Quantification of Structural Heterogeneity Using Fractal Analysis of Contrast-Enhanced CT Image to Predict Survival in Gastric Cancer Patients

Background Malignant tumor essentially implies structural heterogeneity. Fractal analysis of medical imaging has a potential to quantify this structural heterogeneity in the tumor Aims The purpose of this study is to quantify this structural abnormality in the tumor applying fractal analysis to contrast-enhanced computed tomography (CE-CT) image and to evaluate its biomarker value for predicting survival of surgically treated gastric cancer patients. Methods A total of 108 gastric cancer patients (77 men and 31 women; mean age: 69.1 years), who received curative surgery without any neoadjuvant therapy, were retrospectively investigated. Portal-phase CE-CT images were analyzed with use of a plug-in tool for ImageJ (NIH, Bethesda, USA), and the fractal dimension (FD) in the tumor was calculated using a differential box-counting method to quantify structural heterogeneity in the tumor. Tumor FD was compared with clinicopathologic features and disease-specific survival (DSS). Results High FD value of the tumor significantly associated with high T stage and high pathological stage ( P = 0.009, 0.007, respectively). In Kaplan–Meier analysis, patients with higher FD tumors (FD > 0.9746) showed a significantly worse DSS ( P = 0.009, log rank). Multivariate analysis demonstrated that tumor FD, T stage, and N stage were independent prognostic factors for DSS. In subset analysis of lymph-node positive gastric cancers, only tumor FD was an independent prognostic factor for DSS. Conclusion CT fractal analysis can be a useful biomarker for gastric cancer patients, reflecting survival and clinicopathologic features.