A retrospective study enrolled 79 cirrhotic patients (197 nodules) with suspected hepatocellular carcinoma who underwent dual-energy CT (DECT). LI-RADS categories 3, 4, and 5 were evaluated by experienced radiologists. Iodine concentration density (ICD) was measured both in the nodules and in the adjacent non-nodular liver parenchyma during the arterial, portal venous, and equilibrium phase. These values were used to calculate the lesion-to-non-nodular liver ratios (LNR), their absolute differences (∆ICD), and relative ratios (rLNR). Arterial LNR and nodule ICD, as well as ∆ICD and rLNR between the arterial and portal venous phases, were able to distinguish between LI-RADS 3 and LI-RADS 4+5 nodules (p < 0.001, AUC 0.70–0.73), suggesting that spectral CT-derived ICD values can enhance radiologist confidence and improve diagnostic accuracy in challenging LI-RADS classifications.
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