ObjectiveThis study evaluates the potential of dual-energy CT (DECT) for preoperative prediction of tumor budding (TB) and lymphovascular invasion (LVI) in colon cancer.MethodsThis prospective study enrolled 153 patients (mean age 61.33 years +/- 0.88) with pathologically confirmed colon cancer. All participants underwent arterial and venous phase DECT scans within one week before surgery. Two radiologists independently analyzed the images, assessing tumor location, clinical N stage (cN stage), iodine concentration (IC), effective atomic number (Z-eff), and dual-energy index (DEI). The normalized iodine concentration (nIC) was obtained by comparing measured IC to the abdominal aortic IC. Logistic regression identified independent risk factors for high-grade TB and LVI positivity. The Akaike Information Criterion guided model selection, and the area under the curve (AUC) was calculated. Bootstrap validation with 1000 iterations was used for internal validation.ResultsTumor location and cN stage were identified as independent risk factors for high-grade TB, and nICA tumor and cN stage for LVI positivity. The optimal model for predicting high-grade TB included tumor location, cN stage, and DEIV tumor, with an AUC of 0.763 (sensitivity: 75.0%; specificity: 64.7%) and a mean AUC of 0.712. Similarly, the model for LVI positivity included nICA tumor, cN stage, and nICA peripheral fat, with an AUC of 0.811 (sensitivity: 71.7%; specificity: 76.6%) and a mean AUC of 0.814.ConclusionDECT could consistently quantify colon cancer characteristics, and DECT-based models performed well in the preoperative prediction of TB and LVI.