title: Small lung cancers: improved detection by use of bone suppression imaging--comparison with dual-energy subtraction chest radiography.
abstract: OBJECTIVE
  To determine whether use of bone suppression (BS) imaging, used together with a standard radiograph, could improve radiologists' performance for detection of small lung cancers compared with use of standard chest radiographs alone and whether BS imaging would provide accuracy equivalent to that of dual-energy subtraction (DES) radiography.
  
  
  METHODS
  Institutional review board approval was obtained. The requirement for informed consent was waived. The study was HIPAA compliant. Standard and DES chest radiographs of 50 patients with 55 confirmed primary nodular cancers (mean diameter, 20 mm) as well as 30 patients without cancers were included in the observer study. A new BS imaging processing system that can suppress the conspicuity of bones was applied to the standard radiographs to create corresponding BS images. Ten observers, including six experienced radiologists and four radiology residents, indicated their confidence levels regarding the presence or absence of a lung cancer for each lung, first by using a standard image, then a BS image, and finally DES soft-tissue and bone images. Receiver operating characteristic (ROC) analysis was used to evaluate observer performance.
  
  
  RESULTS
  The average area under the ROC curve (AUC) for all observers was significantly improved from 0.807 to 0.867 with BS imaging and to 0.916 with DES (both P < .001). The average AUC for the six experienced radiologists was significantly improved from 0.846 with standard images to 0.894 with BS images (P < .001) and from 0.894 to 0.945 with DES images (P = .001).
  
  
  CONCLUSIONS
  Use of BS imaging together with a standard radiograph can improve radiologists' accuracy for detection of small lung cancers on chest radiographs. Further improvements can be achieved by use of DES radiography but with the requirement for special equipment and a potential small increase in radiation dose.
authors.affiliation: Department of Radiology, MC-2026, University of Chicago, 5841 S Maryland Ave, Chicago, IL 60637, USA. feng@uchicago .edu
authors.forename: Feng
authors.initials: F
authors.lastname: Li
authors.forename: Roger
authors.initials: R
authors.lastname: Engelmann
authors.forename: Lorenzo L
authors.initials: LL
authors.lastname: Pesce
authors.forename: Kunio
authors.initials: K
authors.lastname: Doi
authors.forename: Charles E
authors.initials: CE
authors.lastname: Metz
authors.forename: Heber
authors.initials: H
authors.lastname: Macmahon
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008175:Lung Neoplasms / Q000000981:diagnostic imaging*; D008297:Male; D008875:Middle Aged; D012372:ROC Curve; D011857:Radiographic Image Interpretation, Computer-Assisted; D015900:Radiography, Dual-Energy Scanned Projection / Q000295:instrumentation*; D013902:Radiography, Thoracic / Q000295:instrumentation*; D013382:Subtraction Technique