Feasibility of one-stop multi-energy dynamic photon-counting perfusion CT for resectable HCC evaluation: lesion detection and histopathological correlations

Abstract Objectives To assess the feasibility of one-stop multi-energy dynamic volume perfusion photon-counting CT (VP-PCCT) for hepatocellular carcinoma (HCC) evaluation, including lesion detection and correlations with histopathology. Materials and methods From July 2024 to June 2025, 407 participants with suspected malignant liver lesions prospectively underwent VP-PCCT, and 177 patients with pathology-confirmed HCC who received three-phase energy-integrating detector CT (EID-CT) were retrospectively enrolled for comparisons of image quality and lesion detectability. Single-phase images reconstructed from VP-PCCT perfusion datasets were compared with EID-CT. Perfusion parameters were analyzed between groups stratified separately by histological grade and microvascular invasion (MVI), and logistic regression was employed to identify independent indicators. Results Ninety-two participants [median age, 62 years (IQR, 53–69); 76 males] with pathology-confirmed HCC were included in the VP-PCCT group and matched with 92 in the EID-CT group. Compared with EID-CT, 40-keV VP-PCCT provided comparable image quality for HCC and vessels with a similar tumor detection rate but a lower radiation dose. Poorly-differentiated HCCs showed higher tumor hepatic perfusion index (HPI tumor ) and peritumoral blood flow (BF peritumor ); MVI-positive HCCs exhibited lower tumor arterial liver perfusion (ALP tumor ) and normalized blood flow of peritumoral region (BF norm_peritumor ) (all p < 0.05). HPI tumor [odds ratio (OR): 1.06] and BF peritumor (OR: 1.04) were independent risk factors for poorly differentiated HCC, whereas decreased ALP tumor (OR: 0.97) and BF norm_peritumor (OR: 0.25) were associated with MVI positivity (all p < 0.05). Conclusions One-stop VP-PCCT delivers high-quality morphologic and perfusion evaluation in a single low-dose scan, with hemodynamic profiles that may be associated with histological grade and MVI status. Key Points Question Clinical use of dynamic volume perfusion CT for comprehensively evaluating HCC without additional multiphase contrast-enhanced imaging remains limited. Findings Multi-energy dynamic photon-counting perfusion CT provided high-quality morphologic imaging of HCC at a low dose, with perfusion parameters independently indicating poorly differentiated HCC and MVI. Critical relevance statement One-stop multi-energy dynamic photon-counting perfusion CT enables high-quality morphologic and functional assessment in a single low-dose scan, providing comprehensive HCC evaluation with hemodynamic profiling that may support the assessment of histological grade and MVI.