Accurate Hepatic Fat Fraction Quantification Across Body Sizes Using Photon-Counting CT

Objective: To identify common photon-counting CT (PCCT) virtual monochromatic imaging (VMI) settings for accurate hepatic fat fraction (FF) quantification across different body sizes, including large body habitus. Methods: Six non-iodinated fat lesions (FF 5%-40%) were embedded in anthropomorphic liver phantoms representing medium-sized (25x32.5 cm^2) and large (31x39 cm^2) abdomens. Phantoms were scanned on a PCCT system (NAEOTOM Alpha) at 120 and 140 kV. CT numbers were measured in VMIs at 40-190 keV in 1-keV increments. Linear regression between the ground-truth FF and measured Hounsfield units (HU) was used to estimate FF. Common optimal VMI settings yielding the minimum relative root-mean-square error (rRMSE) in both phantoms were identified. Results: A single VMI setting of 70 keV at 140 kV demonstrated the best overall performance across body sizes, with FF (%) = -0.689HU + 36.51 (R^2 > 0.996), achieving rRMSE [≤]3.4% and absolute RMSE [≤]0.7% in both phantoms. Robust performance (rRMSE [≤] 5%) was consistently maintained across 69-71 keV using identical calibration parameters for both phantoms. These results represented a substantial improvement over previously reported dual-energy CT (DECT) performance, while enabling accurate quantification on PCCT at radiation doses approximately 40% lower than those used in prior DECT protocols. Conclusion: PCCT enables accurate and robust hepatic fat fraction quantification independent of body size. A single protocol at 140 kV with VMIs of 69-71 keV consistently achieved low quantification errors, demonstrating strong potential for opportunistic liver fat assessment using PCCT, especially in obese patients.