosis CT provides the possibility of quanti- fying iodine uptake using syngo.CT Tube voltage AuSn 120 kV CT images revealed a bulky lobulated DE Virtual Unenhanced. Therefore, Effective mAs 650 mAs mesenteric mass in the right hypo- the area with maximum iodine Dose CARE Dose4D chondrial-lumbar region, measuring uptake can be measured. This modulation approx. 19 (AP) × 16 (TR) × 20 (CC) reduces the chances of fetching cm in size. The mass was heterogene- negative tissue specimens. The CTDIvol 13.9 mGy ously enhanced, showing central reconstructed 3D images are DLP 682 mGy*cm hypodense areas suggesting necro- found to be extremely helpful in Rotation time 0.5 s sis. It infiltrated into segments 5 and enabling a clear communication 6 of the right liver lobe, displaced and demonstration to the operating Pitch 0.3 and compressed the ascending surgeons. Slice collimation 64 × 0.6 mm colon, and abutted the right antero- lateral abdominal wall with no signs Slice width 1.5 mm of invasion. Extensive distribution of Reconstruction 1.0 mm hypodense areas featuring moderate increment ascites was present. Reconstruction D30f Iodine uptake of the mass was kernel measured, and accordingly a core needle biopsy was successfully Contrast 350 mg/mL performed in the most enhanced Volume 100 mL + area. The histological result defined 40 mL saline a pleomorphic sarcoma. Flow rate 3 mL/s Start delay Bolus tracking in the descend- ing aorta at 100 HU + 6s 16 Reprint of SOMATOM Sessions 38 · Oncology · Clinical results 1a 1b 1 Axial (Fig. 1a) and coronal MPR (Fig. 1c) images, and cinematic VRT (Figs. 1b and 1d) images depict a bulky lobulated heterogeneously enhanced mesenteric mass in the right hypochondrial-lumbar region. Extensive distribution of hypodense areas featuring moderate ascites was present. 1c 1d 2a 2b 2 Axial VNC (Fig. 2a), mixed (Fig. 2b), and fused (Fig. 2c) images show the mesenteric mass with hetero- geneous enhancement. A coronal view of the fused image (Fig. 2d) demonstrates the most enhanced area with a significant iodine uptake of 2.7 mg/mL. 2c 2d [37] CT App: VNC/ CM/ Mixed 0 8 Mean: 44 1/ 20 4/ 85 2 HU Area: 1.1 cm2 lodine Density 2 7 mg/ml / 37 6 % Reprint of SOMATOM Sessions 38 · 17 Clinical results · Oncology An incidental find of hepatocellular carcinoma Parang Sanghavi, MD; Bhavin Govindji Jankharia, MD Jankharia Imaging Centre, Mumbai, India History Comments Examination Protocol A 61-year-old male patient, being HCC is the most common primary Scanner SOMATOM treated for diabetes and hyper- malignancy of the liver and is Definition Edge tension, came to the hospital for strongly associated with cirrhosis. a routine ultrasonography (USG) Since enhancement patterns are Scan area Abdomen examination. A liver lesion was the key to correct CT assessment and pelvis detected and a mild increase in of HCCs, a higher contrast-to-noise Scan mode TwinBeam hepatic stiffness was shown. A triple ratio (CNR) is required. TBDE enables Dual Energy phase TwinBeam Dual Energy the simultaneous image acquisition Scan length 318 mm (TBDE) CT scan was requested for at two different energy levels to further evaluation. decompose materials and extract Scan direction Caudo-cranial iodine. Images displayed at a lower Scan time 6 s Diagnosis energy level, e.g. 50 keV, using syngo.CT DE Monoenergetic Plus, Tube voltage AuSn 120 kV Noncontrast CT images showed a have a significantly enhanced con- Effective mAs 248 mAs mild bulge of the Glisson’s capsule trast. Iodine maps as well as virtual Dose CARE Dose4D in segment 6 of the right hepatic noncontrast (VNC) images can be modulation lobe (Fig. 1a). Heterogeneous generated and the iodine uptake enhancement, not visualized in can be quantified, using syngo.CT CTDIvol 5.33 mGy the early arterial phase (Fig. 1b), DE Virtual Unenhanced. These lead DLP 140.4 mGy*cm was barely perceptible in the late to improved conspicuity of contrast arterial / portal venous phase, enhancement and lesion characteri- Rotation time 0.33 s suggesting a solitary subcapsular zation. These images may also serve Pitch 0.45 focal lesion (Fig. 1c), measuring as a baseline in follow-up studies Slice collimation 64 × 0.6 mm 2.2 × 1.5 cm in size. The contrast for treatment response assessment was washed-out in the delayed (1,2,3). Slice width 1.5 mm phase (Fig. 1d). DE Monoenergetic Reconstruction 1.0 mm images displayed at 50 keV (Fig. 1e) increment showed significant improvement in lesion visibility and contrast-to-noise References Reconstruction I30f ratio (CNR). DE iodine maps (Fig. 1f) [1] Lee SH, Lee JM, Kim KW, et al. Dual- kernel energy computed tomography to assess revealed a lesion iodine uptake tumor response to hepatic radiofrequen- Contrast 350 mg/mL of 2.2 mg/mL (Fig. 2). Mild diffuse cy ablation: potential diagnostic value of virtual noncontrast images and iodine Volume 70 mL + nodularity was shown in the hepatic maps. Invest Radiol 2011; 46(2):77–84. 50 mL saline parenchyma, corresponding to chronic liver disease. [2] Mukta D. Agrawal, MBBS, MD, Daniella Flow rate 3 mL/s F. Pinho, MD, Naveen M. Kulkarni et al. Hepatocellular carcinoma (HCC) Oncologic Applications of Dual Energy Start delay Bolus tracking in with liver cirrhosis was suspected, CT in the Abdomen RadioGraphics 2014; the descending 34:589–612. and subsequently confirmed [3] Carlo Nicola De Cecco1, Anna Darnell2, aorta with a by MRI. Marco Rengo1, Giuseppe Muscogiuri et threshold of 100 al. Dual-Energy CT: Oncologic Applica- HU and an addi- tions AJR 2012; 199:S98–S105 tional delay of 6 s 18 Reprint of SOMATOM Sessions 38 · Oncology · Clinical results 1a 1b 1 Axial images acquired in noncontrast (Fig. 1a), arterial (Fig. 1b), portal venous (Fig. 1c), and delayed (Fig. d) phases show a mild bulge of the Glisson’s capsule in segment 6 (arrows), barely perceptible as an enhancing focal lesion. A DE Monoen- ergetic image displayed at 50 keV (Fig. 1e) and iodine mapping (Fig. 1f) demonstrate significantly improved conspicuity of contrast enhancement. 1c 1d 1e 1f 2 [6] CT 2 App: VNC/ CM/ Mixed 0 8 Norm ROICT Axial iodine map shows an enhanc- Mean. 53.6/ 29.4/ 82.3 HU App: Au120/ Gn120 ing focal lesion in segment 6, with Stddev: 13.3/ 11.9/ 15.2 HU Mean: 132.6/ 111.8 HU an increased density of 29.4 HU and Arca: 1.1 cm2 Contrast Enhancement: 75.6 HU lodine Density 2 2 mg/ml / 52 8 % an iodine uptake of 2.2 mg/mL. Reprint of SOMATOM Sessions 38 · 19 Clinical results · Oncology Metastatic clear cell renal cell carcinoma and complicated renal cyst Matthias Benz, MD; Professor Daniel Boll, MD Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland History Comments Examination Protocol A 76-year-old male patient, suffering The differential diagnosis of a newly Scanner SOMATOM from metastatic clear cell renal cell visualized renal lesion becomes Definition Edge carcinoma (RCC), underwent a right- essential for management of the Scan area TAP sided nephrectomy and was post- patient and estimation of the operatively treated with Pazapanib. prognosis.[1] In this case, two renal Scan mode TwinBeam A follow-up thoraco-abdomino-pelvic lesions were visualized and both Dual Energy CT examination was ordered for showed elevated attenuation in the Scan length 648 mm restaging. TwinBeam Dual Energy contrast scanning – does the (TBDE) CT was performed. increased density characterize Scan direction Cranio-caudal contrast enhancement? Traditionally, Scan time 22 s Diagnosis it would require another noncontrast AuSn120 kV scan to find out. However, TBDE CT Tube voltage TBDE CT mixed images revealed two enables simultaneous image acqui- Effective mAs 554 mAs small, regular-shaped renal lesions sition at two different energy levels. Dose CARE Dose4D middle anterior (lesion 1) and The same dataset can be processed modulation – upper posterior (lesion 2) to the left using syngo.CT DE Virtual Unen- kidney, measuring 2.1 × 1.6 cm and hanced to generate virtual non- CTDIvol 11.8 mGy 1.2 × 1.5 cm in size, with elevated contrast images as well as iodine DLP 788.2 mGy*cm attenuation. Lesion 1 was hypodense maps. Comparison of the atten- Effective dose 11.8 mSv in the virtual noncontrast (VNC) uation values in the VNC images, image and showed iodine uptake in mixed images, and iodine maps Rotation time 0.33 s the iodine map and iodine/VNC fused reveal iodine uptake in lesion 1 and Pitch 0.25 image (Figs. 1 and 3). This suggested no uptake in lesion 2, which corre- a metastasis. Lesion 2 remained lates with the lesion characteristics Slice collimation 64 × 0.6 mm hyperdense in the VNC image, and of a metastasis (lesion 1) and a Slice width 1.5 mm showed no iodine uptake in the complicated cyst (lesion 2). In such Reconstruction 1.0 mm iodine map and iodine/VNC fused a clinical scenario, TBDE CT helps increment image (Figs. 2 and 3). The lesion the physician to make a confident demonstrated characteristics com- differential diagnosis. Reconstruction Q30f patible with a complicated cyst kernel (Bosniak category II). Contrast 370 mg/mL References [1] L. Pallwein-Prettner et, al. Assessment Volume 90 mL and characterisation of common renal Flow rate 3 mL/s masses with CT and MRI. Insights Imaging (2011) 2:543–556 Start delay 45 s 20 Reprint of SOMATOM Sessions 37 · Oncology · Clinical results 1a 1b 200 [HU] [17] CT App: VNC/ CM/ Mixed 0.8/ Au120/ Sn120 Mean: 16.9/ 51.9/ 68.5/ 70.8/ 59.6 HU Stddev 8 6/ 7 2/ 11 2/ 11 6/ 14 9 H Min: -5.0/ 33.0/ 38.0/ 38.0/ 19.0 HU Max: 36.0/ 78.0/ 100.0/ 107.0/ 92.0 HU Area: 1.1 cm2 lodine Density: 2.3 mg/ml / ??? 200 [U] IF W 600 500 IF 250 1 Lesion 1 is hypodense in VNC (UR) image and shows clear enhancement in mixed (UL), VNC/iodine fused (LL) and iodine (LR) images (Fig. 1a). DE ROI measurements (Fig. 1b) reveal an increased CT value of 51.9 HU with an iodine density of 2.3 mg/mL. 2 3 IF 2 Lesion 2 is hyperdense in VNC (UR) image and shows no 3 An overview of both lesions. enhancement in mixed (UL), VNC/iodine fused (LL) and iodine (LR) images (A). Reprint of SOMATOM Sessions 37 · 21 Clinical results · Oncology An incidental renal mass Professor Alec J. Megibow, MD Department of Radiology, NYU-Langone Medical Center, NY, USA History Examination Protocol A 75-year-old male patient with fying the iodine uptake, which is recent unexplained bowel obstruction more useful in clinical practice. Scanner SOMATOM was sent for a follow-up CT entero- In this case, the unsuspected renal Definition Edge graphy. TwinBeam Dual Energy (TBDE) mass enhanced 38 HU (CM) from Scan area Abdomen CT was performed. 45.9 HU (VNC) to 83.7 HU (mixed). Scan mode TwinBeam This change in HU would be close Diagnosis to what might be observed if a Dual Energy “traditional” noncontrast CT acqui- Scan length 446 mm TBDE images showed a left renal sition were to be compared to a Scan direction Caudo-cranial soft tissue lesion, measuring contrast-enhanced acquisition. This 1.8×2.1×2.1 cm in size, with approach could eliminate the need Scan time 12.6 s contrast enhancement compatible for a noncontrast scan. The value Tube voltage AuSn120 kV with a renal neoplasm. This was of not having to recall the patient Effective mAs 381 mAs later confirmed by PET. There was for another exam and avoidance of no evidence of bowel obstruction additional exposure is obvious. Dose CARE Dose4D or the presence of any obstructing modulation lesions. The patient subsequently CTDIvol 8.16 mGy underwent partial nephrectomy for this unsuspected lesion. Pathology DLP 387.2 mGy*cm revealed a clear cell renal carcinoma. Effective dose 5.81 mSv Rotation time 0.33 s Comments Pitch 0.3 This is a common scenario, in which Slice collimation 64 × 0.6 mm a finding is observed that would require further testing to charac- Slice width 0.75 mm terize for treatment decision. TBDE Reconstruction 0.5 mm CT is ideally suited for these patients, increment allowing simultaneous acquisition Reconstruction Q40f of high and low kV datasets in a kernel single scan. The dataset can then be processed in syngo.CT DE Virtual Contrast 300 mg/mL Unenhanced to create either a Volume 124 mL virtual noncontrast (VNC) (Fig. 1d) image or an iodine map (Figs. 1a, Flow rate 2.5 mL/s 1c and 2) for presenting and quanti- Start delay 60 s 22 Reprint of SOMATOM Sessions 37 · Oncology · Clinical results 1a 1b A A 1c 1d 2 1 Coronal views of an iodine/mixed fused [25] CT image (Figs. 1a, and 1c, different window App: VNC/ CM/ Mixed 0.8/ Au120/ Sn120 settings) and a mixed image (Fig. 1b) Mean: 45.9/ 38.0/ 83.7/ 85.2/ 77.3 HU show an enhanced left renal lesion Stddev: 19.5/ 15.0/ 11.2/ 11.9/ 32.4 HU (arrow) which was isodense in a VNC Min: -5.0/ 2.0/ 43.0/ 48.0/ -6.0 HU image (Fig. 1d, arrow). The enhancement Max: 87.0/ 74.0/ 110.0/ 111.0/ 154.0 HU is much easier to depict in the iodine/ mixed fused images. Area: 1.0 cm2 lodine Density: 1.7 mg/ml / ??? 2 Quantitative measurements show a significant enhancement of 38 HU in the left renal lesion, with an iodine uptake O of 1.7 mg/mL. IF Reprint of SOMATOM Sessions 37 · 23 Clinical results · Orthopedics Gouty tophi and haglund's deformity in the right foot Merli Matteo, RT; Vincent Tobe, MD; Medico Capo Clinica, MD; Ermidio Rezzonico, RT; Prof. Filippo Del Grande, MD Department of Radiology, Lugano Regional Hospital, Public Cantonal Hospital Corporation, Lugano, Switzerland History Examination Protocol An 84-year-old male patient, suffering crystals in order to aid the clinicians Scanner SOMATOM from long-term arthrosis, had been in distincting gouty arthritis from Definition Edge treated for hyperuricemia. Recently, other types of inflammatory arthritis although the serum uric acid test and also to avoid unnecessary and Scan area Right foot results were normal, the patient had ineffective treatment strategies. Scan mode TwinBeam been complaining of pain in the right Dual Energy foot. A TwinBeam Dual Energy (TBDE) While the chemical composition of CT scan was requested for further uric acid precipitates has unique Scan length 230 mm characteristic patterns of CT numbers evaluation. at high versus low kilovolts (kV), Scan direction Cranio-caudal TBDE CT can acquire high and low kV Scan time 8.4 s Diagnosis datasets simultaneously in a single DECT images revealed small discrete scan thus allowing visualization of Tube voltage AuSn120 kV MSU deposition. This is especially Effective mAs 290 mAs uric acid deposits next to the 1st, 2nd and 3rd metatarsophalangeal helpful in anatomic areas where Dose CARE Dose4D joints. Signs of bone erosion of the aspiration can be difficult to perform modulation 2nd distal metatarsal were also as well as in cases of extra-articular seen. A Haglund’s deformity of the MSU deposits around tendon and CTDIvol 6.2 mGy calcaneus was shown with a bony ligament attachment sites where the DLP 154.2 mGy*cm prominence in the posterior superior analysis of intra-articular SF would Effective dose 0.12 mSv1 aspect and this was associated with reveal negative results. a calcaneus spur. Rotation time 0.5 s A Haglund’s deformity was first described by Patrick Haglund in Pitch 0.35 Comments 1927.[4] It is characterized by an Slice collimation 64 × 0.6 mm Before DECT, synovial fluid aspiration enlargement of the bony section 0.75 mm was accepted as the most reliable of the heel (where the Achilles Slice width way of diagnosing gout. Hereby, tendon is attached) which can Reconstruction 0.5 mm the presence of monosodium urate aggravate the retrocalcaneal bursa increment crystals could be confirmed. The causing bursitis and pain. It is Reconstruction Q30f method does, however, have some also sometimes associated with a kernel inherent limitations such as sampling calcaneus spur.[5] In this case, or interpretation errors.[1, 2, and 3] both diagnoses were made in one Therefore, alternative tests are TBDE scan with an effective dose desirable for the detection of MSU of only 0.12 mSv. 1 Estimated by applying a conversion factor of 0.0008. 24 Reprint of SOMATOM Sessions 37 · Orthopedics · Clinical results 1a 2a 1b V(<0): 0.35 cm3 V(<0): 0 35 cm3 2b 1 DECT images revealed small discrete uric acid deposits next 2 Cinematic rendering (Fig. 2a) and MPR (Fig. 2b) images show to the 1st, 2nd and 3rd metatarsophalangeal joints (in green) Haglund’s deformity of the calcaneus with bony prominence along with signs of bone erosion of the 2nd distal metatarsal in the posterior superior aspect, and this was associated (Fig. 1a, arrow). with a calcaneus spur. References [1] Bongartz T, Glazebrook K N, Kavros S J, [3] von Essen R, Holtta AM, Pikkarainen R. [5] Vaishya R, Agarwal A K, Azizi A T, et al. et al. Dual-energy CT for the diagnosis of Quality control of synovial fluid crystal Haglund’s Syndrome: A Commonly gout: an accuracy and diagnostic yield identification. Ann Rheum Dis 1998, Seen Mysterious Condition: Cureus, study. Annals of the Rheumatic Diseases, 57(2):107-9. 2016, 8(10):e820. 2015, 74(6):1072-1077. [4] Lawrence D A, Rolen M F, Khaled Abi M, [2] Segal JB, Albert D. Diagnosis of et al. MRI of heel pain. American crystal-induced arthritis by synovial fluid Journal of Roentgenology, 2013, examination for crystals: lessons from an 200(4):845-55. imperfect test. Arthritis Care Res 1999, 12(6):376. Reprint of SOMATOM Sessions 37 · 25 Legal information: On account of certain regional The statements and outcomes by Siemens Healthineers limitations of sales rights and service availability, customers described herein are based on results that we cannot guarantee that all products included in were achieved in the customer’s unique setting. Since this brochure are available through the Siemens there is no “typical” hospital and many variables exist Healthineers sales organization worldwide. Availability (e.g., hospital size, case mix, level of IT adoption) and packaging may vary by country and is subject to there can be no guarantee that other customers will change without prior notice. Some/All of the features achieve the same results. and products described herein may not be available in the United States. In clinical practice, the use of ADMIRE and SAFIRE may reduce CT patient dose depending on the clinical task, The information in this document contains general patient size, anatomical location, and clinical practice. technical descriptions of specifications and options A consultation with a radiologist and a physicist should as well as standard and optional features which do be made to determine the appropriate dose to obtain not always have to be present in individual cases. diagnostic image quality for the particular clinical task. Siemens Healthineers reserves the right to modify the design, packaging, specifications, and options described herein without prior notice. Please contact your local Siemens sales representative for the most current information. Note: Any technical data contained in this document may vary within defined tolerances. Original images always lose a certain amount of detail when reproduced. 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