Photon-counting CT in gastrointestinal malignancies: a scoping review

Background: Photon-Counting computed tomography(PCCT) offers superior spatial resolution, improved contrast-to-noise ratio and reduced radiation dose compared with conventional CT. This scoping review maps and synthesizes clinical evidence on PCCT applications in gastrointestinal (GI) oncology following the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines METHODS: A systematic search of PubMed, Embase, Web of Science and Cochrane Library (January 2017-December 2025) identified studies evaluating PCCT in adult patients with confirmed GI malignancies. Quality was assessed using the Newcastle-Ottawa Scale and levels of evidence were graded according to the Oxford Centre for Evidence-Based Medicine. Results: Thirteen studies (761 patients) met inclusion criteria. Across pancreatic and hepatic malignancies, individual studies reported improvements in lesion contrast-to-noise ratio at low-keV virtual monoenergetic imaging (range across studies, 45-65%), abdominal radiation dose reductions compared with energy-integrating detector CT (range, 25-40%), and improved inter-reader agreement for pancreatic cancer resectability (κ = 0.61-0.69 with PCCT vs 0.56-0.59 with EID-CT). These ranges represent the spread across heterogeneous individual studies and do not constitute pooled meta-analytic estimates, as no meta-analysis was performed (see Section 2.8). PCCT showed comparable accuracy to MRI for rectal cancer T-staging (70% vs 73.3%) and enabled quantitative iodine-based biomarkers associated with treatment response in rectal and esophageal cancer. Conclusions: PCCT represents a substantial technical advance with early clinical promise in GI oncologic imaging. The most consistent and reproducible findings concern pancreatic adenocarcinoma (improved tumor conspicuity at low-keV VMI and improved inter-reader agreement for vascular involvement) and abdominal radiation dose reduction. Evidence for hepatocellular carcinoma, liver metastases, rectal cancer, and esophageal cancer is preliminary, derived from only one or two studies per tumor type that address heterogeneous research questions, and should therefore be regarded as exploratory and hypothesis-generating. The overall evidence base is predominantly Level 2b-3 and based on retrospective single-centre cohorts and surrogate diagnostic endpoints, underscoring the need for prospective multicentre trials.