2. INTRODUCTION
Common indication of consultation / potential surgery
Ultrasonography : first-line imaging technique
- Expertise
- “Indeterminate lesions”
MRI : second-line imaging technique
Conventional and Functional MR imaging (PWI-DWI)
- Characterization
- (Extension et follow-up)
3. Indeterminate ovarian mass at US: Incremental value of
second imaging test for characterization - Meta-analysis
and Bayesian analysis. Kinkel et al. Radiology 2005
Indeterminate mass at US: MRI > CT or US + Doppler
10. STEP 3 : SOLID TISSUE ?
POST CONTRAST T1
Gadolinium injection is very useful for
adnexal mass characterization
Absence of enhancement is highly
predictive of benign disease
15. STEP 3 : SOLID TISSUE ?
POST CONTRAST T1
Absence of solid tissue = BENIGN
No wall enhancement or no internal enhancement
including purely cystic, endometriotic, fatty mass
Presence of solid tissue = SUSPICIOUS
T2 weighted sequence
Perfusion weighted imaging (PWI)
Diffusion weighted imaging (DWI)
16. STEP 4 : MALIGNANT TISSUE ?
T2 / PWI / DWI
T2 signal : Initial characterization of solid tissue
T2
Intermediate T2 signal
Edema
Cellular
Invasive
T2
Low T2 signal
Fibrous
Muscle
17. PERFUSION : ACQUISITION
Gadolinium injection
0.02 ml/kg / 2ml/sec
T1 gradient echo using 2D or 3D
Repetitive acquisition
Acquisition d'une série d'images
18. PERFUSION : ANALYSIS
---Ext iliac
artery
ROI
---Ovarian
lesion
--Myometrium
DESCRIPTIVE
CURVE TYPE
SEMI QUANTITATIVE
QUANTITATIVE
20. Can dynamic contrast-enhanced MRI predict the nature of ovarian tumors?
Thomassin-Naggara, Bazot et al. Radiology 2008
MALIGNANT
3
2
1
Type 1 : weak enhancement
BENIGN
Type 2 : moderate enhancement with pic followed by a plateau
Type 3 : intense enhancement earlier than myometrium
25. DIFFUSION WEIGHTED IMAGING
Echo Planar Imaging
T2
At least two b values: 0-1000 mm2/s
Fat saturation techniques
Qualitative analysis +++
- Low or high signal intensity on b1000
b1000
- Comparison with T2 (or fusion)
Quantitative analysis
- ADC values
ADC
26. STEP 4 : MALIGNANT TISSUE ?
T2 / PWI / DWI
DWI : Signal
Invasive
malignant
tumor always
T2
Ovarian
cystadenocarcinoma
displays high
b1000 signal ….
T2
Ovarian fibroma
…But some
benign tumors
may also
display high
DWI
b1000 signal
DWI
27. STEP 4 : MALIGNANT TISSUE ?
T2 / PWI / DWI
DWI : Signal
In contrast, the absence of high b1000
signal is highly predictive of benignity
(PLR = 10.1)
Cystadenofibroma
T2
T1FS gado
Thomassin-Naggara, Bazot et al. Eur Radiol 2009
DWI
33. Combination of T2 + DWI
T2
> DWI or (T2 + T1G) alone
Peritoneal Implants
DWI
High signal intensity b 1000
Bilateral ovarian cancer
Low ADC
Sala et al. Radiology 2012
38. WHAT IS YOUR DIAGNOSIS?
A. ADNEXMR SCORE 1
B. ADNEXMR SCORE 2
Benign (PPV < 2%)
C. ADNEXMR SCORE 3
Probably benign (PPV<5%)
D. ADNEXMR SCORE 4
Indeterminate
E. ADNEXMR SCORE 5
Probably malignant (PPV>95%)
42. ADNEXMR SCORING SYSTEM
ADNEXMR SCORE >4 predicts malignancy
with a sensitivity 93.5% and a specificity of 96.6%
Cancer center
ADNEXMR SCORE <3 predicts benignity
with a sensivity 96,6% and a specificity of 93,5%
Follow up
Conservative
surgery
ADNEXMR SCORING system relays radiologist’s suspicions to clinician
and would help to standardize MR imaging reporting with the
potential aim of improving patient management.
Thomassin-Naggara, Bazot et al. Radiology 2013
44. TAKE HOME MESSAGES
Conventional MRI +++
- T1 for cystic component
- T2 for solid component
- Low T2 : benign
- Intermediate T2 : suspicious
DWI ++
- Low signal on b1000 : benign
- High signal for peritoneal implants
PWI +++
- Type 1: benign
- Type 2: overlap (mainly borderline)
- Type 3: invasive
45. CLINICAL TRIAL SIFEM-2013 : EUROPEAN MULTICENTRIC VALIDATION
March 2013-July 2017
UK : A.Rockall
A.Sahdev
M.Lewinski
S.Freeman
M.Hall-Craggs
Italy : G.Masseli
G.Reistano
R.Manfredi
Austria : R.Forstner
Portugal : TM Cunha
AG.Guerra
Belgium : A.Thille
Switzerland :
K.Kinkel
R.Kubik
H.Thoeny
Serbia: S.Stojanovic
Coordonnator :
I.Thomassin-Naggara
(Paris)
Croatia:
I.Giordana
France : M.Bazot
A.Jalaguier
S.Taieb
C.Balleyguier
O.Lucidarme
L.Fournier
I.Millet
N.Perrot
S.Bendavid
E.Poncelet
V.Juhan
C.Malhaire