In Silico Metrological Assessment of 2D ROI Sampling Error Versus Whole-Organ 3D Volumetric CT Attenuation in Hepatic Steatosis: A Multicenter Monte Carlo Simulation on 971 Scans

Purpose: To quantify the sampling error of conventional 2D regions of interest (ROIs) compared with whole-organ 3D volumetric CT attenuation for opportunistic hepatic steatosis screening, and to evaluate its dependency on intraparenchymal spatial heterogeneity. Materials and Methods: In this retrospective computational study (CLAIM-compliant), 971 abdominal CT scans were analyzed across a multicenter derivation cohort (TotalSegmentator v2, n = 841) and an external validation cohort (Medical Segmentation Decathlon Task03, n = 130). Automated 3D liver segmentation was performed using nnU-Net, fo

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