Contemporary Guidelines for Adnexal Mass Imaging: A 2020 Update

A modified CEUS risk stratification model for adnexal masses with solid components: prospective multicenter study and risk adjustment

OBJECTIVES

To evaluate the additional advantages of integrating contrast-enhanced ultrasound (CEUS) into the Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound (US) for the characterization of adnexal lesions with solid components.

MATERIALS AND METHODS

This prospective multicenter study recruited women suspected of having adnexal lesions with solid components between September 2021 and December 2022. All patients scheduled for surgery underwent preoperative CEUS and US examinations. The lesions were categorized according to the O-RADS US system, and quantitative CEUS indexes were recorded. Pathological results served as the reference standard. Univariable and multivariable analyses were performed to identify risk factors for malignancy in adnexal lesions with solid components. Receiver operating characteristic (ROC) curve analysis was employed to assess diagnostic performance.

RESULTS

A total of 180 lesions in 175 women were included in the study. Among these masses, 80 were malignant and 100 were benign. Multivariable analysis revealed that serum CA-125, the presence of acoustic shadowing, and peak intensity (PI) ratio (PImass/PIuterus) of solid components on CEUS were independently associated with adnexal malignancy. The modified CEUS risk stratification model demonstrated superior diagnostic value in assessing adnexal lesions with solid components compared to O-RADS US (AUC: 0.91 vs 0.78, p < 0.001) and exhibited comparable performance to the Assessment of Different NEoplasias in the adnexa (ADNEX) model (AUC 0.91 vs 0.86, p = 0.07).

CONCLUSION

Our findings underscore the potential value of CEUS as an adjunctive tool for enhancing the precision of diagnostic evaluations of O-RADS US.

CLINICAL RELEVANCE STATEMENT

The promising performance of the modified CEUS risk stratification model suggests its potential to mitigate unnecessary surgeries in the characterization of adnexal lesions with solid components.

KEY POINTS

• The additional value of CEUS to O-RADS US in distinguishing between benign and malignant adnexal lesions with solid components requires further evaluation. • The modified CEUS risk stratification model displayed superior diagnostic value and specificity in characterizing adnexal lesions with solid components when compared to O-RADS US. • The inclusion of CEUS demonstrated potential in reducing the need for unnecessary surgeries in the characterization of adnexal lesions with solid components.

O-RADS MRI to classify adnexal tumors: from clinical problem to daily use

Eighteen to 35% of adnexal masses remain non-classified following ultrasonography, leading to unnecessary surgeries and inappropriate management. This finding led to the conclusion that ultrasonography was insufficient to accurately assess adnexal masses and that a standardized MRI criteria could improve these patients' management. The aim of this work is to present the different steps from the identification of the clinical issue to the daily use of a score and its inclusion in the latest international guidelines. The different steps were the following: (1) preliminary work to formalize the issue, (2) physiopathological analysis and finding dynamic parameters relevant to increase MRI performances, (3) construction and internal validation of a score to predict the nature of the lesion, (4) external multicentric validation (the EURAD study) of the score named O-RADS MRI, and (5) communication and education work to spread its use and inclusion in guidelines. Future steps will include studies at patients' levels and a cost-efficiency analysis. Critical relevance statement We present translating radiological research into a clinical application based on a step-by-step structured and systematic approach methodology to validate MR imaging for the characterization of adnexal mass with the ultimate step of incorporation in the latest worldwide guidelines of the O-RADS MRI reporting system that allows to distinguish benign from malignant ovarian masses with a sensitivity and specificity higher than 90%. Key points • The initial diagnostic test accuracy studies show the limitation of a preoperative assessment of adnexal masses using solely ultrasonography.• The technical developments (DCE/DWI) were investigated with the value of dynamic MRI to accurately predict the nature of benign or malignant lesions to improve management.• The first developing score named ADNEX MR Score was constructed using multiple easily assessed criteria on MRI to classify indeterminate adnexal lesions following ultrasonography.• The multicentric adnexal study externally validated the score creating the O-RADS MR score and leading to its inclusion for daily use in international guidelines.

Characterization of adnexal lesions using photoacoustic imaging to improve sonographic O-RADS risk assessment

OBJECTIVE

To assess the impact of photoacoustic imaging (PAI) on the assessment of ovarian/adnexal lesion(s) of different risk categories using the sonographic ovarian-adnexal imaging-reporting-data system (O-RADS) in women undergoing planned oophorectomy.

METHOD

This prospective study enrolled women with ovarian/adnexal lesion(s) suggestive of malignancy referred for oophorectomy. Participants underwent clinical ultrasound (US) examination followed by coregistered US and PAI prior to oophorectomy. Each ovarian/adnexal lesion was graded by two radiologists using the US O-RADS scale. PAI was used to compute relative total hemoglobin concentration (rHbT) and blood oxygenation saturation (%sO2 ) colormaps in the region of interest. Lesions were categorized by histopathology into malignant ovarian/adnexal lesion, malignant Fallopian tube only and several benign categories, in order to assess the impact of incorporating PAI in the assessment of risk of malignancy with O-RADS. Malignant and benign histologic groups were compared with respect to rHbT and %sO2 and logistic regression models were developed based on tumor marker CA125 alone, US-based O-RADS alone, PAI-based rHbT with %sO2 , and the combination of CA125, O-RADS, rHbT and %sO2. Areas under the receiver-operating-characteristics curve (AUC) were used to compare the diagnostic performance of the models.

RESULTS

There were 93 lesions identified on imaging among 68 women (mean age, 52 (range, 21-79) years). Surgical pathology revealed 14 patients with malignant ovarian/adnexal lesion, two with malignant Fallopian tube only and 52 with benign findings. rHbT was significantly higher in malignant compared with benign lesions. %sO2 was lower in malignant lesions, but the difference was not statistically significant for all benign categories. Feature analysis revealed that rHbT, CA125, O-RADS and %sO2 were the most important predictors of malignancy. Logistic regression models revealed an AUC of 0.789 (95% CI, 0.626-0.953) for CA125 alone, AUC of 0.857 (95% CI, 0.733-0.981) for O-RADS only, AUC of 0.883 (95% CI, 0.760-1) for CA125 and O-RADS and an AUC of 0.900 (95% CI, 0.815-0.985) for rHbT and %sO2 in the prediction of malignancy. A model utilizing all four predictors (CA125, O-RADS, rHbT and %sO2 ) achieved superior performance, with an AUC of 0.970 (95% CI, 0.932-1), sensitivity of 100% and specificity of 82%.

CONCLUSIONS

Incorporating the additional information provided by PAI-derived rHbT and %sO2 improves significantly the performance of US-based O-RADS in the diagnosis of adnexal lesions. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Value of deep-learning image reconstruction at submillisievert CT for evaluation of the female pelvis

AIM

To assess the value of deep-learning reconstruction (DLR) at submillisievert computed tomography (CT) for the evaluation of the female pelvis, with standard dose (SD) hybrid iterative reconstruction (IR) images as reference.

MATERIALS AND METHODS

The present study enrolled 50 female patients consecutively who underwent contrast-enhanced abdominopelvic CT for clinically indicated reasons. Submillisievert pelvic images were acquired using a noise index of 15 for low-dose (LD) scans, which were reconstructed with DLR (body and body sharp), hybrid-IR, and model-based IR (MBIR). Additionally, SD scans were reconstructed with a noise index of 7.5 using hybrid-IR. Radiation dose, quantitative image quality, overall image quality, image appearance using a five-point Likert scale (1-5: worst to best), and lesion evaluation in both SD and LD images were analysed and compared.

RESULTS

The submillisievert pelvic CT examinations showed a 61.09 ± 4.13% reduction in the CT dose index volume compared to SD examinations. Among the LD images, DLR (body sharp) had the highest quantitative quality, followed by DLR (body), MBIR, and hybrid-IR. LD DLR (body) had overall image quality comparable to the reference (p=0.084) and favourable image appearance (p=0.209). In total, 40 pelvic lesions were detected in both SD and LD images. LD DLR (body and body sharp) exhibited similar diagnostic confidence (p=0.317 and 0.096) compared with SD hybrid-IR.

CONCLUSION

DLR algorithms, providing comparable image quality and diagnostic confidence, are feasible in submillisievert abdominopelvic CT. The DLR (body) algorithm with favourable image appearance is recommended in clinical settings.

O-RADS combined with contrast-enhanced ultrasound in risk stratification of adnexal masses

BACKGROUND

Ovarian-Adnexal Reporting and Data System (O-RADS) for ultrasound is a lexicon and risk stratification system that includes all risk categories and relevant management recommendation. It has high sensitivity in diagnosing malignant adnexal tumors, but the specificity is lower.

OBJECTIVE

To explore the value of O-RADS combined with contrast-enhanced ultrasound (CEUS) in risk stratification of adnexal masses.

METHODS

A retrospective study was performed on 85 patients with 100 adnexal masses that preoperatively underwent conventional ultrasound as well as CEUS examination and obtained the postoperative pathological results. The masses were classified into O-RADS2, 3, 4, and 5 by conventional ultrasound. After contrast enhancement, the classification of O-RADS was adjusted according to CEUS imaging features. The O-RADS 2 and 3 lesions with suspected malignant features like irregular blood vessels or internal inhomogeneous hyperenhancement were upgraded to O-RADS 4, and the O-RADS 4 lesions with the above features were upgraded to O-RADS 5. The O-RADS 4 lesions with suspicious benign angiographic features like a regular vessel, interior hypoenhancement or non-enhancement were downgraded to O-RADS 3; the O-RADS 5 lesions with rim ring-enhancement and interior non-enhancement were downgraded to O-RADS 3. The sensitivity, specificity, accuracy, PPV, NPV, and AUC of the two methods were compared, taking pathological results as the gold standard.

RESULTS

The sensitivity, specificity, accuracy, PPV, NPV, and AUC of O-RADS and O-RADS combined with CEUS in the diagnosis of malignant adnexal tumors were 96.6%, 66.2%, 75.0%, 53.8%, 97.9%, 0.910 and 96.6%, 91.5%, 93.0%, 82.4%, 98.5%, 0.962, respectively. The specificity, accuracy, PPV, and AUC of O-RADS combined with CEUS were considerably higher than those of O-RADS (P < 0.01). Furthermore, both methods had excellent sensitivity and NPV but there were no significant differences between them(P > 0.05).

CONCLUSION

Combination of O-RADS and CEUS can significantly improve the specificity and PPV in diagnosing malignant adnexal tumors. It seems promising in the clinical application of risk stratification of adnexal masses.

Predictive accuracy and reproducibility of the O-RADS US scoring system among sonologists with different training levels

PURPOSE

To investigate the predictive performance and reproducibility of Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound (US) system in evaluating adnexal masses between sonologists with varying levels of expertise.

METHODS

This was a single-center retrospective study conducted between May 2019 and May 2020, which included 147 adnexal mases with pathological results. Four sonologists with varying experiences independently assigned an O-RADS US category to each adnexal mass twice. The intra- and inter-observer agreement was assessed using weighted kappa values. The area under the curve (AUC), sensitivity, specificity, positive and negative predictive value (PPV and NPV) were assessed for each sonologist.

RESULTS

Of the 147 adnexal mases, 115 (78.2%) lesions were benign and 32 (21.8%) lesions were malignant. Considering O-RADS > 3 as a predictor for adnexal malignancy, the predictive accuracies of the four sonologists were excellent, with AUCs ranging from 0.831 to 0.926. The predictive accuracies of O-RADS US by experienced sonologists were significantly higher compared to inexperienced sonologists (all P values < 0.005). The O-RADS US presented high sensitivity and NPV value for each sonologist. With regard to the reproducibility of O-RADS, the intra- and inter-observer agreement among experienced sonologists performed better than inexperienced sonologists.

CONCLUSION

O-RADS showed difference in the predictive accuracy and reproducibility in the evaluation of adnexal masses among sonologists with different levels of expertise. Training is required for inexperienced sonologists before the generalization of O-RADS classification system in clinical practice.

Diagnostic Performance of Ultrasonography-Based Risk Models in Differentiating Between Benign and Malignant Ovarian Tumors in a US Cohort

Importance

Ultrasonography-based risk models can help nonexpert clinicians evaluate adnexal lesions and reduce surgical interventions for benign tumors. Yet, these models have limited uptake in the US, and studies comparing their diagnostic accuracy are lacking.

Objective

To evaluate, in a US cohort, the diagnostic performance of 3 ultrasonography-based risk models for differentiating between benign and malignant adnexal lesions: International Ovarian Tumor Analysis (IOTA) Simple Rules with inconclusive cases reclassified as malignant or reevaluated by an expert, IOTA Assessment of Different Neoplasias in the Adnexa (ADNEX), and Ovarian-Adnexal Reporting and Data System (O-RADS).

Design, Setting, and Participants

This retrospective diagnostic study was conducted at a single US academic medical center and included consecutive patients aged 18 to 89 years with adnexal masses that were managed surgically or conservatively between January 2017 and October 2022.

Exposure

Evaluation of adnexal lesions using the Simple Rules, ADNEX, and O-RADS.

Main Outcomes and Measures

The main outcome was diagnostic performance, including area under the receiver operating characteristic (ROC) curve (AUC), sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios. Surgery or follow-up were reference standards. Secondary analyses evaluated the models' performances stratified by menopause status and race.

Results

The cohort included 511 female patients with a 15.9% malignant tumor prevalence (81 patients). Mean (SD) ages of patients with benign and malignant adnexal lesions were 44.1 (14.4) and 52.5 (15.2) years, respectively, and 200 (39.1%) were postmenopausal. In the ROC analysis, the AUCs for discriminative performance of the ADNEX and O-RADS models were 0.96 (95% CI, 0.93-0.98) and 0.92 (95% CI, 0.90-0.95), respectively. After converting the ADNEX continuous individualized risk into the discrete ordinal categories of O-RADS, the ADNEX performance was reduced to an AUC of 0.93 (95% CI, 0.90-0.96), which was similar to that for O-RADS. The Simple Rules combined with expert reevaluation had 93.8% sensitivity (95% CI, 86.2%-98.0%) and 91.9% specificity (95% CI, 88.9%-94.3%), and the Simple Rules combined with malignant classification had 93.8% sensitivity (95% CI, 86.2%-98.0%) and 88.1% specificity (95% CI, 84.7%-91.0%). At a 10% risk threshold, ADNEX had 91.4% sensitivity (95% CI, 83.0%-96.5%) and 86.3% specificity (95% CI, 82.7%-89.4%) and O-RADS had 98.8% sensitivity (95% CI, 93.3%-100%) and 74.4% specificity (95% CI, 70.0%-78.5%). The specificities of all models were significantly lower in the postmenopausal group. Subgroup analysis revealed high performances independent of race.

Conclusions and Relevance

In this diagnostic study of a US cohort, the Simple Rules, ADNEX, and O-RADS models performed well in differentiating between benign and malignant adnexal lesions; this outcome has been previously reported primarily in European populations. Risk stratification models can lead to more accurate and consistent evaluations of adnexal masses, especially when used by nonexpert clinicians, and may reduce unnecessary surgeries.

Exploiting the Potential of Photon-Counting CT in Abdominal Imaging

ABSTRACT

Photon-counting computed tomography (PCCT) imaging uses a new detector technology to provide added information beyond what can already be obtained with current CT and MR technologies. This review provides an overview of PCCT of the abdomen and focuses specifically on applications that benefit the most from this new imaging technique. We describe the requirements for a successful abdominal PCCT acquisition and the challenges for clinical translation. The review highlights work done within the last year with an emphasis on new protocols that have been tested in clinical practice. Applications of PCCT include imaging of cystic lesions, sources of bleeding, and cancers. Photon-counting CT is positioned to move beyond detection of disease to better quantitative staging of disease and measurement of treatment response.

Comparative Study of the Efficacy of the Ovarian-Adnexa Reporting and Data System Ultrasound Combined With Contrast-Enhanced Ultrasound and the ADNEX MR Scoring System in the Diagnosis of Adnexal Masses

OBJECTIVE

The aims of this study were to develop the Ovarian-Adnexa Reporting and Data System (O-RADS) and O-RADS + contrast-enhanced ultrasound (O-RADS CEUS) scoring system to distinguish adnexal masses (AMs) and to compare the diagnostic efficacy of these systems with that of a magnetic resonance imaging scoring system (ADNEX MR).

METHODS

We retrospectively evaluated 278 ovarian masses from 240 patients between May 2017 and July 2022. Pathology and adequate follow-up were used as reference standards for comparing the validity of O-RADS, O-RADS CEUS and ADNEX MR scoring to diagnose AMs. Area under the curve (AUC), sensitivity and specificity were calculated. The inter-class correlation coefficient (ICC) was calculated to evaluate inter-reader agreement (IRA) between the two sonographers and two radiologists who analyzed the findings with the three modalities.

RESULTS

The AUCs of O-RADS, O-RADS CEUS and ADNEX MR scores were 0.928 (95% confidence interval [CI]: 0.895-0.956), 0.951(95% CI: 0.919-0.973) and 0.964 (95% CI: 0.935-0.983), respectively. Their sensitivities were 95.7%, 94.3 and 91.4%, and their specificities were 81.3%, 92.3% and 97.1%, respectively. The three modalities had accuracies of 84.9%, 92.8% and 95.7%, respectively. O-RADS had the highest sensitivity but significantly lower specificity (p < 0.001), whereas the ADNEX MR scoring had the highest specificity (p < 0.001) but lower sensitivity (p < 0.001). O-RADS CEUS had intermediate sensitivity and specificity (p < 0.001).

CONCLUSION

The addition of CEUS significantly improves the efficacy of O-RADS in diagnosing AMs. The diagnostic efficacy of the combination is comparable to that of the ADNEX MR scoring system.

Performance of IOTA Simple Rules Risks, ADNEX Model, Subjective Assessment Compared to CA125 and HE4 with ROMA Algorithm in Discriminating between Benign, Borderline and Stage I Malignant Adnexal Lesions

BACKGROUND

Borderline ovarian tumors (BOTs) and early clinical stage malignant adnexal masses can make sonographic diagnosis challenging, while the clinical utility of tumor markers, e.g., CA125 and HE4, or the ROMA algorithm, remains controversial in such cases.

OBJECTIVE

To compare the IOTA group Simple Rules Risk (SRR), the ADNEX model and the subjective assessment (SA) with serum CA125, HE4 and the ROMA algorithm in the preoperative discrimination between benign tumors, BOTs and stage I malignant ovarian lesions (MOLs).

METHODS

A multicenter retrospective study was conducted with lesions classified prospectively using subjective assessment and tumor markers with the ROMA. The SRR assessment and ADNEX risk estimation were applied retrospectively. The sensitivity, specificity, positive and negative likelihood ratios (LR+ and LR-) were calculated for all tests.

RESULTS

In total, 108 patients (the median age: 48 yrs, 44 postmenopausal) with 62 (79.6%) benign masses, 26 (24.1%) BOTs and 20 (18.5%) stage I MOLs were included. When comparing benign masses with combined BOTs and stage I MOLs, SA correctly identified 76% of benign masses, 69% of BOTs and 80% of stage I MOLs. Significant differences were found for the presence and size of the largest solid component (p = 0.0006), the number of papillary projections (p = 0.01), papillation contour (p = 0.008) and IOTA color score (p = 0.0009). The SRR and ADNEX models were characterized by the highest sensitivity (80% and 70%, respectively), whereas the highest specificity was found for SA (94%). The corresponding likelihood ratios were as follows: LR+ = 3.59 and LR- = 0.43 for the ADNEX; LR+ = 6.40 and LR- = 0.63 for SA and LR+ = 1.85 with LR- = 0.35 for the SRR. The sensitivity and specificity of the ROMA test were 50% and 85%, respectively, with LR+ = 3.44 and LR- = 0.58. Of all the tests, the ADNEX model had the highest diagnostic accuracy of 76%.

CONCLUSIONS

This study demonstrates the limited value of diagnostics based on CA125 and HE4 serum tumor markers and the ROMA algorithm as independent modalities for the detection of BOTs and early stage adnexal malignant tumors in women. SA and IOTA methods based on ultrasound examination may present superior value over tumor marker assessment.

Does Combing O-RADS US and CA-125 Improve Diagnostic Accuracy in Assessing Adnexal Malignancy Risk in Women With Different Menopausal Status?

OBJECTIVES

To evaluate the individual and combined performances of the Ovarian-adnexal Reporting and Data System Ultrasound (O-RADS US) and serum cancer antigen 125 (CA-125) in assessing adnexal malignancy risk in women with different menopausal status.

METHODS

This retrospective study included patients with adnexal masses scheduled for surgery based on their preoperative US and histopathology results between January 2018 and January 2020. O-RADS were used to assess adnexal malignancy by two experienced radiologists. The area under the receiver operating characteristic curves (AUCs) were used to compare the accuracy of O-RADS and a combination of O-RADS and CA-125. The weighted κ index was used to evaluate the inter-reviewer agreement.

RESULTS

Overall, the data of 443 lesions in 443 patients were included, involving 312 benign lesions and 131 malignant lesions. There were 361 premenopausal and 82 postmenopausal patients. The inter-reviewer agreement for the two radiologists was very good (weighted κ: 0.833). Combing O-RADS US and CA-125 significantly increased diagnostic accuracy for classifying malignant from benign adnexal masses, compared with O-RADS US alone (AUC: 0.97 vs 0.95, P < .001 for premenopausal population and AUC: 0.93 vs 0.85, P < .001 for postmenopausal population). The AUCs of O-RADS with and without CA-125 ranged from 0.50 to 0.99 for different adnexal pathology subtypes (ie, benign, borderline, Stage I-IV, and metastatic tumors).

CONCLUSION

The addition of CA-125 helps improve discrimination of O-RADS US between benign and malignant adnexal masses, especially in postmenopausal women.

Spectrum of Ovarian Incidentalomas: Diagnosis and Management

Incidental ovarian lesions are asymptomatic lesions that are accidentally discovered during a CT or MRI examinations that involves the pelvic cavity or during a routine obstetric ultrasound study. Incidental ovarian masses are usually benign with a very low risk of malignancy yet underlying malignant pathology may be discovered during the diagnostic work-up of these lesions. Suspicion of malignancy is directly correlating with the increase in the patient's age, the increase in the size of the lesion, the presence of the solid components or thick septa and a high color scale of the ovarian mass. Following standard reporting and management protocols are essential to choose the proper work-up of these lesions to avoid unnecessary additional imaging and operative intervention. In this article, we will provide a review of the characteristic imaging features of some incidental and yet commonly encountered ovarian lesions. We will also summarize the recently published algorithms that are important for consistent reporting and standard management of these lesions.

O-RADS MRI: A Systematic Review and Meta-Analysis of Diagnostic Performance and Category-wise Malignancy Rates

Background US-indeterminate adnexal lesions remain an important indication for gynecologic surgery. MRI can serve as a problem-solving tool through the use of the Ovarian-Adnexal Imaging Reporting and Data System (O-RADS) MRI lexicon, which is based on the ADNEX MR scoring system. Purpose To perform a systematic review and meta-analysis of the diagnostic performance of pelvic MRI interpreted using the ADNEX or O-RADS MRI stratification systems to characterize US-indeterminate adnexal lesions and of the category-wise malignancy rates. Materials and Methods A systematic literature search from May 2013 (publication of the ADNEX MR score) to September 2022 was performed. Studies reporting the use of pelvic MRI interpreted with the ADNEX or O-RADS MRI systems to characterize US-indeterminate adnexal lesions, with pathologic examination and/or follow-up as the reference standard, were included. Summary estimates of diagnostic performance were obtained with the bivariate random-effects model, while category-wise summary malignancy rates of O-RADS MRI 2, 3, 4, and 5 lesions were obtained with a random-effects model. Effects of covariates on heterogeneity and diagnostic performance were investigated through meta-regression. Results Thirteen study parts from 12 studies (3731 women, 4520 adnexal lesions) met the inclusion criteria. Diagnostic performance meta-analysis for 4012 lesions found a 92% summary sensitivity (95% CI: 88, 95) and a 91% summary specificity (95% CI: 89, 93). The meta-analysis of malignancy rates for 3641 lesions showed summary malignancy rates of 0.1% (95% CI: 0, 1) among O-RADS MRI 2 lesions, 6% (95% CI: 3, 9) among O-RADS MRI 3 lesions, 60% (95% CI: 52, 67) among O-RADS MRI 4 lesions, and 96% (95% CI: 92, 99) among O-RADS MRI 5 lesions. Conclusion Pelvic MRI interpreted with the Ovarian-Adnexal Reporting and Data System (O-RADS) MRI lexicon had high diagnostic performance for the characterization of US-indeterminate adnexal lesions. Summary estimates of malignancy rates in the O-RADS MRI 4 and O-RADS MRI 5 categories were higher than predicted ones. © RSNA, 2022 Supplemental material is available for this article. See also the editorial by Lee and Kang in this issue.

Ovarian Cancer Detection in Average-Risk Women: Classic- versus Nonclassic-appearing Adnexal Lesions at US

Background Several US risk stratification schemas for assessing adnexal lesions exist. These multiple-subcategory systems may be more multifaceted than necessary for isolated adnexal lesions in average-risk women. Purpose To explore whether a US-based classification scheme of classic versus nonclassic appearance can be used to help appropriately triage women at average risk of ovarian cancer without compromising diagnostic performance. Materials and Methods This retrospective multicenter study included isolated ovarian lesions identified at pelvic US performed between January 2011 and June 2014, reviewed between September 2019 and September 2020. Lesions were considered isolated in the absence of ascites or peritoneal implants. Lesions were classified as classic or nonclassic based on sonographic appearance. Classic lesions included simple cysts, hemorrhagic cysts, endometriomas, and dermoids. Otherwise, lesions were considered nonclassic. Outcomes based on histopathologic results or clinical or imaging follow-up were recorded. Diagnostic performance and frequency of malignancy were calculated. Frequency of malignancy between age groups was compared using the χ² test, and Poisson regression was used to explore relationships between imaging features and malignancy. Results A total of 970 isolated lesions in 878 women (mean age, 42 years ± 14 [SD]) were included. The malignancy rate for classic lesions was less than 1%. Of 970 lesions, 53 (6%) were malignant. The malignancy rate for nonclassic lesions was 32% (33 of 103) when blood flow was present and 8% (16 of 194) without blood flow (P < .001). For women older than 60 years, the malignancy rate was 50% (10 of 20 lesions) when blood flow was present and 13% (five of 38) without blood flow (P = .004). The sensitivity, specificity, positive predictive value, and negative predictive value of the classic-versus-nonclassic schema was 93% (49 of 53 lesions), 73% (669 of 917 lesions), 17% (49 of 297 lesions), and 99% (669 of 673 lesions), respectively, for detection of malignancy. Conclusion Using a US classification schema of classic- or nonclassic-appearing adnexal lesions resulted in high sensitivity and specificity in the diagnosis of malignancy in ovarian cancer. The highest risk of cancer was in isolated nonclassic lesions with blood flow in women older than 60 years. © RSNA, 2022 See also the editorial by Baumgarten in this issue.

Predictors of malignancy in incidental adnexal lesions identified on CT in patients with prior non-ovarian cancer

PURPOSE

To identify imaging features in incidental adnexal lesions which are associated with malignancy on portal venous phase contrast-enhanced CT in patients with known non-ovarian cancer.

MATERIALS AND METHODS

This IRB-approved, HIPAA-compliant retrospective study was performed at a tertiary cancer center. Portal venous phase contrast-enhanced CT from January 2010 to December 2015 was reviewed to identify women with non-ovarian malignancy and incidental adnexal lesion, with mean 18 months (range 1-80 months) to definitive diagnosis or last imaging follow-up. Imaging features of adnexal lesions were recorded (size, laterality, shape, attenuation, and composition) and correlated with outcome (benign or malignant) using univariate and multivariate logistic regression analysis. A point-based system was used to predict likelihood of malignancy.

RESULTS

Of 276 women (mean age 45 years), 216 (78.3%) had benign lesions, 58 (21.0%) ovarian metastasis, and 2 (0.7%) had primary ovarian malignancy. On logistic regression model, lesion size > 5 cm (p-value, OR, 95% CI 0.01, 9.11, 1.70-48.87), bilaterality (< 0.0001, 28.34, 7.46-107.67), irregular shape (0.01, 12.31, 1.61-94.05), higher-than-simple-fluid attenuation (< 0.0001, 28.27, 5.65-141.59), and heterogeneous composition (0.0017, 10.75, 2.45-47.23) were associated with malignant outcome (AUC 0.97). A point-based system incorporating these five features (possible 0-5 points) had AUC of 0.97. Rate of malignancy was 0% (0/147) if none of the features of malignancy were present, 12.7% (8/63) if one feature was present, 51.7% (15/29) if two features were present, and 100% (37/37) if three or more features present.

CONCLUSION

Risk of malignancy of incidental adnexal lesions in women with prior non-ovarian cancer can be estimated based on lesion features seen on portal venous phase contrast-enhanced CT.

Giant Ovarian Cysts Treated by Single-Port Laparoscopic Surgery: A Case Series

Background

Ovarian cysts are very common diseases of the female reproductive system. Giant ovarian cysts refer to the tumors with diameters greater than 10 cm. In recent years, due to the development of clinical diagnosis, imaging modalities, and the improvement of patients’ cognition of the diseases, the occurrence of giant ovarian cysts has become rare. The purpose of this study was to show a new operation method of single-port laparoscopy to treat giant ovarian cysts.

Methods

We report a case series of five patients with giant ovarian cysts who underwent single-port laparoscopic surgery in the gynecology department of the Shengjing Hospital of China Medical University between June 2020 and March 2021. The inclusion criteria were ovarian cysts at least 20 cm in diameter, and cases when the tumor might be malignant were excluded.

Results

The patients’ mean age was 26.2years. The most common clinical presentation was progressive abdominal distension. Median size of the cysts at imaging was 39.2 cm (range 21–63 cm). All patients underwent single-port laparoscopic surgery, and none of them converted to laparotomy. On final pathological reports, two cysts were serous cystadenomas, and three were mucinous cystadenomas. All patients recovered well and were discharged on time.

Conclusion

Giant ovarian cysts can be treated by single-port laparoscopic surgery. In addition to the well-known advantages of laparoscopic surgery (e.g., small pelvic interference, fast postoperative recovery), it can also play the role of perfect cosmetic results, which has more advantages for young women.

Ovary: MRI characterisation and O-RADS MRI

Ultrasound has a high specificity for the diagnosis of a benign lesion in cases of classic appearing simple cyst, hemorrhagic cyst, endometrioma and dermoid. However, ultrasound can sometimes be limited for definitive characterisation and risk stratification of other types of lesions, including those with echogenic content that may appear solid, with or without blood flow. Frequently, MRI can be used to further characterise these types of lesions, due to its ability to distinguish solid tissue from non-tissue solid components such as fat, blood, or debris. Incorporating the MR imaging into the evaluation of adnexal lesions can improve diagnostic certainty and guide clinical management potentially avoiding inappropriate surgery for benign lesions and expediting appropriate treatment for malignant lesions, particularly in the females with sonographically indeterminate adnexal lesions.