School of Health Sciences

The role of dual-energy

imaging in the detection of
pulmonary lung nodules
A Adair & SJ Willis
10th June 2013

School of Health Sciences

Background
Lung cancer
35,000 deaths each year1
39,000 new cases of lung cancer diagnosed in the UK every year2
Survival rates3: 1 year <35%, 5 years 7.8-9.3%, 10 years 4.9-5.9%

NICE Guidelines (2012)

The first line of radiographic investigation is a posterior-anterior (PA)
projection image of the chest
A patient with suspected or known lung cancer must be offered a contrast
enhanced computed tomography (CT) chest scan 4

Imaging technology advances

Dual Energy Chest Imaging

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Background
Chest X-ray missed diagnosis

Clavicles and ribs obscure lung anatomy

81% of all missed lung cancers are located in upper lobes5

Dual Energy Chest Imaging

Relatively new technique
3 separate images produced
1. Bone window
2. Lung window
3. Traditional chest image

Images available from:

http://radiographics.rsna.org/content/30/4/1037.figures-only

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Aim

To explore the role of dual-energy chest

imaging for patients presenting with
suspected pulmonary nodules indicative of
lung cancer

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Methodology
Systematic Literature Review

To identify primary studies comparing diagnostic accuracy, image quality

and clinical effectiveness of dual energy imaging against CXR and CT for
imaging of pulmonary lung nodules6

Data bases searched:

PubMed Central, ScienceDirect, Scopus & Web of Knowledge

Modified CASP Tool

Determine quality of included citations7

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Results
Radiation Dose

CXR - 0.02mSv8
Dual energy imaging - 0.04mSv8 (max.)
CT - 6.6mSv8

Diagnostic Accuracy
ROC analysis
All studies reported statistically significant differences in detection rates
for pulmonary nodules using dual energy imaging9,I0,11,

Image Quality
Dual energy imaging: superior image quality (than CXR)9,10,11,12

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Dual Energy Imaging Example

Images available from: Fraser, et al (2001) pp77-85

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Results
Improved detection rates
Improves accuracy of detection rates of pulmonary nodules9,10,11,12,13

Sensitivity
CXR9

33.5 - 52.5%

Dual energy imaging9

43.5 - 58.5%

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Conclusion

SLR findings suggest:

In respect of patients who present with suspected pulmonary nodules
indicative of lung cancer,

the use of dual energy chest imaging could offer the potential of a
higher sensitivity for the detection of pulmonary nodules, compared to
standard CXR.

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References &
Acknowledgements
1 - http://www.nhs.uk/Livewell/Lungcancer/Pages/Lungcancermythsandfacts.aspx [Last accessed 12th Feb 2013]
2 - UK Lung Cancer coalition (2012) Patient Information Available from: http://www.uklcc.org.uk/ [Last accessed on 31st May
2013]
3 - http://www.cancerresearchuk.org/cancer-info/cancerstats/types/lung/survival/lung-cancer-survival-statistics [Last accessed
on 31st May 2013]
4 - NICE Guidelines. (2012). Patient Pathways. [online] Available from:
http://www.nice.org.uk/Search.do?x=0&y=0&searchText=patient+pathway+lung+cancer&newsearch=true#/search/?reload.[Las
t accessed 23rd Feb 2013]
5 - Austin, J., Miyagawa, M., Yasuhara, Y., Murakami, T., Ikura, H., Sakamoto, K., Tagashira, H., Arakawa, K., Mochizuki, T.,
(1992) Clinical Evaluation of Pulmonary Nodules with Dual-exposure Dual-energy Subtraction Chest Radiography. Radiation
Medicine 23 (6) pp. 391 397
6 - Sackett, D., Rosenberg, W., Muir-Gray, J., Haynes, R., Richardson, W (1996) Evidence Based Medicine. What is it and
what it isnt British Medical Journal 312: pp. 71 72
7 - Williman, A. and Appleton, S., (2009) Critical appraisal strategies. Sage Publications Limited : London.
8 - Health Protection Agency (2012) Radiation Protection [Online] Available from: http://www.hpa.org.uk/ [Last accessed 12 th
Jan 2013]
9 - Szucs-Farkas, Z., Yuksel-Hatz, A., Patak, M. A., Ruder., Single-exposure dual-energy subtraction chest
radiography: Detection of pulmonary nodules and masses in clinical practice University Hospital of Berne

Acknowledgements: City University London for

their kind financial support to attend UKRC.