Angelica Svalkvist

Comparison of Chest Tomosynthesis and Chest Radiography for Detection of Pulmonary Nodules: Human Observer Study of Clinical Cases

PURPOSE To compare chest tomosynthesis with chest radiography in the detection of pulmonary nodules by using multidetector computed tomography (CT) as the reference method. MATERIALS AND METHODS The Regional Ethical Review Board approved this study, and all participants gave informed consent. Four thoracic radiologists acted as observers in a jackknife free-response receiver operating characteristic (JAFROC) study conducted in 42 patients with and 47 patients without pulmonary nodules examined with chest tomosynthesis and chest radiography. Multidetector CT served as reference method. The observers marked suspected nodules on the images by using a four-point rating scale for the confidence of presence. The JAFROC figure of merit was used as the measure of detectability. The number of lesion localizations relative to the total number of lesions (lesion localization fraction [LLF]) and the number of nonlesion localizations relative to the total number of cases (nonlesion localization fraction [NLF]) were determined. RESULTS Performance of chest tomosynthesis was significantly better than that of chest radiography with regard to detectability (F statistic = 32.7, df = 1, 34.8, P < .0001). For tomosynthesis, the LLF for the smallest nodules (< or = 4 mm) was 0.39 and increased with an increase in size to an LLF for the largest nodules (> 8 mm) of 0.83. The LLF for radiography was small, except for the largest nodules, for which it was 0.52. In total, the LLF was three times higher for tomosynthesis. The NLF was approximately 50% higher for tomosynthesis. CONCLUSION For the detection of pulmonary nodules, the performance of chest tomosynthesis is better, with increased sensitivity especially for nodules smaller than 9 mm, than that of chest radiography.

Effective dose to patients from chest examinations with tomosynthesis.

Chest tomosynthesis, which refers to the principle of collecting low-dose projections of the chest at different angles and using these projections to reconstruct section images of the chest, is an imaging technique recently introduced to health care. The main purpose of the present work was to determine the average effective dose to patients from clinical use of chest tomosynthesis. Exposure data for two chest radiography laboratories with tomosynthesis option (Definium 8000 with VolumeRAD option, GE Healthcare, Chalfont St. Giles, UK) were registered for 20 patients with a weight between 60 and 80 kg (average weight of 70.2 kg). The recorded data were used in the Monte Carlo program PCXMC 2.0 (STUK-Radiation and Nuclear Safety Authority, Helsinki, Finland) to determine the average effective dose for each projection. The effective dose for the chest tomosynthesis examination, including a scout view and the tomosynthesis acquisition, was finally obtained by adding the effective doses from all projections. Using the weighting factors given in ICRP 103, the average effective dose for the examination was found to be 0.13 mSv, whereas the average effective dose for the conventional two-view chest radiography examination was 0.05 mSv. A conversion factor of 0.26 mSv Gy(-1) cm(-2) was found suitable for determining the effective dose from a VolumeRAD chest tomosynthesis examination from the total registered kerma-area product. In conclusion, the effective dose to a standard-sized patient (170 cm/70 kg) from a VolumeRAD chest tomosynthesis examination is ~2 % of an average chest CT and only two to three times the effective dose from the conventional two-view chest radiography examination.

ViewDEX: an efficient and easy-to-use software for observer performance studies

The development of investigation techniques, image processing, workstation monitors, analysing tools etc. within the field of radiology is vast, and the need for efficient tools in the evaluation and optimisation process of image and investigation quality is important. ViewDEX (Viewer for Digital Evaluation of X-ray images) is an image viewer and task manager suitable for research and optimisation tasks in medical imaging. ViewDEX is DICOM compatible and the features of the interface (tasks, image handling and functionality) are general and flexible. The configuration of a study and output (for example, answers given) can be edited in any text editor. ViewDEX is developed in Java and can run from any disc area connected to a computer. It is free to use for non-commercial purposes and can be downloaded from http://www.vgregion.se/sas/viewdex. In the present work, an evaluation of the efficiency of ViewDEX for receiver operating characteristic (ROC) studies, free-response ROC (FROC) studies and visual grading (VG) studies was conducted. For VG studies, the total scoring rate was dependent on the number of criteria per case. A scoring rate of approximately 150 cases h(-1) can be expected for a typical VG study using single images and five anatomical criteria. For ROC and FROC studies using clinical images, the scoring rate was approximately 100 cases h(-1) using single images and approximately 25 cases h(-1) using image stacks ( approximately 50 images case(-1)). In conclusion, ViewDEX is an efficient and easy-to-use software for observer performance studies.

Effect of clinical experience of chest tomosynthesis on detection of pulmonary nodules

Background: The new technique chest tomosynthesis refers to the principle of collecting low-dose projections of the chest at different angles and using these projections to reconstruct section images of the chest at a radiation dose comparable to that of chest radiography. Purpose: To investigate if, for experienced thoracic radiologists, the detectability of pulmonary nodules obtained after only a short initial learning period of chest tomosynthesis improves with additional clinical experience of the new technique. Material and Methods: Two readings of the same clinical chest tomosynthesis cases, the first performed after 6 months of clinical experience and the second after an additional period of 1 year, were conducted. Three senior thoracic radiologists, with more than 20 years of experience of chest radiography, acted as observers, with the task of detecting pulmonary nodules in a jackknife free-response receiver operating characteristics (JAFROC1) study. The image material consisted of 42 patients with and 47 patients without pulmonary nodules examined with chest tomosynthesis. Multidetector computed tomography (MDCT) was used as a reference. The total number of nodules was 131. The JAFROC1 figure of merit (FOM) was used as the principal measure of detectability. Results: The difference in the observer-averaged JAFROC1 FOM of the two readings was 0.004 (95% confidence interval: -0.11, 0.12; F-statistic: 0.01 on 1 and 2.65 df; P=0.91). Thus, no significant improvement in detectability was found after the additional clinical experience of tomosynthesis. Conclusion: The study indicates that experienced thoracic radiologists already within the first months of clinical use of chest tomosynthesis are able to take advantage of the new technique in the task of detecting pulmonary nodules.

Overview of two years of clinical experience of chest tomosynthesis at Sahlgrenska University Hospital

Since December 2006, approximately 3800 clinical chest tomosynthesis examinations have been performed at our department at Sahlgrenska University Hospital. A subset of the examinations has been included in studies of the detectability of pulmonary nodules, using computed tomography (CT) as the gold standard. Visibility studies, in which chest tomosynthesis and CT have been compared side-by side, have been used to determine the depiction potential of chest tomosynthesis. Comparisons with conventional chest radiography have been made. In the clinical setting, chest tomosynthesis has mostly been used as an additional examination. The most frequent indication for chest tomosynthesis has been suspicion of a nodule or tumour. In visibility studies, tomosynthesis has depicted over 90 % of the nodules seen on the CT scan. The corresponding figure for chest radiography has been <30 %. In the detection studies, the lesion-level sensitivity has been approximately 60 % for tomosynthesis and 20 % for chest radiography. In one of the detection studies, an analysis of all false-positive nodules was performed. This analysis showed that all findings had morphological correlates on the CT examinations. The majority of the false-positive nodules were localised in the immediate subpleural region. In conclusion, chest tomosynthesis is an improved chest radiography method, which can be used to optimise the use of CT resources, thereby reducing the radiation dose to the patient population. However, there are some limitations with chest tomosynthesis. For example, patients undergoing tomosynthesis have to be able to stand still and hold their breath firmly for 10 s. Also, chest tomosynthesis has a limited depth resolution, which may explain why pathology in the subpleural region is more difficult to interpret and artefacts from medical devices may occur.

Simulation of dose reduction in tomosynthesis

PURPOSE Methods for simulating dose reduction are valuable tools in the work of optimizing radiographic examinations. Using such methods, clinical images can be simulated to have been collected at other, lower, dose levels without the need of additional patient exposure. A recent technology introduced to healthcare that needs optimization is tomosynthesis, where a number of low-dose projection images collected at different angles is used to reconstruct section images of an imaged object. The aim of the present work was to develop a method of simulating dose reduction for digital radiographic systems, suitable for tomosynthesis. METHODS The developed method uses information about the noise power spectrum (NPS) at the original dose level and the simulated dose level to create a noise image that is added to the original image to produce an image that has the same noise properties as an image actually collected at the simulated dose level. As the detective quantum efficiency (DQE) of digital detectors operating at the low dose levels used for tomosynthesis may show a strong dependency on the dose level, it is important that a method for simulating dose reduction for tomosynthesis takes this dependency into account. By applying an experimentally determined relationship between pixel mean and pixel variance, variations in both dose and DQE in relevant dose ranges are taken into account. RESULTS The developed method was tested on a chest tomosynthesis system and was shown to produce NPS of simulated dose-reduced projection images that agreed well with the NPS of images actually collected at the simulated dose level. The simulated dose reduction method was also applied to tomosynthesis examinations of an anthropomorphic chest phantom, and the obtained noise in the reconstructed section images was very similar to that of an examination actually performed at the simulated dose level. CONCLUSIONS In conclusion, the present article describes a method for simulating dose reduction suitable for tomosynthesis. However, the method applies equally well to any digital radiographic system, although the benefits of correcting for DQE variations may be smaller.

Learning aspects and potential pitfalls regarding detection of pulmonary nodules in chest tomosynthesis and proposed related quality criteria.

Background In chest tomosynthesis, low-dose projections collected over a limited angular range are used for reconstruction of an arbitrary number of section images of the chest, resulting in a moderately increased radiation dose compared to chest radiography. Purpose To investigate the effects of learning with feedback on the detection of pulmonary nodules for observers with varying experience of chest tomosynthesis, to identify pitfalls regarding detection of pulmonary nodules, and present suggestions for how to avoid them, and to adapt the European quality criteria for chest radiography and computed tomography (CT) to chest tomosynthesis. Material and Methods Six observers analyzed tomosynthesis cases for presence of nodules in a jackknife alternative free-response receiver-operating characteristics (JAFROC) study. CT was used as reference. The same tomosynthesis cases were analyzed before and after learning with feedback, which included a collective learning session. The difference in performance between the two readings was calculated using the JAFROC figure of merit as principal measure of detectability. Results Significant improvement in performance after learning with feedback was found only for observers inexperienced in tomosynthesis. At the collective learning session, localization of pleural and subpleural nodules or structures was identified as the main difficulty in analyzing tomosynthesis images. Conclusion The results indicate that inexperienced observers can reach a high level of performance regarding nodule detection in tomosynthesis after learning with feedback and that the main problem with chest tomosynthesis is related to the limited depth resolution.

A phantom study of nodule size evaluation with chest tomosynthesis and computed tomography

The aim of the present study was to investigate nodule size measurements with chest tomosynthesis (TS) and computed tomography (CT). A 26-mm thick phantom, composed of a Polylite block with embedded spheres of different materials and sizes (4-20 mm), was scanned by both CT and TS. Six observers without prior knowledge of the true diameters of the spheres independently measured the diameter of the spheres on the CT and TS images. Four observers were allowed to change the window settings and two of the observers used predetermined fixed viewing conditions. The mean relative errors for all observers and all measured spheres compared with the known diameter of the spheres were 1.4 % (standard deviation, SD: 5.4 %) on CT images and -1.1 % (SD: 5.0 %) on TS images. With regard to the four observers where the window settings were at the discretion of the observer, the mean relative errors were 1.4 % (SD: 6.4 %) on CT images and -1.7 % (SD: 5.7 %) on TS images. Regarding the two observers using identical viewing conditions the mean relative error was 1.5 % (SD: 2.8 %) on CT images and 0.2 % (SD: 2.6 %) on TS images. In conclusion, the study suggests that nodule size measurements on chest TS might be an alternative to measurements on CT.

Monte Carlo simulations of the dosimetry of chest tomosynthesis

The aims of this work were to explore the dosimetry of chest tomosynthesis and to determine conversion factors between air kerma-area product (KAP) and the effective dose for different system configurations and patient sizes. Tomosynthesis systems were modelled with different angular intervals and tube voltages for the collection of the projection images as well as different distributions of the total exposure over the projections. The Monte Carlo-based computer software PCXMC developed by STUK (Radiation and Nuclear Safety Authority in Finland) was used to calculate the effective doses for each modelled tomosynthesis system for various patient sizes. The conversion factor between KAP and effective dose was obtained both for the zero-degree projection alone and for the entire tomosynthesis examination for each system configuration and patient size. The results reveal that the conversion factor for the zero-degree projection can be used to estimate the total effective dose from a tomosynthesis examination with acceptable accuracy, leading to an error smaller than 10 % irrespective of the system configuration and patient size. For higher accuracy, conversion factors between the total KAP and the total effective dose that take the angular interval and exposure configuration into account are presented for each system.

Image quality dependency on system configuration and tube voltage in chest tomosynthesis—A visual grading study using an anthropomorphic chest phantom

PURPOSE To investigate the potential benefit of increasing the dose per projection image in chest tomosynthesis, performed at the current standard dose level, by reducing the angular range covered or the projection image density and to evaluate the influence of the tube voltage on the image quality. METHODS An anthropomorphic chest phantom was imaged using nine different projection image configurations and ten different tube voltages with the GE VolumeRAD tomosynthesis system. The resulting image sets were representative of being acquired at the same total effective dose. This was achieved partly by applying a simulated dose reduction to the projection images due to restrictions concerning the tube load settings on the VolumeRAD system. Four observers were included in a visual grading study where the reconstructed tomosynthesis section images were rated according to a set of image quality criteria. Image quality was evaluated relative to the default configuration and default tube voltage on the VolumeRAD system. RESULTS Overall, the image quality decreased with decreasing projection image density. Regarding angular range covered by the projection images, the image quality increased with decreasing angular range for two of the criteria, whereas for a criterion related to the depth resolution in the section images the reduced angular ranges resulted in inferior image quality as compared to the default configuration. The image quality showed little dependence on the tube voltage. CONCLUSIONS At the standard dose level of the VolumeRAD system, the potential benefits from increasing the dose per projection do not fully compensate for the negative effects resulting from a reduction in the number of projection images. Consequently, the default configuration consisting of 60 projection images acquired over 30° is a good alternative. The tube voltage used in tomosynthesis does not have a large impact on the image quality.