DOI: 10.1148/radiol.2421060015
(Radiology 2007;242:175-181.)
© RSNA, 2007
Abdominal Pain: Coronal Reformations from Isotropic Voxels with 16-Section CT—Reader Lesion Detection and Interpretation Time1
Tracy A. Jaffe, MD,
Lucie C. Martin, MD,
Chad M. Miller, MD,
Kendra M. Franklin, MD,
Elmar M. Merkle, MD,
William M. Thompson, MD,
Rendon C. Nelson, MD,
David M. DeLong, PhD and
Erik K. Paulson, MD
1 From the Department of Radiology, Duke University Medical Center, Erwin Rd, Box 3808, Durham, NC 27710. Received January 4, 2006; revision requested March 2; revision received March 15; accepted April 4; final version accepted June 5.
Address correspondence to T.A.J. (e-mail: jaffe002{at}mc.duke.edu).
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ABSTRACT
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Purpose: To retrospectively assess if reader detection of intraabdominal pathologic findings on coronal reformations from isotropic voxels at 16-section computed tomography (CT) was similar to reader detection on transverse scans.
Materials and Methods: The institutional review board approved this HIPAA-compliant study, and a waiver of informed consent was obtained. Twenty-nine consecutive patients (12 men, 17 women; mean age, 48 years; age range, 21–93 years) with abdominal pain underwent 16-section CT with coronal reformations. Eight independent readers reviewed randomized scans (transverse and coronal) and identified pathologic findings in multiple organ systems. Timing for each interpretation was recorded. One month later, readers reviewed the scan reformatted in the other imaging plane. Agreement between transverse and coronal scans was measured by using Cohen 
coefficients.
Results: Agreement was moderate to near perfect between transverse and coronal interpretations for intraabdominal anatomic and pathologic findings ( = 0.59–1.00). For transverse interpretations, more thoracic pathologic findings were noted than for coronal interpretations; for coronal interpretations, more lymph nodes were noted than for transverse interpretations. Mean transverse interpretation time was 4.9 minutes ± 1.1 (standard deviation) (range, 2.9–6.5 minutes); mean coronal interpretation time was 5.1 minutes ± 0.8 (range, 3.3–6.7 minutes). For each reader, there was no statistically significant difference in interpretation time between transverse and coronal scans (P = .06).
Conclusion: With regard to the presence of intraabdominal pathologic findings, coronal reformations from isotropic voxels are similar to transverse scans in terms of interpretation time and reader agreement.
© RSNA, 2007
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INTRODUCTION
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Technologic advances in computed tomography (CT) have changed the use of this modality in clinical practice. With the increased scanning speed afforded with multidetector CT, there has been a reduction in scan duration, an increase in scan volume, and an increase in spatial resolution along the z-axis. These advances have dramatically changed imaging of the abdomen and pelvis because large areas of anatomic interest now can be scanned with thin sections during a single comfortable breath hold. With 16-section CT, the entire abdomen and pelvis can be scanned within a 12-second breath hold at a resolution less than 1 mm in the x-, y-, and z-axes (1–3). These data sets result in voxels that are both submillimeter in dimension and isotropic, and reformations in any desired plane will have spatial resolution similar to that in the transverse plane (1).
Applications of multidetector CT technology in scanning the abdomen and pelvis are numerous; isotropic multiplanar reformations (MPRs) are now used as adjunct images for CT urography, evaluation of appendicitis and small-bowel obstruction, and skeletal trauma screening. Results of recent studies (4–8) have documented the efficacy of MPRs in improving reader confidence for the aforementioned diagnoses. None of these studies, however, have addressed the additional time required to interpret coronal reformations. In an environment where expedience is an important factor in patient care, reader interpretation time is a consideration. Because interpretation of coronal reformations is a new application with an understood learning curve, interpretation may take longer for coronal images than for routine transverse images.
Little is known about the value of coronal reformations as a separate imaging series. There have been few studies that compare accuracy of interpretations of transverse and coronal reformation series in isolation. Tsubamoto et al (9) and Kozuka et al (10) compared coronal reconstructions from isotropic data sets with transverse thin-section CT scans for the evaluation of solitary pulmonary nodules and mediastinal lymph nodes, respectively; results of these studies indicated comparable diagnostic efficacy for both sequences. Similarly, Begemann et al (11) found MPRs of the spine to be adequate for interpretation of vertebral fractures, which obviates interpretation of the transverse series. To our knowledge, there are no studies of interpretations of transverse scans and coronal reformations created from isotropic data sets to identify abdominal and pelvic pathologic findings. Thus, the purpose of our study was to retrospectively assess if reader detection of intraabdominal pathologic findings on coronal reformations from isotropic voxels at 16-section CT was similar to reader detection on transverse scans.
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MATERIALS AND METHODS
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Patient Demographics
This study was approved by our institutional review board. A waiver of informed consent was obtained for this study. We followed Health Insurance Portability and Accountability Act guidelines.
One author (E.M.M.) is a consultant for Bracco Diagnostics (Princeton, NJ) and Berlex (Wayne, NJ) but had no financial interest in this project. Another author (R.C.N.) is a consultant for GE Healthcare (Milwaukee, Wis) but had no financial interest in this project.
From December 2003 to January 2004, 29 consecutive patients with acute abdominal pain underwent 16-section CT to identify the source of pain. Seventeen women and 12 men with a mean age of 48 years (age range, 21–93 years) were scanned.
Scanning
Scanning was performed from the dome of the diaphragm through the pubic symphysis with a 16-section CT scanner (LightSpeed; GE Healthcare). Patients ingested 300 mL of diatrizoate meglumine diluted in 700 mL solution (Gastrografin; Bracco Diagnostics) or 450 mL of a 2% barium sulfate suspension (Readi-Cat 2; E-Z-Em, Westbury, NY) 1–2 hours before scanning. The type of oral contrast material administered was chosen on the basis of indication, allergy history, and/or patient choice. One hundred fifty milliliters of iopamidol (Isovue [300 mg of iodine per milliliter]; Bracco Diagnostics) was injected at a rate of 3 mL/sec with a mechanical power injector (Empower; E-Z-Em). Scanning was performed during the portal venous phase as determined with bolus tracking and automated triggering technology. The protocol was as follows: 140 kVp; 350 mA; 16 x 0.625-mm detector configuration; pitch, 1.75; table speed, 17.5 mm per rotation; gantry speed, 0.5 second per rotation. Field of view (FOV) varied per patient. The transverse section data were reconstructed twice: first with 5-mm-thick sections at 5-mm intervals in the transverse plane and then with 0.625-mm-thick sections at 0.625-mm intervals in the transverse plane. The second set of reconstructed transverse scans was then reformatted in the coronal plane with 3-mm-thick sections at 5-mm intervals.
Reconstruction was performed with a commercially available console system devoted to rapid reconstruction (Xtream, GE Healthcare); the system consists of dual 2.66-GHz processors (Xenon; Intel, Santa Clara, Calif) with a CT scan generator capable of reconstructing six to 10 scans per second. The scan generator required approximately 2 minutes to reconstruct the transverse and coronal scans. The entire reconstruction and reformation process was performed by the technologists at the operator's console. Up to 15 technologists with 1 to 25 years of experience were responsible for the reconstructions. The transverse and coronal scans were transferred to a picture archiving and communication system workstation (Centricity 1.0; GE Healthcare) as a separate series of scans for interpretation.
Scan Evaluation
Patient identity was concealed on transverse and coronal scans, and both series were loaded onto a workstation (Advantage Windows; GE Healthcare) for review. Two randomly created groups of scans were formed; each group contained either the transverse or the coronal scans obtained in the 29 patients. Group 1 contained 15 transverse and 14 coronal studies; group 2 contained 14 transverse and 15 coronal studies. Eight radiologists (K.M.F., L.C.M., C.M.M., T.A.J., E.M.M., E.K.P., R.C.N., W.M.T.) with training in CT of the abdomen and pelvis served as independent readers. The eight readers had 3.5 years of residency and 1, 1, 4, 6, 14, 20, and 30 years of experience, respectively, in imaging of the abdomen and pelvis. Readers were blinded to clinical information. Readers were instructed to record a start and stop time for each interpretation and to identify pathologic findings in multiple organ systems on the basis of a list of imaging findings on a worksheet (Fig 1). With the exception of the diagnosis "normal," readers could select multiple possible diagnoses for each organ. One month later, readers were asked to interpret the second group of scans (ie, if group 1 contained the transverse scans of a patient, group 2 contained the coronal reformations for that patient).
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Figure 1: Worksheet for readers to use for interpretation of transverse CT scans and coronal reformations. Worksheet includes possible diagnoses in multiple organ systems. s/p = "Status post" after cholecystectomy.
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Statistical Analysis
Agreement between transverse and coronal scan interpretations for each reader was determined by using the statistic. An average value and a range of values were determined for all readers for each diagnosis. Standard errors for a range of and average were computed by using the statistical jackknife method applied over cases. Values of 0.21–0.40 were considered to indicate fair agreement; values of 0.41–0.60, moderate agreement; values of 0.61–0.80, substantial agreement; and values of 0.81–1.00, almost perfect agreement (12,13). Interpretation time differences among readers and between types of scans were assessed with a repeated-measures analysis of variance. The average interpretation time for transverse and coronal scans was examined for correlation with years of experience by using the Kendall 
correlation. The time difference between the two interpretations also was correlated with years of experience. A P value of less than .05 was considered to indicate a statistically significant difference. Statistical software was used (SAS, version 9.1; SAS Institute, Cary, NC).
An average number of images was calculated for all transverse and coronal studies. An average FOV also was calculated for all transverse and coronal studies.
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RESULTS
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Agreement between Transverse and Coronal Scans
Reader agreement was substantial to near perfect between transverse and coronal interpretations for gallbladder, biliary tree, pancretic, small-bowel, colonic, and arterial pathologic findings (Fig 2). Moderate to substantial agreement for liver, renal, and splenic pathologic findings was found (Fig 3). The agreement for pulmonary, cardiac, and lymph nodal pathologic findings was lower than that for other pathologic findings. For transverse interpretations, more thoracic and cardiac pathologic findings were noted than for coronal interpretations, and for coronal interpretations, more lymph nodes were noted than for transverse interpretations, especially in the small-bowel mesentery (Fig 4, Table).
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Figure 2a: CT scans in a 43-year-old woman with acute abdominal pain. (a) Transverse scan obtained with intravenous and oral contrast material shows distended gallbladder with pericholecystic stranding (arrow). These findings were identified by all readers. (b) Coronal reformation shows similar findings (arrow) that were identified by all eight readers.
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Figure 2b: CT scans in a 43-year-old woman with acute abdominal pain. (a) Transverse scan obtained with intravenous and oral contrast material shows distended gallbladder with pericholecystic stranding (arrow). These findings were identified by all readers. (b) Coronal reformation shows similar findings (arrow) that were identified by all eight readers.
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Figure 3a: CT scans in a 36-year-old woman with abdominal pain. (a) Transverse scan obtained with intravenous and oral contrast material demonstrates 3-mm stone (arrow) at lower pole of left kidney. This finding was identified by all readers. (b) Coronal reformation shows stone (arrow) in left lower pole. All eight readers identified stone in coronal plane.
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Figure 3b: CT scans in a 36-year-old woman with abdominal pain. (a) Transverse scan obtained with intravenous and oral contrast material demonstrates 3-mm stone (arrow) at lower pole of left kidney. This finding was identified by all readers. (b) Coronal reformation shows stone (arrow) in left lower pole. All eight readers identified stone in coronal plane.
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Figure 4a: CT scans in a 55-year-old man with crampy abdominal pain and no fever. (a) Transverse scan of midabdomen obtained with intravenous and oral contrast material shows 8-mm mesenteric lymph node (arrow). No readers documented an increase in number of mesenteric lymph nodes on transverse scan. (b) Coronal reformation shows chain of four lymph nodes (arrows), all less than 1 cm in diameter, in root of mesentery. Six readers identified this collection as an increase in number.
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Figure 4b: CT scans in a 55-year-old man with crampy abdominal pain and no fever. (a) Transverse scan of midabdomen obtained with intravenous and oral contrast material shows 8-mm mesenteric lymph node (arrow). No readers documented an increase in number of mesenteric lymph nodes on transverse scan. (b) Coronal reformation shows chain of four lymph nodes (arrows), all less than 1 cm in diameter, in root of mesentery. Six readers identified this collection as an increase in number.
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Time Differences
Mean transverse interpretation time was 4.9 minutes ± 1.1 (range, 2.9–6.5 minutes); mean coronal interpretation time was 5.1 minutes ± 0.8 (range, 3.3–6.7 minutes). For each reader, there was no statistically significant difference in average interpretation time for transverse and coronal scans (P = .06). Furthermore, interpretation time for transverse or coronal scans was independent of the experience of the reader (Kendall : mean transverse time, –0.182; mean coronal time, 0.109 [P = .53–.70]; time difference, –0.255 [P = .33]). There was, however, a statistically significant difference among all readers for time of interpretation (P < .001). In addition, there was a statistically significant difference in interpretation time for each reader on the basis of order of interpretation (group 1 vs group 2). The group 1 interpretation required an average of 0.69 minutes longer than did the group 2 interpretation (P = .01). There were no significant differences in the interaction of interpretation order and type of scan (P = .09).
Scanning Data
For all transverse studies, the mean number of images was 87; for all coronal studies, the mean number of images was 47. The average FOV for transverse studies was 34.4 cm; the average FOV for coronal studies was 44.3 cm.
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DISCUSSION
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Coronal reformations from submillimeter isotropic data sets acquired with 16-section CT have spatial resolution similar to that of corresponding transverse scans (1). Current use of off-axis reformations from submillimeter isotropic data sets obtained with 16-section CT has proved advantageous in cardiac, pulmonary, and musculoskeletal imaging by facilitating the delineation of coronary bypass grafts, pulmonary pathologic findings, and complex skeletal fractures, respectively (9–11, 14–20). Results of recent reports (4,5,7,8,21,22) indicate that multidetector CT with off-axis MPRs also aids in the evaluation of the urinary and gastrointestinal tracts. Matsumoto et al (23) recently reviewed their pediatric experience with coronal reformations of the abdomen and pelvis from isotropic voxels; although no new diagnoses were made with the coronal reformations, these images improved confidence in 25% of the abdominal examinations and 18% of the thoracic examinations.
Investigators of all of the aforementioned studies used the MPRs as an adjunct imaging series to the series in the traditional transverse plane. Results of several studies (9,10,14,24–26) have documented equivalency between coronal reformations from isotropic data sets and corresponding transverse scans for interpretation of pulmonary and mediastinal pathologic findings, as well as pulmonary emboli. Results of our study suggest that comparable results should be seen in the abdomen and pelvis as well. Specifically, reader agreement between the two interpretations (transverse and coronal) for intraabdominal organs ranged from 0.3 to 1.0 for solid organs. High agreement does not necessarily imply high accuracy (13). Our study was structured to evaluate consistency of reader interpretation between transverse and coronal scans.
Results of our study suggest equivalency between coronal and transverse isotropic data sets. We found that the agreement between coronal and transverse scans is weak for cardiac and pulmonary findings. Readers consistently identified more pulmonary and cardiac pathologic findings in the transverse plane. However, only the lung bases were included in both sets of images; this is an important distinguishing factor between our study and those studies that have confirmed equivalency of both sets of images of pulmonary and mediastinal pathologic findings (9,10,18,24,26). A difference in FOV in our study, with an average of 34 cm in the transverse series and 44 cm in the coronal series, makes identification of small pulmonary nodules more difficult in the coronal plane. In the thoracic literature, either the FOVs remained constant or the specific FOV was not divulged (9,10,18,24,26). Fundamentally, there should not be a sizeable difference in FOV for the chest. However, a notable discrepancy between FOVs for the transverse and coronal series of the abdomen and pelvis is expected, largely because of the inclusion of the entire craniocaudal extent of the scanned abdominal and pelvic area.
The converse of our findings is true when interpretations of abdominal and pelvic lymph nodes are compared. An increase in the size or number of these lymph nodes was more commonly identified on the coronal reformations. Matsumoto et al (23) had a similar finding at imaging of the pediatric abdomen and pelvis with 64-section CT. There has been an increase in detection of subcentimeter mesenteric lymph nodes in the era of multidetector CT, largely because of the more widespread use of thin collimation as well as the effortlessness of scrolling through the mesentery that is made possible by picture archiving and communication system workstations (27). We postulate that the increase in recognition of abdominal and pelvic lymph nodes on coronal series has four causes. First, mesenteric nodal proliferation seen as a small cluster of lymph nodes on coronal series is more identifiable to readers than a solitary node on each image in the transverse plane. Second, in the transverse plane, lymph nodes of normal size are often confused with veins; this is not the case in the coronal plane, where vessels often extend longitudinally. Third, lymph nodes in the right lower quadrant of the mesentery can be seen immediately adjacent to the cecum on coronal scans, where they may not be as intimately associated on transverse scans. Fourth, the retroperitoneal lymph nodes seen image-by-image on the transverse series appear to follow a linear orientation on the coronal series.
Despite a significant decrease in the number of images in the coronal data set (47 vs 87), readers took slightly longer to read the coronal scans than the transverse scans (5.1 vs 4.9 minutes); the time difference for each reader, however, was not statistically significant (P = .06). Additionally, we found no correlation between length of time of interpretation and years of experience (P = .53–.70). This finding would argue against the suggestion that the use of the coronal imaging plane increases interpretation time for more senior radiologists with extensive experience in the transverse plane. Our findings differed from those of Kwan et al (28), where readers of thoracic multidetector CT scans took considerably longer to interpret coronal scans than transverse scans (263 seconds ± 56 vs 238 seconds ± 45). This finding was attributed to reader familiarity with the transverse display as well as to a decrease in the importance of the total number of images in the transverse plane in interpretation time because readers were able to scroll quickly through these images at a workstation. Results of our study showed a statistically significant difference among all readers for time of interpretation (P < .001), which means that the fastest radiologist in the reading room was faster than the slowest radiologist regardless of imaging plane. Finally, we found a statistically significant difference in interpretation time for each reader on the basis of the order of reading group 1 versus group 2 (P = .01). The group 1 reading took 41 seconds longer than the group 2 reading, despite a 1-month separation between the two interpretations. There was no interaction between this delay and the type of scan (P = .9). This finding suggests that whereas readers did not experience a learning curve in interpreting coronal images, they did need to acquire mastery in the use of our worksheet and in viewing scans at a particular workstation.
We restricted our reformations to the coronal plane for several reasons. Our experience with multiplanar imaging at abdominal magnetic resonance imaging has indicated that, with a few exceptions, the contribution of coronal planar imaging is greater than that of sagittal planar imaging. The course of bowel loops can be followed most readily in the coronal plane, and the majority of the colon often can be identified in a single coronal section. Most of the large intraabdominal organs lie in the coronal plane, and vessels and lymph node chains also are oriented in this direction. The coronal plane, which is analogous to a frontal view of an abdominal radiograph, also may be more intuitive for surgeons and radiologists. Finally, our protocol required no image manipulation by radiologists either at the operator's console or at a dedicated three-dimensional workstation.
Our study had limitations. We included only a small number of patients with abdominal pain, which in turn means only a small number of diagnoses were included. Because readers selected diagnoses from a worksheet, they in essence participated in a directed search with guidance to prompt lesion detection and increase vigilance. A notable increase in agreement between the two interpretations for pathologic lesions was seen when compared with that for a diagnosis of normal. This would suggest a bias that led readers to increased surveillance. Use of the worksheet may have increased the detection of lesions in both the transverse and coronal planes that readers would have failed to observe if left to their own search pattern. This finding has been termed "superiority-of-search" (29). Whether this arrangement reflects the way we practice radiology on a daily basis is questionable. Additional studies without the use of a worksheet might more closely approximate a typical clinical scenario.
Another potential limitation was that we did not ask readers to characterize lesions but only to identify them. This study was not designed to evaluate the sensitivity or specificity of coronal reformations in lesion detection. Further testing of the equivalency of the coronal series and the transverse series should be done with respect to lesion characterization.
In conclusion, with regard to intraabdominal pathologic findings, we found that interpretation time and reader agreement between coronal reformations from isotropic voxels and transverse scans are similar.
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ADVANCES IN KNOWLEDGE
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- Coronal reformations from isotropic data sets are similar to transverse CT scans for lesion detection in the abdomen and pelvis.
- Interpretation times for transverse CT scans and coronal reformations are similar.
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FOOTNOTES
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Abbreviations: FOV = field of view • MPR = multiplanar reformation
See Materials and Methods for pertinent disclosures.
Author contributions: Guarantor of integrity of entire study, T.A.J.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; approval of final version of submitted manuscript, all authors; literature research, T.A.J.; clinical studies, T.A.J., L.C.M., C.M.M., K.M.F., E.M.M., R.C.N., E.K.P.; statistical analysis, D.M.D.; and manuscript editing, T.A.J., C.M.M., E.M.M., R.C.N., E.K.P.
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TOP
ABSTRACT
INTRODUCTION
