Identification manual for foreign bodies by using the chest phantom and the dual energy subtraction radiography

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1 Identification manual for foreign bodies by using the chest phantom and the dual energy subtraction radiography Kenji Endo, Shuji Sakai Department of Diagnostic Imaging and Nuclear Medicine Tokyo Women's Medical University Hospital

2 There are no conflicts of interest with respect to presenting these research results.

3 Dual energy subtraction (DES) radiography DES is an imaging technique that takes advantage of differences in the degree to which objects attenuate lowand high-energy photons. DES produces two separate images: a soft tissue image and a bone image. soft tissue image bone image

4 Potential of DES radiography Even objects with low attenuation values are clearly visualized on DES radiographs if the differences are large. Thus, it is a possible to detect foreign bodies with DES radiographs that are difficult to detect on conventional radiographs. Conventional radiograph Bone image

5 Foreign bodies of the chest Common items Batteries Pieces of plastic Pieces of jewelry Coins Safety pins Nails/screws Magnets Balloons Bones (fish and chicken) Toys Pen caps Food bolus Balls Buttons Press-through packages (PTPs) Wright CC1, Closson FT. Updates in pediatric gastrointestinal foreign bodies. Pediatr Clin North Am Oct;60(5): Medical items Gauzes Surgical gauzes Drainage tubes Catheters Endoscopic clips Surgical clips

6 Foreign bodies of the chest Common items Medical items Materials of common items Resins (ABS, PS, PC, PU, PVA, PVC, TPE, POM, EVA, PP, silicone, natural rubber, synthetic rubber) Metals (Cu, Zn, Ni, steel) Glass, paraffin, magnet, wood, bone, wax ABS = acrylonitrile butadiene styrene, PS = polystyrene, PC = polycarbonate, PU = polyurethane, PVA = polyvinyl alcohol, PVC = polyvinyl chloride, TPE = thermoplastic elastomer, POM = polyoxymethylene, EVA = ethylene vinyl acetate copolymer and PP = polypropylene Each foreign body was placed in a chest phantom (N1 Lungman, Kyoto Kagaku, Japan) and evaluated by DES radiography.

7 Case 1: Toy made of PVC Conventional radiograph ミスド Bone image Magnification of bone image Toys made of PVC are detected more easily on bone images than on conventional radiographs.

8 Case 2: Toy made of ABS Conventional radiograph Bone image Magnification of bone image Toys made of ABS are not detected on either conventional radiographs or bone images.

9 Case 3: PTP Conventional radiograph Bone image Magnification of bone image PTPs are not detected on either conventional radiographs or bone images.

10 Case 4: Fish bone Conventional radiograph Bone image Magnification of bone image Fish bones are not detected on either conventional radiographs or bone images.

11 Case 5: Wood Conventional radiograph Bone image Magnification of bone image Toys made of wood are not detected on either conventional radiographs or bone images.

12 Case 6: Coin made of Cu and Ni Conventional radiograph Bone image Magnification of bone image Coins made of metals are easily detected on both conventional radiographs and bone images.

13 Case 7: Safety pin and a clip Conventional radiograph Bone image Magnification of bone image Safety pins and clips made of metals are easily detected on both conventional radiographs and bone images.

14 Case 8: Button battery Conventional radiograph Bone image Magnification of bone image Button batteries are easily detected on both conventional radiographs and bone images.

15 Case 9: Marble made of glass Conventional radiograph Bone image Magnification of bone image Toys made of glass are detected on both conventional radiographs and bone images.

16 Case 10: Toy made of TPE Conventional radiograph Bone image Magnification of bone image Toys made of TPE are barely detected on conventional and DES radiographs.

17 Case 11: Toy made of ABS with a semiconductor substrate Conventional radiograph Bone image Magnification of bone image Toys made of ABS with a semiconductor substrate are more easily detected on bone images than on conventional radiographs.

18 Case 12: Toy made of PP Conventional radiograph Bone image Magnification of bone image Toys made of PP are not detected on either conventional radiographs or bone images.

19 Case 13: Toy made of PS Conventional radiograph Bone image Magnification of bone image Toys made of PS are barely detected on conventional and DES radiographs.

20 Case 14: Surgical staple Conventional radiograph Bone image Magnification of bone image Surgical staples are detected more easily on bone images than on conventional radiographs.

21 Case 15: Endoscopic clip Conventional radiograph Bone image Magnification of bone image Endoscopic clips are detected more easily on bone images than on conventional radiographs.

22 Case 16: NaI-123 capsule Conventional radiograph Bone image Magnification of bone image NaI-123 capsules are barely detected on conventional radiographs, and are not detected on bone images.

23 Case 16: NaI-123 capsule Conventional radiograph Soft tissue image Magnification of bone image NaI-123 capsules are barely detected on soft tissue images.

24 Case 17: Catheter Conventional radiograph Bone image Magnification of bone image Catheters inside the aorta are detected more easily on bone images than on conventional radiographs.

25 Case 18: Drainage tube Conventional radiograph Bone image Magnification of bone image Drainage tubes in the pleural cavity are easily detected on both conventional radiographs and bone images.

26 Case 19: Surgical gauze Conventional radiograph Bone image Magnification of bone image Surgical gauzes are easily detected on both conventional radiographs and bone images.

27 Clinical case 1: Surgical clip Conventional radiograph Bone image Magnification of bone image Surgical clips are detected more easily on bone images than on conventional radiographs.

28 Clinical case 2: Gallstone Conventional radiograph Bone image Magnification of bone image Gallstones are detected more easily on bone images than on conventional radiographs.

29 Foreign bodies in DES radiograph Bone image Because the mediastinal intensity is low, it can be detected if foreign bodies are visualized even at a low intensity. However, most foreign bodies visualized on conventional radiographs are also visualized on bone images, and most foreign bodies not visualized on conventional radiographs are also not visualized on bone images. Soft tissue image The intensity of foreign bodies is often lower on soft tissue images than on conventional radiographs. On the other hand, because the mediastinal intensity is high, it is more difficult to detect foreign bodies on DES radiographs than on conventional radiographs.

30 Foreign bodies with PVC, which is a common resin, are barely visualized on conventional radiographs, but are clearly visualized on bone images. Also, foreign bodies with small and thin metals, such as semiconductors, can be detected more clearly on bone images. Semiconductor conventional radiograph Foreign bodies visualized on bone images -common itemssoft tissue image PVC bone image

31 PTPs, woods, fish bones Foreign bodies made of ABS (most of LEGOs) or PP even if they are large Small items made of resins (except for PVC) Wood PTP conventional radiograph Foreign bodies not visualized on either conventional or DES radiographs -common itemssoft tissue image PP ABS bone image

32 Clips or staples, which are made of small metals, can be detected more clearly on bone images. Catheters, tubes or surgical gauzes overlapping with the mediastinum can be detected more clearly on bone images. Normal gauzes are not detected on either conventional radiographs or bone images. Catheter Drainage tube conventional radiograph Foreign bodies on bone images -medical itemssoft tissue image Surgical gauze NaI-123 capsule bone image Gauze Staple Endoscopic clip Loxoprofen tablet

33 Conclusion DES radiography can add beneficial information regarding detection of foreign bodies.

34 Acknowledgment We received generous support from Yuhei Horiuchi, Yuki Fujii, Kosuke Morita and Yutaka Shimada, who are in the Division of Radiological Service at Tokyo Women's Medical University Hospital.

35 Contact information Kenji Endo, MD Department of Diagnostic Imaging and Nuclear Medicine Tokyo Women's Medical University Hospital 8-1 Kawada-cho, Shinjuku-ku, Tokyo, , JAPAN Tel: Fax: