Differential diagnosis between benign and malignant pleural effusion with dual-energy spectral CT

Purpose To investigate the value of spectral CT in the differential diagnosis of benign from malignant pleural effusion. Method and materials 14 patients with benign pleural effusion and 15 patients with malignant pleural effusion underwent non-contrast spectral CT imaging. These patients were later verified by the combination of disease history, clinical signs and other information with the consensus of surgeons and radiologists. Various Spectral CT image parameters measured for the effusion were as follows: CT numbers of the polychromatic 140kVp images, monochromatic images at 40keV and 100keV, the material density contents from the water, fat and blood-based material decomposition images, the effective atomic number and the spectral curve slope. These values were statistically compared with t test and logistic regression analysis between benign and malignant pleural effusion. Results The CT value of benign and malignant pleural effusion in the polychromatic 140kVp images showed no differences (12.61 +/- 3.39HU vs. 14.71 +/- 5.03HU) (P>0.05), however, they were statistically different on the monochromatic images at 40keV (43.15 +/- 3.79 vs. 39.42 +/- 2.60, p=0.005) and 100keV (9.11 +/- 1.38 vs. 6.52 +/- 2.04, p< 0.001). There was difference in the effective atomic number value between the benign (7.87 +/- 0.08) and malignant pleural effusion (7.90 +/- 0.02) (P=0.02). Using 6.32HU as the threshold for CT value measurement at 100keV, one could obtain sensitivity of 100% and specificity of 66.7% with area-under-curve of 0.843 for differentiating benign from malignant effusion. In addition, age and disease history were potential confounding factors for differentiating malignant pleural effusion from benign, since the older age (61.13 +/- 12.51 year-old vs48.57 +/- 12.33 year-old) as well as longer disease history (70.00 +/- 49.28 day vs. 28.36 +/- 21.64 day) were more easily to be found in the malignant pleural effusion group than those in the benign pleural effusion group. By combining above five factors, one could obtain sensitivity of 100% and specificity of 71.4% with area-under-curve of 0.933 for differentiating benign from malignant effusion. Conclusion The CT value measurement at both high and low energy levels and the effective atomic number obtained in a single spectral CT scan can assist the differential diagnosis of benign from malignant pleural effusion. Combining them with patient age and disease history can further improve diagnostic performance. Clinical relevance/Application Clinical findings and Spectral CT imaging can provide significant evidences about the nature of pleural effusion.