Deep learning–based image reconstruction of 40-keV virtual monoenergetic images of dual-energy CT for the assessment of hypoenhancing hepatic metastasis

Objectives To evaluate the diagnostic value of deep learning model (DLM) reconstructed dual-energy CT (DECT) low-keV virtual monoenergetic imaging (VMI) for assessing hypoenhancing hepatic metastases. Methods This retrospective study included 131 patients who underwent contrast-enhanced DECT (80-kVp and 150-kVp with a tin filter) in the portal venous phase for hepatic metastasis surveillance. Linearly blended images simulating 100-kVp images (100-kVp), standard 40-keV VMI images (40-keV VMI), and post-processed 40-keV VMI using a vendor-agnostic DLM (i.e., DLM 40-keV VMI) were reconstructed. Lesion conspicuity and diagnostic acceptability were assessed by three independent reviewers and compared using the Wilcoxon signed-rank test. The contrast-to-noise ratios (CNRs) were also measured placing ROIs in metastatic lesions and liver parenchyma. The detection performance of hepatic metastases was assessed by using a jackknife alternative free-response ROC method. The consensus by two independent radiologists was used as the reference standard. Results DLM 40-keV VMI, compared to 40-keV VMI and 100-kVp, showed a higher lesion-to-liver CNR (8.25 ± 3.23 vs. 6.05 ± 2.38 vs. 5.99 ± 2.00), better lesion conspicuity (4.3 (4.0–4.7) vs. 3.7 (3.7–4.0) vs. 3.7 (3.3–4.0)), and better diagnostic acceptability (4.3 (4.0–4.3) vs. 3.0 (2.7–3.3) vs. 4.0 (4.0–4.3)) ( p < 0.001 for all). For lesion detection (246 hepatic metastases in 68 patients), the figure of merit was significantly higher with DLM 40-keV VMI than with 40-keV VMI (0.852 vs. 0.822, p = 0.012), whereas no significant difference existed between DLM 40-keV VMI and 100-kVp (0.852 vs. 0.842, p = 0.31). Conclusions DLM 40-keV VMI provided better image quality and comparable diagnostic performance for detecting hypoenhancing hepatic metastases compared to linearly blended images. Key Points • DLM 40-keV VMI provides a superior image quality compared with 40-keV or 100-kVp for assessing hypoenhancing hepatic metastasis . • DLM 40-keV VMI has the highest CNR and lesion conspicuity score for hypoenhancing hepatic metastasis due to noise reduction and structural preservation . • DLM 40-keV VMI provides higher lesion detectability than standard 40-keV VMI (p = 0.012) .