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Virtual monoenergetic dual-layer dual-energy CT images in colorectal cancer: CT diagnosis could be improved?

  • Abdominal Radiology
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To compare conventional CT images and virtual monoenergetic images (VMI) at dual-layer dual-energy CT (dlDECT) in patients with colorectal cancer (CRC) through quantitative analysis and to investigate the added value of VMI.

Material and Methods

Sixty-six consecutive patients with histologically documented CRC and available VMI reconstructions were retrospectively investigated. Subsequently, forty-two patients, without any colonic disease at colonoscopy, were selected as control group. Conventional CT images and VMI reconstructions at energy levels ranging from 40 (VMI40) to 100 keV (VMI100) in 10 keV increments, were obtained from the late arterial phase. First, signal-to-noise (SNR) and contrast-to-noise (CNR) ratios were obtained to select the best VMI reconstruction. Finally, the diagnostic accuracy of conventional CT and VMI40 in late arterial phase was evaluated.


On quantitative analysis, SNR and CNR were higher for VMI40 (19.5 ± 7.7 and 11.8 ± 6.2, respectively) with statistically significant differences compared to conventional CT (P < 0.05) and all the other VMI reconstructions (P < 0.05), except for VMI50 (P > 0.05). The addition of VMI40 to conventional CT images significantly improved the area under the curve (AUC) for the diagnosis of CRC, increasing it from 0.875 to 0.943 for reader 1 (P < 0.05) and from 0.916 to 0.954 for reader 2 (P < 0.05). The improvement was greater in the less experienced radiologist (0.068) compared to the more experienced one (0.037).


VMI40 has showed the highest quantitative image parameters. Furthermore, the use of VMI40 can lead to a significant improvement in the diagnostic performance for detecting CRC.

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  1. Bray F, Ferlay J, Soerjomataram I et al (2018) Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. Cancer J Clin 68:394–424.

    Article  Google Scholar 

  2. Wolf AMD, Fontham ETH, Church TR et al (2018) Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society: ACS Colorectal Cancer Screening Guideline. Cancer J Clin 68:250–281.

    Article  Google Scholar 

  3. Nagata K, Takabayashi K, Yasuda T et al (2017) Adverse events during CT colonography for screening, diagnosis and preoperative staging of colorectal cancer: a Japanese national survey. Eur Radiol 27:4970–4978.

    Article  PubMed  Google Scholar 

  4. Horton KM, Abrams RA, Fishman EK (2000) Spiral CT of colon cancer: imaging features and role in management. Radiographics 20:419–430.

    Article  CAS  PubMed  Google Scholar 

  5. Agostini A, Borgheresi A, Mari A et al (2019) Dual-energy CT: theoretical principles and clinical applications. Radiol Med 124:1281–1295.

    Article  PubMed  Google Scholar 

  6. Fulwadhva UP, Wortman JR, Sodickson AD (2016) Use of dual-energy CT and iodine maps in evaluation of bowel disease. Radiographics 36:393–406.

    Article  PubMed  Google Scholar 

  7. D’Angelo T, Cicero G, Mazziotti S et al (2019) Dual energy computed tomography virtual monoenergetic imaging: technique and clinical applications. BJR.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Tatsugami F, Higaki T, Nakamura Y et al (2022) Dual-energy CT: minimal essentials for radiologists. Jpn J Radiol 40:547–559.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Albrecht MH, Vogl TJ, Martin SS et al (2019) Review of clinical applications for virtual monoenergetic dual-energy CT. Radiology 293:260–271.

    Article  PubMed  Google Scholar 

  10. Darras KE, McLaughlin PD, Kang H et al (2016) Virtual monoenergetic reconstruction of contrast-enhanced dual energy CT at 70 keV maximizes mural enhancement in acute small bowel obstruction. Eur J Radiol 85:950–956.

    Article  PubMed  Google Scholar 

  11. Lenga L, Czwikla R, Wichmann JL et al (2018) Dual-energy CT in patients with colorectal cancer: improved assessment of hypoattenuating liver metastases using noise-optimized virtual monoenergetic imaging. Eur J Radiol 106:184–191.

    Article  PubMed  Google Scholar 

  12. Martin SS, Wichmann JL, Pfeifer S et al (2017) Impact of noise-optimized virtual monoenergetic dual-energy computed tomography on image quality in patients with renal cell carcinoma. Eur J Radiol 97:1–7.

    Article  PubMed  Google Scholar 

  13. Lee SM, Kim SH, Ahn SJ et al (2018) Virtual monoenergetic dual-layer, dual-energy CT enterography: optimization of keV settings and its added value for Crohn’s disease. Eur Radiol 28:2525–2534.

    Article  PubMed  Google Scholar 

  14. Nerad E, Lahaye MJ, Maas M et al (2016) Diagnostic accuracy of CT for local staging of colon cancer: a systematic review and meta-analysis. Am J Roentgenol 207:984–995.

    Article  Google Scholar 

  15. Granata V, Faggioni L, Grassi R et al (2022) Structured reporting of computed tomography in the staging of colon cancer: a Delphi consensus proposal. Radiol Med 127:21–29.

    Article  PubMed  Google Scholar 

  16. Badia S, Picchia S, Bellini D et al (2019) The role of contrast-enhanced imaging for colorectal cancer management. Curr Colorectal Cancer Rep 15:181–189.

    Article  Google Scholar 

  17. Nagayama Y, Iyama A, Oda S et al (2019) Dual-layer dual-energy computed tomography for the assessment of hypovascular hepatic metastases: impact of closing k-edge on image quality and lesion detectability. Eur Radiol 29:2837–2847.

    Article  PubMed  Google Scholar 

  18. Taguchi N, Oda S, Imuta M et al (2018) Dual-energy computed tomography colonography using dual-layer spectral detector computed tomography: Utility of virtual monochromatic imaging for electronic cleansing. Eur J Radiol 108:7–12.

    Article  PubMed  Google Scholar 

  19. Cicero G, Ascenti G, Albrecht MH et al (2020) Extra-abdominal dual-energy CT applications: a comprehensive overview. Radiol med 125:384–397.

    Article  PubMed  Google Scholar 

  20. De Cecco CN, Caruso D, Schoepf UJ et al (2016) Optimization of window settings for virtual monoenergetic imaging in dual-energy CT of the liver: a multi-reader evaluation of standard monoenergetic and advanced imaged-based monoenergetic datasets. Eur J Radiol 85:695–699.

    Article  PubMed  Google Scholar 

  21. Hardie AD, Picard MM, Camp ER et al (2015) Application of an advanced image-based virtual monoenergetic reconstruction of dual source dual-energy CT data at low keV increases image quality for routine pancreas imaging. J Comput Assist Tomogr 39:716–720.

    Article  PubMed  Google Scholar 

  22. Cicero G, Mazziotti S, Silipigni S et al (2021) Dual-energy CT quantification of fractional extracellular space in cirrhotic patients: comparison between early and delayed equilibrium phases and correlation with oesophageal varices. Radiol Med 126:761–767.

    Article  PubMed  Google Scholar 

  23. Mileto A, Marin D, Nelson RC et al (2014) Dual energy MDCT assessment of renal lesions: an overview. Eur Radiol 24:353–362.

    Article  PubMed  Google Scholar 

  24. Ascenti G, Mazziotti S, Mileto A et al (2012) Dual-source dual-energy CT evaluation of complex cystic renal masses. Am J Roentgenol 199:1026–1034.

    Article  Google Scholar 

  25. Coursey CA, Nelson RC, Boll DT et al (2010) Dual-energy multidetector CT: How does it work, what can it tell us, and when can we use it in abdominopelvic imaging? Radiographics 30:1037–1055.

    Article  PubMed  Google Scholar 

  26. Ascenti G, Sofia C, Mazziotti S et al (2016) Dual-energy CT with iodine quantification in distinguishing between bland and neoplastic portal vein thrombosis in patients with hepatocellular carcinoma. Clin Radiol 71:938.e1-938.e9.

    Article  CAS  PubMed  Google Scholar 

  27. Ascenti G, Mileto A, Krauss B et al (2013) Distinguishing enhancing from nonenhancing renal masses with dual-source dual-energy CT: iodine quantification versus standard enhancement measurements. Eur Radiol 23:2288–2295.

    Article  PubMed  Google Scholar 

  28. Mileto A, Marin D, Alfaro-Cordoba M et al (2014) iodine quantification to distinguish clear cell from papillary renal cell carcinoma at dual-energy multidetector CT: a multireader diagnostic performance study. Radiology 273:813–820.

    Article  PubMed  Google Scholar 

  29. Boellaard TN, Henneman ODF, Streekstra GJ et al (2013) The feasibility of colorectal cancer detection using dual-energy computed tomography with iodine mapping. Clin Radiol 68:799–806.

    Article  CAS  PubMed  Google Scholar 

  30. Gong H, Zhang K, Wu L-M et al (2016) Dual energy spectral CT imaging for colorectal cancer grading: a preliminary study. PLoS ONE 11:e0147756.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Chuang-bo Y, Tai-ping H, Hai-feng D et al (2017) Quantitative assessment of the degree of differentiation in colon cancer with dual-energy spectral CT. Abdom Radiol 42:2591–2596.

    Article  Google Scholar 

  32. Fan S, Li X, Zheng L et al (2017) Correlations between the iodine concentrations from dual energy computed tomography and molecular markers Ki-67 and HIF-1α in rectal cancer: a preliminary study. Eur J Radiol 96:109–114.

    Article  PubMed  Google Scholar 

  33. Fernandes T, Oliveira MI, Castro R et al (2014) Bowel wall thickening at CT: simplifying the diagnosis. Insights Imaging 5:195–208.

    Article  PubMed  PubMed Central  Google Scholar 

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All authors contributed to the study conception and design.

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Correspondence to Renato Trimarchi.

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The authors have no relevant financial or non-financial interests to disclose.

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This retrospective study was approved by the Review Board of our institution (Policlinico Universitario G. Martino, University of Messina, Italy) and the requirement for informed consent was waived.

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Arico’, F.M., Trimarchi, R., Portaluri, A. et al. Virtual monoenergetic dual-layer dual-energy CT images in colorectal cancer: CT diagnosis could be improved?. Radiol med 128, 891–899 (2023).

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