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Breath-hold Three-dimensional CT of the Liver with Multi-Detector Row Helical CT¹

¹ From the Department of Radiology, Duke University Medical Center, Erwin Rd, Box 3808, Durham, NC 27710. Received June 19, 2000; revision requested July 12; revision received August 17; accepted September 1. Address correspondence to E.K.P. (e-mail: pauls003@mc.duke.edu).

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
PURPOSE: To compare image quality on transverse source images and coronal and sagittal reformations to determine the feasibility of using single–breath-hold three-dimensional liver computed tomography (CT) with multi–detector row helical CT in patients suspected of having hepatic metastases.

MATERIALS AND METHODS: Fifty-three patients underwent the protocol. Coronal and sagittal reformations were constructed. Images were reviewed for duration of scan acquisition and length and adequacy of z-axis coverage. Reformations were scored for visualization of portal and hepatic vein branches, liver edge sharpness, cardiac pulsation and respiratory motion artifacts, noise due to mottle, and overall impression.

RESULTS: Mean z-axis coverage was 207 mm ± 33 (SD) (range, 145–280 mm), with a mean acquisition time of 10.96 seconds ± 1.78 (range, 7.73–14.93 seconds). In 44 (83%) patients, the entire liver was imaged on a single helical scan. Artifact from cardiac motion was not identified on the transverse source images in any patient but was identified on coronal images in eight (15%) and on sagittal images in seven (13%). Similarly, noise due to mottle was not identified on the transverse source images but was identified on coronal images in seven (13%) patients and on sagittal images in six (11%).

CONCLUSION: It is feasible to perform single–breath-hold three-dimensional liver CT with multi–detector row helical CT technology. Reformations provide a unique perspective with which to view the liver and may improve diagnostic capacity.

Index terms: Computed tomography (CT), helical, 761.12115 • Computed tomography (CT), image quality • Computed tomography (CT), technology • Computed tomography (CT), three-dimensional, 761.12117 • Liver, CT, 761.12112, 761.12115, 761.12117 • Liver neoplasms, metastases, 761.33

	INTRODUCTION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
Multi–detector row (hereafter, multidetector-row) helical computed tomography (CT) is a technologic advance that allows the simultaneous acquisition of multiple images during a single rotation of the x-ray tube. An advantage of this technology is the ability to rapidly scan large volumes, such as the liver, while maintaining high z-axis resolution (1). With this technology, single–breath-hold imaging of the liver is a reality for virtually all patients. Furthermore, this technology may allow the development of imaging protocols that have novel applications. To date, relatively little has been written (2,3) in regard to the clinical capabilities of this technique.

Currently, abdominal CT images are acquired and usually viewed in the transverse plane. While transverse CT is useful and adequate for most indications, there are many disease states and clinical scenarios in which coronal, sagittal, oblique, or curved planes are more definitive or contributory to a diagnosis. For example, in the patient for whom resection of hepatic metastases is anticipated, it is critical not only to detect lesions but also to delineate their relationship to the portal veins, hepatic veins, diaphragm, inferior vena cava, and bile ducts. The use of a single–breath-hold three-dimensional (3D) helical CT protocol with multiplanar reformation may facilitate this delineation. Indeed, Rofsky et al (4) recently reported on the use of magnetic resonance imaging to acquire breath-hold 3D images of the liver with isotropic voxels that proved to be both comprehensive and efficient.

The purpose of this study was to compare image quality among the transverse, coronal, and sagittal planes to determine the feasibility of using single–breath-hold 3D CT imaging of the liver with multidetector-row helical CT in patients suspected of having hepatic metastases.

	MATERIALS AND METHODS

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In March 1999, a breath-hold 3D CT protocol was adopted for use in patients referred for the evaluation of known or suspected metastatic disease to the liver (5). This was a prospective study of 53 patients (26 men, 27 women; mean age, 56 years; age range, 19–74 years) who underwent this protocol from March 1999 to October 1999. Patients were excluded from this protocol if they had or were suspected of having a hypervascular primary or metastatic tumor that required imaging during the hepatic arterial dominant phase. Our study proposal was reviewed with our local institutional review board representative, and it was determined that institutional review board approval was not required since 3D CT had already been adopted as the routine imaging protocol in such patients.

Sites and types of primary malignancy included the colorectum (n = 25), the genitourinary tract (n = 12), lymphoma (n = 7), melanoma (n = 2), the lung (n = 2), and other (n = 5).

In this protocol, we used a CT scanner (QX/i Lightspeed; GE Medical Systems, Milwaukee, Wis) that allows the acquisition of four images per gantry rotation. A monophasic 3D helical CT scan of the liver was acquired during a single breath hold. One hundred fifty milliliters of iopamidol (Isovue 300; Bracco Diagnostics, Princeton, NJ; 30 mg of iodine per milliliter) was injected at a rate of 3 mL/sec. The scanning delay was 70 seconds. Technical parameters included a detector row configuration of 4 x 2.5 mm, pitch of 6:1, gantry rotation speed of 0.8 second, table speed of 15 mm per gantry rotation (18.75 mm/sec), 140 kVp, 170–260 mA (mean, 197 mA), and displayed field of view of 30–40 cm (mean, 35 cm).

The 2.5-mm transverse source images were reconstructed at 1-mm intervals (60% overlap). The voxels measured 0.7 x 0.7 x 2.5 mm. The data sets were then transferred to a Windows (Microsoft, Redmond, Wash) workstation with software level 3.1 (Advantage; GE Medical Systems), where reformations in the coronal and sagittal planes were performed. Rendering the data into straight coronal and sagittal planes required less than 5 minutes. Images in these planes could be evaluated interactively on the workstation monitor by scrolling through them.

A number of parameters were evaluated in each patient, including scanning duration, z-axis coverage during the single breath hold, mean liver length, and whether the entire liver was included on the scan. In addition, image quality was evaluated subjectively by two reviewers (K.W., E.K.P.) in consensus. Representative images in the transverse, coronal, and sagittal planes were obtained in each patient. All three planes were reviewed, and image quality was subjectively assessed on a three-point scale. The image quality parameters included venous enhancement, liver edge sharpness, cardiac motion artifact, respiratory motion artifact, noise due to mottle, and overall impression of image quality.

The following scale was used to evaluate venous enhancement: 3, distinct visualization of portal and hepatic veins throughout the liver to within 1 cm of the capsular surface; 2, venous enhancement present but not to within 1 cm of the capsule; and 1, subtle or no enhancement of intrahepatic veins.

Edge sharpness was evaluated as follows: 3, sharp edges; 2, blurred edges present but not affecting diagnostic quality; and 1, extreme blurring interfering with diagnostic quality.

Artifact from cardiac motion was evaluated as follows: 3, no visible artifact from cardiac pulsation; 2, minimal cardiac pulsation artifact that did not interfere with diagnostic quality; and 1, cardiac pulsation artifact sufficient to interfere with diagnostic quality.

Artifact from respiratory motion was evaluated as follows: 3, no respiratory motion artifact; 2, minimal respiratory motion artifact that did not interfere with diagnostic quality; and 1, respiratory motion artifact that interfered with diagnostic quality.

Noise due to mottle was evaluated as follows: 3, no mottle; 2, mottle causing only minimal degradation of diagnostic quality; and 1, mottle causing considerable degradation in diagnostic quality.

Overall impression was evaluated as follows: 3, excellent; 2, good; and 1, adequate.

	RESULTS

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The mean extent of coverage in the z axis for a single helical acquisition of the liver was 207 mm ± 33 (SD) (range, 145–280 mm). The mean superior-to-inferior length of the liver in the z axis was 179 mm ± 29 (range, 114–271 mm). The duration of helical data set acquisition ranged from 7.73 to 14.93 seconds, with a mean of 10.96 seconds ± 1.78. Forty-four (83%) of 53 livers were completely covered in a single breath hold. In three patients, the acquisition began inferior to the dome of the liver. In five patients, the acquisition terminated above the inferior tip of the liver. In one patient, neither the dome nor the caudal tip were included in the acquisition. These scans were included in our analysis.

The results of an assessment of subjective image quality are shown in the Table. In the majority of patients, the images were of diagnostic or excellent quality, with a score of either 2 or 3 for venous enhancement, liver edge sharpness, cardiac motion artifact, and respiratory motion artifact (Fig 1). Venous enhancement was graded as good to excellent in 51 (96%) of the patients; images in only two patients demonstrated minimal or no venous enhancement. In no patient was blurring of the liver edge sufficient to render a scan nondiagnostic. Only one of 53 patients had an image with an identifiable respiratory motion artifact, which was best seen on the sagittal reformation. In this patient, the motion caused minimal degradation in scan quality (Fig 2). Cardiac motion artifact that interfered with diagnostic quality was present in only three patients on the coronal reformations and in only one patient on the sagittal reformations. However, noise due to mottle that interfered with diagnostic ability was present in seven patients on the coronal images and in six patients on the sagittal images. The overall impression of diagnostic scan quality closely paralleled the results of noise due to mottle.

View larger version (143K): [in this window] [in a new window] [Download PPT slide]   Figure 1a. Representative images in a 43-year-old man with Hodgkin disease after splenectomy. (a) Contrast material-enhanced transverse CT scan at the level of the portal vein bifurcation obtained by using the 3D CT protocol demonstrates a normal liver. (b) Coronal reformation demonstrates excellent depiction of branches of the portal and hepatic veins (arrows) to within 1 cm of the liver capsule. (c) Sagittal reformation sharply demonstrates the liver capsule (arrow) with only minimal stair-step artifact.

View larger version (124K): [in this window] [in a new window] [Download PPT slide]   Figure 1b. Representative images in a 43-year-old man with Hodgkin disease after splenectomy. (a) Contrast material-enhanced transverse CT scan at the level of the portal vein bifurcation obtained by using the 3D CT protocol demonstrates a normal liver. (b) Coronal reformation demonstrates excellent depiction of branches of the portal and hepatic veins (arrows) to within 1 cm of the liver capsule. (c) Sagittal reformation sharply demonstrates the liver capsule (arrow) with only minimal stair-step artifact.

View larger version (144K): [in this window] [in a new window] [Download PPT slide]   Figure 1c. Representative images in a 43-year-old man with Hodgkin disease after splenectomy. (a) Contrast material-enhanced transverse CT scan at the level of the portal vein bifurcation obtained by using the 3D CT protocol demonstrates a normal liver. (b) Coronal reformation demonstrates excellent depiction of branches of the portal and hepatic veins (arrows) to within 1 cm of the liver capsule. (c) Sagittal reformation sharply demonstrates the liver capsule (arrow) with only minimal stair-step artifact.

View larger version (143K): [in this window] [in a new window] [Download PPT slide]   Figure 2. Images in a 66-year-old woman with colon cancer metastatic to the liver. Sagittal reformation demonstrates misregistration artifact (arrow) from respiratory motion that occurred early in the acquisition. Numerous metastatic deposits (arrowheads) can be identified.

	DISCUSSION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

We explored the feasibility of using breath-hold 3D CT of the liver with multiplanar reformations by using a multidetector-row CT scanner. With this protocol, the entire liver is rapidly imaged with thin collimation during a single 7–15-second breath hold. This produces a data set that can be manipulated and reviewed on a workstation to produce high–quality multiplanar reformations.

In our study, we used a multidetector-row helical CT scanner, which consists of 16 detector elements aligned along the z axis. Each detector element is 1.25 mm in length, with a cumulative z-axis length of 20 mm. Detectors are electronically arranged in groups of four that determine the section thickness. For example, we used a 4.0 x 2.5-mm detector configuration in which the middle eight detectors were paired, resulting in four 2.5-mm-thick sections. The acquired data set was then reconstructed at 1-mm increments (60% overlap). Compared with single–detector-row helical CT in which section thickness typically ranges from 5 to 8 mm, the 2.5-mm-thick images (3.2 mm at full width at half maximum) reconstructed at 1.0-mm increments should result in less partial volume averaging and, therefore, improved image quality (2,12).

A table speed of 15.00 mm per rotation (18.75 mm/sec) was used, resulting in a pitch of 6:1 (15 mm ÷ 2.5-mm section = 6). Such rapid imaging enabled complete coverage of the liver during a comfortable single breath hold. Indeed, with this protocol the entire liver can be imaged in approximately 11 seconds. A breath hold of this length was well tolerated by our patients.

Noise due to mottle was a cause of image degradation. Noise due to mottle was more evident on the coronal and sagittal reformations than on the transverse source images, likely due to the decreased resolution in the z axis (Fig 3). However, despite the noise due to mottle, image quality was considered diagnostic in the majority of the patients.

View larger version (158K): [in this window] [in a new window] [Download PPT slide]   Figure 3a. Representative images in a 35-year-old man with testicular cancer. (a) Transverse contrast-enhanced CT scan at the level of the right portal vein obtained by using the 3D CT protocol. (b) Coronal and (c) sagittal reformations demonstrate poor image quality. This is the result of noise due to mottle and is more apparent on the reformations than on the transverse source images.

View larger version (152K): [in this window] [in a new window] [Download PPT slide]   Figure 3b. Representative images in a 35-year-old man with testicular cancer. (a) Transverse contrast-enhanced CT scan at the level of the right portal vein obtained by using the 3D CT protocol. (b) Coronal and (c) sagittal reformations demonstrate poor image quality. This is the result of noise due to mottle and is more apparent on the reformations than on the transverse source images.

View larger version (188K): [in this window] [in a new window] [Download PPT slide]   Figure 3c. Representative images in a 35-year-old man with testicular cancer. (a) Transverse contrast-enhanced CT scan at the level of the right portal vein obtained by using the 3D CT protocol. (b) Coronal and (c) sagittal reformations demonstrate poor image quality. This is the result of noise due to mottle and is more apparent on the reformations than on the transverse source images.

While this protocol is straightforward to perform, some technical problems were encountered. The acquisition was too caudal—failing to obtain images of the dome of the liver—or too cephalic—failing to obtain images of the caudal aspect of the liver in nine of 53 patients. In these patients, inadequate coverage was simply the result of underestimating the extent of the liver on the basis of the scout image rather than of a failure of the protocol per se. These issues can be expected with any new protocol and reflect technologist training and experience rather than an inherent limitation of the protocol itself. With education and familiarity, such issues should be minimized. Another potential problem with any 3D CT data set to be viewed on a workstation is the necessity of saving the raw data to the workstation. Generally, the raw data are not archived and are not available retrospectively.

Potential applications of this technique include preoperative planning in patients in whom liver resection is anticipated. With routine transverse CT, lesions may be accurately localized within hepatic segments and the proximity and relationship of a lesion to hepatic vessels and bile ducts may be determined. However, an advantage of the multiplanar reformations is that surgical anatomy relevant to the planned resection may be more clearly delineated, particularly to the hepatic surgeon. Indeed, viewing the relationship of lesions to blood vessels and bile ducts in a coronal plane is similar to viewing the lesions on frontal images obtained at liver resection. In fact, one of the roles of intraoperative ultrasonography is to delineate the relationship of lesions to hepatic blood vessels. Thus, breath-hold 3D CT may be helpful for preoperative planning in patients undergoing evaluation for hepatic surgery.

Another potential application is in lesion characterization. For example, the peripheral nodular enhancement of hepatic hemangiomas may be subtle or indeterminate at transverse CT alone, which could lead to an indeterminate or erroneous diagnosis. In the sagittal or coronal plane, the nodular enhancement may be more clearly demonstrated, allowing a confident diagnosis of hemangioma.

Clearly, breath-hold 3D CT of the upper abdomen could be applied to organs or structures other than the liver. Raptopoulos et al (13) have shown the value of multiplanar reformations in demonstrating pancreatic pathologic findings. Further, in patients with large upper abdominal masses, determination of the organ of origin may be difficult on the basis of transverse CT findings alone. With high-quality multiplanar reformations, the organ of origin may be more clearly understood.

In conclusion, single–breath-hold multidetector-row 3D CT in patients suspected of having hepatic metastasis is a feasible technique with the potential for improving diagnostic capability. However, further research is required to refine the protocol and to determine its clinical utility.

	ACKNOWLEDGMENTS

 
We thank Sally Hinton, RT, for technical assistance.

	FOOTNOTES

 
Abbreviation: 3D = three-dimensional

R.C.N. is a consultant for GE Medical Systems, Milwaukee, Wis.

Author contributions: Guarantor of integrity of entire study, K.W.; study concepts and design, K.W., E.K.P., R.C.N.; literature research, K.W.; clinical studies, K.W.; experimental studies, K.W.; data acquisition, K.W., E.K.P.; data analysis/interpretation, K.W., E.K.P.; manuscript preparation, K.W., E.K.P.; manuscript definition of intellectual content, K.W., E.K.P.; manuscript editing and revision/review, K.W., E.K.P., R.C.N.; manuscript final version approval, K.W., E.K.P.

	REFERENCES

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