Multimodal imaging fractals map immune exclusion and predict survival in colorectal liver metastases

In 270 CRC liver metastases patients, an immune-radiomics joint score (MRI/PET fractal dimensions, SII, KRAS) identified immune-inflamed phenotype (external validation AUC 0.862) and predicted better overall survival (HR 0.31).

• IRJS achieved AUCs of 0.921 (training), 0.886 (temporal validation), and 0.862 (external validation) for identifying immune-inflamed phenotype.
• FD_MRI fractal dimension correlated with α-SMA+ pro-fibrotic stromal density (r = 0.684), potentially reflecting a mechanical barrier excluding CD8+ T cells.
• The model showed significant net reclassification improvement (NRI = 0.384, P < 0.001) over clinical variables.

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