HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kuhlman, J. E. Articles by Broderick, L. S. Search for Related Content PubMed PubMed Citation Articles by Kuhlman, J. E. Articles by Broderick, L. S. Related Collections Chest Radiology

Dual-Energy Subtraction Chest Radiography: What to Look for beyond Calcified Nodules¹

¹ From the Department of Radiology, University of Wisconsin Medical School, Hospital and Clinics, E3/374 CSC, 600 Highland Ave, Madison, WI 53792-3252. Presented as an education exhibit at the 2004 RSNA Annual Meeting. Received March 2, 2005; revision requested April 26 and received May 20; accepted May 23. The University of Wisconsin Department of Radiology receives research support from GE HealthCare. J.E.K. is a stockholder of GE; all remaining authors have no financial relationships to disclose.

View larger version (178K): [in a new window]   Figure 1a.  (a) Standard unsubtracted image obtained in a 79-year-old woman with a history of smoking shows a possible nodule (arrow) in the right upper lobe. (b) Bone-selective image shows that the "nodule" (arrow) represents the calcified costochondral junction of the first right rib.

 

View larger version (169K): [in a new window]   Figure 1b.  (a) Standard unsubtracted image obtained in a 79-year-old woman with a history of smoking shows a possible nodule (arrow) in the right upper lobe. (b) Bone-selective image shows that the "nodule" (arrow) represents the calcified costochondral junction of the first right rib.

 

View larger version (159K): [in a new window]   Figure 2a.  Lung nodule in a 79-year-old man with rales. (a) Standard unsubtracted image shows an indeterminate nodule (arrowhead) in the left lung. (b) Bone-selective image reveals that the nodule (arrowhead) measures 5 mm in diameter and represents a calcified granuloma. No computed tomography (CT) is required for further evaluation of such a nodule.

 

View larger version (192K): [in a new window]   Figure 2b.  Lung nodule in a 79-year-old man with rales. (a) Standard unsubtracted image shows an indeterminate nodule (arrowhead) in the left lung. (b) Bone-selective image reveals that the nodule (arrowhead) measures 5 mm in diameter and represents a calcified granuloma. No computed tomography (CT) is required for further evaluation of such a nodule.

 

View larger version (172K): [in a new window]   Figure 3a.  (a) Standard unsubtracted image obtained prior to surgery in a 59-year-old man with a history of smoking. (b) Soft-tissue–selective image reveals a left apical mass (arrow), a finding that is more easily visualized because the overlying bone structures, including the clavicle, have been removed. (c) Axial CT scan helps confirm a left apical lung cancer.

 

View larger version (132K): [in a new window]   Figure 3b.  (a) Standard unsubtracted image obtained prior to surgery in a 59-year-old man with a history of smoking. (b) Soft-tissue–selective image reveals a left apical mass (arrow), a finding that is more easily visualized because the overlying bone structures, including the clavicle, have been removed. (c) Axial CT scan helps confirm a left apical lung cancer.

 

View larger version (73K): [in a new window]   Figure 3c.  (a) Standard unsubtracted image obtained prior to surgery in a 59-year-old man with a history of smoking. (b) Soft-tissue–selective image reveals a left apical mass (arrow), a finding that is more easily visualized because the overlying bone structures, including the clavicle, have been removed. (c) Axial CT scan helps confirm a left apical lung cancer.

 

View larger version (159K): [in a new window]   Figure 4a.  (a) Standard unsubtracted image obtained in a 55-year-old man with prostate cancer and possible lung nodules. The image demonstrates what appear to be nodular opacities (arrows) in the lungs. (b) Bone-selective image reveals that the multiple "lung nodules" seen in a represent bone metastases. No lung metastases are present. Note the misregistration artifacts due to cardiac pulsation and motion along the border of the left side of the heart (black streak) and along the aorta (white streak). This type of artifact may be seen on dual-energy subtracted images that are obtained with a dual-exposure technique.

 

View larger version (197K): [in a new window]   Figure 4b.  (a) Standard unsubtracted image obtained in a 55-year-old man with prostate cancer and possible lung nodules. The image demonstrates what appear to be nodular opacities (arrows) in the lungs. (b) Bone-selective image reveals that the multiple "lung nodules" seen in a represent bone metastases. No lung metastases are present. Note the misregistration artifacts due to cardiac pulsation and motion along the border of the left side of the heart (black streak) and along the aorta (white streak). This type of artifact may be seen on dual-energy subtracted images that are obtained with a dual-exposure technique.

 

View larger version (166K): [in a new window]   Figure 5a.  (a) Standard unsubtracted image obtained in an 84-year-old man with congestive heart failure. (b) Bone-selective image more clearly depicts extensive calcification (arrows) in the left ventricular wall. Right-sided pleural calcification is also seen. Note the misregistration artifact line along a pacemaker wire, another example of motion artifact that is seen on dual-energy images obtained with the dual-exposure technique. During the short delay between the two exposures, cardiac pulsation can cause motion of the pacemaker wire and subsequent misregistration during subtraction. (c) Axial CT scan helps confirm myocardial calcification in the left ventricular wall and a left ventricular apical aneurysm (arrow) due to a previous myocardial infarction. Note also the right-sided pleural calcification.

 

View larger version (194K): [in a new window]   Figure 5b.  (a) Standard unsubtracted image obtained in an 84-year-old man with congestive heart failure. (b) Bone-selective image more clearly depicts extensive calcification (arrows) in the left ventricular wall. Right-sided pleural calcification is also seen. Note the misregistration artifact line along a pacemaker wire, another example of motion artifact that is seen on dual-energy images obtained with the dual-exposure technique. During the short delay between the two exposures, cardiac pulsation can cause motion of the pacemaker wire and subsequent misregistration during subtraction. (c) Axial CT scan helps confirm myocardial calcification in the left ventricular wall and a left ventricular apical aneurysm (arrow) due to a previous myocardial infarction. Note also the right-sided pleural calcification.

 

View larger version (133K): [in a new window]   Figure 5c.  (a) Standard unsubtracted image obtained in an 84-year-old man with congestive heart failure. (b) Bone-selective image more clearly depicts extensive calcification (arrows) in the left ventricular wall. Right-sided pleural calcification is also seen. Note the misregistration artifact line along a pacemaker wire, another example of motion artifact that is seen on dual-energy images obtained with the dual-exposure technique. During the short delay between the two exposures, cardiac pulsation can cause motion of the pacemaker wire and subsequent misregistration during subtraction. (c) Axial CT scan helps confirm myocardial calcification in the left ventricular wall and a left ventricular apical aneurysm (arrow) due to a previous myocardial infarction. Note also the right-sided pleural calcification.

 

View larger version (164K): [in a new window]   Figure 6a.  (a) Standard unsubtracted image obtained in a 70-year-old woman with a supraglottic tumor. (b) Bone-selective image demonstrates a thin rim of calcification (arrow) at the edge of a right-sided paratracheal mass, findings that suggest a vascular aneurysm. (c) Axial CT scan shows an aberrant right subclavian artery aneurysm with wall calcification.

 

View larger version (190K): [in a new window]   Figure 6b.  (a) Standard unsubtracted image obtained in a 70-year-old woman with a supraglottic tumor. (b) Bone-selective image demonstrates a thin rim of calcification (arrow) at the edge of a right-sided paratracheal mass, findings that suggest a vascular aneurysm. (c) Axial CT scan shows an aberrant right subclavian artery aneurysm with wall calcification.

 

View larger version (98K): [in a new window]   Figure 6c.  (a) Standard unsubtracted image obtained in a 70-year-old woman with a supraglottic tumor. (b) Bone-selective image demonstrates a thin rim of calcification (arrow) at the edge of a right-sided paratracheal mass, findings that suggest a vascular aneurysm. (c) Axial CT scan shows an aberrant right subclavian artery aneurysm with wall calcification.

 

View larger version (140K): [in a new window]   Figure 7a.  (a) Standard unsubtracted image obtained in a 56-year-old woman with shortness of breath, airway compromise, and partial right middle lobe atelectasis. (b) Bone-selective image shows a calcified pleural plaque on the left hemidiaphragm (right arrow), healed posterior right rib fractures (arrowheads), and a calcified nodule in the right lower lobe (left arrow). (c) Soft-tissue–selective image shows a tracheal stenosis (arrow). (d) Axial CT scan helps confirm a tracheal stenosis at the thoracic inlet.

 

View larger version (174K): [in a new window]   Figure 7b.  (a) Standard unsubtracted image obtained in a 56-year-old woman with shortness of breath, airway compromise, and partial right middle lobe atelectasis. (b) Bone-selective image shows a calcified pleural plaque on the left hemidiaphragm (right arrow), healed posterior right rib fractures (arrowheads), and a calcified nodule in the right lower lobe (left arrow). (c) Soft-tissue–selective image shows a tracheal stenosis (arrow). (d) Axial CT scan helps confirm a tracheal stenosis at the thoracic inlet.

 

View larger version (136K): [in a new window]   Figure 7c.  (a) Standard unsubtracted image obtained in a 56-year-old woman with shortness of breath, airway compromise, and partial right middle lobe atelectasis. (b) Bone-selective image shows a calcified pleural plaque on the left hemidiaphragm (right arrow), healed posterior right rib fractures (arrowheads), and a calcified nodule in the right lower lobe (left arrow). (c) Soft-tissue–selective image shows a tracheal stenosis (arrow). (d) Axial CT scan helps confirm a tracheal stenosis at the thoracic inlet.

 

View larger version (152K): [in a new window]   Figure 7d.  (a) Standard unsubtracted image obtained in a 56-year-old woman with shortness of breath, airway compromise, and partial right middle lobe atelectasis. (b) Bone-selective image shows a calcified pleural plaque on the left hemidiaphragm (right arrow), healed posterior right rib fractures (arrowheads), and a calcified nodule in the right lower lobe (left arrow). (c) Soft-tissue–selective image shows a tracheal stenosis (arrow). (d) Axial CT scan helps confirm a tracheal stenosis at the thoracic inlet.

 

View larger version (165K): [in a new window]   Figure 8a.  (a) Standard unsubtracted image obtained in a 54-year-old woman with a history of smoking. (b) Soft-tissue–selective image more clearly demonstrates increased opacity (arrow) in the right infrahilar region. (c) Bone-selective image shows a malpositioned left central venous catheter. Arrow indicates the tip of the catheter, located in the neck. Note the artifacts along the aortic arch (white streak), the border of the left side of the heart (black streak), and the left hemidiaphragm and stomach bubble (parallel white and black streaks) due to misregistration during the subtraction process. (d) Axial CT scan shows a right infrahilar mass that proved to be lung cancer.

 

View larger version (184K): [in a new window]   Figure 8b.  (a) Standard unsubtracted image obtained in a 54-year-old woman with a history of smoking. (b) Soft-tissue–selective image more clearly demonstrates increased opacity (arrow) in the right infrahilar region. (c) Bone-selective image shows a malpositioned left central venous catheter. Arrow indicates the tip of the catheter, located in the neck. Note the artifacts along the aortic arch (white streak), the border of the left side of the heart (black streak), and the left hemidiaphragm and stomach bubble (parallel white and black streaks) due to misregistration during the subtraction process. (d) Axial CT scan shows a right infrahilar mass that proved to be lung cancer.

 

View larger version (190K): [in a new window]   Figure 8c.  (a) Standard unsubtracted image obtained in a 54-year-old woman with a history of smoking. (b) Soft-tissue–selective image more clearly demonstrates increased opacity (arrow) in the right infrahilar region. (c) Bone-selective image shows a malpositioned left central venous catheter. Arrow indicates the tip of the catheter, located in the neck. Note the artifacts along the aortic arch (white streak), the border of the left side of the heart (black streak), and the left hemidiaphragm and stomach bubble (parallel white and black streaks) due to misregistration during the subtraction process. (d) Axial CT scan shows a right infrahilar mass that proved to be lung cancer.

 

View larger version (160K): [in a new window]   Figure 8d.  (a) Standard unsubtracted image obtained in a 54-year-old woman with a history of smoking. (b) Soft-tissue–selective image more clearly demonstrates increased opacity (arrow) in the right infrahilar region. (c) Bone-selective image shows a malpositioned left central venous catheter. Arrow indicates the tip of the catheter, located in the neck. Note the artifacts along the aortic arch (white streak), the border of the left side of the heart (black streak), and the left hemidiaphragm and stomach bubble (parallel white and black streaks) due to misregistration during the subtraction process. (d) Axial CT scan shows a right infrahilar mass that proved to be lung cancer.

 

View larger version (164K): [in a new window]   Figure 9a.  (a, b) Standard unsubtracted images obtained in July 2004 (a) and August 2004 (b) in a 73-year-old woman with non–small cell lung cancer. (c) Soft-tissue–selective image obtained in July 2004 shows extensive meta-static pleural disease. (d) Soft-tissue–selective image obtained in August 2004 shows interval growth of a right hilar mass (arrow) amid the extensive metastatic pleural disease. Dual-energy soft-tissue–selective images help sort out complex, overlapping, and multifocal disease. CT helped confirm an enlarging right hilar mass, along with extensive tumoral involvement of the right pleura.

 

View larger version (163K): [in a new window]   Figure 9b.  (a, b) Standard unsubtracted images obtained in July 2004 (a) and August 2004 (b) in a 73-year-old woman with non–small cell lung cancer. (c) Soft-tissue–selective image obtained in July 2004 shows extensive meta-static pleural disease. (d) Soft-tissue–selective image obtained in August 2004 shows interval growth of a right hilar mass (arrow) amid the extensive metastatic pleural disease. Dual-energy soft-tissue–selective images help sort out complex, overlapping, and multifocal disease. CT helped confirm an enlarging right hilar mass, along with extensive tumoral involvement of the right pleura.

 

View larger version (151K): [in a new window]   Figure 9c.  (a, b) Standard unsubtracted images obtained in July 2004 (a) and August 2004 (b) in a 73-year-old woman with non–small cell lung cancer. (c) Soft-tissue–selective image obtained in July 2004 shows extensive meta-static pleural disease. (d) Soft-tissue–selective image obtained in August 2004 shows interval growth of a right hilar mass (arrow) amid the extensive metastatic pleural disease. Dual-energy soft-tissue–selective images help sort out complex, overlapping, and multifocal disease. CT helped confirm an enlarging right hilar mass, along with extensive tumoral involvement of the right pleura.

 

View larger version (122K): [in a new window]   Figure 9d.  (a, b) Standard unsubtracted images obtained in July 2004 (a) and August 2004 (b) in a 73-year-old woman with non–small cell lung cancer. (c) Soft-tissue–selective image obtained in July 2004 shows extensive meta-static pleural disease. (d) Soft-tissue–selective image obtained in August 2004 shows interval growth of a right hilar mass (arrow) amid the extensive metastatic pleural disease. Dual-energy soft-tissue–selective images help sort out complex, overlapping, and multifocal disease. CT helped confirm an enlarging right hilar mass, along with extensive tumoral involvement of the right pleura.

 

View larger version (157K): [in a new window]   Figure 10a.  (a) Standard unsubtracted image obtained in a 41-year-old man with rectal cancer and chest pain. (b) Bone-selective image more clearly shows a fractured left central venous catheter with an embolized catheter fragment (arrows) in the left pulmonary artery. Indwelling devices are often more conspicuous and easier to evaluate at dual-energy subtraction imaging.

 

View larger version (206K): [in a new window]   Figure 10b.  (a) Standard unsubtracted image obtained in a 41-year-old man with rectal cancer and chest pain. (b) Bone-selective image more clearly shows a fractured left central venous catheter with an embolized catheter fragment (arrows) in the left pulmonary artery. Indwelling devices are often more conspicuous and easier to evaluate at dual-energy subtraction imaging.

 

View larger version (153K): [in a new window]   Figure 11a.  (a) Standard unsubtracted image obtained in a 63-year-old woman with breast cancer. (b) Bone-selective image more clearly demonstrates bilateral breast implants. A coronary artery stent (arrow) is also noted.

 

View larger version (204K): [in a new window]   Figure 11b.  (a) Standard unsubtracted image obtained in a 63-year-old woman with breast cancer. (b) Bone-selective image more clearly demonstrates bilateral breast implants. A coronary artery stent (arrow) is also noted.

 

View larger version (168K): [in a new window]   Figure 12a.  (a) Standard unsubtracted image obtained prior to peripheral vascular surgery in a 70-year-old woman. (b) Bone-selective image more clearly shows a metallic wire fragment (arrow) in the region of the superior vena cava.

 

View larger version (191K): [in a new window]   Figure 12b.  (a) Standard unsubtracted image obtained prior to peripheral vascular surgery in a 70-year-old woman. (b) Bone-selective image more clearly shows a metallic wire fragment (arrow) in the region of the superior vena cava.

 

View larger version (158K): [in a new window]   Figure 13a.  (a) Standard unsubtracted image obtained in a 53-year-old man with colon cancer who had undergone right pneumonectomy. (b) Soft-tissue–selective image reveals a nodule in the left lower lobe. (c) On a bone-selective image, the nodule (arrow) appears to be calcified, a finding that could lead to misdiagnosis of the nodule as a benign lesion. (d) Axial CT scan shows that the nodule is not calcified, but, in fact, represents a metastasis. The appearance of calcification within the nodule in c may have been due to the calcified costochondral junction superimposed over the nodule.

 

View larger version (124K): [in a new window]   Figure 13b.  (a) Standard unsubtracted image obtained in a 53-year-old man with colon cancer who had undergone right pneumonectomy. (b) Soft-tissue–selective image reveals a nodule in the left lower lobe. (c) On a bone-selective image, the nodule (arrow) appears to be calcified, a finding that could lead to misdiagnosis of the nodule as a benign lesion. (d) Axial CT scan shows that the nodule is not calcified, but, in fact, represents a metastasis. The appearance of calcification within the nodule in c may have been due to the calcified costochondral junction superimposed over the nodule.

 

View larger version (199K): [in a new window]   Figure 13c.  (a) Standard unsubtracted image obtained in a 53-year-old man with colon cancer who had undergone right pneumonectomy. (b) Soft-tissue–selective image reveals a nodule in the left lower lobe. (c) On a bone-selective image, the nodule (arrow) appears to be calcified, a finding that could lead to misdiagnosis of the nodule as a benign lesion. (d) Axial CT scan shows that the nodule is not calcified, but, in fact, represents a metastasis. The appearance of calcification within the nodule in c may have been due to the calcified costochondral junction superimposed over the nodule.

 

View larger version (147K): [in a new window]   Figure 13d.  (a) Standard unsubtracted image obtained in a 53-year-old man with colon cancer who had undergone right pneumonectomy. (b) Soft-tissue–selective image reveals a nodule in the left lower lobe. (c) On a bone-selective image, the nodule (arrow) appears to be calcified, a finding that could lead to misdiagnosis of the nodule as a benign lesion. (d) Axial CT scan shows that the nodule is not calcified, but, in fact, represents a metastasis. The appearance of calcification within the nodule in c may have been due to the calcified costochondral junction superimposed over the nodule.

 

View larger version (165K): [in a new window]   Figure 14a.  (a, b) Standard unsubtracted (a) and bone-selective (b) images obtained in a 39-year-old man with a heart murmur. (c) Lateral image demonstrates aortic valve calcifications (arrow) associated with aortic stenosis. Dual-energy subtraction is performed on the posteroanterior view only. However, this does not eliminate the need for a lateral view, which alone depicted the aortic valve calcifications in this case.

 

View larger version (187K): [in a new window]   Figure 14b.  (a, b) Standard unsubtracted (a) and bone-selective (b) images obtained in a 39-year-old man with a heart murmur. (c) Lateral image demonstrates aortic valve calcifications (arrow) associated with aortic stenosis. Dual-energy subtraction is performed on the posteroanterior view only. However, this does not eliminate the need for a lateral view, which alone depicted the aortic valve calcifications in this case.

 

View larger version (150K): [in a new window]   Figure 14c.  (a, b) Standard unsubtracted (a) and bone-selective (b) images obtained in a 39-year-old man with a heart murmur. (c) Lateral image demonstrates aortic valve calcifications (arrow) associated with aortic stenosis. Dual-energy subtraction is performed on the posteroanterior view only. However, this does not eliminate the need for a lateral view, which alone depicted the aortic valve calcifications in this case.

 

---

HOME

HELP

FEEDBACK

SUBSCRIPTIONS

ARCHIVE

SEARCH

TABLE OF CONTENTS

RADIOGRAPHICS

RADIOLOGY

RSNA JOURNALS ONLINE

Copyright © 2006 by the Radiological Society of North America.