Photon-Counting CT Effects on Sensitivity for Liver Lesion Detection: A Reader Study Using Virtual Imaging

Background Detection of hepatic metastases at CT is a daily task in radiology departments that influences medical and surgical treatment strategies for oncology patients. Purpose To compare simulated photon-counting CT (PCCT) with energy-integrating detector (EID) CT for the detection of small liver lesions. Materials and Methods In this reader study (July to December 2023), a virtual imaging framework was used with 50 anthropomorphic phantoms and 183 generated liver lesions (one to six lesions per phantom, 0.4-1.5 cm in diameter). Virtual CT platforms simulated PCCT and EID CT scanners. Phantoms were virtually scanned using routine (6 mGy) and low-dose (1.5 mGy) conditions and reconstructed with three kernels. A subset of 300 scans (150 PCCT vs EID CT pairs) were selected. Four radiologists independently reviewed all scans to mark liver lesions, assigned confidence scores for detection, and rated scan quality. Analysis was performed on a per-lesion basis to determine sensitivity for several variables and on a per-scan basis for scan quality. The McNemar test, two-sided paired t tests, and mixed-effects logistic regression models were fitted; P < .05 was considered indicative of statistically significant difference. Results Consensus reader sensitivity in detecting lesions was 82.1% (451 of 549) for PCCT versus 77.6% (426 of 549) for EID CT (P < .001), with a mean sensitivity gain of 4.3 percentage points ± 1.3 (P < .001 to P = .02 per reader). Readers had better subjective confidence for lesions at PCCT (mean score, 61.5 ± 22 vs 56.1 ± 24 [on a 101-point scale]; P < .001). Sensitivity was lower for lesions smaller than 1 cm, with more pronounced difference between PCCT and EID CT (74.0% [271 of 366] vs 67.2% [246 of 366]; P < .001). At the lower dose level, PCCT showed higher sensitivity than EID CT (68.9% [168 of 244] vs 61.1% [149 of 244]; P < .001) for subcentimeter lesions. In a multivariable model, PCCT was independently associated with increased odds of lesion detection (odds ratio, 1.55; P < .001). Image quality was slightly higher for PCCT (mean score, 55.3 vs 50.6 [on a 101-point scale]; P < .001). Conclusion Compared with EID CT, PCCT showed better sensitivity in the detection of small liver lesions. © RSNA, 2025 Supplemental material is available for this article. See also the editorial by Menu in this issue.