Fundamentals of dual-energy computed tomography and its emerging applications in bladder cancer

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Abstract

Nowadays, computed tomography urography and multiparametric magnetic resonance are the most often used imaging techniques in patients with bladder cancer; however, dual-energy computed tomography is making its way into the oncological field. This narrative review article aimed to show the fundamentals of dual-energy computed tomography by outlining its physical principles, techniques, protocols, and postprocessing images to help those who used this cutting-edge technology as the first approach to fully understand its emerging applications in the evaluation of bladder cancer, a field yet to be explored. In particular, we discuss the usefulness of dual-energy computed tomography by focusing on the main images obtained, such as the iodine map, comparing them to the images obtained with conventional computed tomography scans.

Dual-energy computed tomography applications may be beneficial for bladder cancer diagnosis, staging, and treatment planning. Nevertheless, its application is limited to its availability in healthcare structures and the training of healthcare personnel who can perform and interpret the scans correctly.

About the authors

Federica Masino

Foggia University School of Medicine

Email: federicamasino@gmail.com
ORCID iD: 0009-0004-4289-3289

MD

Italy, Foggia

Laura Eusebi

“Carlo Urbani” Hospital

Email: lauraeu@virgilio.it
ORCID iD: 0000-0002-4172-5126

MD

Italy, Jesi

Manuela Montatore

Foggia University School of Medicine

Email: manuela.montatore@unifg.it
ORCID iD: 0009-0002-1526-5047

MD

Italy, Foggia

Gianmichele Muscatella

Foggia University School of Medicine

Email: muscatella94@gmail.com
ORCID iD: 0009-0004-3535-5802

MD

Italy, Foggia

Rossella Gifuni

Foggia University School of Medicine

Email: rossella.gifuni@unifg.it
ORCID iD: 0009-0009-9679-3861

MD

Italy, Foggia

Vincenzo Ferrara

“Carlo Urbani” Hospital

Email: vincenzoferrara4@gmail.com
ORCID iD: 0000-0001-8625-4308

MD

Italy, Jesi

Massimo Marcellini

“Senigallia” Hospital

Email: massimo.marcellini@sanita.marche.it
ORCID iD: 0000-0002-5281-7819

MD

Italy, Senigallia

Giuseppe Guglielmi

Foggia University School of Medicine; “Dimiccoli” Hospital; “IRCCS Casa Sollievo della Sofferenza” Hospital

Author for correspondence.
Email: giuseppe.guglielmi@unifg.it
ORCID iD: 0000-0002-4325-8330

MD, Professor

Italy, Foggia; Barletta; San Giovanni Rotondo

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Supplementary files

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2. Fig. 1. Attenuation profiles of iodine, calcium, water and fat at different energy ranges. At low energy, iodine has the highest attenuation value, and fat has the lowest. The attenuation values ​​of water do not change at different energy levels. For calcium, the variations in values ​​are less pronounced.

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3. Fig. 2. Three-dimensional reconstruction based on computed tomographic urography data with contrast: a — with visualization; b — without visualization of bones in the background in the coronary plane.

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4. Fig. 3. Atomic map (Zeff) with histogram.

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5. Fig. 4. The spectral curve allows for more accurate characterization of the material, since the attenuation curves of different materials are different. By applying the radiation at different energy levels, it is possible to differentiate materials based on differences in the attenuation coefficients of a single material.

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6. Fig. 5. Virtual monochrome images at an energy level of 40 keV: a - with more effective contrast at a higher noise level; b - at an energy level of 140 keV, the contrast is lower, there are fewer artifacts and noise.

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7. Fig. 6. A patient with hematuria on anticoagulant therapy with suspected thrombus: a — iodine map in the axial plane obtained in the arterial phase (Av=26.79 corresponds to the iodine concentration in mg/ml with a threshold value of 1.3 mg/ml). According to the CT data, the lesion contains iodine, so there is every reason to suspect bladder neoplasms in it; b — iodine map with color overlay obtained in the arterial phase of CT in the axial plane, hydroxyapatite content is not detected; c — iodine map with color overlay obtained in the arterial phase of CT in the coronal plane, hydroxyapatite content is not detected.

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8. Fig. 7. A patient with hematuria and suspected tumor lesion in the bladder: a — axial CT scan shows moderate thickening of the bladder wall with significant iodine concentration, which is highly likely to indicate the presence of a lesion. AV reflects the iodine concentration in mg/ml, which is 6.7 and 16.48 mg/ml for the areas marked with a blue circle and highlighted in yellow (threshold value 1.3 mg/ml), respectively; b, c — spectral curve, which allows describing materials by differences in the attenuation curve.

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9. Fig. 8. Computed tomography in the nephrographic phase. It is advisable to use it for quantitative assessment of iodine concentration and its normalization based on iodine content in the aorta: a — iodine map demonstrating several hard nodules on the bladder wall; b — iodine map with color overlay for better visualization of foci. The average value per foci is 1.5 mg/ml, the Av value of the iliac artery is 8.4 mg/ml, and the threshold value is 1.3 mg/ml.

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10. Fig. in table 3

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