Objective:

To evaluate whether computed tomography (CT)-derived visceral adipose tissue index (VATI) is associated with synchronous metastasis and metastasis-free survival (MFS) after curative-intent surgery in colorectal cancer (CRC), highlighting its potential significance in risk assessment.

Key Findings:

• mCRC showed higher subcutaneous adipose tissue index (SATI), VATI, and visceral-to-subcutaneous fat area ratio (VSR) than nmCRC after matching.
• VATI was independently associated with synchronous metastasis (OR, 1.110; 95% CI, 1.067–1.155; p < 0.001).
• High-VATI group had shorter MFS (log-rank p = 0.001) in the surgical nmCRC cohort.
• VATI remained independently associated with shorter MFS (HR, 1.017; 95% CI, 1.003-1.032; p = 0.021) along with CA19-9, CEA, N stage, and lymphovascular invasion (LVI).
• No statistically significant differences in body composition metrics were observed between early and late metastasis groups.

Interpretation:

Preoperative CT-derived VATI is associated with synchronous metastasis and shorter MFS after curative-intent surgery in CRC, suggesting its potential role in clinical risk stratification.

Limitations:

• The study is retrospective and may be subject to selection bias.
• Prospective validation is required before routine clinical application, and potential confounding factors should be considered.

Conclusion:

Preoperative CT-derived VATI may help refine risk stratification and postoperative surveillance in CRC, but further research is necessary.