Photon-counting detector CT achieved 100% per-lesion sensitivity in detecting colorectal liver metastases in an intra-patient comparison, outperforming a conventional third-generation dual-source energy-integrating CT scanner. The study reported 138 of 138 reference metastases detected by photon-counting CT versus 122 of 138 on conventional CT. For surgical planning and ablation eligibility, this is a clinically consequential imaging performance gap: missing small or low-contrast lesions can alter staging and treatment decisions. The study’s patient-clustered bootstrap difference favored photon-counting CT, signaling improved lesion visibility in a key oncology setting.