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Image quality and pathology assessment in CT Urography: when is the low-dose series sufficient?
Linköping University, Department of Medical and Health Sciences, Division of Radiological Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Department of Radiology in Linköping. Linköping University, Center for Medical Image Science and Visualization (CMIV).ORCID iD: 0000-0002-4013-4615
Linköping University, Department of Medical and Health Sciences, Division of Radiological Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Medical radiation physics.
KTH Royal Inst Technol, Sweden.ORCID iD: 0000-0002-7750-1917
Linköping University, Department of Medical and Health Sciences, Division of Radiological Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Department of Radiology in Linköping. Linköping University, Center for Medical Image Science and Visualization (CMIV).ORCID iD: 0000-0002-9446-6981
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2019 (English)In: BMC Medical Imaging, ISSN 1471-2342, E-ISSN 1471-2342, Vol. 19, no 1, article id 64Article in journal (Refereed) Published
Abstract [en]

Background

Our aim was to compare CT images from native, nephrographic and excretory phases using image quality criteria as well as the detection of positive pathological findings in CT Urography, to explore if the radiation burden to the younger group of patients or patients with negative outcomes can be reduced.

Methods

This is a retrospective study of 40 patients who underwent a CT Urography examination on a 192-slice dual source scanner. Image quality was assessed for four specific renal image criteria from the European guidelines, together with pathological assessment in three categories: renal, other abdominal, and incidental findings without clinical significance. Each phase was assessed individually by three radiologists with varying experience using a graded scale. Certainty scores were derived based on the graded assessments. Statistical analysis was performed using visual grading regression (VGR). The limit for significance was set at p = 0.05.

Results

For visual reproduction of the renal parenchyma and renal arteries, the image quality was judged better for the nephrogram phase (p < 0.001), whereas renal pelvis/calyces and proximal ureters were better reproduced in the excretory phase compared to the native phase (p < 0.001). Similarly, significantly higher certainty scores were obtained in the nephrogram phase for renal parenchyma and renal arteries, but in the excretory phase for renal pelvis/calyxes and proximal ureters. Assessment of pathology in the three categories showed no statistically significant differences between the three phases. Certainty scores for assessment of pathology, however, showed a significantly higher certainty for renal pathology when comparing the native phase to nephrogram and excretory phase and a significantly higher score for nephrographic phase but only for incidental findings.

Conclusion

Visualisation of renal anatomy was as expected with each post-contrast phase showing favourable scores compared to the native phase. No statistically significant differences in the assessment of pathology were found between the three phases. The low-dose CT (LDCT) seems to be sufficient in differentiating between normal and pathological examinations. To reduce the radiation burden in certain patient groups, the LDCT could be considered a suitable alternative as a first line imaging method. However, radiologists should be aware of its limitations.

Place, publisher, year, edition, pages
BioMed Central, 2019. Vol. 19, no 1, article id 64
Keywords [en]
Computed tomography; Urography; Low-dose; Optimization; Image quality; Dose
National Category
Radiology, Nuclear Medicine and Medical Imaging
Identifiers
URN: urn:nbn:se:liu:diva-160048DOI: 10.1186/s12880-019-0363-zISI: 000480486200001PubMedID: 31399078Scopus ID: 2-s2.0-85070460822OAI: oai:DiVA.org:liu-160048DiVA, id: diva2:1349049
Note

Funding Agencies|ALF-and LFoU-grants from Region Ostergotland; Medical Faculty at Linkoping University

Available from: 2019-09-06 Created: 2019-09-06 Last updated: 2019-11-25Bibliographically approved
In thesis
1. Visual grading evaluation of reconstruction methods and dose optimisation in abdominal Computed Tomography
Open this publication in new window or tab >>Visual grading evaluation of reconstruction methods and dose optimisation in abdominal Computed Tomography
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Since its introduction in the 1970’s CT has emerged as a modality of choice because of its high sensitivity in producing accurate diagnostic images. A third of all Computed Tomography (CT) examinations are abdominal CTs which deliver one of the highest doses among common examinations. An increase in the number of CT examinations has raised concerns about the negative effects of ionising radiation as the dose is cumulative over the life span of the individual. Image quality in CT is closely related to the radiation dose, so that a certain dose with an associated small, but not negligible, risk is a prerequisite for high image quality. Typically, dose reduction in CT results in higher noise and a decrease in low contrast resolution which can be detrimental to the image quality produced. New technology presents a wide range of dose reduction strategies, the latest being iterative reconstruction (IR).The aim of this thesis was to evaluate two different classes of iterative reconstruction algorithms: statistical (SAFIRE) and model-based (ADMIRE) as well as to explore the diagnostic value of a low-dose abdominal CT for optimisation purposes.

This thesis included a total of 140 human subjects in four image quality evaluation studies, three of which were prospective studies (Papers I, II and IV) and one retrospective study (Paper III). Visual grading experiments to determine the potential dose reductions, were performed with pairwise comparison of image quality in the same patient at different tube loads (dose) and reconstructed with Filtered back projection (FBP) and SAFIRE strength 1 in a low-dose abdominal CT (Paper I) and FBP and ADMIRE strengths 3 and 5 in a standard dose abdominal CT (Paper II). Paper IV evaluated the impact of slice thicknesses in CT images reconstructed with ADMIRE strengths 3 and 5 when comparing multiplanar reconstruction (MPR) formatted images in a standard dose abdominal CT. Paper III, on the other hand, was an absolute assessment of image quality and pathology between the three phases of a CT Urography (CTU) protocol to explore the diagnostic value of low-dose abdominal CT. The anonymised images were displayed in random order and image quality was assessed by a group of radiologists using image quality criteria from the “European guidelines of quality criteria for CT”. The responses from the reviewer assessment were analysed statistically with ordinal logistic regression i.e. Visual Grading Regression (VGR).

Results in Paper I show that a small dose reduction (5-9 %) was possible using SAFIRE strength 1and indicated the need for further research to evaluate the dose reduction potential of higher strengths of the algorithm. In Paper II a 30% dose reduction was possible without change in ADMIRE algorithm strength as no improvement in image quality was observed between tube loads 98- and 140 mAs. When comparing tube loads 42 and 98 mAs, further dose reduction was possible with ADMIRE strength 3 (22-47%). However, for images reconstructed with ADMIRE strength 5, a dose reduction of 34-74% was possible for some, but not all image criteria. Image quality in low-contrast objects such as the liver parenchyma, was affected and a decline in diagnostic confidence was observed. Paper IV showed potential dose reductions are possible with increasing slice thickness from 1 mm to 2 mm (24-35%) and 1 mm to 3mm (25-41%). ADMIRE strength 3 continued to provide diagnostically acceptable images with possible dose reductions for all image criteria assessed. Despite objective evaluations showing a decrease in noise and an increase in contrast to noise ratio, ADMIRE strength 5 had diverse effects on the five image criteria, depending on slice thickness and further dose reductions were limited to certain image criteria. The findings do not support a general recommendation to replace ADMIRE3 with ADMIRE5 in clinical abdominal CT protocols.

Paper III studied another aspect of optimisation and results show that visualisation of renal anatomy was as expected in favour of the post-contrast phases when compared to the native phase. Assessment of pathology showed no significant differences between the three phases. Significantly higher diagnostic certainty for renal anatomy was observed for the post-contrast phases when compared to the native phase. Significantly high certainty scores were also seen for the nephrographic phase for incidental findings. The conclusion is that a low-dose series seems to be sufficient as a first-line modality in certain patient groups.

This thesis clinically evaluated the effect of IR in abdominal CT imaging and estimated potential dose reductions. The important conclusion from papers I, II and IV is that IR improves image quality in abdominal CT allowing for some dose reductions. However, the clinical utility of the highest strength of the algorithm is limited to certain criteria. The results can be used to optimise the clinical abdominal CT protocol. The conclusion from paper III may increase clinical awareness of the value of the low-dose abdominal protocol when choosing an imaging method for certain patient groups who are more sensitive to radiation.

Abstract [sv]

Datortomografi (DT) används i allt större omfattning vid bilddiagnostik och ger en viss stråldos till patienten. DT är en viktig, snabb och patientvänlig undersökningsteknik. En fördel med denna teknik är att bildmaterialet kan rekonstrueras i olika format för att åskådliggöra anatomin på bästasätt beroende på vilken frågeställning som ska besvaras. Joniserande strålning från dessa undersökningar anses öka risken för negativa effekter även om risken för den enskilde patient är mycket liten. Antalet datortomografiundersökningar ökar från år till år vilket kan leda till ökade stråldoser tillbefolkningen. Optimering av undersökningsteknik och val av undersökning för att minska negativa effekter av röntgenstrålning är därför nödvändig.

Det övergripande målet med avhandlingen var att utvärdera bildkvalitetvid en DT-undersökning av buken (då dessa medför en av de högstastråldoserna bland de vanliga röntgenundersökningarna), att kvantifieramöjlig stråldosminskning med hjälp av iterativa rekonstruktionsalgoritmer och att utvärdera diagnostiska värdet av lågdosundersökningsteknik vid DT-buk. Av de fyra delstudierna var delarbeten I, II och IV prospektiva och delarbete III retrospektivt.

För de prospektiva studierna, samlades bildmaterial in vid en kliniskberättigad undersökning av lågdos-DT av buken (delarbetet I), eller standarddos-DT av buken (delarbetet II och IV). Bilder rekonstruerades meden standard bildrekonstruktionsalgoritm, filtrerad återprojektion (FBP), och med styrka 1 av den iterativa algoritmen SAFIRE (delarbetet I). I delarbeten II och IV, gjordes bildrekonstruktioner med FBP och med styrka 3 och 5 av den iterativa algoritmen ADMIRE. Avidentifierade bildmaterialför varje patient visades parvis i slumpmässig ordning för ett antal granskare och bildkvaliteten bedömdes med hjälp av europeiska bildkriterier. I den retrospektiva studien, delarbete III, hämtades bildmaterialet från utförda DT-urografiundersökningar från bildarkivet. För varje undersökning visades bilder från varje fas i DT-urografiundersökningen separat i slumpmässig ordning. För samtliga delarbeten, hämtades bildkriteriernafrån ”European Guidelines of Quality Criteria for CT” och modifierades för att passa till varje studie. Granskarnas bedömning analyserades med ordinal logistisk regression så kallad visual grading regression (VGR). Resultat från delarbetet I visade att det fanns en signifikant inverkan av dos (p <0,001) och rekonstruktionsalgoritm (p <0,01) på samtliga bildkriterier, med en beräknad möjlig dosminskning på 5–9%. Delarbetet II visade att rekonstruktionsalgoritmen ADMIRE förbättrar bildkvaliteten i jämförelse med FBP. ADMIRE styrka 3 tillåter en dosminskning mellan 22–47% för samtliga bildkriterier medan ADMIRE styrka 5 tillåter en dosminskning mellan 34–74% för nästan alla bedömda bildkriterier utom återgivning av leverns parenkym. Ett mycket oväntat resultat var att bildkvalitén för 70% dosnivå bedömdes som högre eller likvärdig med 100% dosnivå, vilket innebar att stråldosen kan sänkas med 30% utan förändring i algoritm eller styrka.

Resultaten av delarbete III visade att avbildning av njuranatomi var som förväntat för varje fas med fördel för kontrastuppladdningsfaserna jämfört med den nativa fasen. Detta var inte ett oväntat resultat eftersom DT-urografiprotokollet är utformat för att visualisera njuranatomi på bästa möjliga sätt. Vid bedömning av patologiska fynd, erhölls dock små och ickesignifikanta skillnader mellan faserna. Däremot noterades signifikant högre bedömningssäkerhet för patologi i njurarna för de kontrast förstärkta faserna jämfört med nativfasen, och endast för bifynd signifikant högre poäng för parenkymfasen.

Delarbete IV visade att styrka 5 jämfört med styrka 3 av den iterativa rekonstruktionsalgoritmen, har olika effekter på bedömningen av bildkvalitetskriterierna. Ökning av MPR-snittjocklek från 1 mm till 2 mm eller 3mm, ger en förbättring i bildkvalité, vilket möjliggör en viss dosreduktion. Den kliniska användbarheten av ADMIRE styrka 5 är begränsad, medan ADMIRE styrka 3 levererar bättre bildkvalitet för samtliga undersökta bildkriterier vid datortomografiundersökning av buken.

Den viktigaste slutsatsen av delarbeten I, II och IV är att iterativa rekonstruktionsalgoritmer förbättrar bildkvalitet jämfört med FBP för samma stråldos och en dosminskning är möjlig. Detta kan användas för att optimera det kliniska DT-bukundersöknings protokoll. Slutsatsen för delarbetet III var att en lågdos-DT-bukundersökning är ett av många dosreduceringsalternativ, som möjligen kan användas för att minska strålningsbördan hos vissa patientgrupper som är mer känsliga för röntgenstrålning.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2019. p. 90
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1683
National Category
Radiology, Nuclear Medicine and Medical Imaging
Identifiers
urn:nbn:se:liu:diva-160928 (URN)10.3384/diss.diva-160928 (DOI)9789176850718 (ISBN)
Public defence
2019-11-07, Berzelius salen, Universitetssjukhuset, Linköping, 13:00 (English)
Opponent
Supervisors
Available from: 2019-10-15 Created: 2019-10-15 Last updated: 2019-11-15Bibliographically approved

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