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

  • Anton Faron
  • Claus C. Pieper
  • Frederic C. Schmeel
  • Alois M. Sprinkart
  • Daniel L. R. Kuetting
  • Rolf Fimmers
  • Jonel Trebicka
  • Hans H. Schild
  • Carsten Meyer
  • Daniel Thomas
  • Julian A. LuetkensEmail author



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.


Sarcopenia Colorectal cancer Brachytherapy Magnetic resonance imaging 



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



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

Compliance with ethical standards


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.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.


• retrospective

• prognostic study

• performed at one institution


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Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  • Anton Faron
    • 1
  • Claus C. Pieper
    • 1
  • Frederic C. Schmeel
    • 1
  • Alois M. Sprinkart
    • 1
  • Daniel L. R. Kuetting
    • 1
  • Rolf Fimmers
    • 2
  • Jonel Trebicka
    • 3
    • 4
    • 5
    • 6
  • Hans H. Schild
    • 1
  • Carsten Meyer
    • 1
  • Daniel Thomas
    • 1
  • Julian A. Luetkens
    • 1
    Email author
  1. 1.Department of RadiologyUniversity of BonnBonnGermany
  2. 2.Department of Medical Biometry, Informatics, and EpidemiologyUniversity of BonnBonnGermany
  3. 3.Department of Internal Medicine IUniversity of BonnBonnGermany
  4. 4.European Foundation for the Study of Chronic Liver FailureBarcelonaSpain
  5. 5.Faculty of Health SciencesUniversity of Southern DenmarkOdenseDenmark
  6. 6.Institute for Bioengineering of CataloniaBarcelonaSpain

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