Dual-layer spectral CT for advanced tissue characterization: differentiating bladder neoplasm from intraluminal thrombus-A case report

: Background and Clinical Significance: Bladder neoplasms often present with coexisting thrombi and hematuria, appearing as complex intraluminal masses on imaging, and posing a key diagnostic challenge in distinguishing neoplastic tissue from thrombus, to prevent harmful overstaging. Case Presentation: An 82-year-old man with recurrent gross hematuria and urinary disturbances was evaluated by ultrasound, which identified a large endoluminal lesion in the anterior bladder wall. The patient subsequently underwent contrast-enhanced CT using a second-generation dual-layer spectral CT system, which utilizes a dual-layer detector to simultaneously acquire high- and low-energy X-ray data. Conventional CT images confirmed a multifocal, bulky hyperdense lesion along the bladder wall, protruding into the lumen and raising suspicion for a heterogeneous mass, though further characterization was not possible. Spectral imaging enabled the reconstruction of additional maps-such as iodine density, effective atomic number (Z-effective), and electron density-which were used to further characterize these findings. The combination of these techniques clearly demonstrated differences in iodine uptake and tissue composition within the parietal lesions, allowing for a reliable differentiation between neoplastic tissue and intraluminal thrombus. Conclusions: The integration of conventional CT imaging with spectral-derived maps generated in post-processing allowed for accurate and reliable tissue differentiation between bladder neoplasm and thrombus. Spectral imaging holds the potential to prevent tumor overstaging, thereby supporting more appropriate clinical management. The dual-layer technology enables the generation of these maps from every acquisition without altering the scan protocol, thereby having minimal impact on the daily clinical workflow.