External validation of the MR imaging scoring system for the management of adnexal masses

ACR Appropriateness Criteria® Clinically Suspected Adnexal Mass, No Acute Symptoms: 2023 Update

Asymptomatic adnexal masses are commonly encountered in daily radiology practice. Although the vast majority of these masses are benign, a small subset have a risk of malignancy, which require gynecologic oncology referral for best treatment outcomes. Ultrasound, using a combination of both transabdominal, transvaginal, and duplex Doppler technique can accurately characterize the majority of these lesions. MRI with and without contrast is a useful complementary modality that can help characterize indeterminate lesions and assess the risk of malignancy is those that are suspicious. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

O-RADS MRI scoring system: key points for correct application in inexperienced hands

OBJECTIVES

To evaluate the efficacy of the O-RADS MRI criteria in the stratification of risk of malignancy of solid or sonographically indeterminate ovarian masses and assess the interobserver agreement of this classification between experienced and inexperienced radiologists.

METHODS

This single-centre retrospective study included patients from 2019 to 2022 with sonographically indeterminate or solid ovarian masses who underwent MRI with a specific protocol for characterisation according to O-RADS MRI specifications. Each study was evaluated using O-RADS lexicon by two radiologists, one with 17 years of experience in gynaecological radiology and another with 4 years of experience in general radiology. Findings were classified as benign, borderline, or malignant according to histology or stability over time. Diagnostic performance and interobserver agreement were assessed.

RESULTS

A total of 183 patients with US indeterminate or solid adnexal masses were included. Fifty-seven (31%) did not have ovarian masses, classified as O-RADS 1. The diagnostic performance for scores 2-5 was excellent with a sensitivity, specificity, PPV, and NPV of 97.4%, 100%, 96.2%, and 100%, respectively by the experienced radiologist and 96.1%, 92.0%, 93.9%, and 94.8% by the inexperienced radiologist. Interobserver concordance was very high (Kappa index 0.92). Almost all the misclassified cases were due to misinterpretation of the classification similar to reports in the literature.

CONCLUSION

The diagnostic performance of O-RADS MRI determined by either experienced or inexperienced radiologists is excellent, facilitating decision-making with high diagnostic accuracy and high reproducibility. Knowledge of this classification and use of assessment tools could avoid frequent errors due to misinterpretation.

CRITICAL RELEVANCE STATEMENT

Up to 31% of ovarian masses are considered indeterminate by transvaginal US and 32% of solid lesions considered malignant by transvaginal US are benign. The O-RADs MRI accurately classifies these masses, even when used by inexperienced radiologists, thereby avoiding incorrect surgical approaches.

KEY POINTS

• O-RADS MRI accurately classifies indeterminate and solid ovarian masses by ultrasound. • There is excellent interobserver agreement between experienced and non-experienced radiologists. • O-RADS MRI is a helpful tool to assess clinical decision-making in ovarian tumours.

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.

Modified MR scoring system for assessment of sonographically indeterminate ovarian and adnexal masses in the absence of dynamic contrast-enhanced

OBJECTIVES

Dynamic contrast-enhanced (DCE) MRI is not available in all imaging centres to investigate adnexal masses. We proposed modified magnetic resonance (MR) scoring system based on an assessment of the enhancement of the solid tissue on early phase postcontrast series and diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) map and investigated the validity of this protocols in the current study.

MATERIALS AND METHODS

In this cross-sectional retrospective study, pelvic MRI of a total of 245 patients with 340 adnexal masses were studied based on the proposed modified scoring system and ADNEX MR scoring system.

RESULTS

Modified scoring system with the sensitivity of 87.3% and specificity of 94.6% has an accuracy of 92.1%. Sensitivity, specificity, and accuracy of ADNEX MR scoring system is 96.6%, 91%, and 92.9%, respectively. The area under the receiver operating characteristic curve for the modified scoring system and ADNEX MR scoring system is 0.909 (with 0.870-0.938 95% confidence interval [CI]) and 0.938 (with 0.907-0.961 95% CI), respectively. Pairwise comparison of these area under the curves showed no significant difference (P = .053).

CONCLUSIONS

Modified scoring system is less sensitive than the ADNEX MR scoring system and more specific but the accuracy is not significantly different.

ADVANCES IN KNOWLEDGE

According to our study, MR scoring system based on subjective assessment of the enhancement of the solid tissue on early phase postcontrast series and DWI with ADC map could be applicable in imaging centres that DCE is not available.

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.

Ovarian-Adnexal Reporting and Data System for Magnetic Resonance Imaging (O-RADS MRI): Genesis and Future Directions

Imaging plays an important role in characterizing and risk-stratifying commonly encountered adnexal lesions. Recently, the American College of Radiology (ACR) released the Ovarian-Adnexal Reporting and Data System (O-RADS) for ultrasound and subsequently for magnetic resonance imaging (MRI). The goal of the recently developed ACR O-RADS MRI risk stratification system is to improve the quality of imaging reports as well as the reproducibility of evaluating adnexal lesions on MRI. This review focuses on exploring this new system and its future refinements.

Impact of DWI and ADC values in Ovarian-Adnexal Reporting and Data System (O-RADS) MRI score

PURPOSE

Introduce DWI and quantitative ADC evaluation in O-RADS MRI system and observe how diagnostic performance changes. Assess its validity and reproducibility between readers with different experience in female pelvic imaging. Finally, evaluate any correlation between ADC value and histotype in malignant lesions.

MATERIALS AND METHODS

In total, 173 patients with 213 indeterminate adnexal masses (AMs) on ultrasound were subjected to MRI examination, from which 140 patients with 172 AMs were included in the final analysis. Standardised MRI sequences were used, including DWI and DCE sequences. Two readers, blinded to histopathological data, retrospectively classified AMs according to the O-RADS MRI scoring system. A quantitative analysis method was applied by placing a ROI on the ADC maps obtained from single-exponential DWI sequences. AMs considered benign (O-RADS MRI score 2) were excluded from the ADC analysis.

RESULTS

Excellent inter-reader agreement was found in the classification of lesions according to the O-RADS MRI score (K = 0.936; 95% CI). Two ROC curves were created to determine the optimal cut-off value for the ADC variable between O-RADS MRI categories 3-4 and 4-5, respectively, 1.411 × 10^-3 mm²/sec and 0.849 × 10^-3 mm²/sec. Based on these ADC values, 3/45 and 22/62 AMs were upgraded, respectively, to score 4 and 5, while 4/62 AMs were downgraded to score 3. ADC values correlated significantly with the ovarian carcinoma histotype (p value < 0.001).

CONCLUSION

Our study demonstrates the prognostic potential of DWI and ADC values in the O-RADS MRI classification for better radiological standardisation and characterisation of AMs.

Accuracy and reproducibility of the O-RADS MRI risk stratification system based on enhanced non-DCE MRI in the assessment of adnexal masses

OBJECTIVE

Evaluation of the diagnostic performance and reproducibility of the Ovarian-Adnexal Reporting and Data System (O-RADS) Magnetic Resonance Imaging (MRI) risk stratification system based on enhanced non-dynamic contrast-enhanced (non-DCE) MRI in the diagnosis of adnexal masses.

METHODS

Patients who underwent conventional pelvic enhanced non-DCE MRI examination within one month prior to surgery formed the study population. Two experienced radiologists independently evaluated the images and assigned a score according to the O-RADS MRI risk stratification system. One of the radiologists reviewed the images and reassigned the scores after three months. Intra- and inter-observer agreement was evaluated with the k coefficient value. The adnexal masses that attained scores between 1 and 3 were considered benign, while those with scores of 4 or 5 were considered malignant. Analyses were conducted to determine the sensitivity, specificity, positive and negative predictive values, and receiver operating characteristic (ROC) curve, which were then used for evaluating the diagnostic efficacy of the developed system based on enhanced non-DCE MRI scan. The reference standard was histology.

RESULTS

A total of 308 patients (mean age: 42.09 ± 12.42 years, age range: 20-84 years) were enrolled in the study. Among the 362 adnexal masses from the included patients, there were 320 benign masses and 42 malignant masses. In the case of three readers, there were no malignant tumors scored 1-2. The O-RADS MRI score ≥ 4 was associated with malignancy resulted in a good diagnostic efficacy with the areas under the curve (AUC) values of 0.918 (95 % CI, 0.864-0.972), 0.905 (95 % CI, 0.842-0.968), and 0.882 (95 % CI, 0.815-0.950), the sensitivity values of 90.5 % (95 % CI, 87.5-93.5 %), 85.7 % (95 % CI, 82.1-89.3 %), and 83.3 % (95 % CI, 79.5-87.2 %), and the specificity values of 93.1 % (95 % CI, 90.5-95.7 %), 95.3 % (95 % CI, 93.1-97.5 %), and 93.1 % (95 % CI, 90.5-95.7 %) obtained for the three readers, respectively. Excellent intra-observer agreement and inter-observer agreement were observed with the k values of 0.883 (95 % CI, 0.814-0.952) and 0.848 (95 % CI, 0.770-0.926), respectively.

CONCLUSIONS

The O-RADS MRI risk stratification system based on enhanced non-DCE MRI scans exhibited high accuracy and reproducibility in the prediction of adnexal masses malignancy. Enhanced non-DCE MRI scan may offer an alternative diagnostic tool when DCE is not possible.

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.

Diagnostic Accuracies of the Ultrasound and Magnetic Resonance Imaging ADNEX Scoring Systems For Ovarian Adnexal Mass: Systematic Review and Meta-Analysis

We conducted a meta-analysis of IOTA (international ovarian tumor analysis) ADNEX (Assessment of Different NEoplasias in the adneXa) as ultrasound system and MRI (magnetic resonance imaging) ADNEX scoring systems as MR system to assess their diagnostic test accuracy for differentiating benign from malignant adnexal masses of the ovary. We performed an electronic search for relevant publications in the English language up to February 2021 using PubMed, CENTRAL (Cochrane Central Register of Controlled Trials), Web of Science, and Google scholar databases and search engines. We computed the pooled sensitivity, pooled specificity, and summary receiver operating characteristics curve (SROC) using the statistical software STATA (Version 13, College Station, TX, StataCorp LP). Based on 11 studies using IOTA-ADNEX, we observed pooled sensitivity, specificity, area under curve, and diagnostic odds ratio were 96% (95% CI, 94% to 97%), 79% (95% CI, 70% to 86 %), 97% (95% CI, 95% to 98%), and 88 (95% CI, 43 to 180). Based on five studies using MR-ADNEX scoring system the pooled sensitivity, specificity, area under curve and diagnostic odds ratio were 91 % (95% CI, 87% to 94 %), 95% (95% CI, 92% to 97 %), 98% (95% CI, 96% to 99%), and 189 (95% CI, 90 to 396) respectively. Our meta-analysis results demonstrate that the MR-ADNEX scoring system had higher specificity however bit lower sensitivity compared to the IOTA-ADNEX scoring system for discriminating benign from malignant ovarian tumors.

Diagnostic accuracy and validity of the O-RADS MRI score based on a simplified MRI protocol: a single tertiary center retrospective study

BACKGROUND

Adnexal masses (AM) are a common gynecological problem. It is important to use a reliable imaging method in the differentiation of benign and malignant AMs.

PURPOSE

To assess the accuracy and validity of the O-RADS magnetic resonance imaging (MRI) score for characterizing AM using a simplified MRI protocol.

MATERIAL AND METHODS

The study population comprised 332 women who underwent MRI due to the detection of indeterminate AM on ultrasonography between January 2018 and June 2020. An experienced radiologist calculated the O-RADS MRI score into five categories, using an MRI protocol with a simplified dynamic study. Sensitivity, specificity, positive and negative predictive values, and area under the curve (AUC) were calculated (cutoff for malignancy, score ≥ 4). The reference standard was histopathologic diagnosis or imaging findings during >24 months of follow-up.

RESULTS

Of 237 AMs, 28 (11.9%) were malignant. The malignancy rates of AMs with scores of 1, 2, 3, 4, and 5 were 0% (0/12), 0% (0/111), 1.2% (1/77), 50% (10/20), and 100% (17/17), respectively. The O-RADS MRI score showed 96.3% sensitivity, 95.2% specificity, and 95.3% accuracy in malignancy prediction. The AUC for the differentiation of benign and malignant masses were 0.983. False positivity rate was high in cases with an O-RADS MRI score of 4 (50%).

CONCLUSION

The O-RADS MRI score, based on a simplified MRI protocol, has high accuracy and validity in distinguishing benign from malignant sonographically indeterminate AMs. Its use in clinical practice can classify the malignancy risks of masses and prevent unnecessary surgery in benign lesions.

Added Value of Quantitative Analysis of Diffusion-Weighted Imaging in Ovarian-Adnexal Reporting and Data System Magnetic Resonance Imaging

BACKGROUND

The ovarian-adnexal reporting and data system-magnetic resonance imaging (O-RADS-MRI) score decreases the incidence of indeterminate adnexal masses from 18% to 31% with ultrasound till 10.8% to 12.5% with MRI. Further improvement of this score may be useful to improve patients' management.

PURPOSE

To evaluate the added value of quantitative diffusion-weighted imaging (DWI) in the diagnosis of adnexal masses classified according to the O-RADS-MRI score.

STUDY TYPE

Prospective cohort study with retrospective DWI analysis.

POPULATION

Among 402 recruited patients, surgery was done only in 163 women (median-age: 51 years) with 201 indeterminate adnexal masses, which were included in the final analysis.

FIELD STRENGTH/SEQUENCE

Standardized MRI (1.5 and 3-T) including diffusion and dynamic contrast-enhanced sequences (diffusion-weighted single-shot spin-echo echo-planar imaging) were used.

ASSESSMENT

Two radiologists classified the adnexal masses according to O-RADS-MRI and they were blinded to the pathology report. Two methods of quantitative analysis were applied using region-of-interest apparent-diffusion-coefficient (ROI-ADC) and whole-lesion ADC-histogram (WL-ADC).

STATISTICAL TESTS

Fisher's exact and Mann-Whitney-U tests were used to compare variables among malignant and benign lesions. Receiver-operating-characteristic (ROC) curves were constructed to examine the sensitivity/specificity of each parameter. ROI-ADC and WL-ADC of lesions with O-RADS-MRI score-4 were plotted to identify thresholds of malignant lesions. The improvement of the O-RADS-MRI score after adding these thresholds was assessed by two ROC-curves. A P < 0.05 was considered to be statistically significant.

RESULTS

Fifty-eight of the 201 lesions (28.9%) were malignant. The ROI-ADC and the WL-ADC means of malignant lesions were significantly lower than those of benign lesions. Forty-two lesions (20.9%) had an O-RADS-MRI score-4. In this subgroup, 76% of lesions with ROI-ADC < 1.7 × 10^-3  mm² /sec and WL-ADC < 2.6 × 10^-3  mm² /sec were malignant, whereas only 11.8% with ROI-ADC ≥ 1.7 × 10^-3  mm² /sec or a WL-ADC ≥ 2.6 × 10^-3  mm² /sec were malignant. The overall performance of the O-RADS-MRI score combined with these thresholds was improved.

DATA CONCLUSION

Integrating ADC-thresholds in O-RADS-MRI score-4 may discriminate low-to-intermediate and intermediate-to-high malignancy risk groups.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY STAGE: 2.

[Adnexal Masses: Clinical Application of Multiparametric MR Imaging & O-RADS MRI]

Incidental adnexal masses considered indeterminate for malignancy are commonly observed on ultrasonography. Multiparametric MRI is the imaging modality of choice for the evaluation of sonographically indeterminate adnexal masses. Conventional MRI enables a confident pathologic diagnosis of various benign lesions due to accurate tissue characterization of fat, blood, fibrous tissue, and solid components. Additionally, functional imaging sequences, including perfusion- and diffusion-weighted imaging, improve the diagnostic efficacy of conventional MRI in differentiating benign from malignant adnexal masses. The ovarian-adnexal reporting and data system (O-RADS) MRI was recently designed to provide consistent interpretations in assigning risk of malignancy to ovarian and other adnexal masses, and to provide a management recommendation for each risk category. In this review, we describe the clinical application of multiparametric MRI for the evaluation of adnexal masses and introduce the O-RADS MRI risk stratification system.

Current update on malignant epithelial ovarian tumors

Epithelial ovarian cancer (EOC) represents the most frequently occurring gynecological malignancy, accounting for more than 70% of ovarian cancer deaths. Preoperative imaging plays an important role in assessing the extent of disease and guides the next step in surgical decision-making and operative planning. In this article, we will review the multimodality imaging features of various subtypes of EOC. We will also discuss the role of imaging in the staging, management, and surveillance of EOC.

O-RADS MRI score: analysis of misclassified cases in a prospective multicentric European cohort

OBJECTIVE

To retrospectively review the causes of categorization errors using O-RADS-MRI score and to determine the presumptive causes of these misclassifications.

METHODS

EURAD database was retrospectively queried to identify misclassified lesions. In this cohort, 1194 evaluable patients with 1502 pelvic masses (277 malignant / 1225 benign lesions) underwent standardized MRI to characterize adnexal masses with histology or 2 years' follow-up as a reference standard. An expert radiologist reviewed cases with two junior radiologists and lesions termed misclassified if malignant lesion was scored ≤ 3, a benign lesion was scored ≥ 4, the site of origin was incorrect, or a non-adnexal mass was incorrectly categorized as benign or malignant.

RESULTS

There were 139 / 1502 (9.2%) misclassified masses in 116 women including 109 adnexal and 30 non-adnexal masses. False-negative cases corresponded to 16 borderline or invasive malignant adnexal masses rated score ≤ 3 (16 / 139, 11.5%). False-positive cases corresponded to 88 benign masses were rated score 4 (67 / 139, 48.2%) or 5 (18 / 139,12.9%) or considered suspicious non-adnexal lesions (3 / 139, 2.2%). Misclassifications were only due to origin error in 12 adnexal masses (8 benign, 4 malignant) (8.6%, 12 / 139) and 23 non-adnexal masses (18 benign, 5 malignant,16.5%, 23 / 139) perceived respectively as non-adnexal and adnexal masses. Interpretive error (n = 104), failure to recognize technical insufficient exams (n = 9), and perceptual errors (n = 4) were found. Most interpretive was due to misinterpretation of solid tissue or incorrect assignment of mass origin. Eighty-four out of 139 cases were correctly reclassified by the readers with strict adherence to the score rules.

CONCLUSION

Most errors were due to misinterpretation of solid tissue or incorrect assignment of mass origin.

KEY POINTS

• Prospective assignment of O-RADS-MRI score resulted in misclassification of 9.25% of sonographically indeterminate pelvic masses. • Most errors were interpretive (74.8%) due to misinterpretation of solid tissue as defined by the lexicon or incorrect assignment of mass origin. • Pelvic inflammatory disease is a common source of misclassification (8.9%) (12 / 139).

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.

Non-contrast MRI can accurately characterize adnexal masses: a retrospective study

Objective

To determine the accuracy of interpretation of a non-contrast MRI protocol in characterizing adnexal masses.

Methods and materials

Two hundred ninety-one patients (350 adnexal masses) who underwent gynecological MRI at our institution between the 1^st of January 2008 and the 31^st of December 2018 were reviewed. A random subset (102 patients with 121 masses) was chosen to evaluate the reproducibility and repeatability of readers’ assessments. Readers evaluated non-contrast MRI scans retrospectively, assigned a 5-point score for the risk of malignancy and gave a specific diagnosis. The reference standard for the diagnosis was histopathology or at least one-year imaging follow-up. Diagnostic accuracy of the non-contrast MRI score was calculated. Inter- and intra-reader agreement was analyzed with Cohen’s kappa statistics.

Results

There were 53/350 (15.1%) malignant lesions in the whole cohort and 20/121 (16.5%) malignant lesions in the random subset. Good agreement between readers was found for the non-contrast MRI score (к = 0.73, 95% confidence interval [CI] 0.58–0.86) whilst the intra-reader agreement was excellent (к = 0.81, 95% CI 0.70–0.88). The non-contrast MRI score value of ≥ 4 was associated with malignancy with a sensitivity of 84.9%, a specificity of 95.9%, an accuracy of 94.2% and a positive likelihood ratio of 21 (area under the receiver operating curve 0.93, 95% CI 0.90–0.96).

Conclusion

Adnexal mass characterization on MRI without the administration of contrast medium has a high accuracy and excellent inter- and intra-reader agreement. Our results suggest that non-contrast studies may offer a reasonable diagnostic alternative when the administration of intravenous contrast medium is not possible.

Key Points

• A non-contrast pelvic MRI protocol may allow the characterization of adnexal masses with high accuracy.

• The non-contrast MRI score may be used in clinical practice for differentiating benign from malignant adnexal lesions when the lack of intravenous contrast medium precludes analysis with the O–RADS MRI score.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-07737-9.

State of the art in abdominal MRI structured reporting: a review

In the management of several abdominal disorders, magnetic resonance imaging (MRI) has the potential to significantly improve patient's outcome due to its diagnostic accuracy leading to more appropriate treatment choice. However, its clinical value heavily relies on the quality and quantity of diagnostic information that radiologists manage to convey through their reports. To solve issues such as ambiguity and lack of comprehensiveness that can occur with conventional narrative reports, the adoption of structured reporting has been proposed. Using a checklist and standardized lexicon, structured reports are designed to increase clarity while assuring that all key imaging findings related to a specific disorder are included. Unfortunately, structured reports have their limitations too, such as risk of undue report simplification and poor template plasticity. Their adoption is also far from widespread, and probably the ideal balance between radiologist autonomy and report consistency of has yet to be found. In this article, we aimed to provide an overview of structured reporting proposals for abdominal MRI and of works assessing its value in comparison to conventional free-text reporting. While for several abdominal disorders there are structured templates that have been endorsed by scientific societies and their adoption might be beneficial, stronger evidence confirming their imperativeness and added value in terms of clinical practice is needed, especially regarding the improvement of patient outcome.

Magnetic resonance scoring system for assessment of adnexal masses: added value of diffusion-weighted imaging including apparent diffusion coefficient map

OBJECTIVES

To validate prospectively the ADNEX magnetic resonance (MR) scoring system to assess adnexal masses and to evaluate a new, modified ADNEX MR scoring system that incorporates diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) mapping.

METHODS

Between January 2015 and September 2018, 323 consecutive women with adnexal masses diagnosed on transvaginal ultrasound (TVS) underwent standardized MR imaging (MRI) including diffusion and dynamic contrast-enhanced sequences. Of these, 131 underwent subsequent surgery. For interpretation of the MRI examinations, we applied the five-category ADNEX MR scoring system, along with a modified scoring system including DWI with ADC mapping. For both scoring systems, a score was given for all adnexal masses. Histological diagnosis was considered as the gold standard and lesions were classified as benign or malignant. The difference between the predictive values for diagnosing malignancy of the classical and modified scoring systems was assessed on the basis of the areas under the receiver-operating-characteristics (AUC) curves. The sensitivity and specificity for diagnosing malignancy of each score were also calculated.

RESULTS

Among the 131 women with adnexal mass(es) diagnosed on TVS who underwent MRI and subsequent surgery, the surgery revealed 161 adnexal masses in 126 women; five women had no mass. Histological examination confirmed 161 adnexal masses, of which all had been detected on MRI: 32 malignant tumors, 15 borderline tumors, which were classified as part of the malignant group (n = 47), and 114 benign lesions. The AUC for prediction of a malignant lesion was 0.938 (95% CI, 0.902-0.975) using the classical ADNEX MR scoring system and 0.974 (95% CI, 0.953-0.996) using the modified scoring system. Pairwise comparison of these AUCs revealed a significant difference (P = 0.0032). The sensitivity and specificity for diagnosing malignancy with an ADNEX MR score of 4 or more were 95.5% and 86.6%, respectively, using the classic scoring system, and 95.7% and 93.3%, respectively, using the modified scoring system.

CONCLUSION

DWI with ADC mapping could be integrated into the ADNEX MR scoring system to improve specificity, thereby potentially optimizing clinical management by avoiding unnecessary surgery. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Ovarian-Adnexal Reporting Lexicon for MRI: A White Paper of the ACR Ovarian-Adnexal Reporting and Data Systems MRI Committee

MRI is used in the evaluation of ovarian and adnexal lesions. MRI can further characterize lesions seen on ultrasound to help decrease the number of false-positive lesions and avoid unnecessary surgery in benign lesions. Currently, the reporting of ovarian and adnexal findings on MRI is inconsistent because of the lack of standardized descriptor terminology. The development of uniform reporting descriptors can lead to improved interpretation agreement and communication between radiologists and referring physicians. The Ovarian-Adnexal Reporting and Data Systems MRI Committee was formed under the direction of the ACR to create a standardized lexicon for adnexal lesions with the goal of improving the quality and consistency of imaging reports. This white paper describes the consensus process in the creation of a standardized lexicon for ovarian and adnexal lesions for MRI and the resultant lexicon.

Improving the performance of IOTA simple rules: sonographic assessment of adnexal masses with resource-effective use of a magnetic resonance scoring (ADNEX MR scoring system)

PURPOSE

To compare the International Ovarian Tumor Analysis (IOTA) simple rules, simple rules risk ultrasound models, alone or in combination with magnetic resonance (MR) score to predict malignancy in women with adnexal masses.

METHODS

171 women with adnexal masses were included from February 2014 to February 2016. 120 women had histopathological diagnosis obtained from surgery or percutaneous biopsy. The other 51 women were submitted to surveillance with ultrasound (US) for at least 1 year. Patients were examined with US and MR. US reports were rendered using IOTA systems. We compared five diagnostic approaches, aimed at diagnosing women with malignant tumors among those with adnexal masses: We calculated the performance and net benefits (decision curve analysis) for five distinct diagnostic approaches: (1) US simple rules (SR), (2) simple rules risk score (SRRisk), (3) US SR followed by subjective assessment (SA) of indeterminate cases, (4) SR followed by MR score for the indeterminate cases, and (5) MR score for all women.

RESULTS

The MR score for all patients was the approach that yielded the best-standardized net benefit regardless of the risk threshold. However, referring women with indeterminate masses on SR to MR score yielded the second-best net benefit.

CONCLUSION

Although this study leaves no doubt about the superiority of MR score over US-based methods for the discrimination of malignant tumors in women with adnexal masses, restricting the use of MR score only to women with indeterminate masses on US SR is a safe, appropriate way to triage women with adnexal masses.

Validity and Reproducibility of the ADNEX MR Scoring System in the Diagnosis of Sonographically Indeterminate Adnexal Masses

BACKGROUND

The diagnosis of sonographically indeterminate adnexal masses (AM) signifies a major challenge in clinical practice. Early detection and characterization have increased the need for accurate imaging evaluation before treatment.

PURPOSE

To assess the validity and reproducibility of the ADNEX MR Scoring system in the diagnosis of sonographically indeterminate AM.

STUDY TYPE

A prospective multicenter study.

POPULATION

In all, 531 women (mean age, 44 ± 11.2 years; range, 21-79 years) with 572 sonographically indeterminate AM.

FIELD STRENGTH/SEQUENCE

1.5T/precontrast T₁ -weighted imaging (WI) fast spin echo (FSE) (in-phase and out-of-phase, with and without fat suppression); T₂ -WI FSE; diffusion-WI single-shot echo planner with b-values of 0 and 1000 s/mm² ; and dynamic contrast-enhanced perfusion T₁ -WI liver acquisition with volume acceleration (LAVA).

ASSESSMENT

All MRI examinations were evaluated by three radiologists, and the AM were categorized into five scores based on the ADNEX MR Scoring system. Score 1: no AM; 2: benign AM; 3: probably benign AM; 4: indeterminate AM; 5: probably malignant AM. Histopathology and imaging follow-up were used as the standard references for evaluating the validity of the ADNEX MR Scoring system for detecting ovarian malignancy.

STATISTICAL TESTS

Four-fold table test, kappa statistics (κ), and receiver operating characteristic (ROC) curve.

RESULTS

In all, 136 (23.8%) AM were malignant, and 436 (76.2%) were benign. Of the 350 AM classified as score 2, one (0.3%) was malignant; of the 62 AM classified as score 3, six (9.7%) were malignant; of the 73 AM classified as score 4, 43 (58.9%) were malignant; and of the 87 AM categorized as score 5, 86 (98.9%) were malignant. The best cutoff value for predicting malignant AM was score >3 with sensitivity and specificity of 92.9% and 94.9%, respectively. The interreader agreement of the ADNEX MR Scoring was very good (κ = 0.861).

DATA CONCLUSION

The current study supports the high validity and reproducibility of the ADNEX MR Scoring system for the diagnosis of sonographically indeterminate AM.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY STAGE: 2.

Ovarian-Adnexal Reporting Data System Magnetic Resonance Imaging (O-RADS MRI) Score for Risk Stratification of Sonographically Indeterminate Adnexal Masses

IMPORTANCE

Approximately one-quarter of adnexal masses detected at ultrasonography are indeterminate for benignity or malignancy, posing a substantial clinical dilemma.

OBJECTIVE

To validate the accuracy of a 5-point Ovarian-Adnexal Reporting Data System Magnetic Resonance Imaging (O-RADS MRI) score for risk stratification of adnexal masses.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter cohort study was conducted between March 1, 2013, and March 31, 2016. Among patients undergoing expectant management, 2-year follow-up data were completed by March 31, 2018. A routine pelvic MRI was performed among consecutive patients referred to characterize a sonographically indeterminate adnexal mass according to routine diagnostic practice at 15 referral centers. The MRI score was prospectively applied by 2 onsite readers and by 1 reader masked to clinical and ultrasonographic data. Data analysis was conducted between April and November 2018.

MAIN OUTCOMES AND MEASURES

The primary end point was the joint analysis of true-negative and false-negative rates according to the MRI score compared with the reference standard (ie, histology or 2-year follow-up).

RESULTS

A total of 1340 women (mean [range] age, 49 [18-96] years) were enrolled. Of 1194 evaluable women, 1130 (94.6%) had a pelvic mass on MRI with a reference standard (surgery, 768 [67.9%]; 2-year follow-up, 362 [32.1%]). A total of 203 patients (18.0%) had at least 1 malignant adnexal or nonadnexal pelvic mass. No invasive cancer was assigned a score of 2. Positive likelihood ratios were 0.01 for score 2, 0.27 for score 3, 4.42 for score 4, and 38.81 for score 5. Area under the receiver operating characteristic curve was 0.961 (95% CI, 0.948-0.971) among experienced readers, with a sensitivity of 0.93 (95% CI, 0.89-0.96; 189 of 203 patients) and a specificity of 0.91 (95% CI, 0.89-0.93; 848 of 927 patients). There was good interrater agreement among both experienced and junior readers (κ = 0.784; 95% CI, 0.743-0824). Of 580 of 1130 women (51.3%) with a mass on MRI and no specific gynecological symptoms, 362 (62.4%) underwent surgery. Of them, 244 (67.4%) had benign lesions and a score of 3 or less. The MRI score correctly reclassified the mass origin as nonadnexal with a sensitivity of 0.99 (95% CI, 0.98-0.99; 1360 of 1372 patients) and a specificity of 0.78 (95% CI, 0.71-0.85; 102 of 130 patients).

CONCLUSIONS AND RELEVANCE

In this study, the O-RADS MRI score was accurate when stratifying the risk of malignancy in adnexal masses.

[Diagnostic value of imaging (ultrasonography, doppler, CT, MR, PET-CT) for the diagnosis of a suspicious ovarian mass and staging of ovarian, tubal or primary peritoneal cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]

Transvaginal ultrasound is the first-line examination allowing characterizing 80 to 90% of adnexal masses (LP1). If performed by an expert, a subjective analysis is optimal. If performed by a non-expert, combining the use of Simple Rules with subjective analysis can achieve the diagnostic performance of an expert (LP1). Whichever the chosen model (subjective analysis by an expert or combination of the Simple Rules with a subjective analysis by a non-expert), a second-line examination will have to be proposed in the complex or indeterminate cases (about 20% of the masses) (grade A). The best-performing second-line test for characterization is pelvic MRI (LP1). If read by an expert, a pathological hypothesis can or should be suggested (grade D). In case of non-expert reading, the use of the ADNEXMR score allows a reliable assessment of the positive predictive value of malignancy to guide the patient towards the best management (gradeC). For preoperative assessment and evaluation of resectability of ovarian, fallopian tube or primary peritoneal cancer, it is recommended to perform a chest abdomen and pelvis CT with contrast agent injection (LP2, grade B). In the event of a contraindication to the injection of iodinated contrast agent (severe renal insufficiency, GFR <30mL/min), an abdomen and pelvis MRI completed with a non-injected chest CT may be proposed (LP3, grade C). By analogy, the same examinations are recommended to evaluate the disease after neo-adjuvant chemotherapy (LP3, Recommendation grade C). Further studies will be required to determine whether PET-CT provides better lymph node assessment before retroperitoneal and pelvic lymphadenectomy. PET-CT may be used to eliminate lymph node involvement in the absence of suspicious lymph nodes on morphological examination (LP3, grade C). The report should specify the localizations leading to a risk of incomplete cytoreductive surgery and lesions outside the field explored during surgery.

External validation of ADNEX MR SCORING system: a single-centre retrospective study

AIM

To evaluate the accuracy of the ADNEX MR SCORING system for characterising adnexal masses.

MATERIALS AND METHODS

An institutional review board approved this retrospective study. The study population comprised 663 women who underwent magnetic resonance imaging (MRI) from January 2007 to December 2014 to characterise 778 adnexal masses that were indeterminate under ultrasonography (590 benign and 188 malignant). Two radiologists independently reviewed the MRI images. The masses were scored from 1 to 5 according to the ADNEX MR SCORING system. The diagnostic performance of the system was evaluated by receiver operating characteristic (ROC) analysis. Masses scored 4 or greater were considered malignant (including tumours of borderline malignancy or low malignant potential).

RESULTS

The malignancy rates of masses with scores of 2, 3, 4 and 5 were 1.9% (8/419), 12.8% (19/149), 62.6% (57/91) and 87.4% (104/119) for reader 1 and 2.1% (9/424), 13.6% (20/147), 67.6% (71/105) and 86.3% (88/102) for reader 2, respectively. The areas under the ROC curves for the differentiation of benign and malignant masses were 0.929 and 0.923, respectively; the sensitivity, specificity and accuracy of diagnosis were 85.6% (161/188), 91.7% (541/590), and 90.2% (702/778) for reader 1 and 84.6% (159/188), 91.9% (542/590), and 90.1% (701/778) for reader 2, respectively. Tumours of borderline malignancy or low malignant potential had a higher rate of misclassification (46.1%) than other malignant tumours (6-7.4%).

CONCLUSION

The ADNEX MR SCORING system was highly accurate in differentiating benign and malignant adnexal masses, although it may be less accurate for tumours of borderline malignancy or low malignant potential.

Adnexal lesions: Imaging strategies for ultrasound and MR imaging

Adnexal lesions are routinely encountered in general practice. Ultrasound is the first line of investigation in determining the benign or malignant potential of an adnexal lesion. In the cases of classic simple cysts, hemorrhagic cysts, endometriomas, dermoids and obviously malignant lesions, ultrasound may be sufficient for management recommendations. In cases where there is an isolated adnexal lesion, without peritoneal disease or serum CA-125 elevation, and in lesions considered indeterminate on ultrasound, MR imaging with incorporation of the ADNEx MR score can increase the specificity for the diagnosis of benignity or malignancy. This article will review the imaging evaluation of adnexal lesions and how to incorporate the ADNEx MR score to help guide clinical management.

Ovarian Sertoli-Leydig cell tumours: How typical is their typical presentation?

Ovarian Sertoli-Leydig cell tumours (OSLCT) are rare and typically present with androgenic manifestations in women of the 2nd-3rd decade. Out of 228 diagnoses of ovarian sex cord-stromal tumours recorded at an academic institution during a 14-year period, eight women were surgically treated for OSLCT. Patient mean age was 54.8 years (range 19-81), five women being in the postmenopausal stage (62.5%). Only one woman presented with androgenic manifestations (12.5%), four with abnormal/postmenopausal uterine bleeding (50%), and three with abdominal pain (37.5%). Fertility sparing or radical surgery was performed depending on patient age and stage of disease. The only patient with an advanced disease (FIGO stage IV) was referred to palliative care postoperatively. The other seven were at FIGO stage I. Five of them were free from disease at a mean follow-up of 67 months, while the remaining two were lost at follow-up. The youngest woman of the series, treated with fertility-preserving unilateral salpingo-oophorectomy at the age of 19, had two spontaneous pregnancies and deliveries of healthy babies during a 10-year follow-up period. In conclusion, our single institution 14-year experience demonstrates that the diagnosis of OSLCT is particularly challenging since many patients are older than expected and lack androgenic manifestations. Impact statement • What is already known on this subjectOvarian Sertoli-Leydig cell tumours (OSLCT) are rare and are thought to typically present with androgenic manifestations in women of the 2nd-3rd decade. • What the results of this study addOur single institution 14-year experience shows that a high proportion of women with ovarian Sertoli-Leydig cell tumours may not present with androgenic manifestations, and many of them also are in the postmenopausal stage. Most patients have a good prognosis and fertility-preserving surgery in younger women can lead to spontaneous pregnancies and deliveries of healthy children after treatment. • What are the implications of these findings for clinical practice and/or further researchThe diagnosis of OSLCT is particularly challenging and therefore not reached before surgery in most of the cases. However, while hysterectomy with bilateral salpingo-oophorectomy and surgical staging are recommended for women with higher stage or no fertility wish, fertility-sparing surgery should be considered in younger women with early disease. Therefore, further research should focus on non-invasive diagnosis possibly by means of laboratory or imaging techniques.

Role of Imaging Tools for the Diagnosis of Borderline Ovarian Tumors: A Systematic Review and Meta-Analysis

Borderline ovarian tumors (BOTs) have a low malignant potential and occur most often in young women. Its preoperative diagnosis can improve surgical strategy and reproductive approach. This study systematically reviews the literature for the accuracy of transvaginal ultrasound (TVUS), magnetic resonance (MRI), and computed tomography (CT) in the diagnostic of BOTs. We conducted a search in PubMed/Medline of articles in English from the last 5 years and included 14 studies for systematic review, 9 of them in the meta-analysis. The pooled sensibility and specificity was respectively 77.0% and 83.0% for TVUS (5 studies) and 85% and 74% for MRI (4 studies) in differentiating benign from malignant BOTs. CT and positron emission tomography (PET)-CT techniques were heterogeneous between studies, so a meta-analysis was not performed for the 4 studies on CT and PET-CT. However, these 4 studies have also shown a high accuracy in differentiating BOTs from malignant ovarian cancers.