Multi-slice Helical CT Scanning of the Chest

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1 Multi-slice Helical CT Scanning of the Chest Comparison of different low-dose acquisitions Lung cancer is the main cause of deaths due to cancer in human males and the incidence is constantly increasing. A cure rate of only 10% has been reported because most neoplastic lesions are diagnosed too late. However, when lung cancer is diagnosed early and surgical resection performed (stage 1 cancer), 5-year survival is significantly improved and may reach 70%. Elisabeth Asquier MD*, Laurent Brunereau MD*, Florence Fauchier MD*, Philippe Bertrand MD*, Etienne Lemarié MD**, Philippe Rouleau MD* Departments of Radiology* and Pneumology** CHRU Bretonneau, F Tours cedex 01, France time of series and yields thinner sections (5-8 mm) of the entire lung region in a single breath-hold acquisition (10-15 s). In this paper, we used the Multi-slice CT technique to compare several protocols of low-dose CT of the chest with normal-dose CT (150 mas) for the detection of pulmonary nodules or masses and to evaluate the X-ray dose delivered by low-dose and normal-dose Screening for early lung cancer in smokers has been discussed for many years. There are too many limitations and false-negative cases for chest radiography to be accepted as an accurate screening method. Helical CT with the usual X-ray dose ( mas) is superior to chest radiography in the detection of small pulmonary nodules and stage 1 cancer. However, use of this method for annual screening of lung cancer is limited by its irradiation levels, which are significantly higher than that of chest radiography. Helical CT with a low X-ray dose is a promising new technique to screen for early lung cancer, and its accuracy in the detection of small pulmonary nodules has already been reported in previous studies using single-slice CT technology and 10 mm slice thickness. New multislice CT technology providing 4 images per tube rotation has recently been introduced. This technology significantly reduces the acquisition Materials and methods CT examinations All CT examinations were performed on a multi-slice CT scanner (Aquilion Multi, Toshiba Medical Systems, Tokyo, Japan). Eight low-dose protocols with various tube currents (10, 25 mas), various slice thicknesses (5, 8 mm) and various pitches (4.5, 5.5) were compared to a standard normal-dose CT scan of the chest. Parameters of all acquisitions are detailed in table 2. All acquisitions were identically placed on the entire lung region and performed with a single breathhold. Patients We decided to include ten patients per lowdose protocol to compare each of these protocols with our standard normal-dose acquisition. From March 2000 to September 2000, all patients with pulmonary nodules or masses Fig. 1: Agreement between low-dose (8/4.5/8-25 mas) acquisition (left) and normal-dose acquisition (right): Nodule of 7 mm in diameter located in the ventral segment of the right upper lobe which was equally demonstrated by low-dose and normal-dose 12

2 Fig. 2: Overestimation of low-dose (8/4.5/8-25 mas) acquisition (A) Peripheral opacity located in the ventral segment of the right upper lobe interpreted as a nodule on the low-dose acquisition but which was only a small peripheral atelectasis on the normal-dose acquisition. Fig. 3: Underestimation of low-dose (8/4.5/8-25 mas) acquisition (A) Nodule located in the middle lobe clearly demonstrated by the normal-dose acquisition but ill-defined on the low-dose acquisition. Note a second nodule located in the right lower lobe which was well-defined on both low-dose and normal-dose (not shown) Fig. 4: Agreement (8/5.5/8-25 mas) acquisition (A) and normal-dose Nodules of 5 mm in diameter located in both lower lobes which were equally demonstrated by low-dose and normal-dose Multi-slice CT Fig.5: Overestimation of low-dose (8/5.5/8-25 mas) acquisition (A) Peripheral opacity located in the apical segment of the right lower lobe interpreted as a nodule on the low-dose acquisition but which was a focal pleural thickening on the 13

3 Fig. 6: Overestimation of low-dose (8/5.5/8-25 mas) acquisition (A) compared to normal-dose Peripheral opacity located in the apical segment of the right upper lobe interpreted as a nodule on the low-dose acquisition but which was only a vascular bifurcation on the normal-dose acquisition. Fig. 7: Agreement between low-dose (8/4.5/8-10 mas) acquisition (A) and normaldose Nodules of 5 mm in diameter located in the lingula which was equally demonstrated by low-dose and normal-dose Note a bilateral fibrosis related to radiotherapy in apical segments of both lower lobes. Fig. 8: Agreement between low-dose (8/4.5/8-10 mas) acquisition (A) and normaldose Nodules of 7 mm in diameter located in the middle lobe which was equally demonstrated by low-dose and normal-dose Note a right pleural effusion responsible for a total collapse of the right lower lobe. 14 revealed by standard normal-dose CT of the chest underwent an additional randomized lowdose protocol in the same examination. Eighty patients, were included in the study: 48 male and 32 female, aged years (mean age = 59.9 ± 14.7 years). Table 1 Protocol 1: SE = 50% - PPV = 11% Protocol 2: SE = 62% - PPV = 71% Protocol 3: SE = 66% - PPV = 50% Protocol 4: SE = 75% - PPV = 33% Protocol 5: SE = 80% - PPV = 4% Protocol 6: SE = 100% - PPV = 80% Protocol 7: SE = 87% - PPV = 77% Protocol 8: SE = 72% - PPV = 63% Data collection CT evaluation: Analysis of low-dose and normal-dose CT was performed on a dedicated workstation (Alatoview 1.25, Toshiba Medical Systems, Tokyo, Japan) by two experienced radiologists, for each patient. Reviewers were blinded to the scanning parameters used to acquire the CT images. Image quality, number of nodules and size of nodules were independently evaluated for each acquisition as follows: Image quality: Image noise was assessed as the standard deviation (SD) of a large artefact-free region of interest identically placed

4 outside the thorax (air) at the level of the aortic arch on both low-dose and normal-dose Visual analysis of three normal anatomical structures (intermediate bronchus, left inferior pulmonary vein, left inferior pulmonary artery) was performed. When the edges of these structures were well-defined, analysis was classified as excellent. In contrast, when the edges of these structures were ill-defined, analysis was classified as poor. Number of nodules: The number of nodules was recorded for each acquisition. Size of nodules: The size of the smallest and largest nodules were recorded for each acquisition. Absorbed dose evaluation: The absorbed dose delivered by each CT acquisition was quantified with a CTDI body phantom of 32 cm in diameter. This phantom had five channels 1 cm in diameter, for introduction of a 10 cm ionization chamber. One channel was located at the center of the phantom and four channels were located 1 cm beneath the surface of the phantom at 3, 6, 9 and 12 o clock positions. The weighted CTDI (CTDI W ) was cal- Fig. 9: Underestimation of low-dose (8/4.5/8-10 mas) acquisition (A) Nodule located in the right upper lobe clearly demonstrated by the normal-dose acquisition but ill-defined on the low-dose acquisition. This discrepancy between both acquisitions was due to severe noise generated by both shoulders on the low-dose acquisition. Fig. 10: Agreement between low-dose (8/5.5/8-10 mas) acquisition (A) and normal-dose three nodules of 20, 20 and 5 mm in diameter located in both upper lobes which was equally demonstrated by low-dose and normal-dose Multi-slice CT Fig. 11: Underestimation of low-dose (8/5.5/8-10 mas) acquisition (A) compared to normal-dose Nodule located in the apical segment of the left lower lobe clearly demonstrated by the normal-dose acquisition but interpreted as a vascular bifurcation on the low-dose acquisition. 15

5 Fig. 12: Overestimation of low-dose (8/5.5/8-10 mas) acquisition (A) Peripheral opacity located in the left upper lobe interpreted as a nodule on the low-dose acquisition but which was only a peripheral atelectasis on the normaldose acquisition. Fig. 13: Agreement (5/4.5/5-25 mas) acquisition (A) and normal-dose Two nodules of 8 and 5 mm in diameter located in the middle lobe and the lingula which were equally demonstrated by low-dose and normal-dose Fig. 14: Agreement (5/4.5/5-25 mas) acquisition (A) and normal-dose Nodule of 10 mm in diameter located in the left lower lobe which was equally demonstrated by low-dose and normal-dose Fig. 15: Overestimation of low-dose (5/4.5/5-25 mas) acquisition (A) Small opacity located in the apical segment of the left lower lobe interpreted as a nodule on the low-dose acquisition but corresponding to a vascular bifurcation on the normal-dose acquisition. 16

6 Table 2: DLP (30 cm) for lowdose and normal-dose DLP (mgy) low-dose CT 1: 8/4.5/8-25 mas : 8/4.5/8-10 mas : 8/5.5/8-25 mas : 8/5.5/8-10 mas : 5/4.5/5-25 mas : 5/4.5/5-10 mas : 5/5.5/5-25 mas : 5/5.5/5-10 mas normal-dose CT 3/3.5/5-150 mas 571 Noise Nod number Min size Max size Protocol 1 p = 0.86 (ns) p = (s) p = (s) p = 0.16 (ns) Protocol 2 p = (s) p = 0.68 (ns) p = 0.93 (ns) p = 0.24 (ns) Protocol 3 p = (s) p = 0.75 (ns) p = 0.07 (ns) p = 0.2 (ns) Protocol 4 p = (s) p = 0.40 (ns) p = 0.31(ns) p = 0.48 (ns) Protocol 5 p = (s) p = 0.12 (ns) p = 0.05 (ns) p = 0.55 (ns) Protocol 6 p = (s) p = 1 (ns) p = 0.46 (ns) p = 0.35 (ns) Protocol 7 p = (s) p = 1 (ns) p = 0.50 (ns) p = 0.17 (ns) Protocol 8 p = (s) p = 0.35 (ns) p = 0.93 (ns) p = 0.77 (ns) Table 3: Comparison of low-dose protocols and normal-dose CT in the evaluation of noise (Noise), number of nodules (Nod Number), minimum and maximum sizes of nodules (Min size, Max size). Wilcoxon matched pairs test: p<0.05 = statistically significant difference (s) p > 0.05 = non significant (ns). Multi-slice CT culated as the sum of 2/3 of the peripheral dose and 1/3 of the central dose within the phantom. CTDI W was determined for the eight lowdose protocols and for the normal-dose CT, with an aquisition of 10 cm and extrapolated to a Dose Length Product (DLP) of 30 cm. Results Image quality: In comparison with normaldose CT, noise was significantly higher in all lowdose protocols except in protocol 1 (table 3). On the other hand, analysis of anatomical structures was comparable in low-dose protocols and in normal-dose CT. Number of nodules: There was no statistically significant difference in the detection of nodules protocols and normal-dose CT except in protocol 1 (table 3). In addition, by using normal-dose CT as a standard of reference, we were able to calculate sensitivity (SE) and positive predicting value (PPV) for each lowdose protocol in evaluation of the number of nodules (table 1). There was therefore a tendency for 5mm protocols to be more accurate than 8 mm protocols: low-dose protocols using 8 mm slice thickness overestimated the number of nodules in 20 cases (from 1 to 7 nodules), underestimated them in 7 cases (from 1 to 3 nodules) and were in agreement with normal-dose CT in 13 cases. Low-dose protocols using 5 mm slice thickness overestimated the number of nodules in 12 cases (from 1 to 2 nodules), underestimated them in 4 cases (1 nodule) and were in agreement with normal-dose CT in 24 cases. Overestimation of the number of nodules was especially due to misinterpretation of peripheral atelectases, vascular bifurcations or focal pleural thickening. Underestimation of the number of nodules was especially due to the presence of small nodules with low attenuation and to severe noise in the upper part of the lungs related to attenuation of the X-ray beam by the shoulders. Size of nodules: There were no statistically significant differences in the evaluation of the size of the smallest and largest nodules between low-dose protocols and normal-dose CT, except in protocol 1 (table 3). Absorbed dose: All doses are detailed in table 2. Conclusion Low-dose CT of the chest seems to be a reliable method to detect pulmonary nodules and to define their size. There is, however, a tendancy to overestimation of the number of nodules due to confusion with normal vascular structures, local atelectases and pleural thickening. Protocols using 5 mm slice thickness and 10 mas tube current appear to be the best compromise in terms of accuracy and dose. 17

7 Fig. 16: Agreement (5/5.5/5-25 mas) acquisition (A) and normal-dose acquisition (B): Nodule of 8 mm in diameter located in the left lower lobe which was equally demonstrated by low-dose and normal-dose Fig. 17: Agreement (5/5.5/5-25 mas) acqui-sition (A) and normal-dose acquisition (B): Multiple nodules between 2 and 20 mm in diameter located in both lungs which were equally demonstrated by low-dose and normal-dose Fig. 18: Overestimation of low-dose (5/5.5/5-25 mas) acquisition (A) compared to normal-dose acquisition (B): Small opacity located in the middle lobe interpreted as a nodule on the low-dose acquisition but corresponding to a vascular bifurcation on the normal-dose acquisition. Fig. 19: Agreement (5/4.5/5-10 mas) acquisition (A) and normaldose Nodule of 8 mm in diameter located in the right lower lobe which was equally demonstrated by low-dose and normal-dose 18

8 Fig. 20: Agreement 5/4.5/ 5-10 mas) acquisition (A) and normal-dose Nodule of 2 mm in diameter located in the right lower lobe which was equally demonstrated by low-dose and normal-dose acquisitions Fig. 21: Agreement between low-dose (5/4.5/5-10 mas) acquisition (A) and normal dose Nodule of 20 mm in diameter located in the lingula which was equally demonstrated by low-dose and normal-dose Fig. 22: Agreement between low-dose (5/5.5/ 5-10 mas) acquisition (A) and normal-dose Nodule of 8 mm in diameter located in the left upper lobe which was equally demonstrated by low-dose and normal-dose Multi-slice CT Fig. 23: Underestimation of low-dose (5/5.5/5-10 mas) acquisition (A) compared to normal-dose Nodule located in the right lower lobe clearly demonstrated by the normal-dose acquisition but ill-defined on the low-dose acquisition. 19

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