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. 2025 Nov;130(11):1731-1741.
doi: 10.1007/s11547-025-02081-0. Epub 2025 Sep 2.

Radiomics-based prediction of microsatellite instability in colorectal cancer: a non-invasive approach to treatment stratification

Davide Mallardi  1 , Ginevra Danti  2 , Antonio Galluzzo  2 , Linda Calistri  2 , Diletta Cozzi  2 , Daniele Lavacchi  3 , Daniele Rossini  4   5 , Lorenzo Antonuzzo  3   4   6 , Sebastiano Paolucci  7 , Simone Busoni  7 , Francesca Castiglione  8 , Luca Messerini  8 , Fabio Cianchi  4   9 , Vittorio Miele  2   10
Affiliations

Radiomics-based prediction of microsatellite instability in colorectal cancer: a non-invasive approach to treatment stratification

Davide Mallardi et al. Radiol Med. 2025 Nov.

Abstract

Purpose: Management of colorectal cancer (CRC) is determined by the stage of the disease and molecular features, such as microsatellite instability (MSI). MSI-high/deficient mismatch repair (MSI-H/dMMR) tumors respond better to immunotherapy but poorly to 5-FU-based treatments. With increasing use of neoadjuvant chemotherapy there is interest in developing non-invasive, radiomics models based on preoperative contrast-enhanced CT scans to predict MSI status and support personalized therapy.

Material and methods: Adult patients diagnosed with CRC who underwent pre-treatment staging with contrast-enhanced CT and had known MSI status were retrospectively analyzed. Portal venous phase images were assessed. Two radiologists, blinded to MSI status, manually segmented tumor regions on CT images. Radiomic features and statistical modeling were used to develop a predictive model for identifying the MSI-H phenotype.

Results: Analysis was conducted on 54 adult CRC patients who had undergone staging CT scans with known MSI status. Two different models were built considering different brands of CT machines. Twenty statistically significant radiomic features from the portal venous phase of CT images able to differentiate MSI from microsatellite stable (MSS) patients were selected for each model. LASSO regression was applied, selecting features for model construction. The best model's performance demonstrated an area under the ROC curve of 0.844 (95% CI = 0.73-0.96 DeLong, p < 0,05).

Conclusion: The results demonstrate the potential of the radiomics model as a non-invasive, cost-effective tool for MSI evaluation, guiding CRC therapy. It aids in identifying patients who would benefit from immunotherapy or chemotherapy, supporting the therapeutic shift from postoperative to preoperative treatment.

Keywords: Colon; Colon cancer; Immunotherapy; Microsatellite instability; Radiomic model.

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Conflict of interest statement

Declarations. Competing interest: Authors Ginevra Danti and Vittorio Miele are editors in the journal “ La radiologia medica” Other authors declare no conflicts of interest. Ethics approval and consent to participate: The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Careggi University Hospital (protocol code 13261_OSS). Consent for publication: All patients provided written informed consent for the CT examination, and all images were anonymized to protect patients’ privacy.

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