Improvements of diagnostic accuracy and visualization of vertebral metastasis using multi-level virtual non-calcium reconstructions from dual-layer spectral detector computed tomography.

To evaluate feasibility and diagnostic performance of multi-level calcium suppression in spectral detector computed tomography (SDCT) for assessment of bone metastasis. Retrospective IRB-approved study on 21 patients who underwent SDCT (120 kV, reference mAs 116) and MRI. Thoracic and lumbar vertebrae (n = 357) were included and categorized as normal (n = 133) or metastatic (n = 203) based on MRI (STIR, T1w, ±contrast). The multi-level virtual non-calcium (VNCa) algorithm computes dynamic soft tissue/calcium pairs allowing for computation of different suppression index levels to address inter-individual variance of prevalent calcium composition weights. We computed images with low, medium, and high calcium suppression indices and compared them with conventional images (VNCa_low/med/high and conventional images (CI)). For quantitative image analysis, regions of interest were placed in normal and metastatic bone. Two readers reviewed the datasets independently in multiple sessions. They determined the presence of vertebral metastases on a per vertebra basis using a binary scale. Statistic assessment was performed using ANOVA with Tukey HSD, Student's T test, and ROC analysis. Attenuation of both normal and metastatic bone was lower in VNCa images than that in conventional images (e.g., CI/VNCa_low, - 46.3 to 238.8 HU/343.3-60.2 HU; p ≤ 0.05). VNCa_low+med improved separation of normal and metastatic bone in ROC analysis (AUC, CI/VNCa_low/VNCa_med = 0.74/0.95/0.98; p ≤ 0.05). In subjective analysis, both sensitivity and specificity were clearly improved in VNCa_low as compared with CI (0.85/0.84 versus 0.78/0.82). Readers showed a good inter-rater reliability (kappa = 0.65). Multi-level VNCa reconstructed from SDCT improve quantitative separation of normal and metastatic bone and subjective determination of bone metastases when using low to intermediate calcium suppression indices. • Spectral detector CT allows for multi-level calcium suppression in CT images and low and medium calcium suppression indices improved separation of normal and metastatic bone. • Thus, multi-level calcium suppression allows to optimize image contrast in regard to dedicated pathologies. • Low-level virtual non-calcium images (index 25-50) improved diagnostic performance regarding detection of metastasis.