Preoperative Noninvasive Assessment for Predicting Steatosis Grade in Hepatocellular Carcinoma Patients with Chronic Hepatitis B: Comparison of Attenuation Imaging with Controlled Attenuation Parameter
Kun Wang, Minghui Wang, Guoliang Hao, Mingtao Lv, Baowei LiIntroduction/ Background:
Patients with Chronic Hepatitis B-related Hepatocellular Carcinoma (CHB-HCC) carry substantial risk of postoperative liver failure attributable to hepatic steatosis; accurate non-invasive grading of hepatic steatosis is therefore essential for optimized perioperative management. Liver biopsy is the gold standard but invasive, while conventional imaging has limitations. Controlled Attenuation Parameter (CAP) and Attenuation Imaging (ATI) are novel ultrasound-based modalities for steatosis assessment, but their diagnostic performance in CHB-related HCC candidates for hepatectomy remains understudied, with limited data on ATI’s reproducibility in this specific population.
Objectives:
This study primarily aimed to evaluate the diagnostic performance of Attenuation Imaging (ATI) in grading hepatic steatosis among hepatitis B virus-related hepatocellular carcinoma (HCC) candidates for hepatectomy, in comparison with the Controlled Attenuation Parameter (CAP). As a secondary objective, the inter-observer reproducibility of ATI measurements was also assessed.
Methods:
HCC patients with CHB who were scheduled to undergo hepatectomy from January 2022 to January 2025 were prospectively enrolled in this study. All patients underwent ATI and CAP examinations. Steatosis grade, fibrosis stage, and necroinflammatory activity were determined according to histopathology. ATI reproducibility was assessed using Bland-Altman analysis and Intraclass Correlation Coefficients (ICCs). Receiver Operating Characteristic (ROC) analysis was performed to assess the diagnostic performance of ATI and CAP.
Results:
A total of 164 participants were included. ATI had a higher success rate than CAP (98.0% vs 81.6%). The correlation coefficient between the AC value and the CAP values was 0.714. The correlation coefficients between AC and CAP values and histologically-determined steatosis grade were 0.725 and 0.678, respectively. AC and CAP values differed significantly among patients with varying hepatic steatosis grades. For the prediction of steatosis grade ≥S1 and ≥S2, Attenuation Imaging (ATI) yielded Area Under the Receiver Operating Characteristic curve (AUROC) values of 0.926 and 0.914, with optimal AC cutoffs of 0.69 and 0.76 dB/cm/MHz, respectively. Meanwhile, CAP achieved AUROCs of 0.895 and 0.904 for identifying ≥S1 and ≥S2 steatosis, corresponding to optimal cutoff values of 224 and 240 dB/m, respectively. No statistically significant difference in diagnostic performance was observed between the two modalities (Z = 1.057, 0.220; p = 0.29, 0.83). Multivariate analysis identified steatosis grade and Triglyceride (TG) level as significant determinants of AC values, whereas steatosis grade was the sole independent predictor of CAP measurements.
Discussion:
We compared ATI and CAP for hepatic steatosis grading in CHB-related HCC patients undergoing hepatectomy, confirming both modalities have good diagnostic performance for steatosis grade prediction, with no statistically significant difference in their AUROCs. Notably, ATI had a higher examination success rate, which is clinically valuable for patients with liver anatomical changes due to CHB and HCC. ATI’s excellent intra- and inter-observer reproducibility supports its reliability for repeated clinical assessments, and the correlation between AC and CAP values validates their consistency in reflecting hepatic fat deposition. The identification of steatosis grade and TG as determinants of AC values provides insights into the physiological factors influencing ATI measurements, while CAP’s sole association with steatosis grade suggests its more specific focus on fat deposition. Compared with CAP, ATI’s integration with B-mode imaging enables targeted sampling of liver parenchyma, avoiding tumor lesions and artifacts, which may contribute to its higher success rate. Limitations of this study include a single-center design, a relatively small sample size of moderate-to-severe steatosis patients, and potential spatial discrepancies between imaging sampling regions and pathological specimens.
Conclusion:
ATI demonstrates excellent intra- and inter-observer reproducibility and a higher examination success rate than CAP in CHB-related HCC patients, making it a reliable noninvasive modality for preoperative hepatic steatosis grading. While ATI and CAP show comparable diagnostic accuracy for identifying steatosis grade ≥S1 and ≥S2, ATI’s B-mode guidance confers practical clinical advantages for this patient population with altered liver anatomy. As a feasible ultrasound-based technique, ATI can serve as a valuable tool for preoperative screening and dynamic follow-up of hepatic steatosis in CHB-related HCC patients undergoing hepatectomy, aiding in perioperative risk stratification and treatment decision-making. Its association with triglyceride levels also provides a basis for combining clinical biochemical indicators to optimize steatosis assessment in this specific cohort.