Dear Dr. Bunk,

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Additional Editor Comments:

This study evaluates and compares the repeatability of three automated methods for measuring body composition—specifically skeletal muscle area and subcutaneous adipose tissue area—from low-dose chest CT scans in a longitudinal setting. The manuscript is concise, well-organized, and clearly presented. Although it does not introduce significant technical novelty, it represents a valid investigation that offers meaningful insights for the medical field, supported by a large dataset. That said, I have several technical questions that require clarification:

First, I have concerns regarding the radiodensity discrepancies observed among the three methods. The extended FOV method underwent notably different preprocessing compared to the other two methods. It remains unclear how the authors could confidently claim—and rule out—that these discrepancies were not attributable to preprocessing. In particular, the fact that discrepancies persisted when the extended FOV method was applied to datasets from the other two methods suggests to me that its processing pipeline may introduce systematic errors. As the authors noted, downsampling could indeed lead to segmentation issues.

Second, regarding the study population, all CT data are from male participants. The rationale for including only males—or whether only male data were available—is not explained. Further details on the population selection criteria are needed.

Third, some findings appear obvious and contribute little novelty. For example, in line 222, the statement “We also found that scans collected at 120 kVp … compared to those collected at 140 kVp” reflects a well-understood principle that higher kVp reduces attenuation and thus lowers radiodensity measurements. This finding seems unnecessary and not directly relevant to the core aims of the study.

Finally, certain statements are overly vague. For instance, line 95 states: “Participants with higher weight were scanned with a higher kVp to ensure similar image quality as the participants with lower weight.” However, it is unclear how many participants were affected and what specific kVp values were used in these cases.

Minor formality issues:

Line 207, cm2 is not current format of the unit.

Footnote of Table 2. SAT=Subcutaneous Fat. Please stay consistent, SAT = subcutaneous adipose tissue.

Reviewers' comments:

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

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Reviewer #1: The manuscript addresses the repeatability of automated body composition measurements on longitudinal chest CT scans. Specifically, it evaluates three approaches for compensating field-of-view (FOV) changes between scans: truncated FOV, compensated FOV, and extended FOV. Using a substantial cohort of 562 male participants from the NELSON lung cancer screening trial with baseline and short-term follow-up scans, the authors compare these methods for skeletal muscle and subcutaneous adipose tissue (SAT) area measurements. Repeatability was assessed using Bland–Altman plots, paired t-tests, and intraclass correlation coefficients (ICC). The manuscript addresses the repeatability of automated body composition measurements on longitudinal chest CT scans. Specifically, it evaluates three approaches for compensating field-of-view (FOV) changes between scans: truncated FOV, compensated FOV, and extended FOV. Using a substantial cohort of 562 male participants from the NELSON lung cancer screening trial with baseline and short-term follow-up scans, the authors compare these methods for skeletal muscle and subcutaneous adipose tissue (SAT) area measurements. Repeatability was assessed using Bland–Altman plots, paired t-tests, and intraclass correlation coefficients (ICC). The manuscript addresses the repeatability of automated body composition measurements on longitudinal chest CT scans. Specifically, it evaluates three approaches for compensating field-of-view (FOV) changes between scans: truncated FOV, compensated FOV, and extended FOV. Using a substantial cohort of 562 male participants from the NELSON lung cancer screening trial with baseline and short-term follow-up scans, the authors compare these methods for skeletal muscle and subcutaneous adipose tissue (SAT) area measurements. Repeatability was assessed using Bland–Altman plots, paired t-tests, and intraclass correlation coefficients (ICC). The manuscript addresses the repeatability of automated body composition measurements on longitudinal chest CT scans. Specifically, it evaluates three approaches for compensating field-of-view (FOV) changes between scans: truncated FOV, compensated FOV, and extended FOV. Using a substantial cohort of 562 male participants from the NELSON lung cancer screening trial with baseline and short-term follow-up scans, the authors compare these methods for skeletal muscle and subcutaneous adipose tissue (SAT) area measurements. Repeatability was assessed using Bland–Altman plots, paired t-tests, and intraclass correlation coefficients (ICC).

Key findings indicate that the compensated FOV method achieved the highest repeatability but underestimated SAT due to exclusion of non-overlapping regions. Extended FOV produced measurements closest to actual anatomy and exhibited the lowest segmentation error rates, though it introduced a small systematic difference in skeletal muscle area between scans. The authors conclude that extended FOV may be preferable for longitudinal analyses where absolute measurement values are critical.

Concerns:

1. Population Limitation: The study includes only male participants, limiting generalizability. Anatomical differences in women may affect segmentation accuracy. Have the authors considered validating their approach on publicly available datasets that include female subjects (e.g., https://atm22.grand-challenge.org/dataset/)?

2. Assumption of Stability: The assumption of stable body composition over 3–4 months may not universally hold, despite limited supporting evidence cited.

3. Slice Selection Variability: Comparisons between methods are weakened by non-identical slice selection across approaches.

4. Radiodensity Discrepancy: The observed differences in radiodensity measurements between extended FOV and other methods are noted but not fully explained, leaving uncertainty regarding clinical interpretation.

5. Computational Efficiency: The manuscript would benefit from a discussion on computational efficiency and integration into clinical workflows. Specifically, what is the trade-off between computational time and accuracy across the best- and worst-performing methods?

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Reviewer #1: No

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Repeatability of automated body composition measurement on low dose chest CT in male subjects

PONE-D-25-45870R1

Dear Dr. Bunk,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Zhentian Wang, Ph.D.

Academic Editor

PLOS One

Additional Editor Comments (optional):

The authors have addressed all the reviewers' comments satisfactorily.

Reviewers' comments: