Diagnostic accuracy of ttenuation difference and iodine concentration thresholds at rapid-kilovoltage-switching dual-energy CT for detection of enhancement in renal masses

OBJECTIVE. The objective of our study was to evaluate iodine concentration and attenuation change in Hounsfield unit (δHU) thresholds to diagnose enhancement in renal masses at rapid-kilovoltage-switching dual-energy CT (DECT). MATERIALS AND METHODS. We evaluated 30 consecutive histologically confirmed solid renal masses (including nine papillary renal cell carcinomas [RCCs]) and 27 benign cysts (17 simple and 10 hemorrhagic or proteinaceous cysts) with DECT December 2016 and May 2018. A blinded radiologist measured iodine concentration (in milligrams per milliliter) and δHU (attenuation on enhanced CT - attenuation on unenhanced CT) using 70- keV corticomedullary (CM) phase virtual monochromatic and 120-kVp nephrographic (NG) phase images. The accuracies of previously described enhancement thresholds were compared by ROC curve analysis. RESULTS. An iodine concentration of ≥ 2.0 mg/mL and an iodine concentration of ≥ 1.2 mg/mL achieved sensitivity, specificity, and the area under the ROC curve (AUC) of 73.3%, 100.0%, and 0.87 and 86.7%, 100.0%, and 0.93, respectively. On 70-keV CM phase images, δHU ≥ 20 HU and δHU ≥ 15 HU yielded sensitivity, specificity, and AUC of 80.0%, 100.0%, and 0.90 and 90.0%, 100.0%, and 0.95, respectively. The numbers of incorrectly classified papillary RCCs were as follows: iodine concentration of ≥ 2.0 mg/mL, 77.8% (7/9; range, 0.7.1.6 mg/mL); iodine concentration of ≥ 1.2 mg/mL, 44.4% (4/9; range, 0.7.0.9 mg/mL); δHU ≥ 20 HU on 70-keV CM phase images, 66.7% (6/9; range, 4.17 HU); and δHU ≥ 15 HU on 70-keV DECT images, 33.3% (3/9; 4.12 HU). No cyst pseudoenhancement occurred on DECT. For 120-kVp NG phase DECT, δHU ≥ 20 HU and δHU ≥ 15 HU yielded sensitivity, specificity, and AUC of 93.3%, 96.3%, and 0.95 and 100.0%, 88.9%, and 0.94, respectively. With δHU ≥ 20 HU, 22.2% (2/9) (range, 15.18 HU) of papillary RCCs were misclassified and there was one pseudoenhancing cyst. With δHU ≥ 15 HU, no papillary RCCs were misclassified but 11.1% (3/27) of cysts showed pseudoenhancement. Only an iodine concentration of ≥ 2.0 mg/mL showed significantly lower accuracy than other measures (p = 0.031.0.045). CONCLUSION. DECT applied in the CM phase performed best using an iodine concentration of ≥ 1.2 mg/mL or a 70-keV δHU ≥ 15 HU; these parameters improved sensitivity for the detection of enhancement in renal masses without instances of cyst pseudoenhancement.