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AJR Am J Roentgenol. 2011 Nov;197(5):1096-100. doi: 10.2214/AJR.11.6625.

Gray-scale reversal for the detection of pulmonary nodules on a PACS workstation.

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Department of Radiology, Academic Medical Centre, Amsterdam, The Netherlands.



The purpose of this article is to evaluate the impact of gray-scale reversal on the detection of small pulmonary nodules in two-view chest radiography.


One hundred twenty-eight patients (mean age, 62 years) who underwent CT and chest radiography within 6 weeks were retrospectively selected for this study. Seventy-three percent of patients showed variable degrees of radiographic findings of a "dirty lung." A total of 129 solid pulmonary nodules were present in 74 patients (nodule diameter range, 5-30 mm; mean diameter, 13 mm). The remaining 54 patients served as negative control subjects. Six readers with varying experience levels evaluated the images without and with the availability of gray-scale reversal in two separate reading sessions. Figure of merit (FOM), sensitivity per lesion, mean number of false-positive marks per image, and accuracy were calculated.


Five of the six readers showed a slight increase in sensitivity with the use of gray-scale reversal, but on average, the difference was not significant (48% vs 50%; p > 0.05). The mean number of false-positive marks per image also nonsignificantly increased from 0.20 to 0.23. The increases in both sensitivity and the mean number of false-positive marks per image translated into nonsignificant decreases in average FOM (0.79 vs 0.77) and accuracy (72% vs 71%). Data analysis of subgroups of nodules or different reader groups, depending on level of experience, did not reveal significant differences.


Using PACS display of digital chest radiographs, gray-scale reversal does not help the radiologists in detecting pulmonary nodules.

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