Dual-energy computed tomography (DECT) is one of the most promising technological innovations made in the field of imaging in recent years. Thanks to its ability to provide quantitative and reproducible data, and to improve radiologists’ confidence, especially in the less experienced, its applications are increasing in number and variety. In thoracic diseases, DECT is able to provide well-known benefits, although many recent articles have sought to investigate new perspectives. This narrative review aims to provide the reader with an overview of the applications and advantages of DECT in thoracic diseases, focusing on the most recent innovations. The research process was conducted on the databases of Pubmed and Cochrane. The article is organized according to the anatomical district: the review will focus on pleural, lung parenchymal, breast, mediastinal, lymph nodes, vascular and skeletal applications of DECT. In conclusion, considering the new potential applications and the evidence reported in the latest papers, DECT is progressively entering the daily practice of radiologists, and by reading this simple narrative review, every radiologist will know the state of the art of DECT in thoracic diseases.

Objective: The main objective was to assess the geographical distribution and main areas of use of dual-energy CT (DECT) scanners in Italy prior to the implementation of the National Recovery and Resilience Plan (NRRP) within the Next Generation EU (NGEU) framework. Secondary objectives included the level of knowledge of DECT among radiologists and some possible solutions to maximize its use. Methods: Between February and March 2022, an anonymous questionnaire was conducted among the members of the Italian Society of Medical and Interventional Radiology (SIRM), using the Google form platform. Results: A total of 261 radiologists (mean age 41 ± 11.7 years) from 90 Italian cities participated in the questionnaire. 42% of them worked in an academic center, and diagnostic imaging was the main area of work for most participants (87%). Most radiologists had some knowledge gap, especially those who did not have a DECT scanner available in their hospital (48.3%). Weekly use of DECT protocols varied widely between centers. Oncological imaging (70.4%) was the main area of use. Radiologists use DECT to improve contrast resolution (65.9%), characterize materials (64.4%), and reduce the amount of contrast agent (60%). 91.1% of participants reported that DECT improved their diagnostic accuracy. Conclusion: DECT scanners have become increasingly available in Italy in recent years, and their number is expected to increase with the NRRP. There is a wide variation in their use and in the expertise of radiologists, leading to a huge untapped potential, that can be improved by specific training. A similar questionnaire will be conducted at the end of the NRRP in 2027.

Background and Aim: Glioblastoma (GBM) is the most aggressive primary brain tumor in adults, with poor prognosis despite maximal surgical resection, radiotherapy (RT), and temozolomide (TMZ) per the Stupp protocol. IDH-wild-type GBM, the predominant molecular subtype, frequently harbors EGFR amplification and is resistant to therapy, while MGMT promoter methylation predicts improved TMZ response. This study aimed to assess the prognostic impact of EGFR and MGMT status on survival and recurrence patterns in IDH-wild-type GBM. Materials and Methods: We retrospectively analyzed 218 patients with IDH-wild-type GBM treated at the Azienda Ospedaliero-Universitaria Senese (2016–2024). All patients underwent maximal safe surgical resection whenever feasible. The cohort includes patients who received gross total resection (GTR), subtotal resection (STR), or biopsy only, depending on tumor location and clinical condition, followed by intensity-modulated RT (59.4–60 Gy) with concurrent and adjuvant TMZ. EGFR amplification was assessed via FISH/NGS and immunohistochemistry; MGMT promoter methylation was determined using methylation-specific PCR. Progression-free survival (PFS), overall survival (OS), and recurrence patterns (in-field, marginal, out-field) were evaluated using Kaplan–Meier, Cox regression, and logistic regression analyses. Results: Among patients (64.7% male; mean age 61.8), 58.7% had EGFR amplification and 49.1% showed MGMT methylation. Median OS and PFS were 14 and 8 months, respectively. EGFR non-amplified/MGMT methylated tumors had the best outcomes (OS: 22.0 months, PFS: 10.5 months), while EGFR-amplified/MGMT unmethylated tumors fared worst (OS: 10.0 months, PFS: 5.0 months; p < 0.001). MGMT methylation was an independent positive prognostic factor (HR: 0.48, p < 0.001), while EGFR amplification predicted worse survival (HR: 1.57, p = 0.02) and higher marginal recurrence (OR: 2.42, p = 0.01). Conclusions: EGFR amplification and MGMT methylation significantly influence survival and recurrence dynamics in IDH-wild-type GBM. Incorporating these biomarkers into treatment planning may enable tailored therapeutic strategies, potentially improving outcomes in this challenging disease. Prospective studies are needed to validate biomolecularly guided management approaches.

Background: Computed tomography (CT) is widely used to diagnose peritoneal metastases (PM), with debated accuracy. Dual-energy CT (DECT) may improve accuracy, yet its diagnostic performance is still unknown. We explored the potential of DECT for PM detection and quantification. Materials and methods: We retrospectively included patients undergoing staging DECT for cancers with a high risk of peritoneal involvement, followed by staging laparoscopy/laparotomy, which served as the reference standard. Nine readers with varying experience levels (three expert, three intermediate, and three inexpert) reviewed two sets of images, separated by ≥ 60 days, considering the presence/absence of PM, abdominal region(s) involved, and calculated the radiological peritoneal cancer index (PCI). The first set included contrast-enhanced delayed-DECT scans reconstructed as virtual 120-kVp images; the second set also included virtual monoenergetic, 40-keV images and iodine maps. Performance metrics, receiver operating characteristic (ROC) analysis, McNemar, DeLong, and Wilcoxon tests were applied. Results: Twenty patients (mean age 64.2 years; 12 females) were included, 10 with PM. At per-patient analysis, the addition of monoenergetic 40-keV images and iodine maps slightly increased the performance and improved inter-reader agreement, with significant benefit for inexperienced readers only (p = 0.010). Per-region analysis demonstrated a significant advantage with an area under the ROC curve ranging from 0.709 to 0.766 (p < 0.001), confirmed for each reader group; in addition, the inter-reader agreement significantly improved. Quantitative analysis showed a reduction in the differences between CT results and surgical PCI by DECT (4 ± 12 versus 2 ± 9, p < 0.001). Conclusion: DECT-derived reconstructions in the delayed-phase enhanced PM detection and quantification. Relevance statement: Delayed-phase DECT reconstruction showed superior accuracy over conventional CT in detecting and quantifying peritoneal metastases. These findings could help establish a new standard CT protocol for malignancies with peritoneal tropism. Key Points: CT is the most widely used technique for assessing peritoneal metastases. The accuracy of CT for peritoneal metastases is debated; dual-energy CT shows promise. In our study, delayed-phase dual-energy CT provided significant advantages for all readers. Graphical

Background: Clinical target volume (CTV) delineation in glioblastoma remains debated, particularly in the era of modern chemoradiation and image-guided radiotherapy. Whether reduced CTV margins can preserve oncological outcomes without increasing marginal or out-of-field failures remains uncertain. We evaluated the association of the gross tumor volume (GTV)-to-CTV margin with survival, patterns of failure, and its interaction with O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status. Materials and Methods: We retrospectively analyzed a single-center cohort of patients with glioblastoma treated with conventionally fractionated chemoradiation (58–60 Gy in 29–33 fractions). Patients were categorized into two predefined margin groups: <1.5 cm and 1.5 cm. The primary endpoint was overall survival (OS); secondary endpoints included progression-free survival (PFS) and patterns of failure. Survival was assessed using Kaplan–Meier estimates and Cox regression, including an interaction term with MGMT status. Results: Among 102 eligible patients, 95 were included in the margin-based OS analysis. Reduced margins (<1.5 cm; applied range 1.0–1.4 cm) were not associated with worse OS, either overall or within MGMT subgroups. No significant differences were observed in PFS or recurrence patterns, with overlapping distributions and no increase in marginal or out-of-field recurrences. MGMT methylation and gross total resection were independently associated with improved survival, while no statistically significant interaction between margin and MGMT status was detected. Conclusions: In this retrospective exploratory cohort, reduced GTV-to-CTV margins were not associated with a clear signal of worse survival or less favorable recurrence patterns. These findings are consistent with the oncological adequacy of margins around 15 mm and justify cautious prospective evaluation of whether further reduction can be achieved safely, including formal assessment of toxicity, neurocognitive outcomes, and quality of life.