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Incremental Benefit of Maximum-Intensity-Projection Images on Observer Detection of Small Pulmonary Nodules Revealed by Multidetector CT

¹ All authors: Division of Cardiothoracic Imaging and the Image Processing Laboratory, Emory University Hospital and Clinic, 1324 Clifton Rd. N.E., Ste. E-118, Atlanta, GA 30322.

View larger version (20K): [in a new window]   Fig. 1. —Illustration shows basic principles of maximum-intensity-projection (MIP) imaging. Four axial thin-section images contain segments of obliquely oriented vessel (black shapes). Small nodule (in third axial image, white dot) of diameter similar to visible vessel portions is also present. MIP image, or slab, combines these four axial images so that vessel is seen in its entirety, distinct from nodule, and nodule conspicuity is enhanced.

View larger version (121K): [in a new window]   Fig. 2A. —Maximum-intensity-projection (MIP) depiction of central nodules in patients with metastatic disease to the lung. Images A and B are from 44-year-old woman, and images C and D, for comparison, are from 56-year-old man. Axial CT image shows small central nodule in right lower lobe, missed by several reviewers.

View larger version (126K): [in a new window]   Fig. 2B. —Maximum-intensity-projection (MIP) depiction of central nodules in patients with metastatic disease to the lung. Images A and B are from 44-year-old woman, and images C and D, for comparison, are from 56-year-old man. 10-mm MIP slab clearly shows that lesion is not vessel in cross-section but true lung nodule (arrow).

View larger version (115K): [in a new window]   Fig. 2C. —Maximum-intensity-projection (MIP) depiction of central nodules in patients with metastatic disease to the lung. Images A and B are from 44-year-old woman, and images C and D, for comparison, are from 56-year-old man. Axial 3.75-mm CT image reveals tiny nodule in central right lung that was missed by all reviewers.

View larger version (133K): [in a new window]   Fig. 2D. —Maximum-intensity-projection (MIP) depiction of central nodules in patients with metastatic disease to the lung. Images A and B are from 44-year-old woman, and images C and D, for comparison, are from 56-year-old man. 10-mm MIP slab shows nodule (arrow) that was detected by two of five reviewers. Linear scarring is present posterior and lateral to lesion.

View larger version (114K): [in a new window]   Fig. 3A. —Small nodules detected on maximum-intensity-projection (MIP) images in 51-year-old woman (A and B) and 60-year-old man (C and D) with metastatic disease to the lung. Axial 3.75-mm CT image (A) and 10-mm MIP slab (B) show right middle lobe central nodule. Small nodule (arrowhead, B) is clearly distinct from adjacent vessels in B. Because normal MIP images do not contain nodular structures, lesion conspicuity is also enhanced with respect to A. Lesion was missed initially by multiple reviewers.

View larger version (126K): [in a new window]   Fig. 3B. —Small nodules detected on maximum-intensity-projection (MIP) images in 51-year-old woman (A and B) and 60-year-old man (C and D) with metastatic disease to the lung. Axial 3.75-mm CT image (A) and 10-mm MIP slab (B) show right middle lobe central nodule. Small nodule (arrowhead, B) is clearly distinct from adjacent vessels in B. Because normal MIP images do not contain nodular structures, lesion conspicuity is also enhanced with respect to A. Lesion was missed initially by multiple reviewers.

View larger version (139K): [in a new window]   Fig. 3C. —Small nodules detected on maximum-intensity-projection (MIP) images in 51-year-old woman (A and B) and 60-year-old man (C and D) with metastatic disease to the lung. Axial 3.75-mm CT image (C) and 10-mm MIP slab (D) show lesion (arrowhead, D) is more conspicuous on MIP slab. Although nodule is anatomically medial, it was scored as peripheral for purposes of study.

View larger version (133K): [in a new window]   Fig. 3D. —Small nodules detected on maximum-intensity-projection (MIP) images in 51-year-old woman (A and B) and 60-year-old man (C and D) with metastatic disease to the lung. Axial 3.75-mm CT image (C) and 10-mm MIP slab (D) show lesion (arrowhead, D) is more conspicuous on MIP slab. Although nodule is anatomically medial, it was scored as peripheral for purposes of study.

View larger version (122K): [in a new window]   Fig. 4A. —Nodules depicted on multiple axial images summed onto single maximum-intensity-projection (MIP) image in 48-year-old man with melanoma. 3.75-mm axial CT images show left medial nodule to greatest advantage on B (arrow, B). This nodule was overlooked by multiple reviewers.

View larger version (119K): [in a new window]   Fig. 4B. —Nodules depicted on multiple axial images summed onto single maximum-intensity-projection (MIP) image in 48-year-old man with melanoma. 3.75-mm axial CT images show left medial nodule to greatest advantage on B (arrow, B). This nodule was overlooked by multiple reviewers.

View larger version (129K): [in a new window]   Fig. 4C. —Nodules depicted on multiple axial images summed onto single maximum-intensity-projection (MIP) image in 48-year-old man with melanoma. 3.75-mm axial CT images obtained slightly more inferiorly to A and B show second nodule (arrow, C) more clearly on C. This nodule was missed by several reviewers, including some observers who had missed other lesion in A and B.

View larger version (118K): [in a new window]   Fig. 4D. —Nodules depicted on multiple axial images summed onto single maximum-intensity-projection (MIP) image in 48-year-old man with melanoma. 3.75-mm axial CT images obtained slightly more inferiorly to A and B show second nodule (arrow, C) more clearly on C. This nodule was missed by several reviewers, including some observers who had missed other lesion in A and B.

View larger version (101K): [in a new window]   Fig. 4E. —Nodules depicted on multiple axial images summed onto single maximum-intensity-projection (MIP) image in 48-year-old man with melanoma. 10-mm axial MIP slab clearly shows both nodules superimposed on same image (arrows). All reviewers readily identified both.

View larger version (109K): [in a new window]   Fig. 5A. —Missed nodule in azygoesophageal recess in 42-year-old man with melanoma. Magnified views of axial 3.75-mm images show nodule (arrow, B) in right lower lobe in area known as azygoesophageal recess. This nodule is of similar caliber to adjacent vessels, which appear nodular in areas on these thinly collimated images.

View larger version (102K): [in a new window]   Fig. 5B. —Missed nodule in azygoesophageal recess in 42-year-old man with melanoma. Magnified views of axial 3.75-mm images show nodule (arrow, B) in right lower lobe in area known as azygoesophageal recess. This nodule is of similar caliber to adjacent vessels, which appear nodular in areas on these thinly collimated images.

View larger version (111K): [in a new window]   Fig. 5C. —Missed nodule in azygoesophageal recess in 42-year-old man with melanoma. Contiguous magnified axial CT images from A and B in right lower lobe are of 3.75-mm collimation reconstructed at 3-mm intervals. Nodule (arrow, C) is revealed clearly on C but was missed by all observers.

View larger version (97K): [in a new window]   Fig. 5D. —Missed nodule in azygoesophageal recess in 42-year-old man with melanoma. Contiguous magnified axial CT images from A and B in right lower lobe are of 3.75-mm collimation reconstructed at 3-mm intervals. Nodule (arrow, C) is revealed clearly on C but was missed by all observers.

View larger version (106K): [in a new window]   Fig. 5E. —Missed nodule in azygoesophageal recess in 42-year-old man with melanoma. Contiguous axial 10-mm maximum-intensity-projection (MIP) slabs reconstructed at 8-mm intervals show that nodule (arrowhead, E) is clearly not vascular structure. Nodule was detected by four of five reviewers on MIP images. Poorly marginated nodular density in F represents ray sum projection of focus of parenchymal atelectasis or scarring noted on axial images (not shown) through area.

View larger version (96K): [in a new window]   Fig. 5F. —Missed nodule in azygoesophageal recess in 42-year-old man with melanoma. Contiguous axial 10-mm maximum-intensity-projection (MIP) slabs reconstructed at 8-mm intervals show that nodule (arrowhead, E) is clearly not vascular structure. Nodule was detected by four of five reviewers on MIP images. Poorly marginated nodular density in F represents ray sum projection of focus of parenchymal atelectasis or scarring noted on axial images (not shown) through area.

View larger version (91K): [in a new window]   Fig. 6A. —Loss of information with thick-slab maximum-intensity-projection (MIP) images in 37-year-old man with sarcoma. Axial 3.75-mm CT image (A) clearly shows nodule (arrow,A), nearly 1 cm in diameter, in right lower lobe. 10-mm MIP slab (B) also depicts lesion.

View larger version (70K): [in a new window]   Fig. 6B. —Loss of information with thick-slab maximum-intensity-projection (MIP) images in 37-year-old man with sarcoma. Axial 3.75-mm CT image (A) clearly shows nodule (arrow,A), nearly 1 cm in diameter, in right lower lobe. 10-mm MIP slab (B) also depicts lesion.

View larger version (85K): [in a new window]   Fig. 6C. —Loss of information with thick-slab maximum-intensity-projection (MIP) images in 37-year-old man with sarcoma. Sequential 25-mm MIP slab images created with 20-mm reconstruction interval (20% overlap) do not depict lesion well because density from diaphragm and below diaphragm is projected onto final image and obscures nodule. This effect also occurs at apices and increases in severity with thicker MIP slabs.

View larger version (36K): [in a new window]   Fig. 6D. —Loss of information with thick-slab maximum-intensity-projection (MIP) images in 37-year-old man with sarcoma. Sequential 25-mm MIP slab images created with 20-mm reconstruction interval (20% overlap) do not depict lesion well because density from diaphragm and below diaphragm is projected onto final image and obscures nodule. This effect also occurs at apices and increases in severity with thicker MIP slabs.

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