Dual Energy CT: a new tool in evaluation of the urinary tract stones composition in clinical practice - initial study
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1 Dual Energy CT: a new tool in evaluation of the urinary tract stones composition in clinical practice - initial study Poster No.: C-2279 Congress: ECR 2013 Type: Scientific Exhibit Authors: M. Guzi#ski, T. Kra#nicki, K. Tupikowski, J. Bladowska, A. Czarnecka, P. Podgórski, M. S#siadek; Wroc#aw/PL Keywords: DOI: Urinary Tract / Bladder, Kidney, Emergency, CT, CT-Quantitative, CT-High Resolution, Computer Applications-Detection, diagnosis, Lithotripsy, Chemistry, Obstruction / Occlusion, Calcifications / Calculi /ecr2013/C-2279 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 9
2 Purpose Urolithiasis is a widespread condition affecting up to 3% of global population per year with a lifetime risk of about 12% in men and 6% in women, whereas the incidence of renal stone formation as well as the female prevalence are progressively increasing. A wide range of familial, environmental, dietary and systemic factors contribute to the pathogenesis of renal stones and directly influence the stone composition as well as the imaging characteristics and therapeutic management. Eighty per cent of stones are radiopaque due to the calcium content and occur in the form of calcium oxalate, calcium phosphate or mixed. Less radiopaque calculi, such as infection- induced struvite stones account for 5-10% of stones. Radiolucent pure uric acid stones, account for the next 5-10% of stones. Non-contrast enhanced computed tomography (NECT) is the method of choice for patients with suspected urolithiasis. Almost all urinary stones, regardless of composition and size, are easily detectable at NECT due to higher attenuation comparing to the surrounding tissues. However, differentiation the chemical composition of the stones using NECT is affected by significant error. Dual Energy Computed Tomography (DECT) gives a powerful tool which can be a milestone in urinary stone treatment. Using two different X-ray beam energies to the same material it is possible to calculate effective atomic number (Z eff ) of this material. The purpose our study was to determine the usefulness of the assessment of the chemical composition of the stones in patients using DualEnergyCT Methods and Materials Twenty eight consecutive patients with urolithiasis underwent low-dose- NECT scans of the urinary tract. Stones responsible for clinical symptoms were scanned again with DECT (tube voltage 80/140kVp, DFOV5x5cm - more details Fig.1.) The obtained data were analyzed on commercial workstations with dedicated software (GSI Viewer GE). In each stone value of Z effective (Zeff - weighted mean atomic number) was calculated using small ROI method. This value was compared with theoretical Zeff of urinary stones. (Fig. 2). Page 2 of 9
3 Images for this section: Fig. 1: The most important parameters of dual-energy systems using for detection urinary stones Page 3 of 9
4 Fig. 2: Theoretical value of Zeff for each of the common urinary stones, Zeff was calculated with two different # factor values Page 4 of 9
5 Results After analysis of Zeff values 3 different types of stones were recognized: 1. homogeneous calcium oxalate (22 cases) 2. homogeneous uric acid stones (3 cases), 3. heterogeneous stones (3 cases) which consisted of crystals of struvite and calcium phosphate. Clinical procedure; implemented on the basis of Zeff: Calcium oxalate stones were managed by shock-wave lithotrypsy or ureterorenoscopy (URS) (Fig. 3). All uric acid stones were successfully managed with pharmacological treatment only with good. Lithiasis symptoms resolved in all cases and results of the treatment were confirmed by the follow up NECT (Fig. 4 and 5). In all cases of heteregeneous calculi urine cultures were negative, but patients were managed as if they had urinary tract infection (UTI) - due to struvite component. No septic complications were observed in those patients. All stones were managed successfully by URS and expulsive therapy (Fig. 6). Images for this section: Page 5 of 9
6 Fig. 3: DECT scan from stone in left ureter with Z-eff value on level corresponding to high concentration of calcium oxalate. Page 6 of 9
7 Fig. 4: DECT scan from stone in right ureter with Z-eff value on level 7,4-7,9 corresponding to high concentration of uric acid. Page 7 of 9
8 Fig. 5: Fig. A. Oblique scan of low dose NECT revealed urinary tract blockage by uric acid stone in ureter. Fig B. Follow up low dose CT in the same reconstruction showed no stone. Fig. 6: Heterogeneous stones axial DECT image. ROI analysis are on Histogram, Scatterplot and Spectral HU Curve plots. Histogram shows Zeff from central arranged Region of Interest (ROI) on stone -Calcium oxalate main component, green histogram reveals border part of calculi - struvite component Page 8 of 9
9 Conclusion 1. Our initial study provides evidence that urinary stone composition assessed with DECT could be the useful tool in urological practice which may be used in some patients to avoid unnecessary invasive procedures. 2. This method allows also to isolate patients with suspected UTI and negative urine culture and high risk of septic complications which enables to choose appropriate management to avoid them. References 1. Bultitude M, Rees J. Management of renal colic. BMJ Aug 29;345:e5499. doi: /bmj.e Haghighi RR, Chatterjee S, Vyas A, Kumar P, Thulkar S. X-ray attenuation coefficient of mixtures: Inputs for dual-energy CT. Med. Phys. 38 (10): Mc Laughlin PD, Crush L, Maher MM, O'Connor OJ. Recent developments in computed tomography for urolithiasis: diagnosis and characterization. Adv Urol. 2012;2012: doi: /2012/ Kra#nicki T,Podgórski P,Guzi#ski M,Czarnecka A,Tupikowski K,Garcarek J, S#siadek M. (2012) Novel Clinical ApplicationsofDual Energy Computed Tomography, AdvClin Exp Med 21, 6, Alvarez RE,Macovski A (1976) Energy-selective reconstruction in X-ray computerized tomography. PhysMedBiol 21: JohnsonTRC et al. (eds.) (2011)Dual Energy CT in Clinical Practice. Medical Radiology, Springer-Verlag Berlin Heidelberg. 7. Karçaalt#ncaba M, Akta# A. (2011) Dual-energy CT revisited with multidetector CT: review of principles and clinical applications. Diagn Interv Radiol. 17(3): Personal Information M. Guzi#ski - Radiologist, Medical University - Wroc#aw/PL T. Kra#nicki- Medical physicist, Medical University - Wroc#aw/PL K. Tupikowski - Urologist, Medical University - Wroc#aw/PL Page 9 of 9
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