Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement

Endometriosis: assessment on O-RADS and risk of malignant transformation

Endometriosis is a common disease, affecting approximately 10% of women of reproductive age. Several intersecting guidelines and consensus statements provide information on imaging diagnosis and surveillance strategies for endometriomas. SRU consensus panel recommendations provide information on initial detection of endometriosis on routine pelvic imaging. Revised American Society of Reproductive Medicine (rASRM) classification, the #ENZIAN classification, and the deep pelvic endometriosis index (dPEI) aim to assess the overall extent of disease and assist in presurgical planning. The Ovarian-Adnexal Reporting and Data System (O-RADS) aims to risk stratify lesions evaluated with US or MR based on their imaging morphology, from typical benign lesions to atypical presentations and malignant transformation. Emerging data shows increased risk of ovarian cancer in patients with endometriosis, especially following menopause and in those patients with long standing endometriosis. (Chen et al. in Front Oncol. 14:1329133, 2024;Streuli et al. in Climacteric. 20:138-143, 2017;Secosan et al. in Diagnostics (Basel). 10:134, 2020;Inceboz in Womens Health (Lond Engl). 11:711-715, 2015;Cassani et al. in Maturitas. 190, 2024;Gemmell et al. in Hum Reprod Update. 23:481-500, 2017;Giannella et al. in Cancers (Basel). 13:4026, 2021;) Current O-RADS guidelines mandate follow-up of endometriomas up to 2 years with further follow-up based on clinical factors. No consensus guidelines exist for imaging surveillance of patients with deep endometriosis from a malignancy standpoint. This review explores the imaging appearance of endometriomas, imaging features of malignant transformation, surveillance strategies and gaps in current literature, and attempts to better understand the risk of malignancy and to encourage further research for long-term imaging surveillance of endometriosis patients.

Tumor biomarkers contribute to the diagnosis and clinical management of the O-RADS MRI risk stratification system for epithelial ovarian tumors

BACKGROUND

To assess the effectiveness of tumor biomarkers in distinguishing epithelial ovarian tumors (EOTs) and guiding clinical decisions across each Ovarian-Adnexal Reporting and Data System (O-RADS) MRI risk category, the aim is to prevent unnecessary surgeries for benign lesions, avoid delays in treating malignancies, and benefit individuals requiring fertility preservation or those intolerant to over-extensive surgery.

METHODS

A total of 54 benign, 104 borderline, and 203 malignant EOTs (BeEOTs, BEOTs and MEOTs) were enrolled and retrospectively assigned risk scores. The role of tumor biomarkers in diagnosing and managing EOTs within each risk category was evaluated by combining receiver operating characteristic (ROC) curves with clinicopathological characteristics.

RESULTS

A score of 3 was assigned to 66.67% of BeEOTs, 50.96% of BEOTs, and 13.80% of MEOTs, whereas cancer antigen 125 (CA125) ≥ 60.39 U/ml helped identify MEOTs with a low-risk time-intensity curve (TIC) for prompt surgical assessment. Only 3.7% of the BeEOTs were classified as O-RADS MRI 4/5, whereas 48.08% and 86.2% of the BEOTs and MEOTs were classified, respectively. Overall, EOTs with a score of 4/5 are candidates for semi-elective surgery owing to the low probability of benign lesions. For EOTs with a ROMA index less than 20.14% (premenopausal) or 29.9% (postmenopausal), minimally invasive surgery is recommended for diagnostic and therapeutic purposes. Comprehensive staging or cytoreductive surgery is recommended for the remaining patients, especially when fertility preservation is not a priority.

CONCLUSIONS

The O-RADS MRI primarily differentiates BeEOTs with risk scores of 2/4/5 from BEOTs/MEOTs, while tumor biomarkers further enhance the diagnosis and clinical management of EOTs with scores of 3/4/5. Future studies should focus on multi-center, prospective studies with larger sample sizes to validate and refine the integration of O-RADS MRI with tumor biomarkers.

Ovarian-Adnexal Imaging-Reporting and Data System (O-RADS) ultrasound version 2019: a prospective validation and comparison to updated version (v2022) in pathologically confirmed adnexal masses

OBJECTIVE

To evaluate the diagnostic accuracy and reliability of the Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound v2019 in classifying adnexal masses (AMs) and compare the old and updated systems (v2022).

PATIENTS AND METHODS

This prospective study enrolled 977 consecutive women with suspected AMs from three institutions between January 2022 and December 2023. Ultrasound examinations were performed by three experienced radiologists who categorized AMs according to O-RADS ultrasound v2019. The same radiologists retrospectively reviewed the stored ultrasound images and provided the O-RADS ultrasound v2022 classification. Histopathology was used as the reference standard to calculate the diagnostic accuracy of the O-RADS versions in predicting malignant AMs. Inter-observer agreement (IOA) of the O-RADS scoring results was evaluated using the Fleiss kappa (κ) test.

RESULTS

The final analysis included 803 women with 855 AMs (219 (25.6%) malignant and 636 (74.4%) benign). Both O-RADS versions demonstrated good diagnostic accuracy, with area under the curve (AUC) values ranging from 0.906 to 0.923 (v2019) and 0.919 to 0.936 (v2022). The updated v2022 showed a slightly higher accuracy (82.5-86.7% vs. 80.7-85.3%), sensitivity (93.6-95.0% vs. 92.2-94.1%), and specificity (78.1-84.1% vs. 76.1-82.9%) compared to v2019. The IOA for the overall O-RADS classification was perfect for both versions (κ = 0.96-0.97).

CONCLUSIONS

The O-RADS ultrasound classification system demonstrated good diagnostic accuracy and reliability in predicting malignant AMs, with the updated v2022 showing modest improvements.

KEY POINTS

Question Accurate classification of adnexal masses is essential for management. Can updated O-RADS ultrasound v2022 improve diagnostic accuracy and reliability compared to v2019 in predicting malignancies? Findings O-RADS ultrasound v2022 demonstrated slightly higher diagnostic accuracy for identifying malignant adnexal masses compared to v2019, reflecting modest improvements in risk stratification and clinical decision-making. Clinical relevance The updated O-RADS ultrasound v2022 provides improved risk stratification for adnexal masses, enhancing diagnostic confidence, supporting more precise clinical decision-making, and improving patient outcomes through timely intervention or tailored management strategies in ovarian cancer care.

The Ovarian-Adnexal Reporting and Data System (O-RADS) US Score Effect on Surgical Resection Rate

Background The Ovarian-Adnexal Imaging Reporting and Data System (O-RADS) US risk score can be used to accurately stratify ovarian lesions based on morphologic characteristics. However, there are no large multicenter studies assessing the potential impact of using O-RADS US version 2022 risk score in patients referred for surgery for an ovarian or adnexal lesion. Purpose To retrospectively determine the proportion of patients with ovarian or adnexal lesions without acute symptoms who may have been managed conservatively by using the O-RADS US version 2022 risk score. Materials and Methods This multicenter retrospective study included patients with ovarian cystic lesions and nonacute symptoms who underwent surgical resection after US before the introduction of O-RADS US between January 2011 and December 2014. Investigators blinded to the final diagnoses recorded lesion imaging features and O-RADS US risk scores. The frequency of malignancy and the diagnostic performance of the risk score were calculated. The Mann-Whitney test and Fisher exact test were performed, with P < .05 indicating a statistically significant difference. Results A total of 377 patients with surgically resected lesions were included. Among the resected lesions, 42% (157 of 377) were assigned an O-RADS US risk score of 2. Of the O-RADS US 2 lesions, 54% (86 of 157) were nonneoplastic, 45% (70 of 157) were dermoids or other benign tumors, and less than 1% (one of 157) were malignant. Using O-RADS US 4 as the optimal threshold for malignancy prediction yielded a 94% (68 of 72) sensitivity, 64% (195 of 305) specificity, 38% (68 of 178) positive predictive value, and 98% (195 of 199) negative predictive value. Conclusion In patients without acute symptoms who underwent surgery for ovarian and adnexal lesions before the O-RADS US risk score was published, nearly half (42%) of surgically resected lesions retrospectively met the O-RADS US 2 version 2022 criteria. In these patients, imaging follow-up or conservative management could have been offered. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Fournier in this issue.

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.

O-RADS MRI After Initial Ultrasound for Adnexal Lesions: AJR Expert Panel Narrative Review

The Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound (US) and MRI risk stratification systems were developed by an international group of experts in adnexal imaging to aid radiologists in assessing adnexal lesions. The goal of imaging is to appropriately triage patients with adnexal lesions. US is the first-line imaging modality for assessment, whereas MRI can be used as a problem-solving tool. Both US and MRI can accurately characterize benign lesions such as simple cysts, endometriomas, hemorrhagic cysts, and dermoid cysts, avoiding unnecessary or inappropriate surgery. In patients with a lesion that does not meet criteria for one of these benign diagnoses, MRI can further characterize the lesion with an improved specificity for cancer and the ability to provide a probable histologic subtype in the presence of certain MRI features. This allows personalized treatment, including avoiding overly extensive surgery or allowing fertility-sparing procedures for suspected benign, borderline, or low-grade tumors. When MRI findings indicate a risk of an invasive cancer, patients can be expeditiously referred to a gynecologic oncologic surgeon. This narrative review provides expert opinion on the utility of multiparametric MRI when using the O-RADS US and MRI management systems.

A machine learning approach applied to gynecological ultrasound to predict progression-free survival in ovarian cancer patients

In a growing number of social and clinical scenarios, machine learning (ML) is emerging as a promising tool for implementing complex multi-parametric decision-making algorithms. Regarding ovarian cancer (OC), despite the standardization of features that can support the discrimination of ovarian masses into benign and malignant, there is a lack of accurate predictive modeling based on ultrasound (US) examination for progression-free survival (PFS). This retrospective observational study analyzed patients with epithelial ovarian cancer (EOC) who were followed in a tertiary center from 2018 to 2019. Demographic features, clinical characteristics, information about the surgery and post-surgery histopathology were collected. Additionally, we recorded data about US examinations according to the International Ovarian Tumor Analysis (IOTA) classification. Our study aimed to realize a tool to predict 12 month PFS in patients with OC based on a ML algorithm applied to gynecological ultrasound assessment. Proper feature selection was used to determine an attribute core set. Three different machine learning algorithms, namely Logistic Regression (LR), Random Forest (RFF), and K-nearest neighbors (KNN), were then trained and validated with five-fold cross-validation to predict 12 month PFS. Our analysis included n. 64 patients and 12 month PFS was achieved by 46/64 patients (71.9%). The attribute core set used to train machine learning algorithms included age, menopause, CA-125 value, histotype, FIGO stage and US characteristics, such as major lesion diameter, side, echogenicity, color score, major solid component diameter, presence of carcinosis. RFF showed the best performance (accuracy 93.7%, precision 90%, recall 90%, area under receiver operating characteristic curve (AUROC) 0.92). We developed an accurate ML model to predict 12 month PFS.

Diagnostic Performance of the Ovarian-Adnexal Reporting and Data System (O-RADS) Ultrasound Risk Score in Women in the United States

IMPORTANCE

The American College of Radiology (ACR) Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound (US) risk scoring system has been studied in a selected population of women referred for suspected or known adnexal lesions. This population has a higher frequency of malignant neoplasms than women presenting to radiology departments for pelvic ultrasonography for a variety of indications, potentially impacting the diagnostic performance of the risk scoring system.

OBJECTIVE

To evaluate the risk of malignant neoplasm and diagnostic performance of O-RADS US risk scoring system in a multi-institutional, nonselected cohort.

DESIGN, SETTING, AND PARTICIPANTS

This multi-institutional cohort study included a population of nonselected women in the United States who presented to radiology departments for routine pelvic ultrasonography between 2011 and 2014, with pathology confirmation imaging follow up or 2 years of clinical follow up.

EXPOSURE

Analysis of 1014 adnexal lesions using the O-RADS US risk stratification system.

MAIN OUTCOMES AND MEASURES

Frequency of ovarian cancer and diagnostic performance of the O-RADS US risk stratification system.

RESULTS

This study included 913 women with 1014 adnexal lesions. The mean (SD) age of the patients was 42.4 (13.9 years), and 674 of 913 (73.8%) were premenopausal. The overall frequency of malignant neoplasm was 8.4% (85 of 1014 adnexal lesions). The frequency of malignant neoplasm for O-RADS US 2 was 0.5% (3 of 657 lesions; <1% expected); O-RADS US 3, 4.5% (5 of 112 lesions; <10% expected); O-RADS US 4, 11.6% (18 of 155; 10%-50% expected); and O-RADS 5, 65.6% (59 of 90 lesions; >50% expected). O-RADS US 4 was the optimum cutoff for diagnosing cancer with sensitivity of 90.6% (95% CI, 82.3%-95.9%), specificity of 81.9% (95% CI, 79.3%-84.3%), positive predictive value of 31.4% (95% CI, 25.7%-37.7%) and negative predictive value of 99.0% (95% CI, 98.0%-99.6%).

CONCLUSIONS AND RELEVANCE

In this cohort study of a nonselected patient population, the O-RADS US risk stratification system performed within the expected range as published by the ACR O-RADS US committee. The frequency of malignant neoplasm was at the lower end of the published range, partially because of the lower prevalence of cancer in a nonselected population. However, a high negative predictive value was maintained, and when a lesion can be classified as an O-RADS US 2, the risk of cancer is low, which is reassuring for both clinician and patient.

The Influence of Living in Rural Areas on the Evolution and Management of Pediatric Ovarian Cystic Lesions: A Retrospective Study on a Cohort from South Eastern Romania

BACKGROUND

The incidence of ovarian cystic lesions (OCLs) in pediatric patients has been increasing in recent years. An early diagnosis is mandatory for a favourable prognosis but it depends on the primary medical care services and on the socioeconomic status of the patient. The present study aims at assessing the prevalence and the age-specific frequencies of pediatric OCLs, as well as identifying disparities between subjects in the urban and the rural areas, in order to explore the extent to which OCLs occurrence, diagnosis, evolution and treatment differ in the case of patients living in rural areas.

METHODS

A 3-year retrospective study was conducted between 2017 and 2019. All the female patients aged between 0 and 18 with OCLs ≥10 mm (N = 488), diagnosed and treated at "Sf.Ioan" Clinical Emergency Hospital for Children in Galaţi were included in the study. The Chi2 test was used for comparing the distributions of frequencies, and the t-Student test was used for comparing the means of any two normally distributed variables. The statistical significance threshold (p) was set at 0.05.

RESULTS

The prevalence of OCLs ≥10 mm was 14.85%, 47.13% of the subjects originating in rural area (p = 0.62). Different from the urban areas, the rural ones are characterised by a lower proportion of patients with BMI ≥25 (p = 0.002), larger OCLs mean size (p = 0.278), a more frequent complex aspect on ultrasonography (p = 0.01), and a smaller number of general physician referrals (p = 0.005). Moreover, a higher proportion of rural patients were intraoperatively diagnosed with OCLs (p = 0.044), had complicated OCLs (p = 0.012) and had their OCLs surgically treated OCLs (p < 0.01).

CONCLUSION

Taking into consideration the socio-economic situation of south eastern Romania, patients living in rural areas have proven exposed to a higher risk of presenting with larger, complex and complicated OCLs, which most often require surgical treatment.

Measuring intraobserver and intermethod reliability of endometriotic cyst volumes: A comparison between MRI and 3D transvaginal ultrasound in endometriosis

Objectives:

To identify the intraobserver and intermethod reliability of three-dimensional transvaginal ultrasound (3D-TVUS) using the software VOCAL and XI VOCAL compared with magnetic resonance imaging (MRI) for volumetric measurement of ovarian endometrioma.

Methods:

The intermethod and intraobserver reliability of endometrioma volumes were assessed in 16 women diagnosed with endometriosis through laparoscopy with histologic confirmation and presenting with uni- or bilateral endometriomas. In total, volumes of 23 endometriomas were assessed with two-dimensional and three-dimensional transvaginal ultrasound and 6 mm magnetic resonance imaging. Examinations took place at two moments in one menstrual cycle: day 2–4 (T0) and day 20–22 (T1).

Results:

The intraclass correlation for intraobserver reliability is good to very good for all three techniques ranging from the lowest value of 0.953 to the highest of 1.000. MRI has the most narrow limits of agreement (−3.93 to 4.53), followed by XI VOCAL (−5.16 to 5.65) while VOCAL has the widest limits of agreement (−10.22 to 11.39). Intraclass correlations are poor in the comparison of XI VOCAL to MRI, moderate between VOCAL and XI VOCAL, and good for the comparison between VOCAL and MRI. Limits of agreement vary per technique. When comparing 3D imaging techniques with 2D TVUS, XI VOCAL versus 2D TVUS provide the smallest limits of agreement.

Conclusions:

MRI and XI VOCAL provide the best intraobserver reliability. The different imaging techniques are not interchangeable. As TVUS is a more readily available and cost-efficient imaging technique the usage of XI VOCAL is advised.

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

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

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.

Diagnostic accuracy and inter-observer reliability of the O-RADS scoring system among staff radiologists in a North American academic clinical setting

PURPOSE

The objective of this study is to evaluate the diagnostic accuracy, interobserver variability, and common lexicon pitfalls of the ACR O-RADS scoring system among staff radiologists without prior experience to O-RADS.

MATERIALS AND METHODS

After independent review of the ACR O-RADS publications and 30 training cases, three fellowship-trained, board-certified staff radiologists scored 50 pelvic ultrasound exams using the O-RADS system. The diagnostic accuracy and area under receiver operating characteristic were analyzed for each reader. Overall agreement and pair-wise agreement between readers were also analyzed.

RESULTS

Excellent specificities (92 to 100%), NPVs (92 to 100%), and variable sensitivities (72 to 100%), PPVs (66 to 100%) were observed. Considering O-RADS 4 and O-RADS 5 as predictors of malignancy, individual reader AUC values range from 0.94 to 0.98 (p < 0.001). Overall inter-reader agreement for all 3 readers was "very good," k = 0.82 (0.73 to 0.90, 95% CI, p < 0.001). Pair-wise agreement between readers were also "very good," k = 0.86-0.92. 14 out of 150 lesions were misclassified, with the most common error being down-scoring of a solid lesion with irregular outer contours.

CONCLUSION

Even without specific training, experienced ultrasound readers can achieve excellent diagnostic performance and high inter-reader reliability with self-directed review of guidelines and cases. The study highlights the effectiveness of ACR O-RADS as a stratification tool for radiologists and supports its continued use in practice.

Management of adnexal mass: A comparison of five national guidelines

OBJECTIVES

General gynecologists are often the first to face a newly diagnosed adnexal mass. Bothering mass symptoms, fertility issues, and the effect of a possible surgical intervention on fertility in term of mechanical factor and ovarian follicular reserve are all considerations that should be accounted for. This study summarizes and compares five different adnexal mass management guidelines, enabling clinicians to peruse consensus and controversy issues, thus choosing the optimal management method.

DESIGN

We retrieved, reviewed and compared the most recent national guidelines of adnexal mass management from the national societies of the United States (American College of Obstetricians and Gynecologists), England (the Royal College of Obstetricians and Gynecologists), Canada (the Society of Obstetricians and Gynaecologists of Canada), Australia (the Royal Australian College of General Practitioners), and France (French College of Gynaecologists and Obstetricians).

RESULTS

There is a broad consensus regarding the role of transvaginal ultrasound as part of the initial evaluation of an adnexal mass and the radiological characteristics suggesting it being malignant. The role of transabdominal ultrasound or doppler mode is controversial. The use of MRI in cases of indeterminate adnexal masses is widely accepted. Ultrasound-guided aspiration is generally not recommended. There is a broad consensus that CA-125 should not be used as an ovarian cancer disease screening tool, though its role in the initial evaluation of adnexal masses is controversial. Risk prediction models are generally accepted, particularly the 'International Ovarian Tumor Analysis simple rules' and the 'Risk of Malignancy Index'.

CONCLUSION

Adnexal mass management national guidelines, though similar, had noticeable variations in the content, references cited, and recommendations made. While this variation might raise a concern as to the reproducibility of synthesizing literature, it can help practitioners present all spectra of recommendations and available data.

Diagnostic Value of DCE-MRI for Differentiating Malignant Adnexal Masses Compared with Contrast-enhanced-T1WI

PURPOSE

To compare the diagnostic performance of dynamic contrast-enhanced-MR (DCE-MR) and delayed contrast-enhanced (CE)-MRI added to unenhanced MRI, including diffusion weighted image (DWI) for differentiating malignant adnexal tumors, conducting a retrospective blinded image interpretation study.

METHODS

Data of 80 patients suspected of having adnexal tumors by ultrasonography between April 2008 and August 2018 were used for the study. All patients had undergone preoperative MRI and surgical resection at our institution. Four radiologists (two specialized in gynecological radiology and two non-specialized) were enrolled for blinded review of the MR images. A 3-point scale was used: 0 = benign, 1 = indeterminate, and 2 = malignant. Three imaging sets were reviewed: Set A, unenhanced MRI including DWI; Set B, Set A and delayed CE-T1WI; and Set C, Set A and DCE-MRI. Imaging criteria for benign and malignant tumors were given in earlier reports. The diagnostic performance of the three imaging sets of the four readers was calculated. Their areas under the curve (AUCs) were compared using the DeLong method.

RESULTS

Accuracies of Set B were 81%-88%. Those of Set C were 81%-85%. The AUCs of Set B were 0.83 and 0.89. Those of Set C were 0.81-0.86. For two readers, Set A showed lower accuracy and AUC than Set B/Set C (less than 0.80), although those were equivalent in other readers. No significant difference in AUCs was found among the three sequence sets. Intrareader agreement was moderate to almost perfect in Sets A and B, and substantial to almost perfect in Set C.

CONCLUSION

DCE-MR showed no superiority for differentiating malignant adnexal tumors from benign tumors compared to delayed CE-T1WI with conventional MR and DWI.

Computer-Assisted Reporting and Decision Support in Standardized Radiology Reporting for Cancer Imaging

PURPOSE

Recent advances in structured reporting are providing an opportunity to enhance cancer imaging assessment to drive value-based care and improve patient safety.

METHODS

The computer-assisted reporting and decision support (CAR/DS) framework has been developed to enable systematic ingestion of guidelines as clinical decision structured reporting tools embedded within the radiologist's workflow.

RESULTS

CAR/DS tools can reduce the radiology reporting variability and increase compliance with clinical guidelines. The lung cancer use-case is used to describe various scenarios of a cancer imaging structured reporting pathway, including incidental findings, screening, staging, and restaging or continued care. Various aspects of these tools are also described using cancer-related examples for different imaging modalities and applications such as calculators. Such systems can leverage artificial intelligence (AI) algorithms to assist with the generation of structured reports and there are opportunities for new AI applications to be created using the structured data associated with CAR/DS tools.

CONCLUSION

These AI-enabled systems are starting to allow information from multiple sources to be integrated and inserted into structured reports to drive improvements in clinical decision support and patient care.

Adnexal masses in pregnancy: An updated review

Adnexal masses in pregnancy are not commonly encountered. The majority of these masses are discovered incidentally during routine follow-up. However, some of these masses become symptomatic due to their size, location, and impingement of adjacent structures. Several diagnostic modalities can be utilized for the detection of adnexal masses with different sensitivity and specificity rates. The differential diagnosis of adnexal masses discovered during pregnancy is broad and includes both benign and malignant lesions. The management of such lesions has been a subject of debate for years with no consensus regarding the best management plan. Tumor size, site, and the trimester of mass detection are all crucial in management. In this account, we review adnexal masses discovered in pregnancy, the diagnostic modalities utilized for detecting these lesions, their differential diagnosis, and management strategies.

Radiomics and radiogenomics in ovarian cancer: a literature review

Ovarian cancer remains one of the most lethal gynecological cancers in the world despite extensive progress in the areas of chemotherapy and surgery. Many studies have postulated that this is because of the profound heterogeneity that underpins response to therapy and prognosis. Standard imaging evaluation using CT or MRI does not take into account this tumoral heterogeneity especially in advanced stages with peritoneal carcinomatosis. As such, newly emergent fields in the assessment of tumor heterogeneity have been proposed using radiomics to evaluate the whole tumor burden heterogeneity as opposed to single biopsy sampling. This review provides an overview of radiomics, radiogenomics, and proteomics and examines the use of these newly emergent fields in assessing tumor heterogeneity and its implications in ovarian cancer.

Decoding incidental ovarian lesions: use of texture analysis and machine learning for characterization and detection of malignancy

PURPOSE

To compare CT texture features of benign and malignant ovarian lesions and to build a machine learning model to detect malignancy in incidental ovarian lesions.

METHODS

In this IRB-approved, HIPAA-compliant, retrospective study, 427 consecutive patients with incidental ovarian lesions detected on contrast-enhanced CT (348, 81.5% benign and 79, 18.5% malignant) were included. The following CT texture features were analyzed using commercially available software (TexRAD, Feedback Plc, Cambridge, UK): total pixel, mean, standard deviation (SD), entropy, mean value of positive pixels (MPP), skewness, kurtosis and entropy. Three machine learning models were created by combining texture features and patients' age, and performance of these models was assessed using tenfold cross-validation. Receiver operating characteristics (ROC) were constructed to assess sensitivity and specificity. The cutoff value was picked using a cost-weighted method.

RESULTS

Total pixels, mean, SD, entropy, MPP, and skewness were significantly different between benign and malignant groups (p < 0.05). With a selected 10 as a cost factor to optimize cutoff value selection, sensitivity 92%, specificity 60% in the random forest (RF) model, sensitivity 91%, specificity 69% in SVM model, and sensitivity 92%, specificity 61% in the logistic regression, respectively.

CONCLUSION

CT texture analysis could provide objective imaging analysis of incidental ovarian lesions and ML models using CT texture features and age demonstrated high sensitivity and moderate specificity for detection of malignant lesions.

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.

Trends and outcomes of ruptured ovarian cysts

BACKGROUND

Ruptured ovarian cysts are common gynaecological presentation to health institutions with abdominal pain. While this phenomenon is generally self-limiting, surgery may be necessary in cases of haemodynamic compromise or association with torsion. The aim of this audit is to identify the trend of hospital presentations, as well as the review the management of modern gynaecology practice.

METHODS

A retrospective audit of all women who presented to the emergency department with an imaging diagnosis of ruptured ovarian cysts was conducted over a 5-year period at St Vincent's Hospital, Sydney.

RESULTS

During the study period, 408 women were identified. There was a trend towards conservative management, as observed in 84.7% of women, while the remaining 15.4% underwent surgery. Haemorrhagic or ruptured corpus luteum was the most common diagnoses. As expected, women who had surgical intervention were more likely to have larger cysts (20 vs 50%; p<0.05), and larger free fluid findings on imaging (1.4 vs 23.8%; p<0.05) compared with those managed conservatively. There were no statistically significant differences in location of ovarian cysts (right or left) or antecedent to hospital presentation (vaginal intercourse or trauma).

CONCLUSION

Ruptured ovarian cysts of both functional and non-functional types remained a common clinical presentation of acute pain for women to the emergency department. Majority of women were managed conservatively in our cohort, and indications for surgery were large ovarian cysts and large free fluid seen on imaging findings. Surgery was largely feasible with minimal complications.

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.

The diagnostic value of magnetic resonance imaging in differentiating benign and malignant pediatric ovarian tumors

BACKGROUND

The diagnostic workup of ovarian tumors in children and adolescents is challenging because preserving fertility, in addition to oncological safety, is of particular importance in this population. Therefore, a thorough preoperative assessment of ovarian tumors is required.

OBJECTIVE

To investigate the diagnostic value of MR imaging in differentiating benign from malignant ovarian tumors in children and adolescents.

MATERIALS AND METHODS

We conducted a retrospective study of all children and adolescents age <18 years who underwent MR imaging of ovarian tumors during 2014-2019 at a pediatric specialty center. Two radiologists reviewed all MR imaging. We used pathology reports to define the histological diagnosis.

RESULTS

We included 30 girls who underwent MR imaging for an ovarian tumor. Signs indicative for malignancy were tumors with a diameter ≥8 cm, with areas of contrast enhancement, irregular margins, extracapsular tumor growth, and ascites. All benign and malignant ovarian tumors were correctly identified by the radiologists.

CONCLUSION

The diagnostic utility of MR imaging in classifying ovarian tumors in children and adolescents as benign or malignant is promising and might aid in defining the indication for ovarian-sparing versus non-ovarian-sparing surgery. We recommend evaluating these tumors with MR imaging prior to deciding on surgical treatment.

Evaluation of a convolutional neural network for ovarian tumor differentiation based on magnetic resonance imaging

OBJECTIVES

There currently lacks a noninvasive and accurate method to distinguish benign and malignant ovarian lesion prior to treatment. This study developed a deep learning algorithm that distinguishes benign from malignant ovarian lesion by applying a convolutional neural network on routine MR imaging.

METHODS

Five hundred forty-five lesions (379 benign and 166 malignant) from 451 patients from a single institution were divided into training, validation, and testing set in a 7:2:1 ratio. Model performance was compared with four junior and three senior radiologists on the test set.

RESULTS

Compared with junior radiologists averaged, the final ensemble model combining MR imaging and clinical variables had a higher test accuracy (0.87 vs 0.64, p < 0.001) and specificity (0.92 vs 0.64, p < 0.001) with comparable sensitivity (0.75 vs 0.63, p = 0.407). Against the senior radiologists averaged, the final ensemble model also had a higher test accuracy (0.87 vs 0.74, p = 0.033) and specificity (0.92 vs 0.70, p < 0.001) with comparable sensitivity (0.75 vs 0.83, p = 0.557). Assisted by the model's probabilities, the junior radiologists achieved a higher average test accuracy (0.77 vs 0.64, Δ = 0.13, p < 0.001) and specificity (0.81 vs 0.64, Δ = 0.17, p < 0.001) with unchanged sensitivity (0.69 vs 0.63, Δ = 0.06, p = 0.302). With the AI probabilities, the junior radiologists had higher specificity (0.81 vs 0.70, Δ = 0.11, p = 0.005) but similar accuracy (0.77 vs 0.74, Δ = 0.03, p = 0.409) and sensitivity (0.69 vs 0.83, Δ = -0.146, p = 0.097) when compared with the senior radiologists.

CONCLUSIONS

These results demonstrate that artificial intelligence based on deep learning can assist radiologists in assessing the nature of ovarian lesions and improve their performance.

KEY POINTS

• Artificial Intelligence based on deep learning can assess the nature of ovarian lesions on routine MRI with higher accuracy and specificity than radiologists. • Assisted by the deep learning model's probabilities, junior radiologists achieved better performance that matched those of senior radiologists.

Size threshold for follow-up of postmenopausal adnexal cysts: 1 cm versus 3 cm

OBJECTIVES

To assess 3 cm size threshold for follow-up of simple cysts in postmenopausal women.

MATERIALS AND METHODS

Radiology information system was retrospectively queried for "US pelvis complete" over 8 years in women > 50 years, with keywords ovarian cyst, adnexal cyst, ovarian mass, cystic mass, cystic neoplasm, ovarian neoplasm, and ovarian mass. Premenopausal women were excluded. Cysts, were classified as ≤ 1 cm, 1-3 cm, 3-5 cm, and ≥ 7 cm. Largest cysts on each ovary was recorded. EMR and imaging archives were reviewed for assessing size, stability duration, and surgical records. Descriptive statistics and confidence interval were performed.

RESULTS

4388 patients met the initial search criteria. 919 cysts in 896 women (age: 50-91 years, mean: 61.5 years) were identified. We found 162 cysts ≤ 1 cm, 352 1-3 cm, 296 3-7 cm , and 51 ≥ 7 cm cysts. 127 patients with 1-3 cm cysts had no follow-up. Final analysis of 225 1-3 cm cysts included 203 ovarian and 22 paraovarian cysts (average size = 1.95 cm (1.1-3.0 cm)). 103 ovarian cysts had less than 2 years, and 100 cysts had more than 2 years follow-up. All except one ovarian cyst were stable for the entire duration of their follow-up (Mean duration of follow-up 5.4 years) (0.3%, 95% CI 0.0-0.05). 40 cysts resolved. One simple cyst increased in size (followed over 3.25 years) without suspicious imaging features and benign on surgery.

CONCLUSION

1-3 cm cysts represented the most common size range (> 40%) in postmenopausal women, majority of which are stable over follow-up with benign outcome. 3 cm size threshold is appropriate for simple cyst follow-up in postmenopausal women.

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

There are approximately 9.1 pelvic surgeries performed for every histologically confirmed adnexal malignancy in the United States, compared to 2.3 surgeries per malignancy (in oncology centers) and 5.9 surgeries per malignancy (in other centers) in Europe. An important prognostic factor in the long-term survival in patients with ovarian malignancy is the initial management by a gynecological oncologist. With high accuracy of imaging for adnexal mass characterization and consequent appropriate triage to subspecialty referral, the better use of gynecologic oncology can improve treatment outcomes. Ultrasound, including transabdominal, transvaginal, and duplex ultrasound, combined with MRI with contrast can diagnose adnexal masses as benign with specific features (ie, functional masses, dermoid, endometrioma, fibroma, pedunculated fibroid, hydrosalpinx, peritoneal inclusion cyst, Tarlov cyst), malignant, or indeterminate. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Imaging right lower quadrant pain: Not always appendicitis

Although acute appendicitis (AA) is one of the commonest causes of right lower quadrant abdominal pain (RLQP), there are numerous other conditions in the abdomen and pelvis that can simulate the clinical presentation of AA for which imaging is essential in detection. We discuss the approach to evaluation of patients presenting with acute onset RLQP and the choice of various imaging modalities that can be utilized. Although CT remains the workhorse in evaluation, US and MRI, given lack of radiation, play an important ancillary role, particularly in the pediatric and pregnant patients. We present a spectrum of conditions presenting with RLQP which we have classified systematically ranging from conditions affecting the bowel, mesentery/omentum/peritoneum, vasculature, urinary and reproductive systems to give the reader a checklist of conditions to consider when evaluating a case of RLQP.

Ultrasonography features and screening of ovarian masses in reproductive-age women

Ovarian neoplasms can develop at any age, carry a high risk for malignant transformation, reduce the reproductive potential of a woman and are an indication for surgery. The search for optimal screening algorithms for ovarian tumors is still ongoing. The aim of this study was to evaluate the prognostic efficacy of ultrasonography (US) features in differentiating between benign, malignant and borderline tumors in reproductive-age women. We examined 168 reproductive-age women with ovarian masses who underwent surgery in 2012–2015 and compared the results of histopathological examinations with pulsed-Doppler US findings. We did not establish a correlation between the size/volume of the tumor and their morphological structure. We identified the echotexture characteristics associated with malignancy, including the presence of a solid component (р < 0.001); septations (р = 0.029) and projections on the internal surface of the tumor capsule (р < 0.001); moderate or significant buildup of free fluid in the small pelvis (р = 0.007), and the nodular surface of the tumor capsule (р = 0.008). Solid ovarian masses were at increased (31.69-fold) risk of transformation into malignant or borderline tumors, whereas for a mixed (cystic and solid) type the risk of such transformation increased 3.46-fold. We also identified Doppler parameters that can clearly discriminate between benign and malignant growths, including the blood flow rate in the tumor over 1.85 cm/s (р = 0.007) and RMI over 0.16 (р = 0.013). The sensitivity and specificity of our diagnostic model are 87% and 68%, respectively, with a probability threshold of 0.3.

Adnexal masses in pregnancy: an updated review on diagnosis and treatment

Adnexal masses are not common in pregnancy. They are often discovered incidentally during routine ultrasound examinations. In general, 24%-40% of the cases are benign tumors; up to 8% are malignant tumors. Adnexal masses are usually asymptomatic, but sometimes can be responsible for abdominal or pelvic pain. Transvaginal and transabdominal ultrasound is essential to define the morphology of pelvic masses and to distinguish between benign and malignant cases. Magnetic resonance imaging can be a complementary examination when ultrasound findings are equivocal and a useful additional examination to better define tissue planes and relations with other organs. Patient counseling can be challenging because there is no clear consensus on the management of adnexal masses during pregnancy. Treatment options consist of observational management (in case of asymptomatic women with reassuring instrumental findings) or surgery (via laparoscopy or laparotomy). Surgery can be offered as a primary tool when cancer is suspected or when acute complications such as ovarian torsion occur.

Imaging of Benign Adnexal Disease

This article provides an overview of the imaging evaluation of benign ovarian and adnexal masses in premenopausal and postmenopausal women and lesions discovered during pregnancy. Current imaging techniques are discussed, including pitfalls and differential diagnosis when necessary, as well as management. It also reviews the now well-established American College of Radiology (ACR)/Society of Radiologists in Ultrasound consensus guidelines and covers the more recently introduced Ovarian-Adnexal Reporting and Data System by the ACR and the recently published ADNEx Scoring System.

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.

Prevalence, documentation, and communication of incidental findings in focused assessment with sonography for trauma (FAST) examinations

BACKGROUND

As the focused assessment with sonography for trauma (FAST) examination becomes increasingly ubiquitous in the emergency department (ED), a parallel increase in incidental findings can also be expected. The purpose of this study was to determine the prevalence, documentation, and communication of incidental findings on emergency physician-performed FAST examinations.

METHODS

Retrospective review at two academic EDs. Adult trauma patients undergoing FAST examinations used for clinical decision-making at the bedside were identified from an ED ultrasound image archival system. Expert sonologists reviewed ultrasound images for incidental findings, as well as electronic medical records for demographic information, mechanism of injury, type of incidental findings, documentation of incidental findings, and communication of incidental findings to the patient.

RESULTS

A total of 1,452 FAST examinations were reviewed. One hundred and thirty-seven patients with incidental findings were identified (9.4%); 7 patients had an additional incidental finding. Renal cysts were most common (49/144, 34.0%), followed by pelvic cysts in women (32/144, 22.2%). While 31/144 (21.5%) incidental findings were identified and documented in the ultrasound reports or medical records by ED providers, only 6/137 (4.4%) patients were noted to be informed of their incidental findings.

CONCLUSION

Incidental findings were often encountered in FAST examinations, with cysts of the kidneys and pelvis being the most common findings. A vast majority of incidental findings were not documented or noted to be communicated to patients, which can be a barrier to follow-up care.

Mucinous Neoplasms of the Ovary: Radiologic-Pathologic Correlation

Mucinous neoplasms of the ovary account for 10%-15% of ovarian neoplasms. They may be benign, borderline, or malignant. The large majority are benign or borderline, accounting for 80% and 16%-17%, respectively. Mucinous neoplasms of the ovary most commonly affect women in their 20s to 40s. The clinical manifestation is nonspecific, but most mucinous ovarian neoplasms manifest as large unilateral pelvic masses. At gross pathologic analysis, mucinous ovarian neoplasms appear as large multiloculated cystic masses. The contents of the cyst loculi vary on the basis of differences in internal mucin content. At histologic analysis, mucinous ovarian neoplasms are composed of multiple cysts lined by mucinous epithelium, often resembling gastrointestinal-type epithelium. Imaging evaluation most commonly includes US and/or MRI. The imaging findings parallel the gross pathologic features and include a large, unilateral, multiloculated cystic mass. The cyst loculi vary in echogenicity, attenuation, and signal intensity depending on the mucin content. Mucinous neoplasms of the ovary are staged surgically using the FIGO (International Federation of Gynecology and Obstetrics) staging system. Primary treatment is surgical, with adjuvant chemotherapy considered in the uncommon case of mucinous carcinoma with extraovarian disease. Since most mucinous ovarian neoplasms are benign or borderline, the overall prognosis is excellent.

Normative values for ultrasound measurements of the female pelvic organs throughout childhood and adolescence

BACKGROUND

Normative data from pelvic ultrasonography (US) of the pediatric female reproductive organs are outdated and limited by sample size.

OBJECTIVE

The purpose of this study was to report normal uterine and ovarian volumes and endometrial stripe thickness in children and young adults and throughout the menstrual cycle in post-menarchal adolescents.

MATERIALS AND METHODS

Females ages 0 through 20 years who underwent pelvic US between January 2010 and May 2014 were identified. After excluding patients with pelvic and/or endocrine pathology, nomograms of uterine and ovarian volumes and endometrial thickness by age year were created. Data for patients ages 12 years and older with a recorded day of last menstrual period were used to create additional nomograms of volumes/thickness throughout the menstrual cycle. Student's t-tests and linear regression were performed to assess differences in measurements between groups and association of volumes/thickness with age.

RESULTS

During our study period, 5,647 patients underwent 6,953 pelvic US examinations. After further review, 907 examinations from 889 patients were included (mean age: 11.3±6.0 years). Mean pelvic US volumes (cm³) per organ were 25.5±27.0 (uterus), 4.5±4.7 (right ovary) and 4.0±4.1 (left ovary). Mean endometrial thickness was 4.5±3.7 mm. Right ovarian volume was significantly larger than the left (P=0.0126). Uterine volume, ovarian volume and endometrial thickness were significantly associated with age (P-values<0.0001). Plots of mean organ measurements with respect to week of menses are provided.

CONCLUSION

We report normal volumes of the uterus and ovaries and endometrial stripe thickness measured by pelvic US throughout childhood and adolescence with reference to the menstrual cycle. These values are significantly associated with age and vary visually by menstrual cycle week.

Incidental findings in pancreas screening programs for high-risk individuals: Results from three European expert centers

Background

Widespread abdominal imaging has led to a substantial increase in the detection of incidentalomas. Currently, an increasing number of centers offer surveillance of the pancreas to individuals at high risk (IARs) of pancreatic ductal adenocarcinoma (PDAC).

Objective

The aims of this study were to evaluate the frequency and type of incidental findings in a magnetic resonance imaging (MRI)-based surveillance program for IARs for PDAC, and to discuss the benefit of detecting these lesions.

Methods

The outcome of MRI screening was reviewed in 568 individuals from three long-term pancreas surveillance programs conducted at three large European expert centers. All MRIs were studied in detail for the presence of incidental lesions.

Results

The most common lesions were liver cysts, renal cysts and liver hemangioma, which together comprised 75% of all lesions. Only five (0.9%) patients underwent surgery for a benign lesion. Cancer was detected in 11 patients (1.9%); early detection of tumors was beneficial in at least five cases.

Conclusion

The present study demonstrates that extrapancreatic incidentaloma is a common finding in IARs for PDAC, but rarely requires additional treatment. CDKN2A-p16-Leiden mutation carriers were the only patient group found to harbor a substantial number of cancers, and detection resulted in benefit in several cases.

A case report and a literature review of primary retroperitoneal mucinous cystadenoma: the importance of imaging in diagnosis and management

Primary retroperitoneal mucinous cystadenoma (PRMC) is an extremely rare tumor: its histogenesis and its biological behavior remain speculative. Since most retroperitoneal tumors are malignant, a preoperative diagnosis of benignity is essential and it can be reached through imaging examinations, allowing a conservative management approach. We describe the case of a 52-year-old woman with abdominal pain and a palpable mass. Computed tomography of the abdomen revealed a retroperitoneal cystic mass, which was resected successfully through laparoscopy and diagnosed as PRMC. Although there are no pathognomonic, clinical or radiological findings for PRMC, it should be included in the list of differential diagnoses and its imaging criteria of benignity should always be sought, with the aim to exclude malignant tumors.

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.

A systematic approach to adnexal masses discovered on ultrasound: the ADNEx MR scoring system

Adnexal lesions are a common occurrence in radiology practice and imaging plays a crucial role in triaging women appropriately. Current trends toward early detection and characterization have increased the need for accurate imaging assessment of adnexal lesions prior to treatment. Ultrasound is the first-line imaging modality for assessing adnexal lesions; however, approximately 20% of lesions are incompletely characterized after ultrasound evaluation. Secondary assessment with MR imaging using the ADNEx MR Scoring System has been demonstrated as highly accurate in the characterization of adnexal lesions and in excluding ovarian cancer. This review will address the role of MR imaging in further assessment of adnexal lesions discovered on US, and the utility of the ADNEx MR Scoring System.

Screening for ovarian cancer: imaging challenges and opportunities for improvement

The United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) recently reported a reduction in the average overall mortality among ovarian cancer patients screened with an annual sequential, multimodal strategy that tracked biomarker CA125 over time, where increasing serum CA125 levels prompted ultrasound. However, multiple cases were documented wherein serum CA125 levels were rising, but ultrasound screens were normal, thus delaying surgical intervention. A significant factor which could contribute to false negatives is that many aggressive ovarian cancers are believed to arise from epithelial cells on the fimbriae of the fallopian tubes, which are not readily imaged. Moreover, because only a fraction of metastatic tumors may reach a sonographically-detectable size before they metastasize, annual screening with ultrasound may fail to detect a large fraction of early-stage ovarian cancers. The ability to detect ovarian carcinomas before they metastasize is critical and future efforts towards improving screening should focus on identifying unique features specific to aggressive, early-stage tumors, as well as improving imaging sensitivity to allow for detection of tubal lesions. Implementation of a three-stage multimodal screening strategy in which a third modality is employed in cases where the first-line blood-based assay is positive and the second-line ultrasound exam is negative may also prove fruitful in detecting early-stage cases missed by ultrasound.

Indeterminate Adnexal Cysts at US: Prevalence and Characteristics of Ovarian Cancer

Purpose To assess the prevalence of indeterminate adnexal cysts in women presenting to academic medical centers for pelvic ultrasonography (US), determine the incidence of malignancy, and identify cyst and patient characteristics that are predictive of malignancy. Materials and Methods A multicenter study of US-detected adnexal cysts with appropriate follow-up (surgical pathologic examination, imaging and/or clinical examination) was conducted from January 2008 to June 2012. Indeterminate cysts were classified as category 1 (typical benign appearing cysts >5 cm) or category 2 (cysts with avascular solid components) on the basis of a combination of definitions in the existing literature. The incidence of neoplasms and malignant tumors was calculated. Patient and cyst characteristics associated with neoplasm and malignant tumors were evaluated with the χ² test or Fisher exact test for categorical variables and the t test for continuous variables. A backward stepwise logistic regression model was performed for two outcomes: (a) the presence of any neoplasm (benign or malignant) and (b) the presence of a malignant tumor. Results There were 1637 women with an adnexal cyst at US; 391 (mean age = 41.8 years ± 13.5.1; range = 17-91 years) had an indeterminate adnexal cyst at US. The prevalence of indeterminate adnexal cysts was 23.9% (391 of 1637; 95% confidence interval [CI]: 0.22, 0.26). Three hundred three indeterminate cysts in 280 women (mean age = 42.9 years ± 14.1; range = 17-88 years) had adequate follow-up. The incidence of ovarian neoplasms (benign and malignant) was 24.8% (75 of 303 cysts; 95% CI: 0.20, 0.30), and the incidence of malignant tumors was 3.6% (11 of 303 cysts; 95% CI: 0.02, 0.06). The proportion of ovarian neoplasms differed between category 1 and category 2 cysts (17.5% [25 of 143 cysts; 95% CI: 0.12, 0.25] vs 31.3% [50 of 160 cysts; 95% CI: 0.24, 0.39], respectively; P = .001). The proportion of malignant tumors differed between categories 1 and 2 cysts (0% [0 of 143 cysts] vs 6.9% [11 of 160 cysts; 95% CI: 0.03, 0.12]; P < .001). The presence of an avascular nodular component was a significant predictor of malignancy at stepwise logistic regression analysis (odds ratio = 2.83; P ≤ .0001; 95% CI: 1.69, 4.70). Conclusion The presence of an avascular nodular component was the most significant predictor of the presence of malignancy in indeterminate adnexal cysts. The risk of malignancy is higher with category 2 cysts than with category 1 cysts. ^© RSNA, 2018.

The Usefulness of Ultrasound Imaging in Gynecologic Oncology

Pelvic ultrasound examination is the primary imaging modality for evaluating a wide range of female pelvic symptomatology, and is often the first imaging test to detect a gynecologic malignancy. Ultrasound imaging is particularly useful for evaluating the thickness and appearance of the endometrium in patients with abnormal bleeding, and in detecting and characterizing ovarian lesions. This article reviews the ultrasound appearance of gynecologic neoplasms grouped by anatomic site of origin, the ultrasound appearance of select benign pelvic pathology not to be misinterpreted as malignancy, as well as available ultrasound imaging-based guidelines for managing potential gynecologic neoplasms.