Unenhanced magnetic resonance imaging for the evaluation of sonographically indeterminate ovarian and adnexal masses

Moradi, Behnaz; Aghasi, Maryam; Rahmani, Maryam; Sharifi, Elham; Malek, Mahrooz; Yarandi, Fariba; Banihashemian, Masoumeh; Behtash, Nadereh; Abdolghafoorian, Hamed

doi:10.1590/0100-3984.2024.0032

Figures (4)
Tables (3)

Figure 1 Images of a 50-year-old woman with bilateral adnexal masses categorized as indeterminate on transvaginal ultrasound. Axial T1-weighted and sagittal T2-weighted MRI sequences (A and B, respectively), showing a left-sided, multiloculated solid-cystic adnexal mass with intermediate signal intensity in its solid portions. DWI sequences showing high signal intensity at b = 1,000 s/mm² (C) and low ADC signal intensity in solid tissues (D). In the proposed scoring system, based on unenhanced MRI findings, this lesion was given a score of 5 (lymphadenopathy is not shown in the images above). Histopathology confirmed a diagnosis of serous cystadenocarcinoma.

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Figure 2 Images of a 50-year-old woman with bilateral adnexal masses categorized as indeterminate on transvaginal ultrasound (the same patient whose left adnexal mass is shown in ). Axial T1-weighted and sagittal T2-weighted MRI sequences (A and B, respectively), showing a right-sided, multiloculated solid-cystic adnexal mass with intermediate signal intensity in its solid portions. DWI sequences showing high signal intensity at b = 1,000 s/mm² (C) and low ADC signal intensity in solid tissues (D). In the proposed scoring system, based on unenhanced MRI findings, this lesion was given an score of 5 (lymphadenopathy is not shown in the images above). Histopathology confirmed a diagnosis of serous cystadenocarcinoma.

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Figure 3 ROC curve of the unenhanced MRI scoring system for adnexal masses, at a cutoff score for malignancy of ≥ 4.

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Figure 4 Images of a 59-year-old woman with bilateral adnexal masses categorized as indeterminate on transvaginal ultrasound. Axial Tl-weighted and sagittal T2-weighted MRI sequences (A and B, respectively), showing a left-sided, multiloculated solid-cystic adnexal mass with intermediate signal intensity in its solid portions. DWI sequences showing high signal intensity at b = 1,000 s/mm² (C) and intermediate-to-high ADC signal intensity in solid tissues (D). In the proposed scoring system, based on unenhanced MRI, this lesion was given a score of 3. Histopathology confirmed a diagnosis of a borderline serous tumor.

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Table 1 Diagnostic parameters of the proposed unenhanced MRI scoring system.

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Table 2 Characteristics of the adnexal masses evaluated on unenhanced MRI.

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Table 3 Diagnostic parameters of scoring systems for adnexal masses.

Score	Definition	MRI finding
1	No mass	No adnexal mass
2	Benign	Purely cystic masses, fat-containing masses, or endometrioid masses
3	Probably benign/indeterminate	Not classified in other scores
4	Suspicious for malignancy	Solid-appearing tissue with intermediate signal intensity on T2WI, low signal intensity on T1WI, and true diffusion restriction
5	Highly suspicious for malignancy	Peritoneal implants, lymphadenopathy, or ascites after exclusion of benign diagnoses

Variable	(N = 336)
Patient age (years), mean ± SD	43 ± 13
Patient menopausal status, n (%)
Premenopausal	273 (81.3)
Postmenopausal	63 (18.7)
Mass treated surgically, n (%)	196 (58.3)
Follow-up data for the mass, n (%)	140 (41.7)
Mass categorization, n (%)
Benign	218 (64.9)
Malignant	94 (28.0)
Borderline	24 (7.1)
Largest diameter of the mass (mm), mean ± SD	72.61 ± 47.52
Origin of the mass, n (%)
Ovarian	274 (81.5)
Extra-ovarian	62 (18.5)
Malignant/borderline mass type, n (%)
Epithelial	81 (68.6)*
Germ cell	2 (1.7)*
Sex cord	7 (6.0)*
Metastasis	28 (23.7)*

Parameter	Unenhanced MRI scoring system (this study)		Other scoring systems
Parameter	Including borderline cases	Excluding borderline cases	ADNEX MR (2016-2019)	O-RADS MRI (2020-2022)
Sensitivity (%)	86.4	95.7	93.5-94.9	91.1-93.0
Specificity (%)	97.7	97.7	92.9-96.6	91.0-94.9
PPV	95.3	94.7	94.8	89.1
NPV	93.0	98.2	97.4	95.9
PLR	37.5	41.7	37.5	10.9-18.0
NLR	0.14	0.043	0.05	0.09
Accuracy(%)	93.8	97.1	—	93.7

[TFN1] T2WI, T2-weighted imaging; T1WI, T1-weighted imaging.

Unenhanced magnetic resonance imaging for the evaluation of sonographically indeterminate ovarian and adnexal masses

Ressonância magnética sem contraste para avaliação de massas ovarianas e anexiais indeterminadas na ultrassonografia

Abstract