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589 Copyright © 2026 The Korean Society of RadiologyConsiderations in Imaging-Based Assessment of Steatotic Liver Disease to Enhance Harmonization, Longitudinal Interpretation, and Clinical ImplementationJing Guo, Qian Yu, Peipei ZhangDepartment of Medical Ultrasound, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, ChinaKeywords: Steatotic liver disease imaging; QUS harmonization; CT opportunistic screeningWe read with interest the comprehensive review by Chan et al. [1], “Imaging Evaluation for Steatotic Liver Disease.” The authors provide a clear and timely synthesis of principles, performance characteristics, and evolving roles of ultrasound, CT, and MRI use in noninvasive assessment of hepatic steatosis and fibrosis. The discussion addresses emerging directions, including machine-learning–based techniques, opportunistic screening strategies, efforts to standardize imaging guidance, and implications of imaging use in treatment decision-making. We offer several clarifications and suggestions to further enhance the clinical applicability and translational impact of the presented concepts. First, additional emphasis on measurement harmonization and minimum reporting standards may help mitigate real-world variability, particularly that associated with quantitative ultrasound (QUS). The authors appropriately note that intersystem reproducibility may be acceptable when the same algorithm is used, but can be degraded when vendor-specific proprietary algorithms are applied. They also cautioned that commercial QUS should be interpreted carefully when used for diagnosis, longitudinal monitoring, or treatment response assessment, often necessitating vendor-specific thresholds and same-system follow-up. Building on these points, it may be useful to explicitly recommend a minimum reporting checklist for QUS-based research and clinical reporting, including documentation of vendor and system models, acquisition presets, region-of-interest strategies, quality metrics, and fasting or postprandial status. A brief discussion of cross-vendor calibration approaches, including phantom-based methods and standardized reference objects, could also provide practical guidance. Such measures may reduce heterogeneity and improve comparability across centers, which is an essential prerequisite to broad QUS adoption beyond specialized settings.Second, the section on CT-based assessment and opportunistic screening could be further strengthened by framing diagnostic thresholds and potential confounders within a more structured, risk-based workflow. The manuscript notes the absence of a universally accepted CT threshold for steatosis while summarizing commonly used criteria, such as absolute liver attenuation values and liver–spleen differences or ratios. Key limitations are also appropriately highlighted, including the requirement for a normal spleen, the confounding effects of iron overload, and the influence of intravenous contrast timing. Given that interest in incidental detection is currently increasing, we suggest adding a practical “opportunistic CT pathway” that outlines 1) circumstances in which noncontrast versus post-contrast metrics may be reasonably applied, 2) a concise list of red flags—such as iron overload, abnormal splenic attenuation, advanced fibrosis or cirrhosis, and severe hepatic congestion—that may bias attenuation-based estimates, and 3) adopting methods to communicate diagnostic uncertainty in radiology reports. This may be particularly relevant given the authors’ recommendation that CT should not be performed solely to detect or monitor steatosis to minimize ionizing radiation exposure, but can be leveraged when acquired for other clinical indications.Received: February 3, 2026 Accepted: May 10, 2026Corresponding author: Peipei Zhang, MD, Department of Medical Ultrasound, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, No. 16766 Jingshi Road, Jinan 250014, Shandong Province, China• E-mail: 815817477@qq.comThis is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Korean J Radiol 2026;27(6):589-590Letter to the EditoreISSN 2005-8330https://doi.org/10.3348/kjr.2026.0183