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ORIGINAL RESEARCH
Pulmonary Mycobacterial
Disease: Diagnostic Performance of

n THORACIC IMAGING
Low-Dose Digital Tomosynthesis as
Compared with Chest Radiography1
Eun Young Kim, MD
Purpose: To compare the diagnostic performance of a low-radiation-
Myung Jin Chung, MD
dose digital tomosynthesis (DTS) technique with that of
Ho Yun Lee, MD
conventional radiography in the detection of lung lesions
Won-Jung Koh, MD in patients with pulmonary mycobacterial disease.
Hye Na Jung, MD
Kyung Soo Lee, MD Materials and The institutional review board approved this study, and all
Methods: patients provided informed consent. In this study, 100 pa-
tients (65 study patients, 35 control patients) underwent
multidetector computed tomography (CT), chest radiog-
raphy, and low-dose DTS (effective doses: 3.4, 0.02, and
0.05 mSv, respectively). Two radiologists evaluated radio-
graphs and DTS images for the presence of parenchymal
lesions and the number of cavities in each patient; CT
served as the reference standard. Wilcoxon signed rank
and McNemar tests and k statistics were used.

Results: The accuracies of DTS and radiography in depicting my-

cobacterial disease were 97% and 89%, respectively, for
observer 1 (P = .039) and 99% and 93%, respectively,
for observer 2 (P = .031). The accuracies of DTS and
radiography in depicting each lesion type were, respec-
tively, 95% and 77% for bronchiolitis, 92% and 76%
for nodules, 86% and 79% for consolidation, and 93%
and 70% for cavities. Interobserver agreement with DTS
(k = 0.620.94) was superior to that with radiography
(k = 0.460.62). Of a total of 141 cavities found with CT,
means of 27 (19%) cavities at chest radiography and 108
(77%) cavities at DTS (P , .01) were detected by the two
observers.

Conclusion: DTS performed with a low-dose technique is superior to

radiography for the detection of lung lesions in patients
with pulmonary mycobacterial disease.

q
RSNA, 2010

1
From the Department of Radiology and Center for Imaging
Science (E.Y.K., M.J.C., H.Y.L., H.N.J., K.S.L.) and Division
of Pulmonary and Critical Care Medicine, Department of
Medicine (W.J.K.), Samsung Medical Center, Sungkyunkwan
University School of Medicine, 50 Ilwon-dong, Gangnam-gu,
Seoul 135-710, Korea. From the 2009 RSNA Annual
Meeting. Received February 7, 2010; revision requested
April 12; revision received April 25; accepted May 7; final
version accepted May 19. Address correspondence to
M.J.C. (e-mail: mj1.chung@samsung.com).

q
RSNA, 2010

Radiology: Volume 257: Number 1October 2010 n radiology.rsna.org 269

THORACIC IMAGING: Low-Dose Digital Tomosynthesis of Pulmonary Mycobacterial Disease
D
igital tomosynthesis (DTS) is based
on the principle of collecting low-
radiation-dose radiographic pro-
jections at different angles and using
these projections to reconstruct image
sections for improved detection of subtle
lesions (1). The advantages of DTS, as
compared with conventional radiogra-
phy, include depth localization and im-
proved conspicuity of structures achieved
by removing the visual clutter associated
with the overlying anatomy (13).
Pulmonary mycobacterial disease re-
mains a substantial cause of infection
worldwide and is associated with a high
rate of morbidity and mortality, par-
ticularly in patients with altered host
cellular immunity (4). Early identifica-
tion and treatment of active cases are
essential for tuberculosis control. Acid-
fast bacilli are found in the sputum of a
limited number of patients with active
tuberculosis. Therefore, an imaging-
based diagnosis would facilitate the ap-
propriate therapy for infected patients
before the definitive diagnosis was ren-
dered with bacteriology (5). Pulmonary
mycobacterial disease manifests as var-
ious patterns of radiologic abnormali-
ties, including nodules, consolidation,
cavities, and segmental or lobar volume
loss (69). Patients with cavitary pulmo-
nary tuberculosis have a poor prognosis
owing to the large burden of organisms
Advances in Knowledge
n Chest digital tomosynthesis
(DTS) performed with a low-dose
technique is superior to chest
radiography for the detection of
CT-identified lung lesions in
patients with pulmonary myco-
bacterial disease.
n Interobserver agreement regard-
ing the DTS detection of paren-
chymal lesions is moderate to
very good and superior to that
regarding the radiographic detec-
tion of these lesions.
n The increased sensitivity of low-
dose DTS in the detection of lung
lesions is achieved with a modest
increase in radiation dose com-
pared with the dose used for
chest radiography.
270
and the required long time to sputum
smear conversion (10,11). Thus, the
timely detection of cavities for effective
treatment is mandatory in the setting of
tuberculous pulmonary infection (12).
Despite the fact that computed to-
mography (CT) yields more precise
information regarding the extent and
distribution of pulmonary mycobacterial
disease and can be helpful in the evalu-
ation of disease activity, high doses of
radiation are potentially hazardous to
patients with tuberculosis (8,9). The re-
ported effective dose with DTS is approx-
imately 0.12 mSv (2,13). The radiology
staff at our institution have attempted to
perform low-dose DTS, which involves
a lower effective dose (0.05 mSv for
standard patient), by changing the DTS
parameters and establishing lower dose
conditions for chest imaging. Thus, the
purpose of our study was to compare
the diagnostic performance of a low-
dose DTS technique with that of con-
ventional radiography in the detection
of lung lesions in patients with pulmo-
nary mycobacterial disease.
Materials and Methods
Patients
Our institutional review board approved
this prospective study, and prior to
their participation, all included patients
provided written informed consent to
be examined with DTS. From March to
June of 2009, 65 consecutive patients
aged 1686 years (mean age, 50 years 6
18 [standard deviation])32 male
(mean age, 49 years 6 18) and 33
female (mean age, 51 years 6 18)with
pulmonary tuberculosis (n = 42) or
another nontuberculous mycobacterial
disease (n = 23) who had been regu-
larly followed up with chest CT were
prospectively enrolled in this study. In
Implication for Patient Care
n Low-dose DTS is a safe and accu-
rate alternative to chest radiog-
raphy, providing improved sensi-
tivity for the detection of lung
lesions in patients with pulmo-
nary mycobacterial disease.
radiology.rsna.org
Kim et al
addition, 35 patients aged 2575 years
(mean age, 54 years 6 12)24 men
(mean age, 54 years 6 13) and 11 women
(mean age, 55 years 6 10)who had
undergone DTS only to confirm the
chest CT diagnosis that they were le-
sion free, were enrolled as a control
group. In our department, the standard
protocol for patients referred for chest
CT includes posteroanterior chest radi-
ography (with lateral radiograph omit-
ted to reduce radiation exposure). After
undergoing chest radiography, all pa-
tients subsequently underwent DTS.
Eighty-five of the 100 patients underwent
DTS and chest CT on the same day, and
15 patients underwent DTS within 1 week
from the time of the CT examination.
Pulmonary mycobacterial disease was
diagnosed, on average, 39 days before
chest radiography (range, 21 to 322 days),
DTS (range, 21 to 322 days), and CT
(range, 27 to 322 days).
Radiography
Chest radiographic examinations conducted
by using a cesium iodideamorphous
silicon flat-panel detector digital radi-
ography system (Definium 8000; GE
Healthcare, Chalfont St Giles, England)
included the acquisition of poster-
oanterior views at a tube voltage of
120 kVp with automatic exposure con-
trol at a speed equivalent of 400. The
effective dose for a standard patient
(American male patient; height, 176 cm;
weight, 86 kg) was 0.02 mSv, which was
Published online
10.1148/radiol.10100303
Radiology 2010; 257:269277
Abbreviation:
DTS = digital tomosynthesis
Author contributions:
Guarantor of integrity of entire study, M.J.C.; study
concepts/study design or data acquisition or data analysis/
interpretation, all authors; manuscript drafting or manu-
script revision for important intellectual content, all authors;
manuscript final version approval, all authors; literature
research, E.Y.K., M.J.C., H.N.J., K.S.L.; clinical studies,
E.Y.K., M.J.C., H.Y.L., W.J.K., H.N.J.; experimental studies,
M.J.C., H.N.J.; statistical analysis, E.Y.K., M.J.C., H.Y.L.,
H.N.J.; and manuscript editing, all authors
Authors stated no financial relationship to disclose.
n Radiology: Volume 257: Number 1October 2010
THORACIC IMAGING: Low-Dose Digital Tomosynthesis of Pulmonary Mycobacterial Disease Kim et al

determined by using an anthropomorphic Figure 1

chest phantom (Alderson Lung/Chest
Phantom RS-320; Radiology Support
Devices, Long Beach, Calif) and Monte
Carlo software (PCXMC, version 1.5;
STUK, Helsinki, Finland).

DTS
DTS examinations were performed by
using a commercially available unit
(Volume RAD; GE Healthcare) with
the cesium iodideamorphous silicon
flat-panel detector system. We altered
the DTS parameters and established a
lower radiation dose condition for chest
imaging. Sixty low-dose projection im-
ages were acquired within 10 seconds
by using a tube voltage of 100 kVp, a
1:5 dose ratio, and a 0.3-mm additional
copper filter. The detector was fixed in
position, whereas the x-ray tube was
subjected to vertical continuous move-
ment, from 217.5 to +17.5, around
the standard orthogonal posteroante-
rior position. Image data were finally
acquired at 215 to +15. A total of
60 projection images were obtained
from one examination and were used
to reconstruct approximately 54 coro-
nal images with a nominal thickness
of 4 mm without overlap. The entrance
surface dose for this protocol, includ-
ing acquisition of the posteroante-
rior radiograph as the reference image,
was 0.3 mGy. The effective dose was
0.05 mSv for a standard patient, which
was determined by using the assump-
tion that the entire exposure was ren-
dered in the zero angle projectionthat
is, the projection where the direction
of the radiation is perpendicular to the Figure 1: Images in 64-year-old woman with nontuberculous mycobacterial pulmonary disease
detector plane (14). (Mycobacterium avium infection). (a) Posteroanterior radiograph shows no abnormal finding in right
upper lung zone. (b) DTS image shows clustered nodules with branching linear structuresthe
Multidetector CT
so-called tree-in-bud sign (arrow)in right upper lung zone. (c) Coronal and (d) axial CT image
In all patients, helical CT scans were ob- (lung window) findings confirm presence of bronchiolitis (arrows) in anterior segment of right
tained through the entire thorax at end upper lobe.
inspiration by using 64-section equip-
ment (LightSpeed VCT; GE Health- struction algorithm (bone preset), and pomorphic phantom and a dose-length
care). The scanning parameters were 3438-cm field of view. Coronal images product to effective dose conversion fac-
as follows: individual detector width, were reconstructed at 4-mm intervals. tor of 0.017 mSv/(mGy cm) (15).
0.625 mm; gantry rotation time, 400 msec; The coronal reconstructed images fully
tube voltage, 120 kVp; tube current, covered the area from the front surface Detection Study
110150 mAs; and pitch, 0.97. Axial to the back of the chest. The effec- Two subspecialty-trained chest radiolo-
images were reconstructed by using the tive dose for chest CT, 3.4 mSv, was gists (H.Y.L., E.Y.K.), who had 10 and
following parameters: 2.5-mm section based on data from a standard patient 3 years of chest CT scan reading expe-
thickness, high-spatial-frequency recon- model involving the use of the anthro- rience, respectively, and approximately

Radiology: Volume 257: Number 1October 2010 n radiology.rsna.org 271

THORACIC IMAGING: Low-Dose Digital Tomosynthesis of Pulmonary Mycobacterial Disease
Figure 2
2 years and 6 months of clinical expe-
rience with DTS, respectively, worked
independently and analyzed the image
data separately. For each patient, they
were instructed to mark and record the
presence of each finding of pulmonary
mycobacterial disease on the radio-
graphs and DTS images in a blinded
manner. For each observer, the cases
were divided into two groupscases
one to 50 and cases 51100and
the radiographs in the first group of
50 cases and the DTS images in the
latter 50 cases were grouped and re-
ordered randomly. Randomization was
achieved by using a standard random
number generator for determination
of a random reading order. These im-
ages were read during the first session.
During the second session, the chest
radiographs in the latter group (cases
272
Figure 2: Images in 39-year-old man with pul-
monary tuberculosis. (a) Posteroanterior radiograph
shows consolidation in left upper lung field. At
prospective image analysis, two observers detected
no cavity. (b) DTS image shows cavity (arrow) in
left upper lung zone. (c) Coronal CT image (lung
window) findings confirm presence of cavity (arrow)
in left upper lobe.
51 to 100) and the DTS images in the
former group were read. The interval
between the two sessions was 2 weeks.
Because of the large difference in ap-
pearance between the DTS images and
the radiographs, this protocol was con-
sidered to be sufficient to avoid recall
bias. The observers were allowed to
change the window width and window
level and to use function keys to pan
and zoom.
Diverse findings of pulmonary my-
cobacterial disease were subdivided into
five patterns: bronchiolitis, nodules, con-
solidation, cavities, and volume loss. Ac-
cording to the glossary of terms from the
Fleischner Society (16), the findings were
interpreted as follows: Bronchiolitis or
tree in bud was a cluster of micronod-
ules with or without branching linear
structures (Fig 1). A nodule was a round
or oval opacity less than 30 mm in diam-
eter. Consolidation was a homogeneous
increase in opacity in the pulmonary pa-
renchyma that obscured the margins of
vessels and airway walls. A cavity was
a lucent area within an area of pulmo-
nary consolidation, a mass, or a nodule
radiology.rsna.org
Kim et al
(Figs 2, 3). Volume loss was indicated
by a dilated bronchus with or without at-
electasis, or vice versa. Each cavity in a
patient was to be marked on radiographs
and on only one of the 54 DTS images.
We also recorded the total number of
cavities. After the analysis of each pat-
tern of lung disease, mycobacterial dis-
ease was considered to be present when
there was a lesion (or lesions) of consoli-
dation, a cavity (or cavities), a nodule (or
nodules), or a tree-in-bud sign.
Reference Standard
Multidetector CT served as the refer-
ence-standard method for the analysis.
After the two observers completed the
detection study, the records from the
DTS image and radiograph readings
were matched and compared with those
from the multidetector CT scan readings
(both coronal and axial CT images). For
comparison, we referred to the CT scan
reading records that an experienced
chest radiologist (K.S.L., 20 years CT
reading experience) had completed with
consideration of the five patterns of lung
abnormality used in the radiograph and
DTS image readings immediately after
the CT examinations. In addition, the
diagnostic performances of DTS and
radiography were compared in terms
of cavity detection rates on both a per-
patient basis and a per-lesion basis. All
images were assessed by using a picture
archiving and communication system
(Centricity RA 1000; GE Healthcare).
Statistical Analysis
Before the start of the study, the sam-
ple size was determined on the basis
of the results of previous studies in
which chest DTS and chest radiog-
raphy were compared (2,13,14). Ac-
cording to these reports, the average
detectabilities (p) of chest tomosyn-
thesis (p1) and chest radiography (p2)
were 0.64 and 0.40, respectively. The
necessary sample size (N) was calculated
by using the following equation (17):
N = 2 Z crit 2p (1  p ) + Z pwr
2
p1 (1  p1 ) + p2 (1  p2 ) D2 ,
n Radiology: Volume 257: Number 1October 2010
THORACIC IMAGING: Low-Dose Digital Tomosynthesis of Pulmonary Mycobacterial Disease
Figure 3
with a significance level of 10% (ie,
Za = 1.282) and a statistical power of
90% (ie, Zb = 1.960), and where Zcrit
is a Z value with a specific P value as
a significance criterion (P = .05 in this
study), Zpwr is a Z value with specific
statistical power (power of 0.90 in this
study), p is the average of p1 and p2,
Radiology: Volume 257: Number 1October 2010
D is the difference between p1 and p2
(p1 2 p2), and p = (p1 + p2)/2. Under
these conditions, power analysis results
indicated a minimal sample size of 97
patients who underwent chest DTS and
chest radiography in each paired group.
The diagnostic performances of DTS
and radiography, including their sensi-
n radiology.rsna.org
Kim et al
Figure 3: Images in 48-year-old woman with
pulmonary tuberculosis. (a) Posteroanterior radio-
graph shows suspicious thin-walled cavitary lesion
(arrow) in right upper lung zone. At prospective
image analysis, two observers detected one cavity
in right upper lung zone. (b) DTS image reveals true
cavity (white arrow) in right upper lung zone and
shows another thick-walled cavity (black arrow) in
right lower lung zone. (c, d) Findings on coronal
CT images (lung window) confirm presence of two
cavities (arrow)in posterior segment of right upper
lobe (c) and superior segment of right lower lobe (d).
tivity, specificity, and accuracy for the
detection of mycobacterial disease and
each pattern of lung abnormality, were
calculated on a per-patient basis and
compared with the diagnostic perfor-
mance of CT, the reference standard
(18). In addition, DTS and radiogra-
phy were compared with each other, in
terms of these performance values, by
using the McNemar test. The numbers
of cavities detected with DTS and chest
radiography, with CT as the standard
reference, were compared by using the
Wilcoxon signed rank test.
Interobserver agreement between
the two observers was analyzed by us-
ing Cohen k statistics (19). P , .05 was
considered to indicate statistical signifi-
cance. The data were processed and an-
alyzed by using a commercially available
software program (SPSS, version 17.0;
SPSS, Chicago, Ill).
Results
DTS and Radiographic Detection of Each
Finding of Pulmonary Mycobacterial
Disease
The overall accuracies of DTS and ra-
diography in the detection of myco-
bacterial disease were 97% and 89%,
respectively, for observer 1 (P = .039,
McNemar test) and 99% and 93%, re-
spectively, for observer 2 (P = .031, Mc-
Nemar test). The accuracy of DTS for
the detection of mycobacterial disease
was significantly higher than that of ra-
diography (Table 1).
When we evaluated the total of
100 patients for the presence of each
273
THORACIC IMAGING: Low-Dose Digital Tomosynthesis of Pulmonary Mycobacterial Disease Kim et al

parenchymal lung lesion pattern, lobar lesion detection were significantly higher were, respectively, 94% and 81% for
volume loss was observed in 61 patients; than those of radiography (Table 2). For bronchiolitis, 91% and 72% for nod-
bronchiolitis, in 56; consolidation, in observer 1, accuracy values for the DTS ules, 87% and 85% for consolidation,
52; nodules, in 49; and cavities, in 37. and radiographic detection of diverse 90% and 68% for cavities, and 95%
Two patterns were observed in six pa- parenchymal lesions were, respectively, and 88% for volume loss (Table 2). All
tients; three, in 14 patients; four, in 95% and 72% for bronchiolitis, 92% P values, except that for the comparison
25 patients; and five, in 20 patients. One and 79% for nodules, 84% and 73% for of DTS versus radiographic detection of
control patient had an incidental posi- consolidation, 96% and 72% for cavities, consolidation (P = .754, McNemar test)
tive finding of volume loss. Overall, the and 98% and 78% for volume loss. For by observer 2, were lower than .05.
sensitivity and accuracy of DTS for lung observer 2, corresponding accuracies Interobserver agreement regard-
ing DTS findings was good to very
Table 1 good (k = 0.620.94) and superior to
that regarding radiographic findings (k =
Diagnostic Performance of DTS versus Radiography for Mycobacterial Disease
0.460.62). In terms of the diverse
Detection
findings of lung parenchymal lesions
Sensitivity Specificity Accuracy at DTS, agreement was very good for
No. of True-Positive No. of True-Negative No. of Correct the detection of bronchiolitis (k = 0.90)
Examination Findings (n = 65) P Value Findings (n = 35) P Value Results (n = 100) P Value and volume loss (k = 0.94) and good
for the detection of nodules (k = 0.74),
Observer 1 .008 ..99 .039 consolidation (k = 0.62), and cavities
DTS 64 (98) 33 (94) 97 (97)
(k = 0.79) (Table 3). With radiogra-
Radiography 56 (86) 33 (94) 89 (89)
phy, agreement was moderate to good
Observer 2 .125 .500 .031
for detection of the diverse findings of
DTS 64 (98) 35 (100) 99 (99)
pulmonary lesions, with k values of 0.62
Radiography 60 (92) 33 (94) 93 (93)
for bronchiolitis, 0.46 for nodules, 0.53
Note.Numbers in parentheses are percentages. for consolidation, 0.58 for cavities, and
0.61 for volume loss (Table 3).

Table 2
Diagnostic Performance of DTS versus Radiography for Parenchymal Lesion Detection
Observer 1 Observer 2
Lesion Type Sensitivity Specificity Accuracy Sensitivity Specificity Accuracy
Bronchiolitis
DTS 96 (54/56) 93 (41/44) 95 (95/100) 96 (54/56) 91 (40/44) 94 (94/100)
Radiography 59 (33/56) 89 (39/44) 72 (72/100) 79 (44/56) 84 (37/44) 81 (81/100)
P value .000 .687 .000 .002 .453 .002
Nodule
DTS 92 (45/49) 92 (47/51) 92 (92/100) 71 (42/59) 96 (49/51) 91 (91/100)
Radiography 63 (31/49) 94 (48/51) 79 (79/100) 49 (24/49) 94 (48/51) 72 (72/100)
P value .000 ..99 .004 .000 ..99 .001
Consolidation
DTS 73 (38/52) 96 (46/48) 84 (84/100) 86 (45/52) 88 (42/48) 87 (87/100)
Radiography 54 (28/52) 94 (45/48) 73 (73/100) 86 (45/52) 83 (40/48) 85 (85/100)
P value .021 ..99 .027 ..99 .625 .754
Cavity
DTS 95 (35/37) 97 (61/63) 96 (96/100) 92 (34/37) 89 (56/63) 90 (90/100)
Radiography 38 (14/37) 92 (58/63) 72 (72/100) 49 (18/37) 79 (50/63) 68 (68/100)
P value .000 .453 .000 .000 .031 .000
Volume loss
DTS 100 (61/61) 95 (37/39) 98 (98/100) 97 (59/61) 92 (36/39) 95 (95/100)
Radiography 67 (41/61) 95 (37/39) 78 (78/100) 87 (53/61) 90 (35/39) 88 (88/100)
P value .000 ..99 .000 .070 ..99 .039

Note.All except P values are percentages, with numbers used to calculate percentages in parentheses.

274 radiology.rsna.org n Radiology: Volume 257: Number 1October 2010

THORACIC IMAGING: Low-Dose Digital Tomosynthesis of Pulmonary Mycobacterial Disease Kim et al

DTS and Radiographic Determination
of Number of Cavities
A total of 141 cavities were found in 37
patients at multidetector CT: 76 cavities
were in the right lung, and 65 cavities
were in the left lung. The longest diam-
eters of the cavities ranged from 10 to 69
mm, and the average diameter was 24
mm. The two observers detected a mean
of 27 (19%) cavities with chest radiogra-
phy and a mean of 108 (77%) cavities with
DTS (P , .01, Wilcoxon signed rank test).
With radiography, observer 1 detected 20
true cavities in 14 patients and five false
cavities in five patients (38% sensitivity,
92% specificity on a per-patient basis)
and observer 2 detected 34 true cavities
in 18 patients and 18 false cavities in 15
patients (49% sensitivity and 79% speci-
ficity on a per-patient basis) (Table 4).
However, DTS helped observer 1 to iden-
tify 104 cavities in 35 patients (95% sen-
sitivity on per-patient basis) and helped
observer 2 to identify 112 cavities in 34
patients (92% sensitivity on per-patient
basis) (Table 4) (Figs 2, 3). With DTS,
observer 1 detected two false cavities
in two patients (97% specificity on per-
patient basis) and observer 2 detected 11
false cavities in 10 patients (89% speci-
ficity on per-patient basis). The false-
positive radiograph and DTS image read-
ings were mainly due to the misinter-
pretation of volume loss (Fig 4), localized
emphysema, consolidation, or nodules
as cavities.
treatment response, the risk of cumula- for both DTS and radiography) for this
tive radiation exposure from repeated observers detection of this finding.
CT examinations should be considered. To our knowledge, our radiology
The recently developed technique, DTS, staff first attempted to perform a low-
is an interesting alternative, with a low dose DTS technique, which involved
radiation dose (compared with chest CT) less than half the effective dose of
and improved detection (compared with conventional DTS, by altering the DTS
radiography) (2,13,14). The reported parameters. With the low-dose DTS
effective dose for DTS is approximately technique used in this study, 60 pro-
0.12 mSv, which is approximately 10 times jection images were collected, with a
higher than that used for a radiographic radiation dose that corresponded to an
examination (0.010.02 mSv); however,
it is approximately 30 times lower than Table 3
that used for a chest CT examination
(38 mSv) (2,13). With DTS, by collect- Interobserver Agreement on DTS and
Radiographic Parenchymal Lesion
ing a number of projection images at dif-
Detection
ferent angles by using a digital detector,
one can produce an unlimited number Lesion Type k Value
of section images at arbitrary depths
Bronchiolitis
by using a suitable reconstruction algo- DTS 0.90
rithm (1). With better depth resolution Radiography 0.62
and much less overlap of anatomic fea- Nodule
tures, as compared with these factors at DTS 0.74
radiography, the use of DTS might re- Radiography 0.46
sult in increased detection of pulmonary Consolidation
lesions. DTS 0.62
Our study showed the overall supe- Radiography 0.53
rior sensitivity of a low-radiation-dose Cavity
DTS technique, as compared with chest DTS 0.79
radiography, in the detection of pulmo- Radiography 0.58
nary mycobacterial disease findings. Volume loss
Although the consolidation detection DTS 0.94
rate of observer 2 with DTS was not Radiography 0.61
significantly higher than that with chest Note.P , .05 for all comparisons.
radiography, the sensitivities of both
DTS and radiography were high (86%

Table 4
Discussion
Cavity Detection Rates with DTS and Radiography
Although chest radiography is the first
choice for diagnosis and follow-up for pa- DTS Findings Radiographic Findings
tients with pulmonary tuberculosis, low Statistical Analysis Type Sensitivity Specificity PPV Sensitivity Specificity PPV
sensitivity and low specificity are major
Patient based
limitations (20). The problems related
No. of patients with
to the limited sensitivity and specificity
cavity at CT
of radiography are alleviated with use of
(n = 37)
CT. With the development of multidetec-
Observer 1 35/37 (95) 61/63 (97) 35/37 (95) 14/37 (38) 58/63 (92) 14/19 (74)
tor CT, chest CT scanning now offers the Observer 2 34/37 (92) 56/63 (89) 34/41 (83) 18/37 (49) 50/63 (79) 18/31 (58)
advantages of a short acquisition time Lesion based
and improved spatial resolution. How- No. of cavities
ever, with increasing use of CT, higher depicted at CT
doses of radiation and higher costs be- (n = 141)
come problematic. Because patients with Observer 1 104/141 (74) NA 104/106 (98) 20/141 (14) NA 20/25 (80)
pulmonary tuberculosis are relatively Observer 2 112/141 (79) NA 112/123 (91) 34/141 (24) NA 34/52 (65)
young (21) and require frequent follow-up
Note. Numbers in parentheses are percentages. NA = not applicable, PPV = positive predictive value.
for monitoring of disease activity and

Radiology: Volume 257: Number 1October 2010 n radiology.rsna.org 275

THORACIC IMAGING: Low-Dose Digital Tomosynthesis of Pulmonary Mycobacterial Disease Kim et al

effective dose for a standard patient of
approximately 0.83 mSv. Thus, the re-
sulting total effective dose was 0.05 mSv.
This is approximately 2.5 times higher
than the total effective dose for pos-
teroanterior radiography but approx-
imately 70 times lower than that for
multidetector CT, which has a rela-
tively high effective dose of 3.4 mSv.
Furthermore, this dose is lower than
that delivered with two-view radiogra-
phy (0.06 mSv for standard patient),
including posteroanterior- and lateral-
projection acquisitions (22). With this
low radiation dose, DTS had superior
sensitivity compared with radiography
in our study.
There were several limitations to
the present study. First, our evaluation
of disease activity did not include the
analysis of clinical data, including those
from sputum smears and cultures, and
we did not evaluate patient symptoms.
However, the primary objective of this
study was to compare the diagnostic
performances of DTS and radiography
in the detection of diverse pulmonary
mycobacterial disease findings, with
chest CT as the reference standard.
The study was not designed for evalu-
ation of the diagnostic performance of
DTS in the prediction of disease activ-
ity itself. Second, we did not include
lateral chest radiographs in the image
analyses; the inclusion of these images
might have enhanced radiographic sen-
sitivity for lesion detection. However,
in our department, we usually recom-
mend only posteroanterior chest radi-
ography for patients in whom chest CT
is scheduled for further evaluation of
chest disease. Thus, this clinical prac-
tice pattern may have reflected our
routine daily work. In addition, inves-
tigators in a previous study suggested
that one posteroanterior radiograph is
sufficient for tuberculosis screening of
individuals with positive purified pro-
tein derivative skin test results (23).
Third, the cost of DTS should be elabo-
rated. The costs of low-dose CT, DTS,
and chest radiographic examinations
are approximately $200, $30, and $10,
respectively, in our country. Therefore,
DTS is three times more expensive than
chest radiography but still much cheaper
than CT. Thus, DTS may be suitable for
follow-up examinations.
In conclusion, the use of a low-dose
DTS technique is superior to the use of
radiography for the detection of lung
lesions, especially cavitary lesions, in
patients with pulmonary mycobacte-
rial disease. Early detection may lead
to an appropriate therapy before the
definitive diagnosis is rendered with
bacteriology, and the detection of a
cavity may facilitate prediction of the
patients prognosis. Moreover, interob-
server agreement regarding DTS find-
ings is moderate to very good and su-
perior to that regarding radiographic
findings.
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Figure 4

Figure 4: Images in 73-year-old woman with treated pulmonary tuberculosis. (a) Posteroanterior radiograph shows thin-walled cystic lesion (arrow), which was
interpreted as a cavity by two observers. (b) DTS image shows thin-walled cystic lesion (arrow), which also was interpreted as a cavity by two observers. (c) Findings
on coronal CT image (lung window) confirm presence of localized bronchiectasis (arrow) in lingular segment of left upper lobe.

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