Whole-body CT Research Articles

Paraneoplastic Kelch-like protein 11 antibody-associated cerebellar and limbic encephalitis caused by metastatic “burned-out” seminoma – A scar(r)y phenomenon

IntroductionThe diagnosis of paraneoplastic neurologic syndromes is challenging when the primary tumor masquerades as scar tissue (i.e. “burned-out”). MethodsCase report. ResultsA 45-year-old male patient presented with progressive cerebellar symptoms and hearing loss. Initial screening for malignancy and extensive testing of paraneoplastic and autoimmune neuronal antibodies gave negative results. Repeated whole-body FDG-PET CT revealed a single paraaortic lymphadenopathy, metastasis of a regressed testicular seminoma. Anti-Kelch-like protein-11 (KLHL11) encephalitis was finally diagnosed. ConclusionOur case highlights the importance of continued efforts to find an often burned-out testicular cancer in patients with a highly unique clinical presentation of KLHL11 encephalitis.

Whole-body computed tomography after major blunt trauma: is it necessary?

Introduction: Trauma is a significant health problem today. Also, it is the foremost reason for death among people ages 1-45; for this reason, the economic and social effect is more articulated. The whole-body CT scans have become a standard procedure in managing trauma patients in many trauma centers. We think that whole body CT will be beneficial in patients with blunt trauma. Thus, we aimed to examine patients with blunt trauma who applied to the emergency department and had whole-body CT scans. Methods: Patient who applied to blunt trauma and had whole-body CT scans to the emergency department of a tertiary training and research hospital between Jan 1, 2021, and Jan 1, 2022, were examined in this single-center, retrospective study. The study population was established based on inclusion and exclusion criteria. ISS, GCS, and whole-body CT scans were compared for mortality. Results: Cranial bone fracture (p= 0.001), epidural hemorrhage (p= 0.001), traumatic subarachnoid hemorrhage (p= 0.001), cerebral edema (p= 0.003), and thoracic contusion (p= 0.046) were significant for mortality. Also, the number of pathological regions in whole-body CT scans was not associated with mortality (p= 0.587). ISS (p=0.001) and GCS (p= 0.001) predicted mortality in patients who experienced whole-body CT scans. Conclusion: Based on our findings, we can detect organ and tissue injuries quickly and in detail using whole-body CT scanning after major blunt trauma. In addition, various protocols are needed in multiple trauma patients to reduce the number of unnecessary WBCT scans. Therefore, whole-body CT scans may be helpful for selection, as ISS and GCS are markers of mortality. Keywords: Whole-body Tomography, Trauma, Trauma Imaging

Mortality With and Without Whole-Body CT in Severely Injured Children.

The choice of imaging modality-the use of whole-body computed tomography (WB-CT) versus a step-wise diagnostic procedure-in injured children is controversial. In this study we availed ourselves of data from the TR-DGU, the trauma registry of the German Society for Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie), to investigate whether the use of WB-CT improves the outcome. The TR-DGU data from the period 2012-2021 were evaluated. A three-stage analysis began with comparison of children with adults aged ≤ 50 years. As a second step, the observed and expected mortality in children with WB-CT was compared with the mortality in children without WBCT. Finally, predictors of the use of WB-CT were identified so that a propensity score analysis of matched pairs could be performed. A total of 65 092 patients were included, 4573 children (7%) and 60 519 adults (93%), with differences in accident type and injury pattern. Comparison of the ratio of observed to expected mortality revealed no difference between the two groups of children (standardized mortality ratio 0.97 with WB-CT, 0.95 without WB-CT). In adults, however, there was an advantage for the WB-CT group. The propensity score analysis of 1101 matched pairs showed identical mortality in the two groups (3.9% with WB-CT, 4.0% without WB-CT). The TR-DGU data show no benefit of WB-CT compared with step-wise diagnosis in the care of severely injured children. In view of the radiation exposure involved, with the danger of inducing malignancy, the benefits and risks of the use of WB-CT in children should be weighed up carefully in team discussions.

Opportunistic measures of bone mineral density at multiple skeletal sites during whole-body CT in polytrauma patients.

Whole-body CT (WBCT) in polytrauma patients enables the detection of numerous incidental findings, such as estimates of bone mineral density (BMD) at multiple skeletal sites. This could help in better understanding of age- and sex-related changes in BMD through skeleton. Data were retrospectively retrieved from the WBCTs requested during a 2-year period. BMD, expressed in CT Hounsfield units (HU), was measured at frontal and occipital bone, four vertebrae (C4, Th7, L4, and S2), iliac bone, and proximal humerus and femur. Measurements were done on native and postcontrast scans. The population sample was age-, sex-, and visceral fat volume adjusted for analysis. A total of 296 patients were included, with a median age of 51years. BMD varied from the highest HU in cranial bones (629 HU) to the lowest HU in the pelvic bones (114 HU), P < 0.001. Sex differences were independent predictors of BMD in cranial bones and proximal humerus. The age-related decline in BMD was significant in all other bones, but the association with age differed among the measurement's sites. Visceral fat showed the strongest correlation with the lumbar spine and iliac wing, although multivariate analysis revealed it was not an independent predictor of bone density, such as age and sex. BMD varies through skeleton, being the highest in the proximal axial skeleton. Age-related changes in BMD are significant and more pronounced than sex-related changes in almost all bones. Cranial bones do not follow the same pattern compared to other bones.

Whole-body low-dose computed tomography in primary patients with multiple myeloma

Imaging of bone lesions has an important role in diagnosis of multiple myeloma (MM) and evaluating the response to treatment. Computed tomography scan (CT) allows to detect osteolysis, plasmacytoma and the risk of fractures with high sensitivity. In the National Research Center For Hematologysince 2014 all patients with MM are diagnosed with the whole-body low-dose CT.The aim of the study was to demonstrate the sensitivity of the whole-body low-dose CT and to characterize localization, number and size of bone lesions in primary MM patients.Materials and methods. 50 patients with newly diagnosed MM were enrolled in the study. The diagnosis was established in accordance with international diagnostic criteria. All patients received the whole-body low-dose CT. According to the Durie-Salmon and ISS staging systems 62% and 66% of patients had stage III, respectively.Results. 96% of MM patients had bone lesions. In 30% of patients, bone involvement was the only criterion for CRAB. Pelvic bone lesions was most often diagnosed (92%). The destruction of the long bones of the arms and legs were most rarely detected (42% of patients) and mostly small. The presence of intraosseous plasmocytoma was noted in 40% of cases.Conclusion. The whole-body low dose CT was found to be the most sensitive modality for detection osteolytic bone lesions. Low-dose CT is available in MM case with bone disease only, for establish symptomatic stage. This patients require immedate antimyeloma treatment.

Computed tomography with adjusted dose for body mass index may be superior to whole-body radiography especially in elderly patients with multiple myeloma.

Whole-body skeletal radiography has traditionally been used in the management of multiple myeloma for defining treatment strategies. For several reasons, radiography has been replaced by computed tomography (CT) covering the same regions. To evaluate the body mass index (BMI) adjusted effective radiation dose from two different methods of whole-body radiologic imaging for multiple myeloma assessment. The current investigation analyses the dose to patients resulting from the two methods, conventional radiography supplemented with tomosynthesis (203 examinations) and CT (264 examinations). All patients subject to myeloma staging for 4.5 years were included in the study. Exposure parameters were collected from the PACS and conversion factors were calculated using the software packages PCXMC and VirtualDose enabling the calculation of the effective dose to each patient based on BMI. The Mann-Whitney U test was used for comparisons between groups. Patients were subject to a median effective dose of 2.5 mSv for conventional radiography and 5.1 mSv for CT, a statistically significant difference. The effective dose for whole-body CT in assessing multiple myeloma is twice as high as for whole-body skeletal survey with modern digital radiography, but at a low level and considerably less than the levels quoted in the earlier studies of ∼30 mSv when the technique was first explored.

Measurement of enhanced vasa vasorum density in a porcine carotid model using photon counting detector CT.

The onset of atherosclerosis is preceded by changes in blood perfusion within the arterial wall due to localized proliferation of the vasa vasorum. The purpose of this study was to quantify these changes in spatial density of the vasa vasorum using a research whole-body photon-counting detector CT (PCD-CT) scanner and a porcine model. Vasa vasorum angiogenesis was stimulated in the left carotid artery wall of anesthetized pigs ( ) while the right carotid served as a control. After a 6-week recovery period, the animals were scanned on the PCD-CT prior to and after injection of iodinated contrast. Annular regions of interest were used to measure wall enhancement in the injured and control arteries. The exact Wilcoxon-signed rank test was used to determine whether a significant difference in contrast enhancement existed between the injured and control arterial walls. The greatest arterial wall enhancement was observed following contrast recirculation. The wall enhancement measurements made over these time points revealed that the enhancement was greater in the injured artery for 13/16 scanned arterial regions. Using an exact Wilcoxon-signed rank test, a significantly increased enhancement ratio was found in injured arteries compared with control arteries ( ). Vasa vasorum angiogenesis was confirmed in micro-CT scans of excised arteries. Whole-body PCD-CT scanners can be used to detect and quantify the increased perfusion occurring within the porcine carotid arterial wall resulting from an increased density of vasa vasorum.

Quantification of Extracellular Volume in CT in Neoadjuvant Chemotherapy in Breast Cancer: New Frontiers in Assessing the Cardiotoxicity of Anthracyclines and Trastuzumab.

Breast cancer patients undergoing neoadjuvant chemotherapy with anthracyclines or trastuzumab can suffer cardiotoxic issues. Nowadays, the markers of cardiac damage are still not reliable, and extracellular volume (ECV) calculated from CT could be a promising cardiotoxic marker. Eighty-two patients, treated with two different chemotherapy regimens based on doxorubicin (DOX) or epirubicin-trastuzumab (EPI-TRAS), were retrospectively selected and the variations in extracellular volume (ECV) values were measured and analyzed. Whole Body CT (WB-CT) scans were acquired after 1 min, in the portal phase (PP), and after 5 min, in the delayed phases (DP), at the baseline (T0), after one year (T1) and after five years (T5) from the end of chemotherapies. The values measured by two radiologists with different levels of experience were evaluated in order to assess the inter-reader reproducibility assessment (ICC = 0.52 for PP and DP). Further, we performed a population-based analysis and a drug-oriented subgroup analysis in 54 DOX-treated and 28 EPI-TRAS-treated patients. In the general cohort of women treated with any of the two drugs, we observed in the lapse T0-T1 a relative increase (RI) of 25% vs. 20% (PP vs. DP, p < 0.001) as well as in the lapse T0-T5 an RI of 17% vs. 15% (PP vs. DP, p < 0.01). The DOX-treated patients reported in the lapse T0-T1 an RI of 22% (p < 0.0001) in PP and an RI of 16% (p = 0.018) in the DP, with ECV values remaining stably high at T5 both in PP (RI 14.0%, p < 0.0001) and in DP (RI 17%, p = 0.005) highlighting a possible hallmark of a persisting CTX sub-damage. On the other hand, ECV measured in EPI-TRAS-treated women showed an RI in T0-T1 of 18% (p = 0.001) and 29% (p = 0.006) in PP and DP, respectively, but the values returned to basal levels in T5 both in the PP (p = 0.12) and in DP setting (p = 0.13), suggesting damage in the first-year post-treatment and a possible recovery over time. For the 82 patients, an echocardiography was performed at T0, T1= 12 m + 3 m and T5 = 60 m + 6 m with LVEF values at T0 (64% ± 5%), T1 (54% ± 6%) and T5 (53% ± 8%). WB-CT-derived ECV values could provide a valid imaging marker for the early diagnosis of cardiotoxic damage in BC patients undergoing oncological treatments. We detected different patterns during the follow-up, with stably high values for DOX, whereas EPI-TRAS showed a peak within the first year, suggesting different mechanisms of cardiac damage.

Structured reporting of computed tomography in the polytrauma patient assessment: a Delphi consensus proposal

ObjectivesTo develop a structured reporting (SR) template for whole-body CT examinations of polytrauma patients, based on the consensus of a panel of emergency radiology experts from the Italian Society of Medical and Interventional Radiology.MethodsA multi-round Delphi method was used to quantify inter-panelist agreement for all SR sections. Internal consistency for each section and quality analysis in terms of average inter-item correlation were evaluated by means of the Cronbach’s alpha (Cα) correlation coefficient.ResultsThe final SR form included 118 items (6 in the “Patient Clinical Data” section, 4 in the “Clinical Evaluation” section, 9 in the “Imaging Protocol” section, and 99 in the “Report” section). The experts’ overall mean score and sum of scores were 4.77 (range 1–5) and 257.56 (range 206–270) in the first Delphi round, and 4.96 (range 4–5) and 208.44 (range 200–210) in the second round, respectively.In the second Delphi round, the experts’ overall mean score was higher than in the first round, and standard deviation was lower (3.11 in the second round vs 19.71 in the first round), reflecting a higher expert agreement in the second round. Moreover, Cα was higher in the second round than in the first round (0.97 vs 0.87).ConclusionsOur SR template for whole-body CT examinations of polytrauma patients is based on a strong agreement among panel experts in emergency radiology and could improve communication between radiologists and the trauma team.

Post-traumatic acute aortic regurgitation due to cusp rupture in non-calcific bicuspid valve treated with ballon-expandable transcatheter heart valve.

A 65-year-old male truck driver was admitted to the emergency department after a road crush with consequent polytrauma. Patient’s past medical and cardiovascular history were unremarkable. Physical examination showed neck haematoma with multiple contusions, abolished right vesicular murmur, bone deformities. Whole-body CT scan documented multiple bone fractures, right hemothorax and pneumothorax, mediastinal haematoma, bilateral pulmonary contusions and rib fractures, dissection not limiting flow of right subclavian artery, left vertebral artery and both internal carotid arteries with associated pseudoaneurysms. Emergency chest drainage was performed and the patient was intubated because of worsening dyspnoea. Transthoracic echocardiography documented massive aortic insufficiency due to cusp rupture (Panels A and B and Supplementary material online, Videos S1 and S2) in the context of aortic bicuspidia (Sievers Type 1) and pulmonary hypertension with signs of right ventricular dysfunction. Because of patient’s extremely critical condition with hemodynamic instability and pulmonary congestion and concomitant prohibitive surgical risk for urgent aortic valve replacement, off-label transcatheter aortic valve replacement was planned.

Illuminating the Use of Trauma Whole-Body CT Scan During the Global Contrast Shortage.

Use of whole-body CT scan (WBCT) is widespread in the evaluation of traumatically injured patients and may be associated with improved survival. WBCT protocols include the use of IV contrast unless there is a contraindication. This study tests the hypothesis that using plain WBCT scan during the global contrast shortage would result in greater need for repeat contrast-enhanced CT, but would not impact mortality, missed injuries, or rates of acute kidney injury (AKI). All trauma encounters at an academic level-I trauma center between March 1, 2022 and June 24, 2022, excluding burns and prehospital cardiac arrests, were reviewed. Imaging practices and outcomes before and during contrast shortage (beginning May 3, 2022) were compared. The study population included 1,109 consecutive patients (72% male), with 890 (80%) blunt and 219 (20%) penetrating traumas. Overall, 53% of patients underwent WBCT and contrast was administered to 73%. The overall rate of AKI was 6% and the rate of renal replacement therapy (RRT) was 1%. Contrast usage in WBCT was 99% before and 40% during the shortage (p < 0.001). There was no difference in the rate of repeat CT scans, missed injuries, AKI, RRT, or mortality. Trauma imaging practices at our center changed during the global contrast shortage; the use of contrast decreased despite the frequency of trauma WBCT scans remaining the same. The rates of AKI and RRT did not change, suggesting that WBCT with contrast is insufficient to cause AKI. The missed injury rate was equivalent. Our data suggest similar outcomes can be achieved with selective IV contrast use during WBCT.

Immediate CT after hospital arrival and decreased in-hospital mortality in severely injured trauma patients.

Immediate whole-body CT (about 10 min after arrival) in an all-in-one resuscitation room equipped with CT has been found to be associated with shorter time to haemostasis and lower in-hospital mortality. The aim of this study was to elucidate the benefits of immediate whole-body CT after hospital arrival in patients with severe trauma with the hypothesis that immediate CT within 10 min is associated with lower in-hospital mortality. This retrospective cohort study of patients with an injury severity score of more than 15 who underwent whole-body CT was conducted using the Japanese Trauma Databank (2019-2020). An immediate CT was conducted within 10 min after arrival. In-hospital mortality, frequency of subsequent surgery, and time to surgery were compared with immediate and non-immediate CT. Inverse probability weighting was conducted to adjust for patient backgrounds, including mechanism and severity of injury, prehospital treatment, vital signs, and institutional characteristics. Among the 7832 patients included, 646 underwent immediate CT. Immediate CT was associated with lower in-hospital mortality (12.5 versus 15.7 per cent; adjusted OR 0.77 (95 per cent c.i. 0.69 to 0.84); P < 0.001) and fewer damage-control surgeries (OR 0.75 (95 per cent c.i. 0.65 to 0.87)). There was a 10 to 20 min difference in median time to craniotomy, laparotomy, and angiography. These benefits were observed regardless of haemodynamic instability on hospital arrival, while they were identified only in elderly patients with severe injury and altered consciousness. Immediate CT within 10 min after arrival was associated with decreased in-hospital mortality in severely injured trauma patients.

BMI and Waist Circumference in Patients with Multiple Myeloma.

Context: Cancer is associated with many risk factors, including obesity. Specifically, abdominal obesity is linked to metabolic syndrome and is quantified by waist circumference (WC). Compared to WC, body mass index (BMI) is more accessible in the office to assess a patient's overall body fat composition. With preexisting computed tomography (CT) scans in multiple myeloma (MM) patients, WC can be obtained quickly and accurately as a potential prognostic biomarker. Objective: To determine if there is a correlation between BMI and WC in MM patients. Study Design and Analysis: This is a retrospective cohort study using preexisting CT scans of MM patients. Demographic information including age, sex, race, and BMI was gathered. The WC was obtained using Aquarius iNtuition software version 4.4.12. To standardize the CT scan measurements, slices were taken at the L3 vertebra with both transverse processes visible. Setting/Dataset: An academic midwestern healthcare system. Population Studied: A cohort of MM patients with CT scans. Intervention/Instrument: The scans were analyzed with Aquarius iNtuition. Outcome Measures: Average BMI and WC, as well as the correlation between BMI and WC. Results: This study includes 71 MM patients (37 women and 34 men) who had a whole-body low-dose CT scan. The average BMI was in the overweight range for both women and men at 28.7 and 28.8, respectively. Notably, the average WC was 39.4 inches for women and 41.9 inches in men, meeting one of the criteria for metabolic syndrome (>35 inches in women and >40 inches in men). BMI and WC were significantly correlated in both men and women (p <0.001). Conclusions: This is a retrospective analysis of BMI and WC in a cohort of MM patients. Traditionally, BMI has been used to quickly assess the body fat composition of patients. However, WC is a more accurate and readily accessible tool in patients with a CT scan. This measurement is strongly tied to metabolic syndrome and is part of the diagnostic criteria. We found that BMI and WC were significantly correlated in this cohort. Further follow-up is needed with a larger sample size and over a longer period. As body composition in this cohort has not been previously studied, further analyses may provide more biomarkers to aid in disease management.

Ground level falls: computed tomography findings and clinical outcomes by age groups.

This study aimed to determine injury patterns in ground level falls (GLFs) and investigate the effect of age on the severity of injury. We retrospectively identified 4,712 patients who presented to a Level 1 trauma center due to GLFs and analyzed the data of 1,214 patients who underwent computed tomography (CT). Demographics, torso examination findings, and injuries detected on CT were recorded. To investigate the effect of age on injury severity, the patients were grouped as those aged <65 and ≥65 years. The mean age was 57 years, and 55.20% of the patients were female. The mortality rate was 0.50%. Injury was detected in 489 (40.30%) patients on CT. Fractures were the most common injury type. Traumatic intracranial hemorrhage was detected in 32 (2.60%) patients. Only three (0.20%) of the 63 patients with rib fractures had concomitant lung injury. The negative predictive value of the physical examination (PE) was 95.80% for chest injury. Intra-abdominal injury was not detected in any of the 116 patients who underwent abdominal CT. Hospitalization was also higher in the ≥65-year group (p<0.001). All mortalities (n=6) were seen in patients aged ≥65 years. Our results indicate that GLFs cause more injuries in the elderly, resulting in more hospitalizations and mortality. Normal PE findings may reduce the need for whole-body CT in GLF patients who are conscious, cooperative, and oriented.

Automatic organ completion with image stitching for personalized radiation dosimetry in CT examinations.

Computed tomography (CT) image-based patient-specific voxel-based dosimetry has difficulties complementing missing tissues for organs located partially inside or completely outside the image volume. Previous studies constructed patient-specific whole-body models by rescaling reference phantoms or extending regional CT images with manually adjusted phantoms. This study proposes a methodology for automatic organ completion of regional CT images for CT dosimetry using a stitching approach. Virtual clinical trials were performed by truncating whole-body CT images to generate virtual clinical chest and abdominopelvic CT images. Corresponding anchor images for each patient were selected according to sex and similarity of the axial length and water equivalent diameter of the virtual regional CT images. Automatic image stitching was performed by transformation initialization and iteration, while the stitched CT images and organ atlas were used in GPU-based Geant4 Monte Carlo simulations to generate a radiation dose map and absorbed organ dose. To evaluate the performance of the stitching model in radiation dosimetry, organ mass differences and Jaccard's coefficient of stitched and rescaled anchor images were calculated, and the radiation doses were compared among the corresponding values from the VirtualDose®, original whole-body CT, stitching model, regional CT, registration-based rescaling method, and WED-based rescaling method. The anatomical accuracy of stitched images was significantly improved. For organs partially inside the image volume, organ dose estimation from the stitching model could be more accurate than that reported in previous studies. The absolute differences in effective dose from the stitched images were 6.55% and 4.81% for chest and abdominopelvic CT scans, respectively. The proposed automatic stitching model partially complements organs inside or outside the CT scan range and provides more accurate anatomical representations for radiation dosimetry than traditional phantom rescaling methods.

Radiographic, MRI, and CT findings in a young dog with Becker-like muscular dystrophy.

An 8-month-old, male, crossbreed dog was presented for macroglossia, reduced mandibular extension, ptyalism, dysphagia, and regurgitation. Serum creatine kinase and aspartate aminotransferase activity were markedly increased. Thoracic radiographs showed an axial gastro-esophageal hiatal hernia, diaphragmatic thickening, and asymmetry. Magnetic resonance imaging of the head showed a severely enlarged tongue, symmetric increase in size of the geniohyoid and mylohyoid muscles, and diffuse masticatory hypomyotrophy. Whole-body CT ruled out other musculoskeletal abnormalities and further characterized the radiographic and MRI findings. Muscular histopathology was consistent with Becker muscular dystrophy.

Myeloma bone disease imaging on a 1st-generation clinical photon-counting detector CT vs. 2nd-generation dual-source dual-energy CT

ObjectiveSubjective and objective image quality comparison of bone microstructure and disease-related abnormalities in multiple myeloma patients using a 1st-generation dual-source photon-counting detector CT(DS-PCD-CT) and a 2nd-generation dual-source dual-energy (energy-integrating detector) CT (DS-EID-CT).MethodsFifty multiple myeloma patients (mean age 67.7 ± 10.9 years,16 females) were prospectively enrolled. Unenhanced whole-body CTs were clinically indicated and performed on DS-EID-CT and DS-PCD-CT (median time difference: 12 months). DS-PCD-CT was performed in Quantumplus UHR mode and DS-EID-CT was performed using dual-energy mode. DS-PCD-CT kernel was set at Br64 with Quantum iterative reconstruction strength Q1; for DS-EID-CT a comparable I70f kernel with SAFIRE iterative reconstruction strength 1 was used. Two independent radiologists assessed image quality subjectively using a 5-point Likert scale considering delineation and sharpness of trabecular bone and lytic bone lesions in the spine and pelvic bones. Additionally, ImageJ was used for quantification of bony septa inside the cancellous bone and through or the edges of osteolysis.ResultsOverall quality as well as detectability and sharpness in the delineation of lytic bone lesions were superior for DS-PCD-CT compared with DS-EID-CT (p < 0.0001). The inter-reader agreement for subjective image quality readings showed excellent consistency(α = 94.2–98.8). CTDI and DLP mean values for DS-PCD-CT and DS-EID-CT were 1107.4 ± 247.6 mGy*cm and 8.2 ± 1.8 mGy vs. 1344.3 ± 204.6 mGy*cm and 10.1 ± 1.9 mGy. The quantitative metric for bone microstructure in the femoral head showed significantly better visualization of trabeculae in DS-PCD-CT compared with DS-EID-CT (p < 0.0001). Quantitative analyses of edge sharpness of osteolysis showed significant steeper edges for DS-PCD-CT (p < 0.0001).ConclusionDS-PCD-CT significantly improves spatial resolution of bony microstructure and lytic bone lesions compared to DS-EID-CT.Key Points• Application of photon-counting detector CT is superior to dual-source dual-energy integrating detector in clinical workup of multiple myeloma patients.• Compared to energy integrating detectors, photon-counting detectors significantly increase the spatial resolution of bone microstructure including disease-related lytic bone lesions in patients with multiple myeloma.

PMON93 Adenoma Size &amp; Inferior Petrosal Sinus Sampling in Cushing's Disease Diagnosis - Smoke &amp; Mirrors?

Abstract Background The current guidelines on Cushing's Disease management recommend surgically resecting adenomas larger than 10 mm in size.1 For smaller adenomas, inferior petrosal sinus sampling (IPSS) is considered the gold standard to distinguish between Cushing's disease and ectopic ACTH production. We report a case where IPSS testing and the size of the adenoma on MRI were misleading in determining the final diagnosis, prompting us to challenge the existing guidelines. Clinical Case A 40-year-old female with a past medical history of hyperlipidemia, obesity (BMI 42) and prediabetes presented with secondary infertility, galactorrhea, headaches, blurred vision and weight gain (30 lbs) over the past year. Physical examination was notable for acanthosis nigricans of the neck and bilateral milky nipple discharge. Prolactin level was elevated to 46.9 ng/ml (n 4.8-23.3 ng/mL). ACTH was elevated to 83.5 pg/mL (n 7.2-63.3 pg/mL) and cortisol to 17.4 ug/dL (n 2.7-10.5 ug/dL). Salivary cortisol was elevated to 0.216 ug/dL (n &amp;lt;0.112 ug/dL), 24-hour urinary cortisol elevated to 60.2 ug (n &amp;lt;45 ug) and on 1 mg dexamethasone suppression testing, morning cortisol was elevated to 7.2 ug/dL (n &amp;lt;1.8 ug/dL). MRI revealed a 6×7×7 mm right sided pituitary mass. Referral to Neurosurgery for resection was made. Neurosurgery recommended bilateral IPSS for pre-operative tumour lateralisation. 10 ug of DDAVP was used to increase test sensitivity. Central to peripheral ACTH ratio was 1: 1. No significant laterality was noted. In the absence of other identifiable sources on CT imaging, endoscopic endonasal surgical resection was pursued. On pathology, the adenoma was immunoreactive for ACTH, confirming Cushing's Disease. Post-operative morning cortisol was 1.3 ug/dL. The patient was started on hydrocortisone 50 mg in the morning and 20 mg in the afternoon with outpatient taper two weeks following discharge to prednisone 10 mg daily. Conclusion Current guidelines recommend surgery for adenomas &amp;gt;10 mm in size, IPSS for adenomas &amp;lt; 6 mm and further diagnostics (IPSS or serum CRH and DDAVP stimulation tests plus whole-body CT) for those 6-9 mm. IPSS is strongly preferred. 1 IPSS is operator dependent and has low efficacy in tumour lateralisation. With the advent of high-resolution CT imaging and emerging data corroborating non-invasive stimulation tests,2 it may be time to shift away from IPSS as a first line test for adenomas irrespective of size. IPSS can present a costly, invasive, oft misleading, and hence superfluous testing strategy; it is high time the medical community re-evaluates its reliance on it.

Prospective Multireader Evaluation of Photon-counting CT for Multiple Myeloma Screening.

Purpose To determine whether photon-counting CT (PCCT) acquisition of whole-body CT images provides similar quantitative image quality and reader satisfaction for multiple myeloma screening at lower radiation doses than does standard energy-integrating detector (EID) CT. Materials and Methods Patients with monoclonal gammopathy of undetermined significance prospectively underwent clinical noncontrast whole-body CT with EID and same-day PCCT (August-December 2021). Five axial scan locations were evaluated by seven radiologists, with 11% (eight of 70) of images including osteolytic lesions. Images were shown in randomized order, and each reader rated the following: discernibility of the osseous cortex and osseous trabeculae, perceived image noise level, and diagnostic confidence. Presence of lytic osseous lesions was indicated. Contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) were calculated. Comparisons were made using paired t tests and mixed linear effects models. Results Seven participants (four women) were included (mean age, 66 years ± 9 [SD]; body mass index, 30.1 kg/m2 ± 5.2). Mean cortical definition, trabecular definition, image noise, and image quality scores were 83, 67, 75, and 78 versus 84, 66, 74, and 76 for EID and PCCT, respectively (P = .65, .11, .26, and .11, respectively). PCCT helped identify more lesions (79% [22 of 28]) than did EID (64% [18 of 28]). CNRs and SNRs were similar between modalities. PCCT had lower radiation doses than EID (volume CT dose index: EID, 11.37 ± 2.8 vs PCCT, 1.8 ± 0.6 [P = .06]; dose-length product: EID, 1654.1 ± 409.6 vs PCCT, 253.4 ± 89.6 [P = .05]). Conclusion This pilot investigation suggests that PCCT affords similar quantitative and qualitative scores as EID at significantly lower radiation doses. Keywords: CT, CT-Spectral, Skeletal-Axial, Spine, Hematologic Diseases, Whole-Body Imaging, Comparative Studies Supplemental material is available for this article. © RSNA, 2022.

Adipositas and metabolic bone disorder in a 16th century Upper Austrian infant crypt mummy-An interdisciplinary palaeopathological insight into historical aristocratic life.

We describe here the results of a multidisciplinary study on an infant mummy from 16th century Upper Austria buried in the crypt of the family of the Counts of Starhemberg. The macroscopic-anthropological, radiological (whole-body CT scan), histological (skin tissue), and radiocarbon isotope investigations suggested a male infant of 10-18 months' age, most likely dying between 1550 and 1635 CE (probably Reichard Wilhelm, 1625-1626 CE), that presented with evidence of metabolic bone disease with significant bilateral flaring of costochondral joints resembling "rachitic rosary" of the ribs, along with straight long bones and lack of fractures or subperiosteal bleeding residues. Although incompletely developed, the osteopathology points toward rickets, without upper or lower extremities long bone deformation. The differential diagnosis is vitamin C deficiency (scurvy) (also with an incomplete presentation, although overlap between both disorders may be present). As additional pathology, there was significantly enlarged subcutaneous fat tissue (thickness more than 1 cm at the navel and thighs and longitudinal creases of the skin) along with a histologically enlarged subcutaneous fat layer consistent with infantile adipositas as a coincident disorder. Finally, remnants of lung tissue with pleural adhesion of the right lung indicate possibly lethal pneumonia, a disease with an increased prevalence in vitamin D deficient infants. Ultimately, the skull presented with extensive destruction of the bones of the base and dislocation of the bones of the skull squama. These changes, however, are most likely post-mortal pseudopathology, the result of a burial in a flat, narrow coffin because there were no bone fractures or residues of bleeding/tissue reaction that would have occurred whilst the patient was alive.