To assess the effect of bone suppression imaging on observer performance in detecting lung nodules in chest radiographs.Posteroanterior (PA) and lateral digital chest radiographs of 111 (average age 65) patients with a CT proven solitary nodule (median diameter 15mm), and 189 (average age 63) controls were read by 5 radiologists and 3 residents. Conspicuity of nodules on the radiographs was classified in obvious (n=32), moderate (n=32), subtle (n=29) and very subtle (n=18). Observers read the PA and lateral chest radiographs without and with an additional PA bone suppressed image (BSI) (ClearRead Bone Suppression 2.4, Riverain Technologies, Ohio) within one reading session. Multi reader multi case (MRMC) receiver operating characteristics (ROC) were used for statistical analysis.ROC analysis showed improved detection with use of BSI compared to chest radiographs alone (AUC=0.883 versus 0.855; p=0.004). Performance also increased at high specificities exceeding 80% (pAUC=0.136 versus 0.124; p=0.0007). Operating at a specificity of 90 sensitivity increased with BSI from 66% to 71% (p=0.0004). Increase of detection performance was highest for nodules with moderate and subtle conspicuity (p=0.02; p=0.03).Bone suppressed images improve radiologists' detection performance for pulmonary nodules, especially for those of moderate and subtle conspicuity.
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