Metastatic melanoma: pretreatment contrast-enhanced CT texture parameters as predictive biomarkers of survival in patients treated with pembrolizumab

  • Carole DurotEmail author
  • Sébastien Mulé
  • Philippe Soyer
  • Aude Marchal
  • Florent Grange
  • Christine Hoeffel



To determine whether texture analysis features on pretreatment contrast-enhanced computed tomography (CT) images can predict overall survival (OS) and progression-free survival (PFS) in patients with metastatic malignant melanoma (MM) treated with an anti-PD-1 monoclonal antibody, pembrolizumab.

Materials and methods

This institutional-approved retrospective study included 31 patients with metastatic MM treated with pembrolizumab. Texture analysis of 74 metastatic lesions was performed on CT scanners obtained within 1 month before treatment. Mean gray-level, entropy, kurtosis, skewness, and standard deviation values were derived from the pixel distribution histogram before and after spatial filtration at different anatomic scales, ranging from fine to coarse. Lasso penalized Cox regression analyses were performed to identify independent predictors of OS and PFS.


Median OS and PFS were 357 days (range 42–1355) and 99 days (range 35–1185), respectively. Skewness at coarse texture scale (SSF = 6; HR (CI 95%) = 6.017 (1.39, 26.056), p = 0.016), Response evaluation criteria in solid tumors (RECIST) conclusion (HR (CI 95%) = 3.41 (1.17, 9.89), p = 0.024), and body weight (HR (CI 95%) = 0.96 (0.92, 0.995), p = 0.026) were independent predictors of OS. Skewness at coarse texture scale (SSF = 6; HR (CI 95%) = 4.55 (1.46, 14.13), p = 0.0089) and RECIST conclusion (HR (CI 95%) = 10.63 (3.11, 36.29), p = 0.00016) were independent predictors of PFS. Skewness values above − 0.55 at coarse texture scale were significantly associated with both lower OS and lower PFS after administration of pembrolizumab.


Pretreatment CT texture analysis–derived tumor skewness may act as predictive biomarker of OS and PFS in patients with metastatic MM treated with pembrolizumab.

Key Points

• Pretreatment skewness at coarse texture scale in metastases from malignant melanoma was an independent predictor of overall survival and progression-free survival.

• Skewness values above −0.55 at coarse texture scale were significantly associated with both lower OS and lower PFS after administration of pembrolizumab.

• In patients with metastatic MM, texture analysis performed on pretreatment CT may act as a useful tool to select the best candidates for pembrolizumab therapy.


Metastatic melanoma Pembrolizumab Tomography, X-ray computed Biomarkers Survival 



Computed tomography


Eastern cooperative oncology group


Hazard ratio


Serum lactate dehydrogenase


Malignant melanoma


Overall survival


Program cell death 1


Progression-free survival


Response evaluation criteria in solid tumors


Region of interest


Standard deviation


Spatial scale image filtration



The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Carole Durot, MD, Centre Hospitalo-universitaire de Reims.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors has significant statistical expertise.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.


• retrospective

• diagnostic or prognostic study

• performed at one institution


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Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  1. 1.Department of RadiologyReims University HospitalReimsFrance
  2. 2.Department of RadiologyHenri Mondor University HospitalCréteilFrance
  3. 3.Department of RadiologyCochin University HospitalParisFrance
  4. 4.Department of BiopathologyReims University HospitalReimsFrance
  5. 5.Department of DermatologyReims University HospitalReimsFrance
  6. 6.CRESTICUniversity of Reims Champagne-ArdenneReimsFrance

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