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Background Pulmonary MRI with ultrashort echo time (UTE) has been compared with chest CT for nodule detection and classification. However, direct comparisons of these methods' capabilities for Lung CT Screening Reporting and Data System (Lung-RADS) evaluation remain lacking. Purpose To compare the capabilities of pulmonary MRI with UTE with those of standard- or low-dose thin-section CT for Lung-RADS classification. Materials and Methods In this prospective study, standard- and low-dose chest CT (270 mA and 60 mA, respectively) and MRI with UTE were used to examine consecutive participants enrolled between January 2017 and December 2020 who met American College of Radiology Appropriateness Criteria for lung cancer screening with low-dose CT. Probability of nodule presence was assessed for all methods with a five-point visual scoring system by two board-certified radiologists. All nodules were then evaluated in terms of their Lung-RADS classification using each method. To compare nodule detection capability of the three methods, consensus for performances was rated by using jackknife free-response receiver operating characteristic analysis, and sensitivity was compared by means of the McNemar test. In addition, weighted κ statistics were used to determine the agreement between Lung-RADS classification obtained with each method and the reference standard generated from standard-dose CT evaluated by two radiologists who were not included in the image analysis session. Results A total of 205 participants (mean age: 64 years ± 7 [standard deviation], 106 men) with 1073 nodules were enrolled. Figure of merit (FOM) ( P < .001) had significant differences among three modalities (standard-dose CT: FOM = 0.91, low-dose CT: FOM = 0.89, pulmonary MRI with UTE: FOM = 0.94), with no evidence of false-positive findings in participants with all modalities ( P > .05). Agreements for Lung-RADS classification between all modalities and the reference standard were almost perfect (standard-dose CT: κ = 0.82, P < .001; low-dose CT: κ = 0.82, P < .001; pulmonary MRI with UTE: κ = 0.82, P < .001). Conclusion In a lung cancer screening population, ultrashort echo time pulmonary MRI was comparable to standard- or low-dose CT for Lung CT Screening Reporting and Data System classification. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Wielpütz in this issue.

Over the past few decades, pulmonary imaging technologies have advanced from chest radiography and nuclear medicine methods to high-spatial-resolution or low-dose chest CT and MRI. It is currently possible to identify and measure pulmonary pathologic changes before these are obvious even to patients or depicted on conventional morphologic images. Here, key technological advances are described, including multiparametric CT image processing methods, inhaled hyperpolarized and fluorinated gas MRI, and four-dimensional free-breathing CT and MRI methods to measure regional ventilation, perfusion, gas exchange, and biomechanics. The basic anatomic and physiologic underpinnings of these pulmonary functional imaging techniques are explained. In addition, advances in image analysis and computational and artificial intelligence (machine learning) methods pertinent to functional lung imaging are discussed. The clinical applications of pulmonary functional imaging, including both the opportunities and challenges for clinical translation and deployment, will be discussed in part 2 of this review. Given the technical advances in these sophisticated imaging methods and the wealth of information they can provide, it is anticipated that pulmonary functional imaging will be increasingly used in the care of patients with lung disease. © RSNA, 2021 Online supplemental material is available for this article.

Purpose: To determine the image quality improvement including vascular structures using deep learning reconstruction (DLR) for ultra-high-resolution CT (UHR-CT) and area-detector CT (ADCT) compared to a commercially available hybrid-iterative reconstruction (IR) method., Materials and Method: Thirty-two patients suspected of renal cell carcinoma underwent dynamic contrast-enhanced (CE) CT using UHR-CT or ADCT systems. CT value and contrast-to-noise ratio (CNR) on each CT dataset were assessed with region of interest (ROI) measurements. For qualitative assessment of improvement for vascular structure visualization, each artery was assessed using a 5-point scale. To determine the utility of DLR, CT values and CNRs were compared among all UHR-CT data by means of ANOVA followed by Bonferroni post hoc test, and same values on ADCT data were also compared between hybrid IR and DLR methods by paired t test., Results: For all arteries except the aorta, the CT value and CNR of the DLR method were significantly higher compared to those of the hybrid-type IR method in both CT systems reconstructed as 512 or 1024 matrixes (p < 0.05)., Conclusion: DLR has a higher potential to improve the image quality resulting in a more accurate evaluation for vascular structures than hybrid IR for both UHR-CT and ADCT.

Purpose: To evaluate the capability ML-based CT texture analysis for improving interobserver agreement and accuracy of radiological finding assessment in patients with COPD, interstitial lung diseases or infectious diseases., Materials and Methods: Training cases (n = 28), validation cases (n = 17) and test cases (n = 89) who underwent thin-section CT at a 320-detector row CT with wide volume scan and two 64-detector row CTs with helical scan were enrolled in this study. From 89 CT data, a total of 350 computationally selected ROI including normal lung, emphysema, nodular lesion, ground-glass opacity, reticulation and honeycomb were evaluated by three radiologists as well as by the software. Inter-observer agreements between consensus reading with and without using the software or software alone and standard references determined by consensus of pulmonologists and chest radiologists were determined using κ statistics. Overall distinguishing accuracies were compared among all methods by McNemar's test., Results: Agreements for consensus readings obtained with and without the software or the software alone with standard references were determined as significant and substantial or excellent (with the software: κ = 0.91, p < 0.0001; without the software: κ = 0.81, p < 0.0001; the software alone: κ = 0.79, p < 0.0001). Overall differentiation accuracy of consensus reading using the software (94.9 [332/350] %) was significantly higher than that of consensus reading without using the software (84.3 [295/350] %, p < 0.0001) and the software alone (82.3 [288/350] %, p < 0.0001)., Conclusion: ML-based CT texture analysis software has potential for improving interobserver agreement and accuracy for radiological finding assessments in patients with COPD, interstitial lung diseases or infectious diseases., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background Deep learning may help to improve computer-aided detection of volume (CADv) measurement of pulmonary nodules at chest CT. Purpose To determine the efficacy of a deep learning method for improving CADv for measuring the solid and ground-glass opacity (GGO) volumes of a nodule, doubling time (DT), and the change in volume at chest CT. Materials and Methods From January 2014 to December 2016, patients with pulmonary nodules at CT were retrospectively reviewed. CADv without and with a convolutional neural network (CNN) automatically determined total nodule volume change per day and DT. Area under the curves (AUCs) on a per-nodule basis and diagnostic accuracy on a per-patient basis were compared among all indexes from CADv with and without CNN for differentiating benign from malignant nodules. Results The CNN training set was 294 nodules in 217 patients, the validation set was 41 nodules in 32 validation patients, and the test set was 290 nodules in 188 patients. A total of 170 patients had 290 nodules (mean size ± standard deviation, 11 mm ± 5; range, 4-29 mm) diagnosed as 132 malignant nodules and 158 benign nodules. There were 132 solid nodules (46%), 106 part-solid nodules (36%), and 52 ground-glass nodules (18%). The test set results showed that the diagnostic performance of the CNN with CADv for total nodule volume change per day was larger than DT of CADv with CNN (AUC, 0.94 [95% confidence interval {CI}: 0.90, 0.96] vs 0.67 [95% CI: 0.60, 0.74]; P < .001) and CADv without CNN (total nodule volume change per day: AUC, 0.69 [95% CI: 0.62, 0.75]; P < .001; DT: AUC, 0.58 [95% CI: 0.51, 0.65]; P < .001). The accuracy of total nodule volume change per day of CADv with CNN was significantly higher than that of CADv without CNN ( P < .001) and DT of both methods ( P < .001). Conclusion Convolutional neural network is useful for improving accuracy of computer-aided detection of volume measurement and nodule differentiation capability at CT for patients with pulmonary nodules. © RSNA, 2020 Online supplemental material is available for this article.

Purpose: To directly compare the utility for therapeutic outcome prediction of dynamic first-pass contrast-enhanced (CE)-perfusion area-detector computed tomography (ADCT), MR imaging assessed with the same mathematical method and 2-[fluorine-18]-fluoro-2-deoxy-d-glucose-positron emission tomography combined with CT (PET/CT) for non-small cell lung cancer (NSCLC) patients treated with chemoradiotherapy., Materials and Methods: Forty-three consecutive stage IIIB NSCLC patients, consisting of 25 males (mean age ± standard deviation: 66.6 ± 8.7 years) and 18 females (66.4 ± 8.2 years) underwent PET/CT, dynamic CE-perfusion ADCT and MR imaging, chemoradiotherapy, and follow-up examination. In each patient, total, pulmonary arterial, and systemic arterial perfusions were calculated from both perfusion data and SUV max on PET/CT, assessed for each targeted lesion, and averaged to determine final values. Receiver operating characteristics analyses were performed to compare the utility for distinguishing responders from non-responders using Response Evaluation Criteria in Solid Tumor (RECIST) 1.1 criteria. Overall survival (OS) assessed with each index were compared between two groups by means of the Kaplan-Meier method followed by the log-rank test., Results: Area under the curve (Az) for total perfusion on ADCT was significantly larger than that of pulmonary arterial perfusion (P < 0.05). Az of total perfusion on MR imaging was significantly larger than that of pulmonary arterial perfusion (P < 0.05). Mean OS of responder and non-responder groups were significantly different for total and systemic arterial (P < 0.05) perfusion., Conclusion: Dynamic first-pass CE-perfusion ADCT and MR imaging as well as PET/CT are useful for early prediction of treatment response by NSCLC patients treated with chemoradiotherapy.

Purpose: To compare the effect of different acquisition and reconstruction methods on the radiation dose and accuracy of CT number measurements, using a 320-detector row CT and a Quantitative Imaging Biomarker Alliance (QIBA) recommended phantom., Materials and Methods: Acquisitions were performed on a 320-detector row CT, as 64- and 80-detector row helical and wide detector step-and-shoot (i.e., wide volume) acquisitions with tube currents of 400 mA, 100 mA, 50 mA, 20 mA, and 10 mA. Image was reconstructed with the filtered back projection (FBP), adaptive iterative dose reduction using 3D processing (AIDR 3D), and forward projected model-based iterative reconstruction (FIRST) methods. The difference between measured CT numbers and the actual -856HU value of the phantom insert was determined by each CT acquisition protocol. Differences in actual and measured CT numbers were compared among acquisitions and among reconstruction methods by means of Tukey's HSD test., Results: The CT number obtained with 64-detector row helical acquisition was significantly larger than that obtained with others (p < 0.0001). At each tube current, the CT number reconstructed with FIRST was significantly smaller than that with others (p < 0.0001)., Conclusion: Acquisition and reconstruction methods are significantly affecting radiation dose reduction and accuracy of CT number measurements on a phantom study.

Quantitative features obtained from computed tomography (CT) scans are being explored for clinical applications. Various classes of quantitative features exist for chest CT including radiomics features, emphysema measurements, lung nodule volumetric measurements, dual energy quantification, and perfusion parameters. A number of research articles have shown promise in diagnosis and prognosis prediction of oncologic patients or those with diffuse lung diseases using these feature classes. Nevertheless, a prerequisite for the quantification is the evaluation of variation in measurements in terms of repeatability and reproducibility, which are distinct aspects of precision but are often not separable from each other. There are well-known sources of measurement variability including patient factors, CT acquisition (scan and reconstruction) factors, and radiologist (or measurement-related) factors. The purpose of this article is to review the effects of CT reconstruction parameters on the quantitative imaging features and efforts to correct or neutralize variations induced by those parameters.

Objective: The purpose of this study was to compare the diagnostic accuracy of whole-body MRI, coregistered FDG PET/MRI, integrated FDG PET/CT, and conventional imaging examination including bone scintigraphy, contrast-enhanced brain MRI, and CT for malignant pleural mesothelioma (MPM) staging according to the new International Association for the Study of Lung Cancer (IASLC) system., Subjects and Methods: The study subjects were 23 consecutively registered patients with MPM (15 men, eight women; mean age, 68 years for both sexes) who had prospectively undergone whole-body FDG PET/CT, whole-body MRI, conventional radiologic examination, surgical or conventional treatments, pathologic examination, and follow-up conventional imaging examinations between January 2011 and December 2017. TNM staging was evaluated by two independent readers. Kappa statistics and chi-square tests were used for evaluation agreements on each factor and clinical stage between each method and final diagnosis. The diagnostic accuracy of each method was statistically compared by use of McNemar test., Results: The kappa values for each factor between each method and final diagnosis were significant (p < 0.0001) and ranged between 0.33 and 0.91. Kappa values between final diagnosis and stage evaluation were also significant (p < 0.0001) and ranged between 0.57 and 0.91. The diagnostic accuracy of N and stage assessment of whole-body MRI and FDG PET/MRI was significantly higher than that of conventional imaging examination (N factor, p < 0.05; stage, p < 0.05)., Conclusion: The diagnostic accuracy of whole-body MRI, FDG PET/MRI, and FDG PET/CT for TNM stage assessment based on the new IASLC MPM staging system is greater than that of conventional imaging examination.

Objective: The purpose of this study is to directly compare the capability of gadolinium-based blood volume (BV) mapping from MRI (BV-MRI) with ultrashort TE (UTE) with that of CT and perfusion SPECT in predicting the postoperative lung function of patients with non-small cell lung cancer (NSCLC)., Subjects and Methods: Unenhanced and contrast-enhanced MRI with UTE, thin-section CT, and perfusion SPECT examinations and measurements of the percentage of forced expiratory volume in 1 second (FEV 1 ) before and after lung resection were performed for 29 patients with NSCLC (16 men [mean age, 66 years] and 13 women [mean age, 66 years]). BV-MRI with UTE was generated as a percentage of the signal change between unenhanced and contrast-enhanced MRI. The postoperative percentage of FEV 1 was predicted from perfusion fractions derived from BV-MRI with UTE and from SPECT. Quantitatively and qualitatively predicted postoperative percentages of FEV 1 from CT were calculated from the functional lung volumes and the number of segments. Each predicted postoperative percentage of FEV 1 was then correlated with the actual postoperative percentage of FEV 1 , and the limits of agreement for each actual and predicted postoperative percentage of FEV 1 were evaluated by Bland-Altman analysis., Results: Correlations between actual and predicted postoperative percentages of FEV 1 for all methods were strong and significant (0.88 ≤ r ≤ 0.95). The limits of agreement (mean ± 1.96 × SD) for BV-MRI with UTE (4.2% ± 6.5%) and quantitatively assessed CT (4.1% ± 6.5%) were smaller than those for qualitatively assessed CT (4.2% ± 9.8%) and perfusion SPECT (5.7% ± 8.7%)., Conclusion: BV-MRI with UTE has the potential to predict the postoperative lung function of patients with NSCLC more accurately than qualitatively assessed CT and SPECT, and it can be considered to be at least as useful as quantitatively assessed CT.

Objective:: The purpose of the current study is to create a contrast medium extraction method using raw-data-based electron density (rED) and CT number from dual-energy CT (DECT) for automatic delineation of the contrast region., Methods:: A CT-ED phantom containing tissue-equivalent inserts and an acrylic phantom with an iodinated contrast medium were scanned by DECT. The contrast medium extraction system was created using Python. The accuracy of the contrast medium extraction was evaluated by measuring the diameter in terms of the full width at half maximum (FWHM) and the ratio of the volume (ROV)., Results:: Mean-2SD CT numbers and the difference of the CT numbers (DCT) of the contrast medium at 0-130 mg ml -1 contrast medium concentration and the bone materials were more than -33 and -20 HU, respectively. In the correlation of rED and CT number, the gradient with the contrast medium phantom was greater than that with the CT-ED phantom. The accuracy of the contrast medium at 80 kV/135 kV and 100 kV/135 kV tube voltages. The gradient of the CT-ED and contrast medium phantoms were different. The gradient in the CT-ED phantom and the contrast medium was 0.0012 and 0.0003 at 80 kV/135 kV, and 0.0015 and 0.0005 at 100 kV/135 kV tube voltages, respectively. The ratio of the measured to the actual diameter in FWHM and ROV was 0.98-1.00 at 2-130 mg ml -1 . At a tube voltage of 100 kV/135 kV. The ratio of the measured to the actual diameter in ROV was 0.66 and FWHM was 0.90 at 2 mg ml -1 contrast medium concentration. The ratio of the measured to the actual diameter in FWHM and ROV was 0.98-1.00 at 3-130 mg ml -1 ., Conclusion:: We created the contrast medium extraction method with rED and CT number images. The contrast medium extraction method could be used with DECT images at 80 kV/135 kV. The method is expected to only extract images from the region containing the contrast medium., Advances in Knowledge:: We created the contrast medium extraction method using raw-data-based electron density and CT number from DECT and it is expected to only extract information from the region containing the contrast medium.

Background: The heterogeneous distribution of emphysema is a key feature of chronic obstructive pulmonary disease (COPD) patients that typically is evaluated using high-resolution chest computed tomography (HRCT). Oxygen-enhanced pulmonary magnetic resonance imaging (OEMRI) is a new method to obtain information regarding regional ventilation, diffusion, and perfusion in the lung without radiation exposure. We aimed to compare OEMRI with HRCT for the assessment of heterogeneity in COPD patients., Methods: Forty patients with stable COPD underwent quantitative HRCT, OEMRI, and pulmonary function tests, including arterial blood gas analysis. OEMRI was also performed on nine healthy control subjects. We measured the severity of emphysema (percent low attenuation volume; LAV%) in whole lungs and the standard deviations (SDs) of the LAV% values of 10 isovolumetric partitions (SD-LAV) as an index of cranial-caudal heterogeneity. Similarly, relative enhancement ratios of oxygen (RERs) in whole lungs from OEMRI and SD-RER were analyzed., Results: COPD patients showed a lower mean RER than control subjects (12.6% vs 22.0%, p<0.01). The regional heterogeneity of the RERs was not always consistent with the LAV distribution. Both the HRCT (LAV% and SD-LAV) and the OEMRI (RER and SD-RER) indices were significantly associated with the diffusion capacity (DLCO) and partial pressure of oxygen in arterial blood (PaO2). The PaO2 was associated only with the heterogeneity index of HRCT (SD-LAV) (R2 = 0.39); however, the PaO2 was associated with both the mean RER and heterogeneity (SD-RER) in the multivariate analysis (R2 = 0.38)., Conclusions: OEMRI-derived parameters were directly associated with oxygen uptake in COPD patients. Although the OEMRI-derived parameters were not identical to the HRCT-derived parameters, the cranial-caudal heterogeneity in HRCT or OEMRI was complementary to that in evaluations of oxygen uptake in the lungs. Functional imaging seems to provide new insights into COPD pathophysiology without radiation exposure., Competing Interests: None of the authors have any conflicts of interest to declare regarding the publication of this manuscript, except for Dr. Ohno and Dr. Togashi, who have research grants from Toshiba Medical Systems Corporation. This funding does not alter our adherence to PLOS ONE policies on sharing data and materials.

Purpose: To directly compare the effect of a reconstruction algorithm on nodule detection capability of the computer-aided detection (CADe) system using standard-dose, reduced-dose and ultra-low dose chest CTs with and without adaptive iterative dose reduction 3D (AIDR 3D)., Materials and Methods: Our institutional review board approved this study, and written informed consent was obtained from each patient. Standard-, reduced- and ultra-low-dose chest CTs (250 mA, 50 mA and 10 mA) were used to examine 40 patients, 21 males (mean age ± standard deviation: 63.1 ± 11.0 years) and 19 females (mean age, 65.1 ± 12.7 years), and reconstructed as 1 mm-thick sections. Detection of nodule equal to more than 4 mm in dimeter was automatically performed by our proprietary CADe software. The utility of iterative reconstruction method for improving nodule detection capability, sensitivity and false positive rate (/case) of the CADe system using all protocols were compared by means of McNemar's test or signed rank test., Results: Sensitivity (SE: 0.43) and false-positive rate (FPR: 7.88) of ultra-low-dose CT without AIDR 3D was significantly inferior to those of standard-dose CTs (with AIDR 3D: SE, 0.78, p < .0001, FPR, 3.05, p < .0001; and without AIDR 3D: SE, 0.80, p < .0001, FPR: 2.63, p < .0001), reduced-dose CTs (with AIDR 3D: SE, 0.81, p < .0001, FPR, 3.05, p < .0001; and without AIDR 3D: SE, 0.62, p < .0001, FPR: 2.95, p < .0001) and ultra-low-dose CT with AIDR 3D (SE, 0.79, p < .0001, FPR, 4.88, p = .0001)., Conclusion: The AIDR 3D has a significant positive effect on nodule detection capability of the CADe system even when radiation dose is reduced., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Situs inversus totalis (SIT) is a rare congenital anomaly. Generally, laparoscopic surgery is difficult to perform in patients with SIT because of both the potential challenges associated with unexpected vascular anomalies and the lack of standardized strategy for handling such cases. This is the first report of laparoscopic total gastrectomy with lymph node dissection for advanced gastric cancer in a patient with SIT. A 79-year-old man with SIT was diagnosed with advanced gastric cancer. We performed laparoscopic total gastrectomy with modified D2 lymph node dissection (D2 without splenectomy) and esophagojejunal anastomosis using an overlap method involving retrocolic Roux-en-Y reconstruction. The total operating time was 232 min, and blood loss was 110 mL. There were no postoperative complications. In summary, laparoscopic total gastrectomy for gastric cancer can be performed safely, even in a patient with SIT., (© 2017 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.)

Objective: To evaluate the accuracy of raw-data-based effective atomic number (Z eff ) values and monochromatic CT numbers for contrast material of varying iodine concentrations, obtained using dual-energy CT., Methods: We used a tissue characterization phantom and varying concentrations of iodinated contrast medium. A comparison between the theoretical values of Z eff and that provided by the manufacturer was performed. The measured and theoretical monochromatic CT numbers at 40-130 keV were compared., Results: The average difference between the Z eff values of lung (inhale) inserts in the tissue characterization phantom was 81.3% and the average Z eff difference was within 8.4%. The average difference between the Z eff values of the varying concentrations of iodinated contrast medium was within 11.2%. For the varying concentrations of iodinated contrast medium, the differences between the measured and theoretical monochromatic CT values increased with decreasing monochromatic energy. The Z eff and monochromatic CT numbers in the tissue characterization phantom were reasonably accurate., Conclusion: The accuracy of the raw-data-based Z eff values was higher than that of image-based Z eff values in the tissue-equivalent phantom. The accuracy of Z eff values in the contrast medium was in good agreement within the maximum SD found in the iodine concentration range of clinical dynamic CT imaging. Moreover, the optimum monochromatic energy for human tissue and iodinated contrast medium was found to be 70 keV. Advances in knowledge: The accuracy of the Z eff values and monochromatic CT numbers of the contrast medium created by raw-data-based, dual-energy CT could be sufficient in clinical conditions.

Rationale and Objectives: This study aimed to compare sub-solid nodule detection performances (SSNDP) on chest computed tomography (CT) with Adaptive Iterative Dose Reduction using Three Dimensional Processing (AIDR 3D) between 7 mAs (0.21 mSv) and 42 mAs (1.28 mSv) in total and in subgroups classified by nodular size, characteristics, and location, and analyze the association of SSNDP with size-specific dose estimate (SSDE)., Materials and Methods: As part of the Area-detector Computed Tomography for the Investigation of Thoracic Diseases Study, a Japanese multicenter research project, 68 subjects underwent chest CT with 120 kV, 0.35 seconds per rotation, and three tube currents: 240 mA (84 mAs), 120 mA (42 mAs), and 20 mA (7 mAs). The research committee of the study project outlined and approved our study protocols. The institutional review board of each institution approved this study. Axial 2-mm-thick CT images were reconstructed using AIDR 3D. Standard reference was determined by CT images at 84 mAs. Four radiologists recorded SSN presence by continuously distributed rating on CT at 7 mAs and 42 mAs. Receiver operating characteristic analysis was used to evaluate SSNDP at both doses in total and in subgroups classified by nodular longest diameter (LD) (≥5 mm), characteristics (pure and part-solid), and locations (ventral, intermediate, or dorsal; central or peripheral; and upper, middle, or lower). Detection sensitivity was compared among five groups of SSNs classified based on particular SSDE to nodule on CT with AIDR 3D at 7 mAs., Results: Twenty-two part-solid and 86 pure SSNs were identified. For larger SSNs (LD ≥ 5 mm) as well as subgroups classified by nodular locations and part-solid nodules, SSNDP was similar in both methods (area under the receiver operating characteristics curve: 0.96 ± 0.02 in CT at 7 mAs and 0.97 ± 0.01 in CT at 42 mAs), with acceptable interobserver agreements in five locations. For larger SSNs (LD ≥ 5 mm), on CT at 42 mAs, no significant differences in detection sensitivity were found among the five groups classified by SSDE, whereas on CT with 7 mAs, four groups with SSDE of 0.65 or higher were superior in detection sensitivity to the other group, with SSDE less than 0.65 mGy., Conclusions: For SSNs with 5 mm or more in cases with normal range of body habitus, CT at 7 mAs was demonstrated to have comparable SSNDP to CT at 42 mAs regardless of nodular location and characteristics, and SSDE higher than 0.65 mGy is desirable to obtain sufficient SSNDP., (Copyright © 2017 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Purpose To compare the capability of pulmonary thin-section magnetic resonance (MR) imaging with ultrashort echo time (UTE) with that of standard- and reduced-dose thin-section computed tomography (CT) in nodule detection and evaluation of nodule type. Materials and Methods The institutional review board approved this study, and written informed consent was obtained from each patient. Standard- and reduced-dose chest CT (60 and 250 mA) and MR imaging with UTE were used to examine 52 patients; 29 were men (mean age, 66.4 years ± 7.3 [standard deviation]; age range, 48-79 years) and 23 were women (mean age, 64.8 years ± 10.1; age range, 42-83 years). Probability of nodule presence was assessed for all methods with a five-point visual scoring system. All nodules were then classified as missed, ground-glass, part-solid, or solid nodules. To compare nodule detection capability of the three methods, consensus for performances was rated by using jackknife free-response receiver operating characteristic analysis, and κ analysis was used to compare intermethod agreement for nodule type classification. Results There was no significant difference (F = 0.70, P = .59) in figure of merit between methods (standard-dose CT, 0.86; reduced-dose CT, 0.84; MR imaging with UTE, 0.86). There was no significant difference in sensitivity between methods (standard-dose CT vs reduced-dose CT, P = .50; standard-dose CT vs MR imaging with UTE, P = .50; reduced-dose CT vs MR imaging with UTE, P >.99). Intermethod agreement was excellent (standard-dose CT vs reduced-dose CT, κ = 0.98, P < .001; standard-dose CT vs MR imaging with UTE, κ = 0.98, P < .001; reduced-dose CT vs MR imaging with UTE, κ = 0.99, P < .001). Conclusion Pulmonary thin-section MR imaging with UTE was useful in nodule detection and evaluation of nodule type, and it is considered at least as efficacious as standard- or reduced-dose thin-section CT. © RSNA, 2017 Online supplemental material is available for this article.

The Fleischner Society Guidelines for management of solid nodules were published in 2005, and separate guidelines for subsolid nodules were issued in 2013. Since then, new information has become available; therefore, the guidelines have been revised to reflect current thinking on nodule management. The revised guidelines incorporate several substantive changes that reflect current thinking on the management of small nodules. The minimum threshold size for routine follow-up has been increased, and recommended follow-up intervals are now given as a range rather than as a precise time period to give radiologists, clinicians, and patients greater discretion to accommodate individual risk factors and preferences. The guidelines for solid and subsolid nodules have been combined in one simplified table, and specific recommendations have been included for multiple nodules. These guidelines represent the consensus of the Fleischner Society, and as such, they incorporate the opinions of a multidisciplinary international group of thoracic radiologists, pulmonologists, surgeons, pathologists, and other specialists. Changes from the previous guidelines issued by the Fleischner Society are based on new data and accumulated experience. © RSNA, 2017 Online supplemental material is available for this article. An earlier incorrect version of this article appeared online. This article was corrected on March 13, 2017.

Objectives: To determine the value of a raw data-based metal artifact reduction (SEMAR) algorithm for image quality improvement in abdominal CT for patients with small metal implants., Methods: Fifty-eight patients with small metal implants (3-15 mm in size) who underwent treatment for hepatocellular carcinoma were imaged with CT. CT data were reconstructed by filtered back projection with and without SEMAR algorithm in axial and coronal planes. To evaluate metal artefact reduction, mean CT number (HU and SD) and artefact index (AI) values within the liver were calculated. Two readers independently evaluated image quality of the liver and pancreas and visualization of vasculature using a 5-point visual score. HU and AI values and image quality on images with and without SEMAR were compared using the paired Student's t-test and Wilcoxon signed rank test. Interobserver agreement was evaluated using linear-weighted κ test., Results: Mean HU and AI on images with SEMAR was significantly lower than those without SEMAR (P < 0.0001). Liver and pancreas image qualities and visualizations of vasculature were significantly improved on CT with SEMAR (P < 0.0001) with substantial or almost perfect agreement (0.62 ≤ κ ≤ 0.83)., Conclusions: SEMAR can improve image quality in abdominal CT in patients with small metal implants by reducing metallic artefacts., Key Points: • SEMAR algorithm significantly reduces metallic artefacts from small implants in abdominal CT. • SEMAR can improve image quality of the liver in dynamic CECT. • Confidence visualization of hepatic vascular anatomies can also be improved by SEMAR.

The increase in the radiation exposure from CT examinations prompted the investigation on the various dose-reduction techniques. Significant dose reduction has been achieved and the level of radiation exposure of thoracic CT is expected to reach the level equivalent to several chest X-ray examinations. With more scanners with advanced dose reduction capability deployed, knowledge on the radiation dose reduction methods has become essential to clinical practice as well as academic research. This article reviews the history of dose reduction techniques, ongoing changes brought by newer technologies and areas of further investigation., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To prospectively and directly compare the capability for assessments of regional ventilation and pulmonary functional loss in smokers of xenon-ventilation CT obtained with the dual-energy CT (DE-CT) and subtraction CT (Sub-CT) MATERIALS AND METHODS: Twenty-three consecutive smokers (15 men and 8 women, mean age: 69.7±8.7years) underwent prospective unenhanced and xenon-enhanced CTs, the latter by Sub-CT and DE-CT methods, ventilation SPECT and pulmonary function tests. Sub-CT was generated from unenhanced and xenon-enhanced CT, and all co-registered SPECT/CT data were produced from SPECT and unenhanced CT data. For each method, regional ventilation was assessed by using a 11-point scoring system on a per-lobe basis. To determine the functional lung volume by each method, it was also calculated for individual sublets with a previously reported method. To determine inter-observer agreement for each method, ventilation defect assessment was evaluated by using the χ2 test with weighted kappa statistics. For evaluation of the efficacy of each method for pulmonary functional loss assessment, functional lung volume was correlated with%FEV 1 ., Results: Each inter-observer agreement was rated as substantial (Sub-CT: κ=0.69, p<0.0001; DE-CT: κ=0.64, p<0.0001; SPECT/CT: κ=0.64, p<0.0001). Functional lung volume for each method showed significant to good correlation with%FEV 1 (Sub-CT: r=0.72, p=0.0001; DE-CT: r=0.74, p<0.0001; SPECT/CT: r=0.66, p=0.0006)., Conclusion: Xenon-enhanced CT obtained by Sub-CT can be considered at least as efficacious as that obtained by DE-CT and SPECT/CT for assessment of ventilation abnormality and pulmonary functional loss in smokers., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Assessment of regional pulmonary perfusion as well as nodule and tumor perfusions in various pulmonary diseases are currently performed by means of nuclear medicine studies requiring radioactive macroaggregates, dual-energy computed tomography (CT), and dynamic first-pass contrast-enhanced perfusion CT techniques and unenhanced and dynamic first-pass contrast enhanced perfusion magnetic resonance imaging (MRI), as well as time-resolved three-dimensional or four-dimensional contrast-enhanced magnetic resonance angiography (MRA). Perfusion scintigraphy, single-photon emission tomography (SPECT) and SPECT fused with CT have been established as clinically available scintigraphic methods; however, they are limited by perfusion information with poor spatial resolution and other shortcomings. Although positron emission tomography with 15O water can measure absolute pulmonary perfusion, it requires a cyclotron for generation of a tracer with an extremely short half-life (2 min), and can only be performed for academic purposes. Therefore, clinicians are concentrating their efforts on the application of CT-based and MRI-based quantitative and qualitative perfusion assessment to various pulmonary diseases. This review article covers 1) the basics of dual-energy CT and dynamic first-pass contrast-enhanced perfusion CT techniques, 2) the basics of time-resolved contrast-enhanced MRA and dynamic first-pass contrast-enhanced perfusion MRI, and 3) clinical applications of contrast-enhanced CT- and MRI-based perfusion assessment for patients with pulmonary nodule, lung cancer, and pulmonary vascular diseases. We believe that these new techniques can be useful in routine clinical practice for not only thoracic oncology patients, but also patients with different pulmonary vascular diseases.

Purpose: To directly compare the capability of three reconstruction methods using, respectively, forward projected model-based iterative reconstruction (FIRST), adaptive iterative dose reduction using three dimensional processing (AIDR 3D) and filter back projection (FBP) for radiation dose reduction and accuracy of computer-aided volumetry (CADv) measurements on chest CT examination in a phantom study., Materials and Methods: An anthropomorphic thoracic phantom with 30 simulated nodules of three density types (100, -630, and -800 HU) and five different diameters was scanned with an area-detector CT at tube currents of 270, 200, 120, 80, 40, 20, and 10mA. Each scanned data set was reconstructed as thin-section CT with three methods, and all simulated nodules were measured with CADv software. For comparison of the capability for CADv at each tube current, Tukey's HSD test was used to compare the percentage of absolute measurement errors for all three reconstruction methods. Absolute percentage measurement errors were then compared by means of Dunett's test for each tube current at 270mA (standard tube current)., Results: Mean absolute measurement errors of AIDR 3D and FIRST methods for each nodule type were significantly lower than those of the FBP method at 20mA and 10mA (p<0.05). In addition, absolute measurement errors of the FBP method at 20mA and 10mA was significantly higher than that at 270mA for all nodule types (p<0.05)., Conclusion: The FIRST and AIDR 3D methods are more effective than the FBP method for radiation dose reduction, while yielding better measurement accuracy of CADv for chest CT examination., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Computed tomography (CT) has important roles for lung cancer screening, and therefore radiation dose reduction by using iterative reconstruction technique and scanning methods receive widespread attention., Purpose: To evaluate the effect of two reconstruction techniques (filtered back projection [FBP] and adaptive iterative dose reduction using three-dimensional processing [AIDR 3D]) and two acquisition techniques (wide-volume scan [WVS] and helical scan as 64-detector-row CT [64HS]) on the lung nodule identifications of using a chest phantom., Material and Methods: A chest CT phantom including lung nodules was scanned using WVS and 64HS at nine different tube currents (TCs; range, 270-10 mA). All CT datasets were reconstructed with AIDR 3D and FBP. Standard deviation (SD) measurements by region of interest placement and qualitative nodule identifications were statistically compared. 64HS and WVS were evaluated separately, and FBP images acquired with 270 mA was defined as the standard reference., Results: SDs of all datasets with AIDR 3D showed no significant differences (P > 0.05) with standard reference. When comparing nodule identifications, area under the curve on WVS with AIDR 3D with TC <30 mA, on 64HS with AIDR 3D with TC <40 mA, and on reconstructions with FBP and each scan method with TC <60 mA was significantly lower than with standard reference (P < 0.05). With the same TC and reconstruction, SDs and nodule identifications of WVS were not significantly different from 64HS (P > 0.05)., Conclusion: In term of SD of lung parenchyma and nodule identification, AIDR 3D can achieve more radiation dose reduction than FBP and there is no significant different between WVS and 64HS., (© The Foundation Acta Radiologica 2015.)

Objective: The purpose of this study was to evaluate agreement between standard-dose CT (SDCT) and ultralow-dose CT (ULDCT) findings with respect to emphysema quantification. ULDCT images were reconstructed with and without iterative reconstruction (IR). Adaptive iterative dose reduction with 3D processing was used for IR., Materials and Methods: Fifty patients who underwent SDCT and ULDCT were included. The tube current for SDCT was 250 mA, and that for ULDCT was 10 mA. SDCT, ULDCT without IR, and ULDCT with IR were used for emphysema quantification. The low-attenuation volume percentage (LAV%) in the lungs at four thresholds (-970, -950, -930, and -910 HU), mean lung attenuation, and total lung volume were computed. Concordance correlation coefficients (CCC) were used to assess the agreement of emphysema quantification between SDCT and ULDCT., Results: The LAV% CCC values were 0.310-0.789 between SDCT and ULDCT without IR and 0.934-0.966 between SDCT and ULDCT with IR. The agreement of LAV% improved when IR was used for ULDCT. The mean lung attenuation CCC value between SDCT and ULDCT without IR was substantial (0.957), whereas that between SDCT and ULDCT with IR was poor (0.890). The total lung volume CCC values were substantial (0.982 with IR, 0.983 without IR)., Conclusion: ULDCT with and without IR can substitute for SDCT in emphysema quantification.

Background: We investigated whether scintigraphy was superior to radiography for detecting migrated seeds after brachytherapy for prostate cancer., Methods: We studied 57 patients with early prostate cancer who were treated with free (125)I transperineal brachytherapy. Scintigraphy was used to detect seed migration on postoperative day (POD) 1, radiography was used on POD 2, and both tests were used on POD 30., Results: The total number of implanted seeds in this study was 3,753 in 57 patients. Overall, there were 19 seed migrations in 12 patients. On POD 1, there were 4 seed migrations in 4 patients that were detected by scintigraphy. On POD 2, there were 10 seed migrations in 9 patients that were detected by radiography. On POD 30, 17 seed migrations were detected in 10 patients by radiography and 18 seeds migrations were detected by scintigraphy. However, 1 seed migration which was located outside of the detectable range of radiography was detected only by scintigraphy., Conclusions: Both scintigraphy and radiography have similar abilities to detect migrated seeds 1 month after (125)I brachytherapy for prostate cancer. While both tests have advantages and disadvantages, it is reasonable to only use radiography if scintigraphy is not available.

Purpose: To evaluate the utility of three-dimensional (3D) lung motion on inspiratory and expiratory CT for pulmonary functional loss in smoking-related COPD in comparison with lung destruction and air trapping assessments., Method and Materials: Forty-four consecutive smokers and COPD patients prospectively underwent inspiratory and expiratory CT. A 3D motion vector map was generated from these CTs, and regional motion magnitudes were measured at the horizontal axis (X-axis), the ventrodorsal axis (Y-axis), and the craniocaudal axis (Z-axis). All mean magnitudes within the entire lung (MMLX, MMLY, and MMLZ) were normalized by expiratory CT lung volume. Moreover, CT-based functional lung volume (FLV) on inspiratory CT and air trapping lung volume (ATLV) on expiratory CT were assessed quantitatively. To evaluate the capability for pulmonary function loss assessment, all MMLs were correlated with pulmonary function tests. Then, discrimination analysis was performed to determine the concordance capability for clinical stage, and correct classification capabilities were compared by means of McNemar's test., Results: Multiple regression analysis showed MMLY (β=0.657, p<0.001) and FLV (β=0.375, p=0.019) were correlated with percentage of predicted forced expiratory volume in 1 second. Correct classification capabilities using patient characteristics and MMLs (68.2 (30/44)%) were significantly higher than those obtained by patient characteristics, FLV, and ATLV (54.5 (24/44)%), p=0.031)., Conclusion: 3D lung motion parameter assessment is useful for smoking-related COPD assessment as well as lung parenchymal destruction and/or air trapping evaluations., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: To determine the accuracy of pulmonary MR imaging with ultrashort echo time (UTE) for lung and mediastinum assessments using computed tomography (CT) as the reference standard, for various pulmonary parenchyma diseases., Methods: Eight-five consecutive patients (46 males: mean age, 69 years and 39 females: mean age, 69 years) with various pulmonary parenchyma diseases were examined with chest standard- and low-dose CTs and pulmonary MR imaging with UTE. This was followed by visual assessment using a 5-point system of the presence of nodules or masses, ground-glass opacity, micronodules, nodules, patchy shadow or consolidation, emphysema or bullae, bronchiectasis, reticular opacity, and honeycomb and traction bronchiectasis. Presence of aneurysms, pleural or pericardial effusions, pleural thickening or tumor, and lymph adenopathy was also evaluated using a 5-point system. To compare the capability of the methods for lung parenchyma and mediastinum evaluation, intermethod agreement was evaluated by means of kappa statistics and χ2 test. Receiver operating characteristic analyses were used to compare diagnostic performance of all methods., Results: Intermethod agreements between pulmonary MR imaging and standard-dose and low-dose CT were significant and either substantial or almost perfect (0.67 ≤ κ ≤ 0.98; P < 0.0001). Areas under the curve for emphysema or bullae, bronchiectasis or traction bronchiectasis and reticular opacity on standard-dose CT were significantly larger than those on low-dose CT (emphysema or bullae: P = 0.0002; reticular opacity: P < 0.0001) and pulmonary MR imaging (emphysema or bullae: P < 0.0001; bronchiectasis: P = 0.008; reticular opacity: P < 0.0001)., Conclusion: Pulmonary MR imaging with UTE is useful for lung and mediastinum assessment and evaluation of radiological findings for patients with various pulmonary parenchyma diseases., (© 2015 Wiley Periodicals, Inc.)

Purpose: To determine the capability and influence of the mathematical method on dynamic contrast-enhanced (CE-) perfusion area detector CT (ADCT) for early prediction of treatment response as well as progression free and overall survival (PFS and OS) of non-small cell lung cancer (NSCLC) patients treated with chemoradiotherapy., Materials and Methods: Sixty-six consecutive stage III NSCLC patients underwent dynamic CE-perfusion ADCT examinations, chemoradiotherapy and follow-up examinations. Response Evaluation Criteria in Solid Tumors (RECIST) criteria were used to divide all patients into responders and non-responders. Differences in each of the indices for all targeted lesions between measurements obtained 2 weeks prior to the first and the third course of chemotherapy were determined for all patients. ROC analyses were employed to determine the capability of perfusion indices as markers for distinguishing RECIST responders from non-responders. To evaluate their capability for early prediction of therapeutic effect, OS of perfusion index-based responders and non-responders were compared by using the Kaplan-Meier method followed by log-rank test., Results: Area under the curve (Az) for total perfusion by means of the dual-input maximum slope method was significantly larger than that of pulmonary arterial perfusion using the same method (p=0.007) and of perfusion with the single-input maximum slope method (p=0.007). Mean OS demonstrated significantly difference between responder- and non-responder groups for total perfusion (p=0.02)., Conclusion: Mathematical models have significant influence on assessment for early prediction of treatment response, disease progression and overall survival using dynamic CE-perfusion ADCT for NSCLC patients treated with chemoradiotherapy., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To directly compare the capability of hybrid-type iterative reconstruction (i.e., adaptive iterative dose reduction using 3D processing: AIDR 3D) and filter back projection (FBP) for radiation dose reduction during dynamic contrast-enhanced (CE-) perfusion area-detector CT (ADCT) for lung and nodule perfusion assessment., Materials and Methods: Thirty-six patients with lung cancers who underwent perfusion ADCT (SD-ADCT) at 120 mA and were enrolled in this study. ADCT data at 80 mA (reduced-dose ADCT: RD-ADCT), 60 mA (low-dose ADCT: LD-ADCT) and 40 mA (very low-dose ADCT: VLD-ADCT) were computationally simulated using SD-ADCT data, and reconstructed with and without AIDR 3D. Image noise and lung and nodule perfusion parameters were evaluated using ROI measurements. To determine the utility of AIDR 3D for dose reduction, image noise was compared between each protocol with and without AIDR 3D by means of the t-test. Correlations and limits of agreement for parameters obtained with SD-ADCT and other protocols were also evaluated., Results: Image noise of all protocols with AIDR 3D was significantly lower than that of LD-ADCT and VLD-ADCT without AIDR 3D (p<0.05). Significant correlations for image noise between SD-ADCT and all protocols with AIDR 3D (0.45 ≤ r ≤ 0.99, p<0.0001) were equal to or better than that without AIDR 3D (0.28 ≤ r ≤ 0.99, p<0.0001). The limits of agreement for perfusion parameters with AIDR 3D were smaller than those without AIDR 3D for each tube current., Conclusion: AIDR 3D is more effective than FBP for dose reduction of perfusion ADCT while maintaining image quality and reducing measurement errors., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To prospectively compare the diagnostic capability of diffusion-weighted MR imaging obtained with fast advantage spin-echo sequence (FASE-DWI) and echo planar imaging sequence (EPI-DWI), short inversion time inversion recovery fast advanced spin-echo (STIR FASE) imaging and FDG PET/CT for N-stage assessment of non-small cell carcinoma (NSCLC) patients., Materials and Methods: 95 consecutive operable NSCLC patients underwent STIR FASE imaging, FASE-DWI and EPI-DWI with a 3T system, integrated PET/CT, surgical treatment and pathological and follow-up examinations. Probability of lymph node metastasis was visually assessed using a 5-point visual scoring system. ROC analyses were used to compare diagnostic capability of all methods, while their diagnostic performance was also compared by means of McNemar's test on a per node basis. Finally, McNemar's test was also used for statistical comparison of accuracy of N-stage assessment., Results: Areas under the curve (Azs) for STIR FASE imaging (Az=0.95) and FASE-DWI (Az=0.92) were significantly larger than those for EPI-DWI (Az=0.78; p<0.0001 for STIR FSE imaging and FASE-DWI) and PET/CT (Az=0.85; p=0.0001 for STIR FSE imaging, p=0.03 for FASE-DWI) on a per node basis analysis. Accuracy of N-stage assessment using STIR FASE imaging (84.2% [80/95]) and FASE-DWI (83.2% [79/95]) was significantly higher than that using EPI-DWI (76.8% [73/95]; p=0.02 for STIR FASE imaging, p=0.03 for FASE-DWI) and PET/CT (73.7% [70/95]; p=0.002 for STIR FSE imaging, p=0.004 for FASE-DWI)., Conclusion: Qualitative N-stage assessments of NSCLC patients obtained with FASE-DWI as well as STIR FASE imaging are more sensitive and/or accurate than those obtained with EPI-DWI and FDG PET/CT., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

We present a case of a 67-year-old man with intussusception of the right ureter associated with a fibroepithelial polyp. The concentric sign and line sign are characteristic radiological findings in intussusception, and these findings could be seen in the present case. Although this entity is rare, its radiological findings are specific. Multidetector row computed tomography and its multiplanar reconstruction make the diagnosis feasible, although the qualitative diagnosis of the tumor was difficult., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: To compare predictive capabilities of non-contrast-enhanced (CE)- and dynamic CE-perfusion MRIs, thin-section multidetector computed tomography (CT) (MDCT), and perfusion scan for postoperative lung function in non-small cell lung cancer (NSCLC) patients., Materials and Methods: Sixty consecutive pathologically diagnosed NSCLC patients were included and prospectively underwent thin-section MDCT, non-CE-, and dynamic CE-perfusion MRIs and perfusion scan, and had their pre- and postoperative forced expiratory volume in one second (FEV1 ) measured. Postoperative percent FEV1 (po%FEV1 ) was then predicted from the fractional lung volume determined on semiquantitatively assessed non-CE- and dynamic CE-perfusion MRIs, from the functional lung volumes determined on quantitative CT, from the number of segments observed on qualitative CT, and from uptakes detected on perfusion scans within total and resected lungs. Predicted po%FEV1 s were then correlated with actual po%FEV1 s, which were %FEV1 s measured postoperatively. The limits of agreement were also determined., Results: All predicted po%FEV1 s showed significant correlation (0.73 ≤ r ≤ 0.93, P < 0.0001) and limits of agreement with actual po%FEV1 (non-CE-perfusion MRI: 0.3 ± 10.0%, dynamic CE-perfusion MRI: 1.0 ± 10.8%, perfusion scan: 2.2 ± 14.1%, quantitative CT: 1.2 ± 9.0%, qualitative CT: 1.5 ± 10.2%)., Conclusion: Non-CE-perfusion MRI may be able to predict postoperative lung function more accurately than qualitatively assessed MDCT and perfusion scan., (© 2014 Wiley Periodicals, Inc.)

Positron emission tomography / computed tomography (PET/CT), with its metabolic data of (18) F-fluorodeoxyglucose (FDG) cellular uptake in addition to morphologic CT data, is an established technique for staging of lung cancer and has higher sensitivity and accuracy for lung nodule characterization than conventional approaches. Its strength extends outside the chest, with unknown metastases detected or suspected metastases excluded in a significant number of patients. Lastly, PET/CT is used in the assessment of therapy response. Magnetic resonance imaging (MRI) in the chest has been difficult to establish, but with the advent of new sequences is starting to become an increasingly useful alternative to conventional approaches. Diffusion-weighted MRI (DWI) is useful for distinguishing benign and malignant pulmonary nodules, has high sensitivity and specificity for nodal staging, and is helpful for evaluating an early response to systemic chemotherapy. Whole-body MRI/PET promises to contribute additional information with its higher soft-tissue contrast and much less radiation exposure than PET/CT and has become feasible for fast imaging and can be used for cancer staging in patients with a malignant condition., (© 2014 Wiley Periodicals, Inc.)

Purpose: To compare lung nodule detection performance (LNDP) in computed tomography (CT) with adaptive iterative dose reduction using three dimensional processing (AIDR3D) between ultra-low dose CT (ULDCT) and low dose CT (LDCT)., Materials and Methods: This was part of the Area-detector Computed Tomography for the Investigation of Thoracic Diseases (ACTIve) Study, a multicenter research project being conducted in Japan. Institutional Review Board approved this study and informed consent was obtained. Eighty-three subjects (body mass index, 23.3 ± 3.2) underwent chest CT at 6 institutions using identical scanners and protocols. In a single visit, each subject was scanned using different tube currents: 240, 120 and 20 mA (3.52, 1.74 and 0.29 mSv, respectively). Axial CT images with 2-mm thickness/increment were reconstructed using AIDR3D. Standard of reference (SOR) was determined based on CT images at 240 mA by consensus reading of 2 board-certificated radiologists as to the presence of lung nodules with the longest diameter (LD) of more than 3mm. Another 5 radiologists independently assessed and recorded presence/absence of lung nodules and their locations by continuously-distributed rating in CT images at 20 mA (ULDCT) and 120 mA (LDCT). Receiver-operating characteristic (ROC) analysis was used to evaluate LNDP of both methods in total and also in subgroups classified by LD (>4, 6 and 8 mm) and nodular characteristics (solid and ground glass nodules)., Results: For SOR, 161 solid and 60 ground glass nodules were identified. No significant difference in LNDP for entire solid nodules was demonstrated between both methods, as area under ROC curve (AUC) was 0.844 ± 0.017 in ULDCT and 0.876 ± 0.026 in LDCT (p=0.057). For ground glass nodules with LD 8mm or more, LNDP was similar between both methods, as AUC 0.899 ± 0.038 in ULDCT and 0.941 ± 0.030 in LDCT. (p=0.144)., Conclusion: ULDCT using AIDR3D with an equivalent radiation dose to chest x-ray could have comparable LNDP to LDCT with AIDR3D except for smaller ground glass nodules in cases with normal range body habitus., (Copyright © 2015 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.)

Background: Regional iodine distribution assessment on dual-energy computed tomography (DECT) has been suggested as useful for management of acute pulmonary thromboembolism (APTE) patients. However, no reported studies have made a direct comparison between quantitatively assessed DECT and right-to-left ventricular (RV/LV) ratio on CT for differentiation of right heart dysfunction (RHD) from non-right heart dysfunction (NRHD) in APTE patients., Purpose: To determine the capability of DECT for differentiation of RHD from NRHD in APTE patients., Material and Methods: Thirteen APTE patients underwent DECT and echocardiography at onset of APTE. Patients were divided into RHD (n = 7) and NRHD (n = 6) groups based on echocardiography. A normalized lung perfused blood volume map was generated, and two kinds of overall perfusion (OP) index were determined, one placed over each lung field (OP index A) and as the average from six regions of interest (ROIs) placed over each lung field (OP index B). The heterogeneity index was also determined as the standard deviation for the six ROIs. RV/LV ratio evaluations were also performed. To assess differences between the two groups, each index was statistically compared with the Mann-Whitney U test. The receiver-operating curve-based positive test was then performed to determine the feasible threshold value for dividing patients into the two groups. Finally, differentiation capabilities of the indexes were compared using McNemar's test., Results: Significant differences between the two groups were found for both OP indexes and RV/LV ratio (P < 0.05). For each of the feasible threshold values, accuracy of each OP index with and without RV/LV ratio was better than that of the RV/LV ratio., Conclusion: Quantitative DECT has good potential for differentiation of APTE patients with and without right heart dysfunction., (© The Foundation Acta Radiologica 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Purpose: To prospectively compare the capabilities of dynamic perfusion area-detector computed tomography (CT), dynamic magnetic resonance (MR) imaging, and positron emission tomography (PET) combined with CT (PET/CT) with use of fluorine 18 fluorodeoxyglucose (FDG) for the diagnosis of solitary pulmonary nodules., Materials and Methods: The institutional review board approved this study, and written informed consent was obtained from each subject. A total of 198 consecutive patients with 218 nodules prospectively underwent dynamic perfusion area-detector CT, dynamic MR imaging, FDG PET/CT, and microbacterial and/or pathologic examinations. Nodules were classified into three groups: malignant nodules (n = 133) and benign nodules with low (n = 53) or high (n = 32) biologic activity. Total perfusion was determined with dual-input maximum slope models at area-detector CT, maximum and slope of enhancement ratio at MR imaging, and maximum standardized uptake value (SUVmax) at PET/CT. Next, all indexes for malignant and benign nodules were compared with the Tukey honest significant difference test. Then, receiver operating characteristic analysis was performed for each index. Finally, sensitivity, specificity, and accuracy were compared with the McNemar test., Results: All indexes showed significant differences between malignant nodules and benign nodules with low biologic activity (P < .0001). The area under the receiver operating characteristic curve for total perfusion was significantly larger than that for other indexes (.0006 ≤ P ≤ .04). The specificity and accuracy of total perfusion were significantly higher than those of maximum relative enhancement ratio (specificity, P < .0001; accuracy, P < .0001), slope of enhancement ratio (specificity, P < .0001; accuracy, P < .0001), and SUVmax (specificity, P < .0001; accuracy, P < .0001)., Conclusion: Dynamic perfusion area-detector CT is more specific and accurate than dynamic MR imaging and FDG PET/CT in the diagnosis of solitary pulmonary nodules in routine clinical practice., (© RSNA, 2014.)

Purpose: To evaluate the effects of adaptive iterative dose reduction using 3D processing (AIDR 3D) for quantification of two measures of emphysema: percentage of low-attenuation volume (LAV%) and size distribution of low-attenuation lung regions., Method and Materials: Fifty-two patients who underwent standard-dose (SDCT) and low-dose CT (LDCT)were included. SDCT without AIDR 3D, LDCT without AIDR 3D, and LDCT with AIDR 3D were used for emphysema quantification. First, LAV% was computed at 10 thresholds from −990 to −900 HU. Next, at the same thresholds, linear regression on a log–log plot was used to compute the power law exponent (D)for the cumulative frequency-size distribution of low-attenuation lung regions. Bland–Altman analysis was used to assess whether AIDR 3D improved agreement between LDCT and SDCT for emphysema quantification of LAV% and D., Results: The mean relative differences in LAV% between LDCT without AIDR 3D and SDCT were 3.73%–88.18% and between LDCT with AIDR 3D and SDCT were −6.61% to 0.406%. The mean relative differences in D between LDCT without AIDR 3D and SDCT were 8.22%–19.11% and between LDCT with AIDR3D and SDCT were 1.82%–4.79%. AIDR 3D improved agreement between LDCT and SDCT at thresholds from −930 to −990 HU for LAV% and at all thresholds for D., Conclusion: AIDR 3D improved the consistency between LDCT and SDCT for emphysema quantification of LAV% and D., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To compare the use of dynamic oxygen-enhanced magnetic resonance (MR) imaging with the use of quantitatively assessed computed tomography (CT) for assessment of clinical stage and evaluation of pulmonary functional change due to treatment in patients with asthma., Materials and Methods: The institutional review board of Kobe University Hospital approved this study, and written informed consent was obtained from each subject. Thirty consecutive patients with asthma (17 men and 13 women; age range, 27-78 years) underwent dynamic oxygen-enhanced MR imaging, multidetector CT, and assessment of forced expiratory volume in 1 second. All patients were classified as having one of four stages of asthma according to the guidelines of the National Asthma Education and Prevention Program. Relative enhancement ratio ( RER relative enhancement ratio ) and wash-in time maps were generated by means of pixel-by-pixel analyses. Regions of interest were placed on images of the lung in all sections, and all measurements were averaged to determine mean RER relative enhancement ratio and mean wash-in time for each subject. Percentage of airway wall area and mean lung density were determined at quantitative CT. For comparison of the modalities for assessment of clinical stage, indexes of subjects at all clinical stages were compared by means of the Tukey honestly significant difference test. Evaluation of pulmonary functional improvement was assessed by correlating improvement of each index with that of forced expiratory volume., Results: Mean wash-in time was significantly different among patients with asthma of different clinical stages (P < .05), but significant differences between mean RER relative enhancement ratio and percentage of airway wall area were observed for a limited number of clinical stages (P < .05). Improvement of mean RER relative enhancement ratio (r = 0.63, P = .0002) and mean wash-in time (r = -0.75, P < .0001) was significantly correlated with forced expiratory volume., Conclusion: Dynamic oxygen-enhanced MR imaging has potential as a tool for assessment of clinical stage and evaluation of pulmonary functional change due to treatment in patients with asthma., (© RSNA, 2014.)

Rationale and Objectives: The purpose of this study was to analyze the relationship between airflow limitation and two types of computed tomography (CT) measurements: expiratory/inspiratory (E/I) ratio and E/I difference of percentage of low-attenuation lung regions (LAA%)., Materials and Methods: Thirty patients who underwent inspiratory and expiratory CT scans were included in this study. The CT data were used to calculate the LAA% E/I ratio and E/I difference. Other types of CT measurements were also obtained, including the E/I ratio and E/I difference of lung volume, mean lung density, standard deviation, skewness, and kurtosis. LAA% was calculated at 20 thresholds (-990 to -800 HU). Pearson's correlation between the measurements and forced expiratory flow in 1 second was used to determine the efficacy of LAA% E/I ratio and E/I difference. P values of <5.88 × 10⁻⁵ were considered statistically significant with Bonferroni correction., Results: The LAA% E/I ratio and E/I difference significantly correlated with forced expiratory flow in 1 second. The best correlation coefficient for the LAA% E/I ratio was -0.699 (P = 1.75 × 10⁻⁵) and for the LAA% E/I difference was -0.723 (P = 6.53 × 10⁻⁶). The best correlation coefficient for the LAA% E/I difference was stronger than that for the other types of CT measurements., Conclusions: The LAA% E/I ratio and E/I difference significantly correlated with airflow limitation in chronic obstructive pulmonary disease., (Copyright © 2014 AUR. Published by Elsevier Inc. All rights reserved.)

Computed tomography currently accounts for the majority of radiation exposure related to medical imaging. Although technological improvement of CT scanners has reduced the radiation dose of individual examinations, the benefit was overshadowed by the rapid increase in the number of CT examinations. Radiation exposure from CT examination should be kept as low as reasonably possible for patient safety. Measures to avoid inappropriate CT examinations are needed. Principles and information on radiation dose reduction in chest CT are reviewed in this article. The reduction of tube current and tube potential are the mainstays of dose reduction methods. Study results indicate that routine protocols with reduced tube current are feasible with diagnostic results comparable to conventional standard dose protocols. Tube current adjustment is facilitated by the advent of automatic tube current modulation systems by setting the appropriate image quality level for the purpose of the examination. Tube potential reduction is an effective method for CT pulmonary angiography. Tube potential reduction often requires higher tube current for satisfactory image quality, but may still contribute to significant radiation dose reduction. Use of lower tube potential also has considerable advantage for smaller patients. Improvement in image production, especially the introduction of iterative reconstruction methods, is expected to lower radiation dose significantly. Radiation dose reduction in CT is a multifaceted issue. Understanding these aspects leads to an optimal solution for various indications of chest CT., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objective: The purpose of this study was to investigate efficacy of two types of emphysema quantification: percentage of low-attenuation lung regions (%LA); and size distribution of these regions. On a log-log plot, cumulative frequency-size distribution of low-attenuation lung regions can be fitted by a straight line whose slope (D) has been reported to reflect diffusing capacity. In this study, %LA and D were compared with pulmonary function test (PFT) parameters, especially with ratio of diffusing capacity of carbon monoxide to effective alveolar ventilation (i.e., DLCO/VA)., Materials and Methods: Thin-section unenhanced CT images were acquired from 30 patients (25 men, five women; mean [SD] age, 70.1 ± 12.1 years), of whom 25 had received diagnosis of COPD, and %LA and D were calculated at 20 thresholds, ranging from -995 to -900 HU. To determine utility of %LA and D, we used Pearson's correlation for emphysema quantification and PFT. Significance of the coefficients was determined with Bonferroni correction (p < 0.0025). Finally, the relationships between emphysema quantification and DLCO/VA were examined by linear models and Akaike information criterion (AIC)., Results: The correlation coefficients for %LA and DLCO/VA were statistically significant at all the thresholds (optimal coefficient, -0.761). The correlation coefficients for D and DLCO/VA were statistically significant at the thresholds from -945 to -900 HU (optimal coefficient, -0.646). AIC values showed that the most accurate prediction of DLCO/VA was obtained by the model incorporating both %LA and D., Conclusion: Both %LA and D showed significant correlation with DLCO/VA. Combining %LA and D resulted in more accurate evaluation of DLCO/VA than did using %LA or D alone.

Objective: The purpose of this article is to review advanced imaging of pulmonary nodules, including pathologic and pharmacokinetic background, conventional contrast-enhanced CT and MRI assessment, dynamic contrast-enhanced CT and MRI techniques, and dual-source and area-detector CT systems for pulmonary nodule evaluation., Conclusion: Clinicians need to understand the underlying principles and pathologic and pharmacokinetic backgrounds of contrast-enhanced CT and MRI to further improve diagnostic performance. With adjustments in image acquisition and postprocessing, contrast-enhanced CT and MRI, especially the dynamic versions, can have enhanced clinical application for pulmonary nodules and expanded clinical relevance for other thoracic diseases.

Purpose: To prospectively and directly compare oxygen-enhanced (O2-enhanced) MRI with thin-section CT for pulmonary functional loss and disease severity assessment in connective tissue disease (CTD) patients with interstitial lung disease (ILD)., Materials and Methods: Thin-section CT, O2-enhanced MRI, pulmonary function test and serum KL-6 were administered to 36 CTD patients with ILD (23 men, 13 women; mean age: 63.9 years) and nine CTD patients without ILD (six men, and three women; mean age: 62.0 years). A relative-enhancement ratio (RER) map was generated from O2-enhanced MRI and mean relative enhancement ratio (MRER) for each subject was calculated from all ROI measurements. CT-assessed disease severity was evaluated with a visual scoring system from each of the thin-section CT data. MRER and CT-assessed disease severities of CTD patients with and without ILD were then statistically compared. To assess capability for pulmonary functional loss and disease severity assessment in CTD patients, correlations of MRER and CT-assessed disease severity with pulmonary functional parameters and serum KL-6 in all subjects were statistically determined., Results: MRER and CT-assessed disease severity showed significant differences between CTD patients with (MRER: 0.15 ± 0.08, CT-assessed disease severity: 13.0 ± 7.4%) and without ILD (MRER: 0.25 ± 0.06, p=0.0011; CT-assessed disease severity: 1.6 ± 1.6%, p<0.0001). MRER and CT-assessed disease severity correlated significantly with pulmonary functional parameters and serum KL-6 in all subjects (0.61 ≤ r ≤ 0.79, p<0.05)., Conclusion: O2-enhanced MRI was found to be as useful as thin-section CT for pulmonary functional loss and disease severity assessment of CTD patients with ILD., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Purpose: The purpose of this study was to compare diagnostic capabilities for assessment of recurrence in non-small cell lung cancer (NSCLC) patients by contrast-enhanced whole-body MRI (CE-WB-MRI) with and without CE-Quick 3D and double RF fat suppression technique (DFS), FDG-PET/CT and conventional radiological examinations., Materials and Methods: A total of 134 pathologically proven and completely resected NSCLC patients (78 males, 56 females; mean age: 72 years) underwent FDG-PET/CT, CE-WB-MRI with and without Quick 3D and DFS at 3T as well as conventional radiological examinations. The probability of recurrence was assessed with a 5-point scoring system on a per-patient basis, and final diagnosis was made by consensus between two readers. The capability for overall recurrence assessment by all the methods was compared by means of ROC analysis and their sensitivity, specificity and accuracy by means of McNemar's test., Results: Although areas under the curve did not show any significant differences, specificity (100%) and accuracy (95.5%) of CE-WB-MRI with CE-Quick 3D and DFS were significantly higher than those of FDG-PET/CT (specificity: 93.6%, p=0.02; accuracy: 89.6%, p=0.01) and conventional radiological examinations (specificity: 92.7%, p=0.01; accuracy: 91.0%, p=0.03). In addition, specificity of CE-WB-MRI without CE-Quick 3D and DFS (100%) was significantly higher than that of FDG-PET/CT (p=0.02) and conventional radiological examinations (p=0.01)., Conclusion: Specificity and accuracy of CE-WB-MRI with CE-Quick 3D and DFS for assessment of recurrence in NSCLC patients are at least as high as, or higher than those of others., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: The objective of our study was to prospectively compare the capability of dynamic area-detector CT analyzed with different mathematic methods and PET/CT in the management of pulmonary nodules., Subjects and Methods: Fifty-two consecutive patients with 96 pulmonary nodules underwent dynamic area-detector CT, PET/CT, and microbacterial or pathologic examinations. All nodules were classified into the following groups: malignant nodules (n = 57), benign nodules with low biologic activity (n = 15), and benign nodules with high biologic activity (n = 24). On dynamic area-detector CT, the total, pulmonary arterial, and systemic arterial perfusions were calculated using the dual-input maximum slope method; perfusion was calculated using the single-input maximum slope method; and extraction fraction and blood volume (BV) were calculated using the Patlak plot method. All indexes were statistically compared among the three nodule groups. Then, receiver operating characteristic analyses were used to compare the diagnostic capabilities of the maximum standardized uptake value (SUVmax) and each perfusion parameter having a significant difference between malignant and benign nodules. Finally, the diagnostic performances of the indexes were compared by means of the McNemar test., Results: No adverse effects were observed in this study. All indexes except extraction fraction and BV, both of which were calculated using the Patlak plot method, showed significant differences among the three groups (p < 0.05). Areas under the curve of total perfusion calculated using the dual-input method, pulmonary arterial perfusion calculated using the dual-input method, and perfusion calculated using the single-input method were significantly larger than that of SUVmax (p < 0.05). The accuracy of total perfusion (83.3%) was significantly greater than the accuracy of the other indexes: pulmonary arterial perfusion (72.9%, p < 0.05), systemic arterial perfusion calculated using the dual-input method (69.8%, p < 0.05), perfusion (66.7%, p < 0.05), and SUVmax (60.4%, p < 0.05)., Conclusion: Dynamic area-detector CT analyzed using the dual-input maximum slope method has better potential for the diagnosis of pulmonary nodules than dynamic area-detector CT analyzed using other methods and than PET/CT.

The purpose of this study was to assess the efficacy of arterial-dominant phase images of gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (EOB)-enhanced magnetic resonance imaging (MRI) for evaluation of arterial blood supply in hepatocellular carcinoma (HCC) in comparison with that of multiphasic dynamic computed tomography (CT). This study comprised 30 patients (22 men and 8 women, mean age: 68.0 years) with 40 pathologically proven HCCs (well differentiated: 3, moderately differentiated: 30, poorly differentiated: 7, mean diameter: 45.1 mm), all of whom underwent EOB-enhanced MRI and dynamic CT preoperative assessment. Regions of interest were placed over HCCs and the adjacent normal liver, and signal intensities or CT values were measured by two experienced abdominal radiologists on the arterial-dominant phase images of EOB-enhanced MRI and dynamic CT images. HCC-to-liver contrasts [Michelson's contrast: C(M)=(S(HCC)-S(Liver))/(S(HCC)+S(Liver))] were calculated and compared among the modalities. HCC-to-liver contrasts were also visually scored on a 5-point scale and compared. The mean C(M) and visual score for dynamic CT were significantly higher than those for EOB-enhanced MRI. Good agreements were obtained among the two observers. Dynamic CT is a more suitable modality than EOB-enhanced MRI for evaluation of arterial blood supply in HCC. This should be taken into account for diagnosis and management of HCC., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: To assess the effects of image reconstruction method on hepatic CT perfusion (CTP) values using two CT protocols with different radiation doses., Materials and Methods: Sixty patients underwent hepatic CTP and were randomly divided into two groups. Tube currents of 210 or 250 mA were used for the standard dose group and 120 or 140 mA for the low dose group. The higher currents were selected for large patients. Demographic features of the groups were compared. CT images were reconstructed by using filtered back projection (FBP), image filter (quantum de-noising, QDS), and adaptive iterative dose reduction (AIDR). Hepatic arterial and portal perfusion (HAP and HPP, ml/min/100ml) and arterial perfusion fraction (APF, %) were calculated using the dual-input maximum slope method. ROIs were placed on each hepatic segment. Perfusion and Hounsfield unit (HU) values, and image noises (standard deviations of HU value, SD) were measured and compared between the groups and among the methods., Results: There were no significant differences in the demographic features of the groups, nor were there any significant differences in mean perfusion and HU values for either the groups or the image reconstruction methods. Mean SDs of each of the image reconstruction methods were significantly lower (p<0.0001) for the standard dose group than the low dose group, while mean SDs for AIDR were significantly lower than those for FBP for both groups (p=0.0006 and 0.013). Radiation dose reductions were approximately 45%., Conclusions: Image reconstruction method did not affect hepatic perfusion values calculated by dual-input maximum slope method with or without radiation dose reductions. AIDR significantly reduced images noises., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)