Gastrointestinal - Learning Modules - CTisus.com CT Scanning

The Potential Role of Cinematic Rendering of the the Stomach in Lesion Detection and Classification: Early Observations in Clinical Practice

Linda C Chu, MD
Johns Hopkins Hospital
Department of Radiology

CT Imaging of the Stomach

Oral Contrast (750-1000 cc of water 15-20 minutes prior to the study with last 250 cc as the patient is placed in the scanner
IV Contrast (100-110 cc of Omnipaue-350 injected at 5 cc/sec)
Dual Phase Acquisition
- Arterial (30-35 sec) and Venous (60-70 sec)
Data Reconstruction is .75 mm thick sections reconstructed at .5 mm intervals

CT Imaging of the Stomach

Visualization Techniques used for Evaluation of the Stomach
- Axial, coronal and sagittal
- MIP techniques especially useful for suspected GI bleed or varices
- Classic VRT (volume rendering) for definition of soft tissue interfaces and vascular mapping
- Cinematic Rendering

“Evaluation of stomach neoplasms by traditional 3-dimensional (3D) computed tomography methods such as volume rendering and maximum-intensity projection plays an important role in lesion detection and characterization, preoperative planning, staging, and follow-up. Recently, a new 3D visualization method has become available known as cinematic rendering (CR). This novel technique makes use of a complex global lighting model to impart photorealistic levels of detail to 3D images. Although this new technique has yet to be systematically studied for the evaluation of stomach neoplasms, its intrinsic ability to create realistic shadowing effects to enhance understanding of the 3D relative locations of anatomic structures and to enhance detail and texture may prove valuable for a variety of applications.”
Evaluation of Stomach Neoplasms With 3-Dimensional Computed Tomography: Focus on the Potential Role of Cinematic Rendering
Steven P. Rowe, Linda C. Chu, Elliot K. Fishman
J Comput Assist Tomogr 2018;42: 661–666

“Recently, a novel method of 3D CT volumetric data visualization became available. This method, known as cinematic rendering (CR), makes use of standard acquisition CT volumetric data composed of isotropic voxels and is fundamentally similar to VR. However, whereas VR uses a ray casting lighting model to create 3D images from acquired volumes, CR instead makes use of a complex global lighting model that takes into account a number of potential interactions of photons with the material in the imaged volume; this leads to enhanced surface detail and a photorealistic quality to the images.”
Evaluation of Stomach Neoplasms With 3-Dimensional Computed Tomography: Focus on the Potential Role of Cinematic Rendering
Steven P. Rowe, Linda C. Chu, Elliot K. Fishman
J Comput Assist Tomogr 2018;42: 661–666

"Computed tomography is the imaging method of choice for evaluating stomach neoplasms, and traditional 3D methodologies have previously been shown to have value in lesion detection, staging, and follow-up for treatment response. With the addition of enhanced surface detail intrinsic to CR, the role of 3D CT visualizations in stomach neoplasm imaging may be expanded. Prospective trials with pathologic correlation that evaluate the ability of CR to enhance detection of subtle mucosal irregularities, study whether CR provides better lesion characterization through highlighting intratumoral texture, and lead to improved preoperative planning would be of value."
Evaluation of Stomach Neoplasms With 3-Dimensional Computed Tomography: Focus on the Potential Role of Cinematic Rendering
Steven P. Rowe, Linda C. Chu, Elliot K. Fishman
J Comput Assist Tomogr 2018;42: 661–666

Cinematic Rendering: What does it add to a classic CT exam?

Better 3D lighting model due to the ability to use a more advanced lighting model technique
Use of advanced lighting models helps accentuate subtle changes in the gastric fold pattern
Enhancement changes of the gastric fold pattern as well as gastric masses can be better defined

Clinical Applications and Case Illustrations

Gastric Adenocarcinoma
Other Gastric Cancers (GIST, Carcinoid Tumor, Metastases to the Stomach)
Inflammatory Disease (gastritis)
Gastric Varices (may be related to cirrhosis)
Congenital Disease (duplication cyst)

Gastric Adenocarcinoma With Infiltration of the Gastric Antrum

Infiltrating Gastric Adenocarcinoma

Metastatic Breast Cancer to the Stomach with Linitis Plastica

Carcinoid Tumor Gastric Antrum is Hypervascular and Shown Well on Axial, VRT and MIP Images

Cinematic Rendering of a Hypervascular Carcinoid Tumor in the Gastric Antrum

1 cm Gastric GIST Tumor in Patient with Neurofibromatosis

Gastric GIST Tumor Simulates a Mass Arising off the Tail of the Pancreas

Multiple Gastric Carcinoid Tumors in Patient with MEN 1 Syndrome

The CR nicely defines the enhancing Multiple Gastric Carcinoid Tumors

Renal Cell Carcinoma Metastatic to the Stomach Presenting with GI Bleed

Axial and Coronal CT Scans Define a lobulated Mass in the Body of the Stomach

Cinematic Rendering Defines the Lobulated Ulcerating Masses and Defines Their Extent and Infiltration

Chemical Gastritis from NSAIDs Simulates a Gastric Adenocarcinoma

Thickened Mass-like Antral Folds in a Patient with Cirrhosis and Portal Hypertension Simulates a Gastric Tumor

Biopsy Proven Inflamed Edematous Antral Folds due to Hepatic Gastropathy

The Potential Role of Cinematic Rendering of the the Stomach in Lesion Detection and Classification: Early Observations in Clinical Practice

Gastric Duplication Cyst Presents as on Intraluminal Cystic Mass Defined with Axial. Coronal and VRT Displays

Different Lighting and Shadowing help Define the Intraluminal Nature of the Gastric Duplication Cyst

Interactive Display for Visualization of the Gastric Duplication Cyst Can Be Valuable to the Referring Clinician for Pre-Operative Planning

Potential Limitations of Cinematic Rendering in Practice

There is an infinite number of potential rendering parameters and the “correct” one is necessary for optimal detection of pathology
The quality of the cinematic rendering is dependent on the data acquisition and study parameters
Although it takes under 5 minutes to do a study in many practices 3D is under-reimbursed or not-reimbursed

Conclusion

Cinematic Rendering provides unique information across a range of gastric pathologies and may help will the differential diagnosis
Cinematic Rendering may help with pre-operative planning by increasing accuracy of staging
Cinematic Rendering is a potential example of Radiology’s push to value over volume so may become more frequently used in the future

Acknowledgements

Elliot K. Fishman, MD
Steven P Rowe, MD, PhD
Linda C Chu, MD