Voxel Normalization in LDCT Imaging: Its Significance in Texture Feature Selection for Pulmonary Nodule Malignancy Classification: Insights from Two Centers

<b>Background:</b> Lung cancer is the leading cause of cancer-related mortality globally. Early detection via low-dose computed tomography (LDCT) can reduce mortality, but its implementation is challenged by the absence of objective diagnostic criteria and the necessity for extensive manual interpretation. Public datasets like the Lung Image Database Consortium often lack pathology-confirmed diagnoses, which can lead to inaccuracies in ground truth labels. Variability in voxel sizes across these datasets also complicates feature extraction, undermining model reliability. Many existing methods for integrating nodule boundary annotations use deep learning models such as generative adversarial networks, which often lack interpretability. <b>Methods:</b> This study assesses the effect of voxel normalization on pulmonary nodule classification and introduces a Fast Fourier Transform-based contour fusion method as a more interpretable alternative. Utilizing pathology-confirmed LDCT data from 415 patients across two medical centers, both machine learning and deep learning models were developed using voxel-normalized images and attention mechanisms, including transformers. <b>Results:</b> The results demonstrated that voxel normalization significantly improved the overlap of features between datasets from two different centers by 64%, resulting in enhanced selection stability. In the ROI-based radiomics analysis, the top-performing machine-learning model achieved an accuracy of 92.6%, whereas the patch-based deep-learning models reached 98.5%. Notably, the FFT-based method provided a clinically interpretable integration of expert annotations, effectively addressing a major limitation of generative adversarial networks. <b>Conclusions:</b> Voxel normalization enhances reliability in pulmonary nodule classification while the FFT-based method offers a viable path toward interpretability in deep learning applications. Future research should explore its implications further in multi-center contexts.