Original Research| Volume 174, P165-175, October 2022

Colon cancer CT staging according to mismatch repair status: Comparison and suggestion of imaging features for high-risk colon cancer

Published:August 24, 2022DOI:


      • Radiologic assessment of colon cancer stage differs between dMMR and pMMR tumours.
      • pMMR tumours: nodal internal heterogeneity is associated with positive lymph nodes.
      • dMMR tumours: diameter of lymph nodes is associated with positive lymph nodes.



      Neoadjuvant treatment with either chemotherapy or immunotherapy is gaining momentum in colon cancers (CC). To reduce over-treatment, increasing staging accuracy using computed tomography (CT) is of high importance.


      To assess and compare CT imaging features of CC between mismatch repair-proficient (pMMR) and MMR-deficient (dMMR) tumours and identify CT features that can distinguish high-risk (pT3-4, N+) CC according to MMR status.


      Primary staging CTs of 266 patients who underwent primary surgical resection of a colon tumour were retrospectively and independently evaluated by two radiologists. Logistic regression analysis was performed to identify significant associations between imaging features and positive lymph node status. Receiver operating characteristic (ROC) curves of significantly associated features were assessed and validated in an external cohort of 104 patients.


      Among pT3 tumours only, dMMR CC were significantly larger than pMMR CC in both length and thickness (length 59.39 ± 26.28 mm versus 48.70 ± 23.72, respectively, p = 0.031; thickness 20.54 mm ± 11.17 versus 16.34 ± 8.73, respectively, p = 0.027). For pMMR tumours, nodal internal heterogeneity on CT was significantly associated with a positive lymph node status (odds ratio (OR) = 2.66, p = 0.027), while for dMMR tumours, the largest short diameter of the nodes was associated with lymph node status (OR = 2.01, p = 0.049). The best cut-off value of the largest short diameter of involved nodes was 10.4 mm for dMMR and 7.95 mm for pMMR. In the external validation cohort, AUCs for predicting involved nodes based on the largest short diameter was 0.764 for dMMR tumours using 10 mm size cut-off and 0.624 for pMMR tumours using 7 mm cut-off.


      These data show that CT imaging features of primary CC differ between dMMR and pMMR tumours, suggesting that the assessment of CT-based CC staging should take MMR status into consideration, especially for lymph node status, and thus may help in selecting patients for neoadjuvant treatment.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to European Journal of Cancer
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Korsbakke K.
        • Dahlback C.
        • Karlsson N.
        • et al.
        Tumor and nodal staging of colon cancer: accuracy of preoperative computed tomography at a Swedish high-volume center.
        Acta Radiol Open. 2019; 82058460119888713
        • Maupoey Ibanez J.
        • Pamies Guilabert J.
        • Frasson M.
        • et al.
        Accuracy of CT colonography in the preoperative staging of colon cancer: a prospective study of 217 patients.
        Colorectal Dis. 2019; 21: 1151-1163
        • So J.S.
        • Cheong C.
        • Oh S.Y.
        • et al.
        Accuracy of preoperative local staging of primary colorectal cancer by using computed tomography: reappraisal based on data collected at a highly organized cancer center.
        Ann Coloproctol. 2017; 33: 192-196
        • Nerad E.
        • Lahaye M.J.
        • Maas M.
        • et al.
        Diagnostic accuracy of CT for local staging of colon cancer: a systematic review and meta-analysis.
        AJR Am J Roentgenol. 2016; 207: 984-995
        • Foxtrot Collaborative G.
        Feasibility of preoperative chemotherapy for locally advanced, operable colon cancer: the pilot phase of a randomised controlled trial.
        Lancet Oncol. 2012; 13: 1152-1160
        • Chalabi M.
        • Fanchi L.F.
        • Dijkstra K.K.
        • et al.
        Neoadjuvant immunotherapy leads to pathological responses in MMR-proficient and MMR-deficient early-stage colon cancers.
        Nat Med. 2020; 26: 566-576
        • van den Berg I.
        • van de Weerd S.
        • Roodhart J.M.L.
        • et al.
        Improving clinical management of colon cancer through CONNECTION, a nation-wide colon cancer registry and stratification effort (CONNECTION II trial): rationale and protocol of a single arm intervention study.
        BMC Cancer. 2020; 20: 776
        • Seymour M.T.
        • Morton D.
        • Investigators obotIFT
        FOxTROT: an international randomised controlled trial in 1052 patients (pts) evaluating neoadjuvant chemotherapy (NAC) for colon cancer.
        J Clin Oncol. 2019; 37: 3504
        • Dighe S.
        • Swift I.
        • Magill L.
        • et al.
        Accuracy of radiological staging in identifying high-risk colon cancer patients suitable for neoadjuvant chemotherapy: a multicentre experience.
        Colorectal Dis. 2012; 14: 438-444
        • Karoui M.
        • Rullier A.
        • Piessen G.
        • et al.
        Perioperative FOLFOX 4 versus FOLFOX 4 plus cetuximab versus immediate surgery for high-risk stage II and III colon cancers: a phase II multicenter randomized controlled trial (PRODIGE 22).
        Ann Surg. 2020; 271: 637-645
        • Gelsomino F.
        • Barbolini M.
        • Spallanzani A.
        • et al.
        The evolving role of microsatellite instability in colorectal cancer: a review.
        Cancer Treat Rev. 2016; 51: 19-26
        • Benson 3rd, A.B.
        • Venook A.P.
        • Cederquist L.
        • et al.
        Colon cancer, version 1.2017, NCCN clinical practice guidelines in oncology.
        J Natl Compr Canc Netw. 2017; 15: 370-398
        • Buckowitz A.
        • Knaebel H.P.
        • Benner A.
        • et al.
        Microsatellite instability in colorectal cancer is associated with local lymphocyte infiltration and low frequency of distant metastases.
        Br J Cancer. 2005; 92: 1746-1753
        • Kim W.K.
        • Park M.
        • Park M.
        • et al.
        Identification and selective degradation of neopeptide-containing truncated mutant proteins in the tumors with high microsatellite instability.
        Clin Cancer Res. 2013; 19: 3369-3382
        • Wu J.
        • Zhang Q.
        • Zhao Y.
        • et al.
        Radiomics analysis of iodine-based material decomposition images with dual-energy computed tomography imaging for preoperatively predicting microsatellite instability status in colorectal cancer.
        Front Oncol. 2019; 9: 1250
        • Fan S.
        • Li X.
        • Cui X.
        • et al.
        Computed tomography-based radiomic features could potentially predict microsatellite instability status in stage II colorectal cancer: a preliminary study.
        Acad Radiol. 2019; 26: 1633-1640
        • Wu J.
        • Lv Y.
        • Wang N.
        • et al.
        The value of single-source dual-energy CT imaging for discriminating microsatellite instability from microsatellite stability human colorectal cancer.
        Eur Radiol. 2019; 29: 3782-3790
        • Japanese Society for Cancer of the C, Rectum
        Japanese classification of colorectal, appendiceal, and anal carcinoma: the 3d English Edition [Secondary Publication].
        J Anus Rectum Colon. 2019; 3: 175-195
        • Rollven E.
        • Abraham-Nordling M.
        • Holm T.
        • Blomqvist L.
        Assessment and diagnostic accuracy of lymph node status to predict stage III colon cancer using computed tomography.
        Cancer Imaging. 2017; 17: 3
        • Rollven E.
        • Blomqvist L.
        • Oistamo E.
        • et al.
        Morphological predictors for lymph node metastases on computed tomography in colon cancer.
        Abdom Radiol (NY). 2019; 44: 1712-1721
        • Kanamoto T.
        • Matsuki M.
        • Okuda J.
        • et al.
        Preoperative evaluation of local invasion and metastatic lymph nodes of colorectal cancer and mesenteric vascular variations using multidetector-row computed tomography before laparoscopic surgery.
        J Comput Assist Tomogr. 2007; 31: 831-839
        • Le D.T.
        • Uram J.N.
        • Wang H.
        • et al.
        PD-1 blockade in tumors with mismatch-repair deficiency.
        N Engl J Med. 2015; 372: 2509-2520
        • Golia Pernicka J.S.
        • Gagniere J.
        • Chakraborty J.
        • et al.
        Radiomics-based prediction of microsatellite instability in colorectal cancer at initial computed tomography evaluation.
        Abdom Radiol (NY). 2019; 44: 3755-3763
        • Lim D.R.
        • Kuk J.K.
        • Kim T.
        • Shin E.J.
        Comparison of oncological outcomes of right-sided colon cancer versus left-sided colon cancer after curative resection: which side is better outcome?.
        Medicine (Baltimore). 2017; 96e8241
        • Smyrk T.C.
        • Watson P.
        • Kaul K.
        • Lynch H.T.
        Tumor-infiltrating lymphocytes are a marker for microsatellite instability in colorectal carcinoma.
        Cancer. 2001; 91: 2417-2422
        • Phillips S.M.
        • Banerjea A.
        • Feakins R.
        • et al.
        Tumour-infiltrating lymphocytes in colorectal cancer with microsatellite instability are activated and cytotoxic.
        Br J Surg. 2004; 91: 469-475