ArticleBMC medical imaging2026
Pre-treatment MRI-derived fractal dimension as a prognostic marker in cervical cancer treated with definitive radiotherapy with or without concurrent chemotherapy.
Article in BMC medical imaging, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundPre-treatment magnetic resonance imaging (MRI) plays a central role in local staging and treatment planning for cervical cancer. Fractal dimension (FD) analysis quantifies tumor structural complexity on MRI and has emerged as a non-invasive imaging biomarker. This study aimed to evaluate the prognostic significance of MRI-derived FD in patients with cervical cancer treated with definitive radiotherapy (RT) with or without concurrent chemotherapy (CCRT).
methodsThis retrospective study included 84 patients with histologically confirmed cervical cancer treated with definitive RT, most of whom received concurrent chemotherapy (CCRT), between 2019 and 2025. FD was calculated from pre-treatment T2-weighted MRI using the box-counting method. Fractal analysis was performed on axial, coronal, and sagittal planes, and the mean FD was obtained by averaging values across all planes. Associations between FD and HPV/p16 status, baseline hemoglobin levels, FIGO stage, and tumor volume were assessed using Spearman correlation analysis. Progression-free survival (PFS) and overall survival (OS) were analyzed using Cox proportional hazards regression models.
resultsThe median FD was 1.44 (range: 1.20-1.61). FD showed a weak but statistically significant positive correlation with FIGO stage (p = 0.024) and a moderate positive correlation with tumor volume (p < 0.001). No significant associations were observed between FD and HPV/p16 status or baseline hemoglobin levels (p > 0.05). Each 0.1-unit increase in FD was significantly associated with worse OS (hazard ratio [HR] = 4.668, p < 0.001) and PFS (HR = 4.769, p < 0.001). FD was not significantly associated with local recurrence or distant metastasis.
conclusionsMRI-based fractal analysis may provide a quantitative measure of tumor morphological complexity and intratumoral heterogeneity and demonstrates a significant association with survival outcomes in cervical cancer patients treated with definitive RT or CCRT. FD analysis, derived from routine pre-treatment MRI, may complement conventional clinical parameters for risk stratification; however, further validation in larger and less selected patient cohorts is required.
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