The Effect of X-ray Dose Photon-Counting Detector Computed Tomography on Nodule Properties in a Lung Cancer Screening Cohort: A Prospective Study

OBJECTIVES The aim of the study was to evaluate the effect of photon-counting detector (PCD-)CT dose reduction to x-ray equivalent levels on nodule detection, diameter, volume, and density compared to a low-dose reference standard using semiautomated and manual methods. MATERIALS AND METHODS Between February and July 2023, 101 prospectively enrolled participants underwent noncontrast same-study low- and chest x-ray-dose CT scans using PCD-CT. Patients who were not referred for lung cancer screening or nodule follow-up, as well as those with nodules smaller than 5 mm in diameter, were excluded. Nodule detection and measurement of nodule diameters and volumes was semiautomatically performed for low- and x-ray-dose scans using computer-aided diagnosis software. Additionally, 2 blinded readers manually measured largest nodule diameters and examined nodule density. Nodules were classified using Lung-RADS v2022. Image quality was assessed with subjective and objective measures. RESULTS Mean CTDIvol for x-ray dose scans was 0.11 ± 0.03 mGy, compared to 0.65 ± 0.15 mGy for low-dose images (P < 0.001). One hundred seventy-two nodules larger than 5 mm were detected in 53 of the 101 participants (32 male, 61.6 ± 12.5 years; 21 female, 60.3 ± 12.5 years). The semiautomated method had high overall sensitivity for nodule detection (0.94) on x-ray dose scans, with a higher sensitivity for solid nodules (>0.95) and lower for subsolid nodules (>0.86). Nodules not detected on x-ray dose scans were significantly smaller. Semiautomated measurements underestimated nodule diameter for solid nodules on x-ray dose scans (P = 0.01), but no significant effect for nodule volume was found (P = 0.775). Readers rated nodule density less dense on x-ray dose scans (R1: P < 0.001, R2: P = 0.006). There was no significant difference in nodule diameter for both readers between scan doses (R1: P = 0.141; R2: P = 0.554). There were good to excellent correlations between semiautomated and reader nodule diameters. Agreement and accuracy between low-dose and x-ray dose Lung-RADS classifications across methods were good (Cohens' к = 0.73, 0.62, 0.76 for semiautomated method, R1 and R2; resp. Accuracy: 0.82, 0.78, 0.85). No Lung-RADS classification changes were observed with semiautomated volumetric measurements of nodules. CONCLUSIONS Semiautomated nodule detection is highly sensitive in PCD-CT x-ray dose scans. Semiautomated nodule volume measurement is more robust to image quality changes than nodule diameter. Accurate semiautomated and manual nodule measurements are feasible on x-ray dose scans, but nodule density was in tendency underestimated. Nodule classification using Lung-RADS was shown to be accurate on x-ray dose scans.