O-RADS MRI SCORE: An Essential First-Step Tool for the Characterization of Adnexal Masses

The ovarian-adnexal reporting and data system on magnetic resonance imaging (O-RADS MRI) score is now a well-established tool to characterize pelvic gynecological masses based on their likelihood of malignancy. The main added value of O-RADS MRI over O-RADS US is to correctly reclassify lesions that were considered suspicious on US as benign on MRI. The crucial issue when characterizing an adnexal mass is to determine the presence/absence of solid tissue and thus need to perform gadolinium injection. O-RADS MR score was built on a multivariate analysis and must be applied as a step-by-step analysis: 1) Is the mass an adnexal mass? 2) Is there an associated peritoneal carcinomatosis? 3) Is there any significant amount of fatty content? 4) Is there any wall enhancement? 5) Is there any internal enhancement? 6) When an internal enhancement is detected, does the internal enhancement correspond to solid tissue or not? 7) Is the solid tissue malignant? With its high value to distinguish benign from malignant adnexal masses and its high reproducibility, the O-RADS MRI score could be a valuable tool for timely referral of a patient to an expert center for the treatment of ovarian cancers. Finally, to make a precise diagnosis allowing optimal personalized treatment, the radiologist in gynecological imaging will combine the O-RADS MRI score with many other clinical, biological, and other MR criteria to suggest a pathological hypothesis. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY STAGE: 3.

O-RADS MRI scoring system has the potential to reduce the frequency of avoidable adnexal surgery

OBJECTIVE

To assess the potential impact of the O-RADS MRI score on the decision-making process for the management of adnexal masses.

METHODS

EURAD database (prospective, European observational, multicenter study) was queried to identify asymptomatic women without history of infertility included between March 1st and March 31st 2018, with available surgical pathology or clinical findings at 2-year clinical follow-up. Blinded to final diagnosis, we stratified patients into five categories according to the O-RADS MRI score (absent i.e. non adnexal, benign, probably benign, indeterminate, probably malignant). Prospective management was compared to theoretical management according to the score established as following: those with presumed benign masses (scored O-RADS MRI 2 or 3) (follow-up recommended) and those with presumed malignant masses (scored O-RADS MRI 4 or 5) (surgery recommended).

RESULTS

The accuracy of the score for assessing the origin of the mass was of 97.2 % (564/580, CI95% 0.96-0.98) and was of 92.0 % (484/526) for categorizing lesions with a negative predictive value of 98.1 % (415/423, CI95% 0.96-0.99). Theoretical management using the score would have spared surgery in 229 patients (87.1 %, 229/263) with benign lesions and malignancy would have been missed in 6 borderline and 2 invasive cases. In patients with a presumed benign mass using O-RADS MRI score, recommending surgery for lesions >= 100 mm would miss only 4/77 (4.8 %) malignant adnexal tumors instead of 8 (50 % decrease).

CONCLUSION

The use of O-RADS MRI scoring system could drastically reduce the number of asymptomatic patients undergoing avoidable surgery.

O-RADS MRI risk stratification system: pearls and pitfalls

In 2021, the American College of Radiology (ACR) Ovarian-Adnexal Reporting and Data System (O-RADS) MRI Committee developed a risk stratification system and lexicon for assessing adnexal lesions using MRI. Like the BI-RADS classification, O-RADS MRI provides a standardized language for communication between radiologists and clinicians. It is essential for radiologists to be familiar with the O-RADS algorithmic approach to avoid misclassifications. Training, like that offered by International Ovarian Tumor Analysis (IOTA), is essential to ensure accurate and consistent application of the O-RADS MRI system. Tools such as the O-RADS MRI calculator aim to ensure an algorithmic approach. This review highlights the key teaching points, pearls, and pitfalls when using the O-RADS MRI risk stratification system.Critical relevance statement This article highlights the pearls and pitfalls of using the O-RADS MRI scoring system in clinical practice.Key points• Solid tissue is described as displaying post- contrast enhancement.• Endosalpingeal folds, fimbriated end of the tube, smooth wall, or septa are not solid tissue.• Low-risk TIC has no shoulder or plateau. An intermediate-risk TIC has a shoulder and plateau, though the shoulder is less steep compared to outer myometrium.

Reasons why it is time to change imaging guidelines on endometriosis

In light of the rising number of patients referred for magnetic resonance imaging (MRI) due to suspected endometriosis and the high expectations of these patients, there is a need for new imaging guidelines to optimally protocol and indicate MRI and transvaginal ultrasonography (TVUS) examinations. This is crucial for accurately addressing the inquiries of gynecologists, encompassing complete mapping and preoperative staging, and facilitating effective communication with patients. In this context, the development of a standardized lexicon, as well as dedicated imaging classifications, is recommended to aid in the comprehensive management of patients. CLINICAL RELEVANCE STATEMENT: The radiologist should use a standardized lexicon and provide a score along with details about the specific compartments affected by endometriosis disease. This helps in offering clearer guidance to the surgeon. KEY POINTS: • An optimal staging is based on the combination of clinical examination, transvaginal US, and MRI. • MRI is able to detect location that is hidden at the beginning of a laparoscopic surgery and thus the need for dedicated MR classifications to correctly stage the disease. • Deep pelvic endometriosis index (dPEI) classification is externally validated and highly correlated with operating time, hospital stay, and postoperative complications.

French community grid for the evaluation of radiological artificial intelligence solutions (DRIM France Artificial Intelligence Initiative)

PURPOSE

The purpose of this study was to validate a national descriptive and analytical grid for artificial intelligence (AI) solutions in radiology.

MATERIALS AND METHODS

The RAND-UCLA Appropriateness Method was chosen by expert radiologists from the DRIM France IA group for this statement paper. The study, initiated by the radiology community, involved seven steps including literature review, template development, panel selection, pre-panel meeting survey, data extraction and analysis, second and final panel meeting, and data reporting.

RESULTS

The panel consisted of seven software vendors, three for bone fracture detection using conventional radiology and four for breast cancer detection using mammography. A consensus was reached on various aspects, including general target, main objective, certification marking, integration, expression of results, forensic aspects and cybersecurity, performance and scientific validation, description of the company and economic details, possible usage scenarios in the clinical workflow, database, specific objectives and targets of the AI tool.

CONCLUSION

The study validates a descriptive and analytical grid for radiological AI solutions consisting of ten items, using breast cancer and bone fracture as an experimental guide. This grid would assist radiologists in selecting relevant and validated AI solutions. Further developments of the grid are needed to include other organs and tasks.

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.

Endometriosis MR mimickers: T2-hypointense lesions

Endometriosis is a common crippling disease in women of reproductive age. Magnetic resonance imaging (MRI) is considered the cornerstone radiological technique for both the diagnosis and management of endometriosis. While its sensitivity, especially in deep infiltrating endometriosis, is superior to that of ultrasonography, many sources of false-positive results exist, leading to a lack of specificity. Hypointense lesions or pseudo-lesions on T2-weighted images include anatomical variants, fibrous connective tissues, benign and malignant tumors, feces, surgical materials, and post treatment scars which may mimic deep pelvic infiltrating endometriosis. False positives can have a major impact on patient management, from diagnosis to medical or surgical treatment. This educational review aims to help the radiologist acknowledge MRI criteria, pitfalls, and the differential diagnosis of deep pelvic infiltrating endometriosis to reduce false-positive results. Critical relevance statement MRI in deep infiltrating endometriosis has a 23% false-positive rate, leading to misdiagnosis. T2-hypointense lesions primarily result from anatomical variations, fibrous connective tissue, benign and malignant tumors, feces, surgical material, and post-treatment scars. Key points • MRI in DIE has a 23% false-positive rate, leading to potential misdiagnosis.• Anatomical variations, fibrous connective tissues, neoplasms, and surgical alterations are the main sources of T2-hypointense mimickers.• Multisequence interpretation, morphologic assessment, and precise anatomic localization are crucial to prevent overdiagnosis.• Gadolinium injection is beneficial for assessing endometriosis differential diagnosis only in specific conditions.

Endometriosis MR mimickers: T1-hyperintense lesions

Endometriosis is a chronic and disabling gynecological disease that affects women of reproductive age. Magnetic resonance imaging (MRI) is considered the cornerstone radiological technique for both the diagnosis and management of endometriosis. While MRI offers higher sensitivity compared to ultrasonography, it is prone to false-positive results, leading to decreased specificity. False-positive findings can arise from various T1-hyperintense conditions on fat-suppressed T1-weighted images, resembling endometriotic cystic lesions in different anatomical compartments. These conditions include hemorrhage, hyperproteic content, MRI artifacts, feces, or melanin. Such false positives can have significant implications for patient care, ranging from incorrect diagnoses to unnecessary medical or surgical interventions and subsequent follow-up. To address these challenges, this educational review aims to provide radiologists with comprehensive knowledge about MRI criteria, potential pitfalls, and differential diagnoses, ultimately reducing false-positive results related to T1-hyperintense abnormalities.Critical relevance statementMRI has a 10% false-positive rate, leading to misdiagnosis. T1-hyperintense lesions, observed in the three phenotypes of pelvic endometriosis, can also be seen in various other causes, mainly caused by hemorrhages, high protein concentrations, and artifacts.Key points• MRI in endometriosis has a 10% false-positive rate, leading to potential misdiagnosis.• Pelvic endometriosis lesions can exhibit T1-hyperintensity across their three phenotypes.• A definitive diagnosis of a T1-hyperintense endometriotic lesion is crucial for patient management.• Hemorrhages, high protein concentrations, lipids, and artifacts are the main sources of T1-hyperintense mimickers.

O-RADS scoring system for adnexal lesions: Diagnostic performance on TVUS performed by an expert sonographer and MRI

RATIONALE AND OBJECTIVE

To determine the diagnostic performance of transvaginal ultrasound (TVUS) performed by an US specialist and MRI based on the O-RADS scoring system.

MATERIALS AND METHODS

Between March 5th 2013 and December 31st 2021, 227 patients, referred to our center, underwent TVUS and pelvic MRI for characterization of an adnexal lesion proven by surgery or two years of negative follow-up. All lesions were classified according to O-RADS US and O-RADS MRI risk scoring systems. Imaging data were then correlated with histopathological diagnosis or negative follow-up for 2 years.

RESULTS

The prevalence of malignancy was 11.1%. Sensitivity of O-RADS US / O-RADS MRI were respectively of 83.3%/83.3% and specificity was 73.2%/92.9% (p < 0.001). O-RADS MRI was more accurate than O-RADS US even when performed by an US specialist (p < 0.001). When MRI was used after US, 51 lesions were reclassified correctly by MRI and only 4 lesions incorrectly reclassified. Most of the lesions (49/51) rated O-RADS US 4 or 5 and reclassified correctly by MRI were benign, mainly including cystadenomas or cystadenofibromas. Only 4 lesions were misclassified by MRI but correctly classified by ultrasound.

CONCLUSION

Our study suggests that MR imaging has equally high sensitivity but higher specificity than TVUS for the characterization of adnexal lesions based on O-RADS scoring system. MRI should be the recommended second-line technique when a mass is discovered during TVUS and is rated O-RADS 4 and 5 over than TVUS by an US specialist.

ENDOGRADE: A four level classification to rate surgical complexity in endometriosis

OBJECTIVES

We studied a post operative classification of surgical complexity in endometriosis.

STUDY DESIGN

Retrospective monocentric observational study was conducted between January 2001 to December 2019 and included 764 women with DE that underwent surgery. We retrospectively graded surgical complexity through operative reports according to the ENDOGRADE classification, that grades the surgical complexity of DE in four progressive levels.

RESULTS

Operating time was longer for patients rated ENDOGRADE 3 (228±93 min) compared to patients rated ENDOGRADE 2 (120± 51 min) (p<10-3) and for patients rated ENDOGRADE 4 (301±99 min) compared to patients rated ENDOGRADE 3 (228±93 min), (p<10-3). Eighty percent (20/25) of peroperative complications were rated ENDOGRADE 3 or 4, 20% (5/25) were rated ENDOGRADE 1 or 2 (p = 0.01). Patients rated ENDOGRADE 2, 3 and 4 were 10.3 times (95CI=2.4-44.9, p = 2.10-3), 12.2 times (95CI=2.9-50.2, p = 5.10-4) and 38.3 times (95CI=9.1-162, p = 7.10-7) more likely to experience postoperative complications than those rated ENDOGRADE 1. According to multivariate analysis, only patients rated ENDOGRADE 2, 3, and 4 had a significantly higher risk of postoperative complications with an OR=16.0 (95CI=2.0-127.4, p = 9.10-3), OR=16.2 (95CI=1.6-159.7, p = 0.02) and OR=104.2 (95CI=24.6-440.5, p = 4.10-3), respectively.

CONCLUSION

ENDOGRADE classification of surgical complexity in DE is correlated to operating time, per- and post-operative complications.

European Society of Breast Imaging (EUSOBI) guidelines on the management of axillary lymphadenopathy after COVID-19 vaccination: 2023 revision

Axillary lymphadenopathy is a common side effect of COVID-19 vaccination, leading to increased imaging-detected asymptomatic and symptomatic unilateral axillary lymphadenopathy. This has threatened to negatively impact the workflow of breast imaging services, leading to the release of ten recommendations by the European Society of Breast Imaging (EUSOBI) in August 2021. Considering the rapidly changing scenario and data scarcity, these initial recommendations kept a highly conservative approach. As of 2023, according to newly acquired evidence, EUSOBI proposes the following updates, in order to reduce unnecessary examinations and avoid delaying necessary examinations. First, recommendation n. 3 has been revised to state that breast examinations should not be delayed or rescheduled because of COVID-19 vaccination, as evidence from the first pandemic waves highlights how delayed or missed screening tests have a negative effect on breast cancer morbidity and mortality, and that there is a near-zero risk of subsequent malignant findings in asymptomatic patients who have unilateral lymphadenopathy and no suspicious breast findings. Second, recommendation n. 7 has been revised to simplify follow-up strategies: in patients without breast cancer history and no imaging findings suspicious for cancer, symptomatic and asymptomatic imaging-detected unilateral lymphadenopathy on the same side of recent COVID-19 vaccination (within 12 weeks) should be classified as a benign finding (BI-RADS 2) and no further work-up should be pursued. All other recommendations issued by EUSOBI in 2021 remain valid.

Resolution of Pain after Percutaneous Image-Guided Cryoablation of Extraperitoneal Endometriosis

PURPOSE

To retrospectively evaluate the relief of pain after percutaneous image-guided cryoablation of symptomatic extraperitoneal endometriosis (EE).

MATERIAL AND METHODS

From 2017 to 2022, cryoablation of EE was performed at a single institution on a total of 47 lesions in 42 consecutive patients (median age, 37 years; interquartile range [IQR], 33-39.5 years). Patient and procedural characteristics were reviewed retrospectively. Tolerance and outcomes in terms of pain and patient satisfaction were evaluated.

RESULTS

The median follow-up duration was 13.5 months (IQR, 1.1-37.7 months) after cryoablation. The median pain-free survival rate was 93.8% (95% confidence interval [CI], 77.3-98.4) at 6 months and 82.7% (95% CI, 58.8-93.5) after 12 months. Pain decreased from a median of 8/10 (IQR, 7-9) on the visual analog scale to 0/10 (IQR, 0-1) at the last follow-up (P < .0001). The median Patient Global Impression of Change score recorded at the last follow-up was 1/7 (IQR, 1-2). The efficacy rate of cryoablation to avoid secondary surgery was 92.8% (39/42) per patient and 93.6% (44/47) per nodule treated. Four patients (9.5%, 4/42) experienced an adverse event in the days following the procedure, and 1 patient (2%) experienced a severe adverse event.

CONCLUSIONS

Percutaneous cryoablation is safe and effective in significantly reducing pain and obtaining local control of EE.

Adnexal Lesion Imaging: Past, Present, and Future

Currently, imaging is part of the standard of care for patients with adnexal lesions prior to definitive management. Imaging can identify a physiologic finding or classic benign lesion that can be followed up conservatively. When one of these entities is not present, imaging is used to determine the probability of ovarian cancer prior to surgical consultation. Since the inclusion of imaging in the evaluation of adnexal lesions in the 1970s, the rate of surgery for benign lesions has decreased. More recently, data-driven Ovarian-Adnexal Reporting and Data System (O-RADS) scoring systems for US and MRI with standardized lexicons have been developed to allow for assignment of a cancer risk score, with the goal of further decreasing unnecessary interventions while expediting the care of patients with ovarian cancer. US is used as the initial modality for the assessment of adnexal lesions, while MRI is used when there is a clinical need for increased specificity and positive predictive value for the diagnosis of cancer. This article will review how the treatment of adnexal lesions has changed due to imaging over the decades; the current data supporting the use of US, CT, and MRI to determine the likelihood of cancer; and future directions of adnexal imaging for the early detection of ovarian cancer.

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.

Multicenter External Validation of the Deep Pelvic Endometriosis Index Magnetic Resonance Imaging Score

Importance

Preoperative mapping of deep pelvic endometriosis (DPE) is crucial as surgery can be complex and the quality of preoperative information is key.

Objective

To evaluate the Deep Pelvic Endometriosis Index (dPEI) magnetic resonance imaging (MRI) score in a multicenter cohort.

Design, Setting, and Participants

In this cohort study, the surgical databases of 7 French referral centers were retrospectively queried for women who underwent surgery and preoperative MRI for DPE between January 1, 2019, and December 31, 2020. Data were analyzed in October 2022.

Intervention

Magnetic resonance imaging scans were reviewed using a dedicated lexicon and classified according to the dPEI score.

Main outcomes and measures

Operating time, hospital stay, Clavien-Dindo-graded postoperative complications, and presence of de novo voiding dysfunction.

Results

The final cohort consisted of 605 women (mean age, 33.3; 95% CI, 32.7-33.8 years). A mild dPEI score was reported in 61.2% (370) of the women, moderate in 25.8% (156), and severe in 13.1% (79). Central endometriosis was described in 93.2% (564) of the women and lateral endometriosis in 31.2% (189). Lateral endometriosis was more frequent in severe (98.7%) vs moderate (48.7%) disease and in moderate vs mild (6.7%) disease according to the dPEI (P < .001). Median operating time (211 minutes) and hospital stay (6 days) were longer in severe DPE than in moderate DPE (operating time, 150 minutes; hospital stay 4 days; P < .001), and in moderate than in mild DPE (operating time; 110 minutes; hospital stay, 3 days; P < .001). Patients with severe disease were 3.6 times more likely to experience severe complications than patients with mild or moderate disease (odds ratio [OR], 3.6; 95% CI, 1.4-8.9; P = .004). They were also more likely to experience postoperative voiding dysfunction (OR, 3.5; 95% CI, 1.6-7.6; P = .001). Interobserver agreement between senior and junior readers was good (κ = 0.76; 95% CI, 0.65-0.86).

Conclusions and Relevance

The findings of this study suggest the ability of the dPEI to predict operating time, hospital stay, postoperative complications, and de novo postoperative voiding dysfunction in a multicenter cohort. The dPEI may help clinicians to better anticipate the extent of DPE and improve clinical management and patient counseling.

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.

Acute ATP loss during irreversible electroporation mediates caspase independent cell death

Irreversible electroporation (IRE) has been reported to variably cause apoptosis, necrosis, oncosis or pyroptosis. Intracellular ATP is a key substrate for apoptosis which is rapidly depleted during IRE, we sought to understand whether intracellular ATP levels is a determinant of the mode of cell death following IRE. A mouse bladder cancer cell line (MB49) was treated with electric fields while increasing the number of pulses at a fixed electric field strength, and pulse width. Cell proliferation and viability and ATP levels were measured at different timepoints post-treatment. Cell death was quantified with Annexin-V/Propidium Iodide staining. Caspase activity was measure with a fluorometric kit and western blotting. A pan-caspase (Z-VAD-FMK) inhibitor was used to assess the impact of signal inhibition. We found cell death following IRE was insensitive to caspase inhibition and was correlated with ATP loss. These findings were confirmed by cell death assays and measurement of changes in caspase expression on immunoblotting. This effect could not be rescued by ATP supplementation. Rapid and acute ATP loss during IRE interferes with caspase signaling, promoting necrosis. Cell necrosis from IRE is expected to be immunostimulatory and may be effective in cancer cells that carry mutated or defective apoptosis genes.

Deep pelvic infiltrating endometriosis: MRI consensus lexicon and compartment-based approach from the ENDOVALIRM group

PURPOSE

The purpose of this consensus article was to develop guidelines by a focused panel of experts to elaborate a lexicon of image interpretation, and a standardized region-based reporting of deep infiltrating endometriosis (DIE) with magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Evidence-based data and expert opinion were combined using the RAND-UCLA Appropriateness Method to attain consensus guidelines. Experts scoring of pelvic compartment delineation and reporting template were collected; responses were analyzed and classified as "RECOMMENDED" versus "NOT RECOMMENDED" (when ≥ 80% consensus among experts) or uncertain (when < 80% consensus among experts).

RESULTS

Consensus regarding pelvic compartment delineation and DIE reporting was attained using the RAND-UCLA Appropriateness Method. The pelvis was divided in nine compartments and extrapelvic lesions were assigned to an additional (tenth) compartment. A consensus was also reached for each structure attributed to a compartment and each reporting template item among the experts. No consensus was reached for a normal aspect of uterosacral ligament, but a consensus was reached for an unequivocal involvement leading to a positive diagnosis and an equivocal involvement leading to uncertain diagnosis. Tailored MRI lexicon and standardized region-based report were proposed.

CONCLUSION

These consensus recommendations should be used as a guide for DIE reporting and staging with MRI. Standardized MRI compartment-based structured reporting is recommended to enable consistent accuracy and help select the best therapeutic approach.

How to optimize MRI breast protocol? The value of combined analysis of ultrafast and diffusion-weighted MRI sequences

PURPOSE

The purpose of this retrospective study was to demonstrate the validity of early enhancement criteria on ultrafast magnetic resonance imaging (MRI) sequence to predict malignancy in a large population, and the benefit of diffusion-weighted imaging (DWI) to improve the performance of breast MRI.

MATERIAL AND METHODS

Women who underwent breast MRI examination between April 2018 and September 2020 and further breast biopsy were retrospectively included. Two readers quoted the different conventional features and classified the lesion according to the BI-RADS classification based on the conventional protocol. Then, the readers checked for the presence of early enhancement (≤ 30 s) on ultrafast sequence and the presence of an apparent diffusion coefficient (ADC) ≥ 1.5 × 10^-3 mm²/s to classify the lesions based on morphology and these two functional criteria only.

RESULTS

Two hundred fifty-seven women (median age: 51 years; range: 16-92 years) with 436 lesions (157 benign, 11 borderline and 268 malignant) were included. A MRI protocol plus two simple functional features, early enhancement (≤ 30 s) and an ADC value ≥ 1.5 × 10^-3 mm²/s, had a greater accuracy than the conventional protocol to distinguish benign from malignant breast lesions with or without ADC value (P = 0.01 and P = 0.001, respectively) on MRI, mainly due to better classification of benign lesions (increased specificity) with increasing diagnostic confidence of 3.7% and 7.8% respectively.

CONCLUSION

BI-RADS analysis based on a simple short MRI protocol plus early enhancement on ultrafast sequence and ADC value has a greaterr diagnostic accuracy than a conventional protocol and may avoid unnecessary biopsy.

Accuracy of combined physical examination, transvaginal ultrasonography, and magnetic resonance imaging to diagnose deep endometriosis

OBJECTIVES

To assess the ability of physical examination (PE), transvaginal ultrasonography (TVUS), and magnetic resonance imaging (MRI) alone and combined to diagnose deep infiltrating endometriosis (DIE).

DESIGN

We retrospectively queried our pelvic MRI database to identify women who underwent PE, TVUS, and pelvic MRI for DIE up to 12 months before surgery between January 1, 2016 and August 31, 2020. The presence of uterosacral ligaments (USL), vaginal, rectosigmoid (RS), parametrial, or sacrorectogenital septum (lateral) DIE shown by PE, TVUS, and MRI were correlated with surgical and histological findings.

SETTING

Academic hospital.

PATIENT(S)

We included 178 patients.

INTERVENTION(S)

Clinical and imaging evaluation of women who were diagnosed at surgery with deep pelvic endometriosis.

MAIN OUTCOME MEASURE(S)

The sensitivity, specificity, positive and negative predictive values, and accuracy of each technique separately and combined were assessed for each location. When the 3 techniques were combined, 2 models were tested as follows: all 3 techniques positive and concordant; and ≥2 techniques positive and concordant.

RESULT(S)

The prevalence of USL, vaginal, RS, and lateral DIE were 94.4%, 20.2%, 34.3%, and 32.6%, respectively. In addition, MRI was more sensitive than PE, TVUS or any combination to detect DIE. Moreover, MRI and model B were the most accurate for detecting USL and RS locations with an accuracy of 90.4% and 82.6%, a sensitivity of 91.1% and 50%, and a specificity of 77.8% and 90.9%, respectively. Model B was the most accurate for the vaginal location with an accuracy, sensitivity, and specificity of 82.6%, 50%, and 90.9%, respectively. Finally, MRI was more accurate than any combination for identifying a lateral location with an accuracy, sensitivity, and specificity of 75.1%, 36%, and 93.8%, respectively.

CONCLUSION(S)

A combination of PE, TVUS, and MRI was more accurate than each technique separately to diagnose DIE because of the equally high sensitivity of each, as well as the high specificity of PE and TVUS.

Uterine junctional zone and adenomyosis: comparison of MRI, transvaginal ultrasound and histology

The uterine junctional zone is the subendometrial area in the myometrium that contributes to peristalsis and aids in spermatozoa and blastocyst transport. Alterations in the appearance of the junctional zone on transvaginal sonography (TVS) or magnetic resonance imaging (MRI) are associated with adenomyosis. The lack of standardization of description of its appearance and ill-defined boundaries on both histology and imaging hamper understanding of the junctional zone and limit its role in the diagnosis of adenomyosis. The objectives of this review were to investigate the accordance in definition of the junctional zone across different diagnostic approaches and to examine how imaging findings can be linked to histological findings in the context of diagnosis of adenomyosis. A comprehensive literature review was conducted of articles describing the appearance on imaging and the histological structure of the uterine junctional zone. Our review suggests that the junctional zone is distinguished from the middle and outer myometrium by gradual changes in smooth-muscle cell density, extracellular space, connective tissue, water content and vascular properties. However, while the signal intensity from the junctional zone to the middle myometrium changes abruptly on MRI, the histopathological changes are gradual and its border may be difficult or impossible to distinguish on two-dimensional TVS. Moreover, the thickness of the junctional zone measured on MRI is larger than that measured on TVS. Thus, these two imaging modalities reflect this zone differently. Although a thickened junctional zone is often used to diagnose adenomyosis on MRI, the presence of adenomyosis can be described more accurately as interruptions of the junctional zone by endometrial tissue, which leads to direct signs on imaging such as subendometrial lines and buds on two- and three-dimensional TVS or bright foci on MRI. The histopathological criteria for diagnosis are based on enlargement of the uterus with severe adenomyosis, and might not reflect its early stages. Clinicians should be aware that findings on MRI cannot be extrapolated readily to ultrasound. An understanding of this is necessary when investigating the uterine junctional zone as a functional unit and the association between visualization of direct features of adenomyosis in the junctional zone and clinical symptoms. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

How to improve O-RADS MRI score for rating adnexal masses with cystic component?

OBJECTIVES

To test the performance of the Ovarian-Adnexal Reporting Data System (O-RADS) MRI in characterizing adnexal masses with cystic components and to test new specific MRI features related to cystic components to improve the ability of the O-RADS MRI score to stratify lesions according to their risk of malignancy.

METHODS

The EURopean ADnexal study (EURAD) database was retrospectively queried to identify adnexal masses with a cystic component. One junior and 13 radiologists independently reviewed cases blinded to the pathological diagnosis. For each lesion, the size of the whole lesion, morphological appearance, number of loculi, presence of a thickened wall, thickened septae, signal intensity of the cystic components on T1-weighted/T2-weighted/diffusion weighted, mean value of the apparent diffusion coefficient, and O-RADS MRI score were reported. Univariate and multivariate logistic regression analysis was performed to determine significant features to predict malignancy.

RESULTS

The final cohort consisted of 585 patients with 779 pelvic masses who underwent pelvic MRI to characterize an adnexal mass(es). Histology served as the standard of reference. The diagnostic performance of the O-RADS MRI score was 0.944, 95%CI [0.922-0.961]. Significant criteria associated with malignancy included an O-RADS MRI score ≥ 4, ADCmean of cystic component > 1.69, number of loculi > 3, lesion size > 75 mm, the presence of a thick wall, and a low T1-weighted, a high T2-weighted, and a low diffusion-weighted signal intensity of the cystic component. Multivariate analysis demonstrated that an O-RADS MRI score ≥ combined with an ADC mean of the cystic component > 1.69, size > 75 mm, and low diffusion-weighted signal of the cystic component significantly improved the diagnostic performance up to 0.958, 95%CI [0.938-0.973].

CONCLUSION

Cystic component analysis may improve the diagnosis performance of the O-RADS MRI score in adnexal cystic masses.

KEY POINTS

• O-RADS MRI score combined with specific cystic features (area under the receiving operating curve, AUROC = 0.958) improves the diagnostic performance of the O-RADS MRI score (AUROC = 0.944) for predicting malignancy in this cohort. • Cystic features that improve the prediction of malignancy are ADC mean > 1.69 (OR = 7); number of loculi ≥ 3 (OR = 5.16); lesion size > 75 mm (OR = 4.40); the presence of a thick wall (OR = 3.59); a high T2-weighted signal intensity score 4 or 5 (OR = 3.30); a low T1-weighted signal intensity score 1, 2, or 3 (OR = 3.45); and a low diffusion-weighted signal intensity (OR = 2.12). • An adnexal lesion with a cystic component rated O-RADS MRI score 4 and an ADC value of the cystic component < 1.69 associated with a low diffusion-weighted signal, has virtually a 0% risk of malignancy.

[Imagerie dans les cancers de l'ovaire]

IMAGING OF OVARIAN CANCERS Imaging of ovarian lesions is based on the triptych: pelvic ultrasound with Doppler, magnetic resonance imaging (MRI) and computed tomography (CT). Endovaginal pelvic ultrasound is the first-line examination; tools are available to help with its interpretation (IOTA group rules, O-RADS US classification). When an ovarian mass is detected on ultrasound and if its characterization is «undetermined» or complex, MRI with perfusion sequences is used to clarify the criteria. Finally, a thoraco- abdominopelvic CT scan is necessary for extension assessment in the case of ovarian cancer, in particular to look for peritoneal carcinosis and to anticipate surgical difficulties.

Breast cancer screening in women with extremely dense breasts recommendations of the European Society of Breast Imaging (EUSOBI)

Breast density is an independent risk factor for the development of breast cancer and also decreases the sensitivity of mammography for screening. Consequently, women with extremely dense breasts face an increased risk of late diagnosis of breast cancer. These women are, therefore, underserved with current mammographic screening programs. The results of recent studies reporting on contrast-enhanced breast MRI as a screening method in women with extremely dense breasts provide compelling evidence that this approach can enable an important reduction in breast cancer mortality for these women and is cost-effective. Because there is now a valid option to improve breast cancer screening, the European Society of Breast Imaging (EUSOBI) recommends that women should be informed about their breast density. EUSOBI thus calls on all providers of mammography screening to share density information with the women being screened. In light of the available evidence, in women aged 50 to 70 years with extremely dense breasts, the EUSOBI now recommends offering screening breast MRI every 2 to 4 years. The EUSOBI acknowledges that it may currently not be possible to offer breast MRI immediately and everywhere and underscores that quality assurance procedures need to be established, but urges radiological societies and policymakers to act on this now. Since the wishes and values of individual women differ, in screening the principles of shared decision-making should be embraced. In particular, women should be counselled on the benefits and risks of mammography and MRI-based screening, so that they are capable of making an informed choice about their preferred screening method. KEY POINTS: • The recommendations in Figure 1 summarize the key points of the manuscript.

Ovarian cancer reporting lexicon for computed tomography (CT) and magnetic resonance (MR) imaging developed by the SAR Uterine and Ovarian Cancer Disease-Focused Panel and the ESUR Female Pelvic Imaging Working Group

OBJECTIVES

Imaging evaluation is an essential part of treatment planning for patients with ovarian cancer. Variation in the terminology used for describing ovarian cancer on computed tomography (CT) and magnetic resonance (MR) imaging can lead to ambiguity and inconsistency in clinical radiology reports. The aim of this collaborative project between Society of Abdominal Radiology (SAR) Uterine and Ovarian Cancer (UOC) Disease-focused Panel (DFP) and the European Society of Uroradiology (ESUR) Female Pelvic Imaging (FPI) Working Group was to develop an ovarian cancer reporting lexicon for CT and MR imaging.

METHODS

Twenty-one members of the SAR UOC DFP and ESUR FPI working group, one radiology clinical fellow, and two gynecologic oncology surgeons formed the Ovarian Cancer Reporting Lexicon Committee. Two attending radiologist members of the committee prepared a preliminary list of imaging terms that was sent as an online survey to 173 radiologists and gynecologic oncologic physicians, of whom 67 responded to the survey. The committee reviewed these responses to create a final consensus list of lexicon terms.

RESULTS

An ovarian cancer reporting lexicon was created for CT and MR Imaging. This consensus-based lexicon has 6 major categories of terms: general, adnexal lesion-specific, peritoneal carcinomatosis-specific, lymph node-specific, metastatic disease -specific, and fluid-specific.

CONCLUSIONS

This lexicon for CT and MR imaging evaluation of ovarian cancer patients has the capacity to improve the clarity and consistency of reporting disease sites seen on imaging.

KEY POINTS

• This reporting lexicon for CT and MR imaging provides a list of consensus-based, standardized terms and definitions for reporting sites of ovarian cancer on imaging at initial diagnosis or follow-up. • Use of standardized terms and morphologic imaging descriptors can help improve interdisciplinary communication of disease extent and facilitate optimal patient management. • The radiologists should identify and communicate areas of disease, including difficult to resect or potentially unresectable disease that may limit the ability to achieve optimal resection.

O-RADS MRI Classification of Indeterminate Adnexal Lesions: Time-Intensity Curve Analysis Is Better Than Visual Assessment

Background The MRI Ovarian-Adnexal Reporting and Data System (O-RADS) enables risk stratification of sonographically indeterminate adnexal lesions, partly based on time-intensity curve (TIC) analysis, which may not be universally available. Purpose To compare the diagnostic accuracy of visual assessment with that of TIC assessment of dynamic contrast-enhanced MRI scans to categorize adnexal lesions as benign or malignant and to evaluate the influence on the O-RADS MRI score. Materials and Methods The European Adnex MR Study Group, or EURAD, database, a prospective multicenter study of women undergoing MRI for indeterminate adnexal lesions between March 2013 and March 2018, was queried retrospectively. Women undergoing surgery for an adnexal lesion with solid tissue were included. Solid tissue enhancement relative to outer myometrium was assessed visually and with TIC. Contrast material washout was recorded. Lesions were categorized according to the O-RADS MRI score with visual and TIC assessment. Per-lesion diagnostic accuracy was calculated. Results A total of 320 lesions (207 malignant, 113 benign) in 244 women (mean age, 55.3 years ± 15.8 [standard deviation]) were analyzed. Sensitivity for malignancy was 96% (198 of 207) and 76% (157 of 207) for TIC and visual assessment, respectively. TIC was more accurate than visual assessment (86% [95% CI: 81, 90] vs 78% [95% CI: 73, 82]; P < .001) for benign lesions, predominantly because of higher specificity (95% [95% CI: 92, 98] vs 76% [95% CI: 68, 81]). A total of 21% (38 of 177) of invasive lesions were rated as low risk visually. Contrast material washout and high-risk enhancement (defined as earlier enhancement than in the myometrium) were highly specific for malignancy for both TIC (97% [95% CI: 91, 99] and 94% [95% CI: 90, 97], respectively) and visual assessment (97% [95% CI: 92, 99] and 93% [95% CI: 88, 97], respectively). O-RADS MRI score was more accurate with TIC than with visual assessment (area under the receiver operating characteristic curve, 0.87 [95% CI: 0.83, 0.90] vs 0.73 [95% CI: 0.68, 0.78]; P < .001). Conclusion Time-intensity curve analysis was more accurate than visual assessment for achieving optimal diagnostic accuracy with the Ovarian-Adnexal Reporting and Data System MRI score. Clinical trial registration no. NCT01738789 © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Vargas and Woo in this issue.

Prognosis of triple-negative breast cancer associated with pregnancy: A propensity score-matched analysis from the French CALG (Cancer Associé à la Grossesse) network

Introduction

Triple-negative (TN) breast cancer represents one third of pregnancy-associated breast cancers (PABC). The aims of the current study were to describe oncological and obstetrical outcomes of patients with TN-PABC and to compare their prognosis with TN-non-PABC patients using a propensity score.

Materials and methods

Between January 2005 and December 2020, data of patients with histologically proven TN-PABC were collected and compared with data of TN-non-PABC patients under the age of 46 years diagnosed during the same period using a propensity score (PS).

Results

After PS matching (tumor size and lymph node involvement),there were 59 patients in each group. The median follow-up was 14 months (IQR 4.8–40.1) for the TN-PABC group and 60 months (IQR 30.7–101.4) for the TN-non-PABC group. Eight recurrences occurred in the TN-PABC group and 10 in the TN-non-PABC group (adjusted OR (AOR) = 0.60 (0.21–1.60), HR (Cox adjusted model- AHR) = 1.25 (0.53–2.94)). Two patients died in the TN-PABC group, and six in the TN-non-PABC group with an AOR = 0.23 (0.03–1.01) and an AHR = 0.58 (0.12–2.69). All the patients diagnosed during the second (n = 17) and third trimesters (n = 28) continued their pregnancies, with a median term at delivery of 38 WG (IQR 36–39). All patients gave birth to healthy newborns.

Conclusion

Although the TN subtype is associated with poor prognosis in pregnant patients due to advanced stage at diagnosis and high lymph node involvement, our PS-matched case-control study showed that pregnancy per se does not worsen the prognosis in terms of recurrence-free and overall survival.

•

Triple-negative breast cancer are associated with poor prognosis.

•

Breast cancers occurring during pregnancy differ from those occurring in the post-partum period.

•

Pregnancy per se does not worsen the prognosis in triple-negative breast cancer.

O-RADS MRI Risk Stratification System: Guide for Assessing Adnexal Lesions from the ACR O-RADS Committee

MRI plays an important role as a secondary test or problem-solving modality in the evaluation of adnexal lesions depicted at US. MRI has increased specificity compared with US, decreasing the number of false-positive diagnoses for malignancy and thereby avoiding unnecessary or over-extensive surgery in patients with benign lesions or borderline tumors, while women with possible malignancies can be expeditiously referred for oncologic surgical evaluation. The Ovarian-Adnexal Reporting and Data System (O-RADS) MRI Committee is an international collaborative effort formed under the direction of the American College of Radiology and includes a diverse group of experts on adnexal imaging and management who developed the O-RADS MRI risk stratification system. This scoring system assigns a probability of malignancy based on the MRI features of an adnexal lesion and provides information to facilitate optimal patient management. The widespread implementation of a codified reporting system will lead to improved interpretation agreement and standardized communication between radiologists and referring physicians. In addition, it will allow for high-quality multi-institutional collaborations-an important unmet need that has hampered the performance of high-quality research in this area in the past. This article provides guidelines on using the O-RADS MRI risk stratification system in clinical practice, as well as in the educational and research settings.

Use of tyrosine kinase inhibitors during pregnancy for oncogenic-driven advanced non-small cell lung carcinoma

INTRODUCTION

Lung cancer associated with pregnancy is rare but on the increase. The use of tyrosine kinase inhibitor (TKI) therapy for advanced oncogenic-driven non-small cell lung carcinoma (NSCLC) has improved overall survival. Oncological and obstetric outcomes of patients diagnosed with NSCLC and treated by TKIs during pregnancy have been poorly evaluated.

METHODS

Three cases of NSCLC treated by TKIs during pregnancy were collected from the prospective database of the Cancer Associé à La Grossesse (CALG) network (France) in addition to eight cases identified by a systematic review performed between 2000 and 2021.

RESULTS

Among the eleven reported patients, six received an EGFR- and five an ALK-TKI. All patients were young nonsmokers and four had brain metastases at diagnosis. TKI treatment was initiated during the first trimester for three patients. Premature delivery was induced in 10/11 patients. Anamnios occurred in one patient treated by osimertinib and trastuzumab. Five newborns were hypotrophic. No newborn malformations were observed. Diffusion of the TKIs, confirmed by blood cord sampling, represented about 1/3 (EGFR-TKI) and 1/8 (ALK-TKI) of the maternal concentration. No developmental abnormalities were observed in the children (follow-up 30 months). The anti-tumor efficacy and tolerance of TKIs, when reported, appears similar to that described in the general population.

CONCLUSIONS

Our results support the rationale for using TKIs during pregnancy, both in terms of maternal NSCLC disease control and the relatively mild effects on the fetus. Our data will serve to better inform patients about the risks associated with TKIs used during pregnancy, contributing to shared decision making.

Axillary lymphadenopathy at the time of COVID-19 vaccination: ten recommendations from the European Society of Breast Imaging (EUSOBI)

Unilateral axillary lymphadenopathy is a frequent mild side effect of COVID-19 vaccination. European Society of Breast Imaging (EUSOBI) proposes ten recommendations to standardise its management and reduce unnecessary additional imaging and invasive procedures: (1) in patients with previous history of breast cancer, vaccination should be performed in the contralateral arm or in the thigh; (2) collect vaccination data for all patients referred to breast imaging services, including patients undergoing breast cancer staging and follow-up imaging examinations; (3) perform breast imaging examinations preferentially before vaccination or at least 12 weeks after the last vaccine dose; (4) in patients with newly diagnosed breast cancer, apply standard imaging protocols regardless of vaccination status; (5) in any case of symptomatic or imaging-detected axillary lymphadenopathy before vaccination or at least 12 weeks after, examine with appropriate imaging the contralateral axilla and both breasts to exclude malignancy; (6) in case of axillary lymphadenopathy contralateral to the vaccination side, perform standard work-up; (7) in patients without breast cancer history and no suspicious breast imaging findings, lymphadenopathy only ipsilateral to the vaccination side within 12 weeks after vaccination can be considered benign or probably-benign, depending on clinical context; (8) in patients without breast cancer history, post-vaccination lymphadenopathy coupled with suspicious breast finding requires standard work-up, including biopsy when appropriate; (9) in patients with breast cancer history, interpret and manage post-vaccination lymphadenopathy considering the timeframe from vaccination and overall nodal metastatic risk; (10) complex or unclear cases should be managed by the multidisciplinary team.

Three artificial intelligence data challenges based on CT and ultrasound

PURPOSE

The 2020 edition of these Data Challenges was organized by the French Society of Radiology (SFR), from September 28 to September 30, 2020. The goals were to propose innovative artificial intelligence solutions for the current relevant problems in radiology and to build a large database of multimodal medical images of ultrasound and computed tomography (CT) on these subjects from several French radiology centers.

MATERIALS AND METHODS

This year the attempt was to create data challenge objectives in line with the clinical routine of radiologists, with less preprocessing of data and annotation, leaving a large part of the preprocessing task to the participating teams. The objectives were proposed by the different organizations depending on their core areas of expertise. A dedicated platform was used to upload the medical image data, to automatically anonymize the uploaded data.

RESULTS

Three challenges were proposed including classification of benign or malignant breast nodules on ultrasound examinations, detection and contouring of pathological neck lymph nodes from cervical CT examinations and classification of calcium score on coronary calcifications from thoracic CT examinations. A total of 2076 medical examinations were included in the database for the three challenges, in three months, by 18 different centers, of which 12% were excluded. The 39 participants were divided into six multidisciplinary teams among which the coronary calcification score challenge was solved with a concordance index > 95%, and the other two with scores of 67% (breast nodule classification) and 63% (neck lymph node calcifications).

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.

Magnetic resonance imaging classification of deep pelvic endometriosis: description and impact on surgical management

STUDY QUESTION

Is an MRI classification of deep pelvic endometriosis (DE) able to correctly predict the risk of DE surgery.

SUMMARY ANSWER

A new radiological classification, that we have called the deep pelvic endometriosis index (dPEI) classification, is accurate and reproducible to assess the extension of the disease in central and lateral compartments and well correlated with operating time, hospital stay duration and the risk of voiding dysfunction.

WHAT IS KNOWN ALREADY

Few imaging classifications are currently available to predict the extent of DE to help preoperative assessment of surgical outcomes and provide the patient with objective information about the risk of surgical complications.

STUDY DESIGN, SIZE, DURATION

Retrospective monocentric observational study was conducted between 01 January 2017 and 31 December 2018 and included 150 women (mean age = 34.5 years, 20-52 years) with DE on MRI and who subsequently underwent surgery.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two radiologists independently graded the disease according to MRI-based Enzian classification (A (rectovaginal septum and vagina locations), B (uterosacral locations) and C (rectosigmoid locations)) and a new radiological classification, that we have called the dPEI, that grades the severity of DE as: mild, moderate or severe DE. MRI findings and classification were correlated with surgical and pathological results.

MAIN RESULTS AND THE ROLE OF CHANCE

MRI-based and surgical Enzian classifications were concordant for A lesions in 78.7% (118/150), for B lesions in 34.7% (52/150) and for C lesions in 82.7% (124/150). Operating time and hospital stays were longer in Group A2 (rectovaginal septum and vagina, 1-3 cm) compared to A0, B2 (uterosacral, 1-3 cm) compared to B0, C3 (rectosigmoid >3 cm) compared to C2 (rectosigmoid 1-3 cm) or C0 (P < 0.001), in severe compared to moderate DE patients, and in moderate compared to mild extensive patients (P < 0.01). Patients with vaginal or rectosigmoid involvement were respectively six and three times more likely to experience high-grade complications according to Clavien-Dindo classification than patients without vaginal or rectosigmoid disease (P < 0.001). Postoperative voiding dysfunction was correlated with A lesions (odds ratio (OR) = 6.82, 95% CI 2.34-20.5), moderate or severe DE (OR = 4.15, 95% CI 1.26-17.9), the presence of at least unilateral lateral pelvic involvement (OR = 3.6, 95% CI 1.14-11.2, P = 0.03) and C lesions (OR = 2.6, 95% CI 1.03-6.8, P < 0.01).

LIMITATIONS, REASONS FOR CAUTION

The study was conducted in an expert center and needs to be validated in a multicenter study. There is a limited number of patients with lateral pelvic endometriosis beyond the parietal fascia, probably due to the low prevalence of this disease presentation.

WIDER IMPLICATIONS OF THE FINDINGS

MRI imaging can be used to accurately predict postoperative complications for women with DE. This may help the clinician to preoperatively inform a patient about the risks of surgery. Larger clinical studies are required to validate these results.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used for this study. I.T.N.: Remunerated lecture GE, Hologic, Guerbet, Canon; Advisory board: Siemens - These relationships are on the topic of breast imaging, not related to the topic of this paper. Other coauthors have no conflict of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Fertility preservation in women with malignant and borderline ovarian tumors: Experience of the French ESGO-certified center and pregnancy-associated cancer network (CALG)

OBJECTIVE

To describe strategy and results of fertility preservation (FP) in patients with malignant and borderline ovarian tumors.

METHODS

Consecutive cohort study of 43 women with malignant or borderline ovarian tumors who underwent FP between February 2013 and July 2019. The study was conducted in national expert center in Tenon University Hospital, Sorbonne University: French ESGO-certified ovarian cancer center and pregnancy-associated cancer network (CALG). Main outcome measure was FP technique proposed by multidisciplinary committee, FP technique used, time after surgery, number of fragments, histology and follicle density (if ovarian tissue freezing), number of expected, retrieved and frozen oocytes (if ovarian stimulation).

RESULTS

Pathological diagnosis was malignant epithelial ovarian tumor in five women (11.6%), rare malignant ovarian tumor in 14 (32.6%), borderline in 24 (55.8%), and mostly unilateral (79.1%) and stage I (76.7%). Mean age at diagnosis was 26.8 ± 6.9 years and mean tumor size 109.7 ± 61 mm. Before FP, mean AFC was 11.0 ± 6.1 and AMH levels were 2.7 ± 4.6 ng/mL. Six ovarian tissue-freezing procedures were performed (offered to 13). Twenty-four procedures of ovarian stimulation and oocyte freezing were performed after surgical treatment for 19 women (offered to 28) with a median interval of 188 days. The mean number of mature oocytes retrieved per stimulation was 12.4 ± 12.8. At least 10 mature oocytes were frozen for 52.6% of the women. No FP was offered to five women.

CONCLUSION

Oocyte and ovarian tissue cryopreservation should be offered to patients with malignant and borderline ovarian tumors. More data are needed to confirm ovarian stimulation and ovarian tissue grafting safety.

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.