Fat Content Quantification Using Dual-Energy CT for Differentiation of Anterior Mediastinal Lesions from Normal or Hyperplastic Thymus

Background: Detection of fat content in thymic lesions is crucial to differentiate thymic hyperplasia from thymic tumors or other anterior mediastinal pathologies. Purpose: To assess the feasibility of dual-energy CT (DECT) fat content quantification for the differentiation of anterior mediastinal lesions from benign thymic lesions and the normal spectrum of the thymus. Materials and Methods: Chest DECT images of 465 patients (median 61 years, 63% female) were visually evaluated by two radiologists and semiquantitatively scored based on the degree of fatty degeneration ranging from completely fatty (score 0) to predominantly soft-tissue (score 3), and anterior mediastinal mass (score 4). A subset of scans (n =134 including all cases with scores 2-4 and 20 randomly-selected cases from scores 0 and 1) underwent quantitative DECT analysis (fat fraction, iodine density, and conventional CT value). DECT values were compared across the semiquantitative scores. Results: Results of visual evaluation included 35 with predominantly solid thymus (score 3) and 15 with anterior mediastinal mass (score 4). The most common clinical diagnoses of the 15 masses (including 8 with pathologic confirmation) were metastases (n = 10) and lymphoma (n = 4). CT values in the abnormal thymus were significantly higher than those in score 3 (median: 69.7 HU versus 19.9 HU, P <0.001). There was no significant difference in iodine density values (median: 1.7 mg/ml versus 1 mg/ml, P = 0.09). However, the fat fraction value was significantly lower in the abnormal thymus (score 4) than in the predominantly soft-tissue attenuation thymuses (score 3) (median: 12.8% versus 38.7%, P <0.001). ROC curve analysis showed that fat fraction had an AUC of 0.96 (P <0.001), with a cutoff of <39.2% fat fraction yielding 100% sensitivity and 85% specificity. Conclusion: DECT fat fraction measurements of the thymus may provide additional value in distinguishing anterior mediastinal lesions from benign thymus. Use of DECT may reduce the need for subsequent imaging evaluation. (C) 2021 Elsevier Inc. All rights reserved.