CT-Dual Energy - Applications in Oncology -Tutorial

Hi, this is mode I pushed and welcome back to another tutorial. Of our series of the Land City tutorials today, we're going to focus on dual energy applications in oncology. To an energy city. His. Three major benefits. The first is better delineation and detection of pathology. Second is improved characterization, so we have enhanced capabilities of. Quantifying your findings. And characterizing your findings and the third would be more gentle. Imaging with lesser dose and reducing the necessity for follow-up imaging. In this particular case. The patient was suspected to have vascular pathology, so conventional. See T angiography was performed in arterial and venous face. That you see here in arterial and venous phase. And Nope, vascular pathology was found actually. However, as a side finding patient showed severe liver cirrhosis with this irregular margin of the liver. And some subtle areas of hepatic. Hyper 2 nation. And on standard. Venus images you could already. Have a slight suspicion of the washout phenomenon here, however, only very subtle. With a lower diagnostic confidence. So this patient would actually be rather examined in a. Later he will face as compared to an early editable face like in city angiography. But we didn't know that. In the beginning so. When you reconstruct motor plus images at 40K V. This hypertension areas become by far more conspicuous. For instance, this area here. As. Improve delineation. On the standard material image. It would likely. Be underestimated, it's actually larger. In size. And here we see another hypervascular lesion that you could already. Maybe diagnose on the standard image, but however look at another region here. This region is only. Possible to see if on the motor plus Imagewear, whereas here on this side we. Didn't see the lesion initially so we have improved detection for hypervascular liver lesions. And as a next step we can. On top of this, improved lesion detection rate. We can further characterize the lesion and. So on top of this enhanced lesion delineation and detection rate by locally via. Monogenic images you can see in the iodine map when you draw dual energy region of interests in both the lesion here. When you look at the iron uptake, one for 1.4 milligram per milliliter, that this is significantly increased compared to. Normal liver parenchyma. That of course does not have any iron uptake in the early aterial phase. The same principle works also not only for hypervascular but also for hypo vascular liver lesions in this patient. For instance, with colorectal liver metastasis. This was a staging scan. And on standard images was a very poor contrast condition in this city scan we have a subtle hypat invasion in this area of the liver. The subgroups allow ever here maybe would also be visible, but delineation and also your diagnostic confidence is quite low in that case when you go down to more energetic at 50. Akhavi the donation becomes much easier with a sharp margin to the healthy liver parenchyma or so. This lesion becomes more conspicuous. And then on top. You have an even increased detection rate cause in the right liver lobe another area of hypoattenuation becomes apparent and this is when you compare it side by side. Is actually not visible in this particular scan. So potentially changing the. Clinical course of this patient. Becausw surgery options are different with by lower involvement of metastatic disease, so another case where do Lanja city move more imaging is beneficial for improved lesion detection. The legendary nation has also been investigated for pancreatic adenocarcinoma, where you also where the assessment of the extent of the molecular lesion is crucial. So in this patient here, for instance, with this pancreatic adenocarcinoma, in more energetic images, you have a very distinct delineation of the primary cancer and normally enhancing. Pancreatic parenchyma. And also. Both 55 KV or 40K V may be useful, so depending on your clinical impression in the specific contrast condition. Just try out what works best for you and also As for instance, this case is already a sufficient contrast on standard images, so 55 is a better option, whereas in the last case when we go back here we had a very poor contrast, so 50. Was was chosen and I would personally also suggest to have another look at 40K V to fully exploit the contrast enhancing potential of majetic imaging. So this principle also works very well for the assessment of renal cell carcinoma. For instance, in this patient in CT, images of the nephro genic phase, we already suspect Hypo attenuating area in the mid level of the right kidney, but again. Specially here on the top of the lesion. The donation, for instance here on the very later aside, becomes completely uncertain and very ambiguous. Not easy to define. The exact extent of malignant disease, whereas here when you go towards lower. More getic levels. View my here stands for virtual monostatic imaging. Also, you can call this model. Plus it's the same basically. When you go to 40K V, you have a very improved legend emulation and then also you can be quite certain on the top of the kidney that here is. The start of the healthy. Kidney parenchyma and this was not possible using the standard images. There's also other literature describing the usefulness of iron uptake for the assessment of, for instance, lung carcinoma. Here we see a malignant tumor. Of the right lung, showing distinct iodine uptake. This was further quantified by means of. The add an uptake in milligram per milliliter volume. So I don't imaging allows for a more comprehensive, both qualitative and quantitative analysis in suspected lung carcinoma, and this is actually true for. Almost all malignant primary entities. Kidney cyst is a great application of tool energy sitting. Cause especially not only the detection but the improved lesion characterization. Is is a very important advantage of tool Energy City when you look at this case, for instance with the cystic lateral lesion. Normally we would quantify this in non con images and contrast enhanced images. And then talk about mean. I run related attenuation to define if this is enhancing or not, but it has been shown that the iodine concentration or the island uptake. That we talked about earlier is actually actually allows for better diagnostic accuracy in determining if this lesion is malignant or benign entity, and this paper it has been shown that and I run threshold of 0.5 milligram per milliliter in a renal cystic lesion. Has a sensitivity of 100% an almost perfect specificity of 98% in the diagnosis of malignancy and another benefit again is that you have this measurements with a single contrast enhanced image acquisition. There's no need for true non con, so you have those savings and as an additional benefit you have no miss registration for your measurements unlike Standard City because on. True nonconnah images. It can be very challenging and small cystic lesions to really make and perform reproducible measurement of the lesion. And with that, I thank you very much. And now let's move on to the hands-on part. So this is the patient I showed you before in the presentation that was suspected to have vascular disease and then this hyper attenuation in the liver was found. For instance, actually just. Let's have an overview of the liver and. We see, for instance here. Subtle hyper attenuation. But very indeterminate. If this is HTC. Or maybe just a perfusion defect or aterial venous malformation? So you are really. Your confidence is low. Your detection would also be low and. Just the diagnostics urgency is is low. In that particular case, so let's focus on this lesion here just to give an example. And let's open this patient. In the monogenic plus workflow. No, it's loading and hopefully monogenic. Locate the levels will increase the conspicuity of this hyper 10 huatian so that we can delineate the lesions better and hopefully access. All areas of this cirrhotic parenchyma in a better. In a better fashion, and when we now look at the standard level of 70. This also doesn't get much better. But we. Now let's go down to Ultra lock heavy levels, OK? So this might be in loophole nicely. This lesion here, for instance, is shown as well here. Becomes much easier here. There is potentially HTC here. And by the way, afterwards HTC was Multifocal confirmed Histopathologically. So here are two 2 lesions. These were all not really. Visible and Accessibility of high diagnostic conference when we wouldn't have those tool energy. Additional reconstructions. For instance, here on the upper part of the right lower liver lobe. Large reason here also here. Here are two, so you have seen again. Just focus on this. Lesions, for instance, let me go back just to compare this with the standard. Image impression this would be our now retrospectively we could say OK, I know there is hypertension but initially you. Your confidence would be just too low to make a firm diagnosis. Also. We see a large malignant lesion here on the. Right adrenal gland which was. Then found two. Be a metastasis and also here. We can. Increase the conspicuity of vital areas of the tumor, and here the central necrosis is more. Better to delineate. And also just to. Give an example. It has been shown that I ordered Maps actually. Can very well predict the malignancy of adrenal. Lesions especially in those that are not primary. Hypodense consistent with adenoma. It's often MRI is. Recommended an there's evidence that we can predict the malignancy of renal mass are better using the Android and apps. And again, you would do this just to give an example here. I mean in this case it's quite clear that this is metastasis, but. Just to show this again, you go to. Virtual unenhanced this opens up the the island map. And while this is loading. I would like to show you in another. Example of mood plus, because this is the same patient in the Venus phase also here. Not a very strong item signal, and this was actually the 1st. Investigation reporting out the usefulness of tool energy. City Motor Plus was on liver veins actually and we can see this nicely in this particular patient. For instance, in the decision where the patient with cirrhotic liver disease could. Benefit from and. Intra Patrick Portosystemic shunt the delineation, an diagnosis of liver veins is crucial and in this patient for instance you can barely see the liver veins here for instance you see the liver vein but the other. Veins here probably, it's just like not possible to delineate them in an appropriate fashion. And when you then go. Two more plus. This substantially. Increases your diagnostic. Capabilities to say OK there is like the liver brains are of this diameter, diameter. They're paid and. And so on. Let's just wait a second until this loads. And let's go back to the liver veins. Maybe at this level? Then we go to 40. And we see much better. Visual visualization of the liver veins. And also the portal veins better depicted on monogenic images. So again, a very nice application of motor plus also for venous imaging. So let's go back to our material data set and having. Have you a whole week and? Diagnosis, adrenal metastasis better. Again, this would show a virtual non con. This would be the island overlay image and we would measure this metastasis by normalizing the dual energy. Contrast, for instance, with the order. And then draw this Ahri in a vital area of the tumor. Just refrain of measuring two centralny to avoid. Measurement of necrosis in Iran uptake assessment. Then again, it's very important to extend the arrow I text here in the left upper corner you click that and then you see an iodine density of 1.4 milligram per milliliter, which is actually. Indicates quite an extent of hyper vascularization and malignant potential. Here is another interesting case example how a dual energy city can provide additional information in your diagnosis of oncology city data sets. And can. Provide you all. Another possibility is to. Characterize distance, for instance. We see here the primary tumor was a. Neuroendocrine tumor actually of the right lung nicely shown here. And we see that this lesions is located quite centrally. Is around here the pulmonary artery tree? And maybe this. Could lead to a vessel narrowing at least, so I would like actually to have more contrast in this particular primary artery part here. So let's go to monadic. Plus and increase this contrast a bit more. And we can go down to this. Material segment here. And when we go to 40K V OK, we see a sufficient contrast. Now in this virtual city pulmonary angiography we say see that there is no narrowing of. The vessel. So at least here we can have a higher diagnostic confidence. In our diagnosis. And let's go back to the standard images. And. With any lung tumor. We are always. We always want to diagnose the adrenal gland check for my title, metastatic involvement, and this is quite clear here. On the left side we see this large. Malignant adrenal mass so this is very likely an adrenal metastasis. And when we go to the right side, our diagnosis and conference is not as high we have. Smaller adrenal mass here. This could potentially be a metastasis, but could also be. Like it's. Slightly hypo, more hyper dense than this lesion here. This could also be an adenoma even if this is unlikely with the history of the patient an our findings so far, so let's characterize this lesion. A bit more. Using our item Maps and virtual noncontrast images, we click for this purpose here on liver virtual contrast. And first, now we can have with a single contrast enhanced dual energy reconstruction series. We can measure this lesion now in our virtual unenhanced phase. Which. Would look like that. So let's. Go and normalize or contrast for the 1st. Powered and then measure this. Lesion here with the dual Angie region of interest and now we get all this. Dual energy values actually. And we see now this can be an adenoma cause we have on virtual and contrast. We have a primary. Density of this lesion of 27 Hounsfield so this is very unlikely to be an abnormal. It's more suspicious in suggestive of metastatic disease. Here, and this is further supported by the contrast enhancement. So on standard images this would enhance or this actually enhances 288 Hounsfield numbers with a relative enhancement of 61 Hounsfield units. Also very suggestive for American lesion rather than a benign adenoma. And the most important value get from the item Maps is the iron density itself, cause it indicates the perfusion and blood uptake of this. Lesion and with 2.8 milligram per milliliter. This is actually already. Quite a bit. If you just compare this, for instance to. Muscle tissue here you would have 0.6 milligram per milliliter. Or liver. In this area would be 1.8 milligram, but substantially lower than this malignant lesion. So this provides you with better characterization of this lesion. OK, let's go back to our standard images. As I mentioned before, always keep the source images in mind. Maybe remove this circle and also hide the lines. So we go more towards the pelvis. And evaluate this also for. Or call the staging and look at this massive and extensive metal artifacts because the patient has bilateral hip endoprosthesis. This is actually a substantially hampering the evaluation of the cowdell pelvis, especially when you go here on the dorsal parts of the bladder. Ask the rectum. Is not easy to. See what's going on here so we would like to reduce this artifacts and we can also do this with more getic plus. When we click that now. Before we had we were interested in this high contrast images. Now we will be more. Focus on. The higher. KAVI levels and let's choose, for instance, a level of 120 and see if this is reducing our artifacts, and this looks actually much better, so we can actually. Assess the pelvic, the pelvis in a much better way, and let's compare this also with all prior. Image so this was actually our source image. Extensive metal artifacts with mono plus at the appropriate energy levels. This substantially reduced. Still difficult in this patient, but again in challenging scenarios dual energy has many options too. Overcome specific problems and to aid you in your diagnosis. So I hope this was helpful and see you next time.

Energy CT CT Dual Energy CT CT CT CT CT CT Dual Energy Energy CT Dual Energy 200 IODINE UPTAKE FOR ASSESSMENT OF LUNG CARCINOMA IMPROVED LESION DELINEATION AND VISUALIZATION IMPROVED LESION DELINEATION AND VISUALTERIZATION IMPROVED LESION CHARACTERIZATION - KIDNEY ASSESSMENT OF RENAL CELL CARCINOMA IMPROVED LESION VISUALIZATION IMPROVED LESION DELINEATION AND CHARACTERIZATION o, o. CT Dual Energy Energy Energy [7] CT Visual assessment Quantification of iodine uptake VMI+ 55 Standard mixed venous Standard mixed 55 Standard mixed venous Standard mixed Standard mixed arterial Standard mixed arterial Standard mixed anteriai Iodinemap Iodine map Virtual virtual App VNC/ CM/ Mixed 0 6/ 100/ Sni50 Mean iodine-related attenuation: 13.6 HU Please note that the learning material is for training purposes only! Mean: 27 87 81 107 1/ 58 9 Mean: 87 8/ 107 1/ 58_9 Mean: 27 60 91 87 8/ 107 1/ 58 9 Mean: 27 87 8/ 107 1/ 58 9 Mean: 27 41 87 81 107 1/ 58 9 Mean: 27 4/ 60 87 8/ 107 1/ 58 9 Mean: 27 41 87 8/ 107 1/ 58 9 Mean: 27 4/ 87 8/ 107 1/ 58 9 Mean: 27 41 8/ 107 1/ 58 9 WonoenergeticA Won oenergetic Plus Wonoenergetic Plus Vonoenergetic Plus Wonoerergetic Plus Wonoenergetic Ptus runoenergetic Plus Wonoenergetic Monoenergetic Plus Vonoenergetic Aus vanoene tic Plus Vonoene Plus Vonoenergetic Alus ronoenergetic Plus Plus ean iodine concentration: 0.7 mg/ml iodine -gso 14 7/ 153/ 15 14 7/ 153/ 15 9/20.9/24.1 7/ 153/ 15 9/20.9/24.1 Mixe Stddev: 14 7/ 15.3/ 15.9/20.9/24.1 Il 3071 S —- Min: -13.0/24 0/34.0/42.0/-20 Min: -13.0/24.0/ 34.0/42.0/-20 Min: -13.0/24 0/34.0/42.0/-20 Reacng Reading MM Reacng Reacing Rearing Max: 60.0/94.0/ 124.0/ 151.0/ 120.0 HU 990/11 KW Gemischt O Luno Area: 0.9 Area: 0.9 cm2 Area: 0.9 crn2 Reading Stdabw 13.5,' 12.0/ 13.1 Stdabw 13.5,' 12.0/' 13.1 Stdabw 18.3/' 17.2/20.6 HU Lung Iodine Density: 2.8 mg/ml 147.6 % Iodine Density: 2.8 mg/ml 14(.6 % Iodine Density: 2.8 mg/ml 14>.6 % Iodine Density: 2.08 mg/ml 147.6 % odine Density: 2.8 mg/ml 147.6 % Flache 1.5 cm2 1.5 cm2 Reading MM Rearing MM Reaong Rearing Fat Fraction: 20.5 % Fat Fraction: 20.5% Joddichte 0.0 / Joddichte• mg/ml / Joddichte• / Joddichte mg/ml ??? Éettanteil: -0.8 % Éettanteil. -0.8 % Harn Plaques Plaques Reading CT Reading Reacing APPLICATIONS IN ONCOLOGY Art* VNCJ KW Gemischt OS Art* KW Gemischt OS Arm VNCJ KW Gemischt OS Anw VNC/ KM/ Gemischt 0.5 VNCJ KW Gemischt 0.5 593 egg Stdabw 17.2/20.6 HU Stdabw 18.3.' 17.2/20.6 HU Stdabw 13.5/' 12.0/ 13.1 Stdabw 18.3/' 17.2/20.6 HU Stdabw The herein illustrated statements made by Siemens' customers and physicians are based on their own Flache 1.6frn2 Mean iodine-related attenuation: 17.7 HU Joddichte mg/ml ??? Joddichte 0.0 / Jodd.chte / ??? Jodichte / ??? Jodichte ??? Fettantell 0.0'.% Fettantell Fettantell 0.0% Fettantell 0.01% Fettantedl and discrete opinion. The speaker is responsible for obtaining permission to use any previously Mean iodine concentration: 0.7 mg/ml Mean iodine concentrati n: 0.7 mg/ml Mean iodine-related attenuation: 13.6 HU Mean iodine-related attenuation: 17.7 HU Mean iodine-related enuation: 13.6 HU Mean iodine-related atte nuation: 13.6 HU Mixed Mix Mixe Mean iodine concentrati n: 0.7 mg/ml : 0.6 mg/mL Mean iodine concentra Perfusion map Non small-cell lung carcinoma shows distinct iodine [Il CT Hypervascular lesions with venous wash-out Hypervascular lesions With venous wash-out App: VNC/ CW Mixed 0.5/90/ sni50 All names and data of patients, parameters and configuration dependent designations are fictional [1] CT [7] CT uptake, which can be further quantified Sensitivity Specificity information in this material contains general technical descriptions of specifications and options as well App: VNC/ CW Mixed 0.5/90/ Sni50 Mean. 66.8/34.3/ 101.81117.8/ 85.3 and examples only. Mean. 66.8/34.3/ 101.81117.8/ 85.3 HU in mg/ mL volume [email protected] Min: -3.0/-21.0146 0/ 29.0/-22_0 HU Min: -3.0/-21.0146 0/29.0/-22_0 HU Stddev: 20.3/20.8/23.6 HU Stddev: 20.3/20.8/23.6/ 32.1/32.7 HU VMI+ 40 Iodine-related attenuation: 15 93.3% 91000/0 91.4% 97.7% 93.3% Standard mixed venous Standard mixed Standard n 55 15 o Findings Navigator Max: Area: 1.4 cm2 Min: -3.0/-21.0146.0/ 29.0/-22.0 HU Max: 60.0/94.0/ 124.0/ 151.0/ 120.0 HU Max: 129.0/97.0/ 168.0/218.0/ 130.0 HU Area: 1 4 cm2 Area: 1.4 cm2 Iodine concentration: 0.5 mg/mL : 0.6 mg/mL 1000/0 91.4% 93.3% 97.7% MORITZ H. ALBRECHT, MD Iodine Density' 14 mg/ml 11 _8 % Iodine Density' 1.4 mg/ml 11 _8 % 0.6 mg/mL VMI+ facilitates the delineation and detection of hypervascular liver Iodine imaging allows for more o Findings Navigator Low kev VMI+ reconstructions allow improved assessment of hypovascular comprehensive both qualitative and quant tati\ VMI+ at low energies (55 keV) allows improved pancreas-to-lesion contrast in the future availability of said Functionalities in any specific country is not guaranteed. Please contact your Measuring the iodine concentration improves diagnostic accuracy for the detection of Due to regulatory reasons their availability cannot be guaranteed. Please contact your local Siemens lesions (HCC) In nephrogenic phase images, the VMI+ algorithm enhances the conspicuity oi Lung abscess shows liver lesions analyis in suspected lung carcinoma malignant renal cysts compared to traditional HU measurements the diagnosis of pancreatic adenocarcinoma only peripheral enhancement hypodense renal cell carcinomas Perfusion maps further aid in lesion characterization Another benefit: no misreqistration for HU measurement unlike standard CT roc Is Better visualization of colorectal liver metastases and greater sensitivity Tools Frellesen, Wichmann, Bauer et al, EJR 2015 Frel/esen, Wichmann, Bayer et al, EJR 2015 Martin, Albrecht, EJR 2017 Otrakji, Kalra et al, RadioGraphics 2016 Mileto, Marin al., AJR 2014 Tools Mixing Ratio Ratio pu