Quantitative multi-energy CT in oncology: State of the art and future directions

Multi-energy computed tomography (CT) involves acquisition of two or more CT measurements with distinct energy spectra. Using the differential attenuation of tissues and materials at different X-ray energies, multi-energy CT allows distinction of tissues and materials. Multi-energy technology encompasses different types of CT systems, such as dual-energy CT and photon-counting CT, that can use information from the energy and type of material present in acquired images to create multiple datasets. These scanners have overcome many of the limitations of conventional CT, making it possible to improve the diagnostic performance of CT and expand its use to new applications through better tissue characterization and multiple quantitative parameters. Quantitative imaging biomarkers based on multi-energy CT have enormous potential in oncologic imaging, from the diagnosis and characterization of tumor phenotypes to the evaluation of the response to treatment. Nevertheless, implementing these techniques in clinical practice remains challenging. This article reviews the basic principles underlying multi-energy CT and the most recent technical developments in these systems together with their advantages and limitations to establish the value of quantitative imaging derived from multi-energy CT in the field of oncology.