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Objectives To demonstrate the feasibility of an automated, non-invasive approach to estimate bone marrow (BM) infiltration of multiple myeloma (MM) by dual-energy computed tomography (DECT) after virtual non-calcium (VNCa) post-processing. Methods Individuals with MM and monoclonal gammopathy of unknown significance (MGUS) with concurrent DECT and BM biopsy between May 2018 and July 2020 were included in this retrospective observational study. Two pathologists and three radiologists reported BM infiltration and presence of osteolytic bone lesions, respectively. Bone mineral density (BMD) was quantified CT-based by a CE-certified software. Automated spine segmentation was implemented by a pre-trained convolutional neural network. The non-fatty portion of BM was defined as voxels &gt; 0 HU in VNCa. For statistical assessment, multivariate regression and receiver operating characteristic (ROC) were conducted. Results Thirty-five patients (mean age 65 ± 12 years; 18 female) were evaluated. The non-fatty portion of BM significantly predicted BM infiltration after adjusting for the covariable BMD ( p  = 0.007,  r  = 0.46). A non-fatty portion of BM &gt; 0.93% could anticipate osteolytic lesions and the clinical diagnosis of MM with an area under the ROC curve of 0.70 [0.49–0.90] and 0.71 [0.54–0.89], respectively. Our approach identified MM-patients without osteolytic lesions on conventional CT with a sensitivity and specificity of 0.63 and 0.71, respectively. Conclusions Automated, AI-supported attenuation assessment of the spine in DECT VNCa is feasible to predict BM infiltration in MM. Further, the proposed method might allow for pre-selecting patients with higher pre-test probability of osteolytic bone lesions and support the clinical diagnosis of MM without pathognomonic lesions on conventional CT. Key Points •  The retrospective study provides an automated approach for quantification of the non-fatty portion of bone marrow, based on AI-supported spine segmentation and virtual non-calcium dual-energy CT data.  •  An increasing non-fatty portion of bone marrow is associated with a higher infiltration determined by invasive biopsy after adjusting for bone mineral density as a control variable (p  =  0.007, r  =  0.46).  •  The non-fatty portion of bone marrow might support the clinical diagnosis of multiple myeloma when conventional CT images are negative (sensitivity 0.63, specificity 0.71).

european radiology

Feasibility of artificial intelligence–supported assessment of bone marrow infiltration using dual-energy computed tomography in patients with evidence of monoclonal protein — a retrospective observational study