A Narrative Review of Photon-Counting CT and Radiomics in Cardiothoracic Imaging: A Promising Match?

Photon-counting computed tomography (PCCT) represents a major technological innovation compared to conventional CT, offering improved spatial resolution, reduced electronic noise, and intrinsic spectral capabilities. These advances open new perspectives for synergy with radiomics, a field that extracts quantitative features from medical images. The ability of PCCT to generate multiple types of datasets, including high-resolution conventional images, iodine maps, and virtual monoenergetic reconstructions, increases the richness of extractable features and potentially enhances radiomics performance. This narrative review investigates the current evidence on the interplay between PCCT and radiomics in cardiothoracic imaging. Phantom studies demonstrate reduced reproducibility between PCCT and conventional CT systems, while intra-scanner repeatability remains high. Nonetheless, PCCT introduces additional complexity, as reconstruction parameters and acquisition settings significantly may affect feature stability. In chest imaging, early studies suggest that PCCT-derived features may improve nodule characterization, but existing machine learning models, such as those applied to interstitial lung disease, may require recalibration to accommodate the new imaging paradigm. In cardiac imaging, PCCT has shown particular promise: radiomic features extracted from myocardial and epicardial tissues can provide additional diagnostic insights, while spectral reconstructions improve plaque characterization. Proof-of-concept studies already suggest that PCCT radiomics can capture myocardial aging patterns and discriminate high-risk coronary plaques. In conclusion, evidence supports a growing synergy between PCCT and radiomics, with applications already emerging in both lung and cardiac imaging. By enhancing the reproducibility and richness of quantitative features, PCCT may significantly broaden the clinical potential of radiomics in computed tomography.