Fat-free muscle area measured by magnetic resonance imaging predicts overall survival of patients undergoing radioembolization of colorectal cancer liver metastases



To investigate the clinical potential of fat-free muscle area (FFMA) to predict outcome in patients with liver-predominant metastatic colorectal cancer (mCRC) undergoing radioembolization (RE) with 90Yttrium microspheres.


Patients with mCRC who underwent RE in our center were included in this retrospective study. All patients received liver magnetic resonance imaging including standard T2-weighted images. The total erector spinae muscle area and the intramuscular adipose tissue area were measured at the level of the origin of the superior mesenteric artery and subtracted to calculate FFMA. Cutoff values for definition of low FFMA were 3644 mm2 in men and 2825 mm2 in women. The main outcome was overall survival (OS). For survival analysis, the Kaplan-Meier method and Cox regressions comparing various clinic-oncological parameters which potentially may affect OS were performed.


Seventy-seven patients (28 female, mean age 60 ± 11 years) were analyzed. Mean time between MRI and the following RE was 17 ± 31 days. Median OS after RE was 178 days. Patients with low FFMA had significantly shortened OS compared to patients with high FFMA (median OS: 128 vs. 273 days, p = 0.017). On multivariate Cox regression analysis, OS was best predicted by FFMA (hazard ratio (HR) 2.652; p < 0.001). Baseline bilirubin (HR 1.875; p = 0.030), pattern of tumor manifestation (HR 1.679; p = 0.001), and model of endstage liver disease (MELD) score (HR 1.164; p < 0.001) were also significantly associated with OS.


FFMA was associated with OS in patients receiving RE for treatment of mCRC and might be a new prognostic biomarker for survival prognosis.

Key Points

• Fat-free muscle area (FFMA) as a measure of lean muscle area predicts survival in metastatic colorectal liver cancer following radioembolization.

• FFMA can easily be assessed from routine pre-interventional liver magnetic resonance imaging.

• FFMA might be a new promising biomarker for assessment of sarcopenia.

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Fig. 1
Fig. 2



Adipose tissue area


Colorectal cancer


Computed tomography


Eastern Cooperative Oncology Group performance status


Fat-free muscle area


Liver-predominant metastatic colorectal cancer


Model of endstage liver disease


Magnetic resonance imaging


Overall survival


Proton density fat fraction




Skeletal muscle index


Transjugular intrahepatic portosystemic shunt


Total muscle area


90Yttrium microspheres


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Corresponding author

Correspondence to Julian A. Luetkens.

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The scientific guarantor of this publication is PD Dr. Julian A. Luetkens.

Conflict of interest

The authors of this manuscript declare relationships with the following companies: C.M. is a consultant for SIRTEX Medical; C.C.P. received speakers’ fees from Philips Healthcare.

Statistics and biometry

One of the authors (R.F.) has significant statistical expertise.

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Written informed consent was waived by the Institutional Review Board.

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Institutional Review Board approval was obtained.


• retrospective

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• performed at one institution

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Faron, A., Pieper, C.C., Schmeel, F.C. et al. Fat-free muscle area measured by magnetic resonance imaging predicts overall survival of patients undergoing radioembolization of colorectal cancer liver metastases. Eur Radiol 29, 4709–4717 (2019). https://doi.org/10.1007/s00330-018-5976-z

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  • Sarcopenia
  • Colorectal cancer
  • Brachytherapy
  • Magnetic resonance imaging