Differential diagnosis of adnexal masses: risk of malignancy index, ultrasonography, magnetic resonance imaging, and radioimmunoscintigraphy

Indirect comparison of the diagnostic performance of 18F-FDG PET/CT and MRI in differentiating benign and malignant ovarian or adnexal tumors: a systematic review and meta-analysis

Objective

To compare the value of fluorodeoxyglucose positron emission tomography (FDG-PET)/computed tomography (CT) and magnetic resonance imaging (MRI) in differentiating benign and malignant ovarian or adnexal tumors.

Materials and methods

English articles reporting on the diagnostic performance of MRI or ¹⁸F-FDG PET/CT in identifying benign and malignant ovarian or adnexal tumors published in PubMed and Embase between January 2000 and January 2021 were included in the meta-analysis. Two authors independently extracted the data. If the data presented in the study report could be used to construct a 2 × 2 contingency table comparing ¹⁸F-FDG PET/CT and MRI, the studies were selected for the analysis. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) was used to evaluate the quality of the included studies. Forest plots were generated according to the sensitivity and specificity of ¹⁸F-FDG PET/CT and MRI.

Results

A total of 27 articles, including 11¹⁸F-FDG PET/CT studies and 17 MRI studies on the differentiation of benign and malignant ovarian or adnexal tumors, were included in this meta-analysis. The pooled sensitivity and specificity for ¹⁸F-FDG PET/CT in differentiating benign and malignant ovarian or adnexal tumors were 0.94 (95% CI, 0.87–0.97) and 0.86 (95% CI, 0.79–0.91), respectively, and the pooled sensitivity and specificity for MRI were 0.92 (95% CI: 0.89–0.95) and 0.85 (95% CI: 0.79–0.89), respectively.

Conclusion

While MRI and ¹⁸F-FDG PET/CT both showed to have high and similar diagnostic performance in the differential diagnosis of benign and malignant ovarian or adnexal tumors, MRI, a promising non-radiation imaging technology, may be a more suitable choice for patients with ovarian or accessory tumors. Nonetheless, prospective studies directly comparing MRI and 18F-FDG PET/CT diagnostic performance in the differentiation of benign and malignant ovarian or adnexal tumors are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08815-3.

Diagnostic accuracy of transvaginal ultrasound examination for assigning a specific diagnosis to adnexal masses: A meta-analysis

Transvaginal ultrasound (TVUS) is a standard imaging modality for differentiating patients with benign or malignant suspected adnexal mass. To date, numerous studies have assessed the diagnostic accuracy of TVUS in various settings but with variable results. Therefore, the purpose of the present study was to perform a meta-analysis to evaluate the diagnostic accuracy of TVUS for the differentiation of adnexal masses. An electronic search in the Medline, Scopus, Cochrane and Embase databases from inception till November 2019 was carried out. Meta-analysis was performed to obtain pooled sensitivity and specificity of TVUS to distinguish malignant from benign adnexal masses. The quality assessment of diagnostic accuracy studies-2 tool was used to assess the quality of trials. A total of 41 studies with 18,391 patients were included. The pooled sensitivity and specificity of TVUS was 92% (95% CI: 90-94%) and 89% (95% CI: 85-92%), respectively. The area under the receiver operating characteristic curve was 0.96 (95% CI: 0.84-1.00). There was considerable heterogeneity with a statistically significant chi-square test (P<0.001) and I² of 99%. Meta-regression results indicated that index test standards, patient selection bias and study design were potential sources of heterogeneity (P<0.05). The funnel plot was symmetrical and low publication bias was confirmed by an insignificant Deek's test (P=0.90). The present systematic review and meta-analysis indicated that TVUS is useful in differentiating between benign and malignant tumours among patients with suspected adnexal mass with high sensitivity and specificity.

Evaluation of adnexal tumours in the International Ovarian Tumor Analysis system in reference to histopathological results

Aim of the study

To retrospectively evaluate how the International Ovarian Tumor Analysis (IOTA) simple rules used in ultrasound examinations estimate the probability of malignant and benign tumour occurrence in the studied population.

Material and methods

The study was performed on a group of 425 patients with ovarian tumours operated in the Clinic of Surgical and Oncological Gynecology at the Medical University of Lodz in the years 2014-2015. Adnexal tumours were rated according to IOTA simple rules, classifying them as probably malignant, probably benign, or unclassified. The results of the study were compared with final histopathological results. The statistical analysis was performed using STATISTICA 13 PL with Medical Pack.

Results

We analysed data on n = 43 (11%) patients with malignant, n = 346 (86%) patients with benign, and n = 12 (3%) patients with borderline tumours, respectively. Malignant tumour patients were significantly older (mean age 61.0 ±11.6 vs. 43.6 ±16.2 years, p< 0.001), had higher BMI (mean 27.3 ±7.0 vs. 25.2 ±5.2, p< 0.05), more pregnancies (median 2 vs. 1, p = 0.001), and higher cancer antigen 125 (CA 125) concentrations (median 251.5 vs. 18.5, p< 0.001) than patients with a benign tumour. Also, they more often suffered from diabetes mellitus (19% vs. 8%, p = 0.02) and arterial hypertension (60% vs. 42%, p< 0.01) than benign tumour patients.

Conclusions

In our study, IOTA performance in predicting or ruling out a malignant tumour was highly satisfactory and similar to that of CA 125. Both the methods may be complementary and used to assess the risk of malignant vs. benign ovarian neoplasm, although the context of other clinical variables may also be important.

Comparison of Qualitative (Time Intensity Curve Analysis), Semi-Quantitative, and Quantitative Multi-Phase 3T DCEMRI Parameters as Predictors of Malignancy in Adnexal

Objective:

The present study aimed to compare the qualitative (time intensity curve analysis), the semi-quantitative and the quantitative multiphase 3T dynamic contrast-enhanced (DCE) MRI parameters as predictors of malignancy in adnexal masses. Materials and

Methods:

In this prospective study, women with an adnexal mass who were scheduled for surgical resection or were followed for more than one year period to confirm the benignity of their lesions, underwent multiphase 3T DCE-MRI. The qualitative (time intensity curve), semi-quantitative (SImax, SIrel, WIR) and quantitative (Ktrans, Kep, Vb) analyses were performed on DCE-MRI sequences and their predictive values were compared.

Results:

A total of 17 benign and 14 malignant lesions were included. According to the qualitative analysis, none of the lesions with Type I time intensity curves (TIC) were malignant and none of the masses with Type III TICs were benign. The accuracy of the quantitative parameters in detection of malignancy was found to be higher than that of semi-quantitative variables, particularly when calculated for a small ROI within the high signal area of the mass (sROI) rather than the largest ROI including the whole mass (lROI), and when inter-MRI variations were omitted using ratios. The Kep(tumor)/Kep(myometrium) ratio measured from sROI was the best parameter for differentiating a malignant lesion with a sensitivity of 100% and a specificity of 92.3%.

Conclusion:

We concluded that a Type I TIC confirms a benign lesion, and a type III TIC confirms the malignancy and further evaluation is not recommended for these lesions. So complementary quantitative analysis is only recommended for adnexal masses with type II TICs.

A preliminary study: The sequential use of the risk malignancy index and contrast-enhanced ultrasonography in differential diagnosis of adnexal masses

The aim of this study was to explore the sequential use of risk malignancy index (RMI) combined with contrast-enhanced ultrasonography (CEUS) in identification diagnosis of adnexal masses.This study contained 2 steps: first, 151 patients were analyzed retrospectively with RMI 1, RMI 2, and RMI 3 indices; receiver operating characteristic (ROC) curves were plotted to analyze area under the curves (AUC), and then RMI cut-off value was obtained according to maximum Youden index (YI, Sensitivity + Specificity - 1) and calculating diagnostic sensitivity, specificity, positive/negative predictive value, and accuracy. Second, 151 cases were divided into 2 groups randomly (105 in study group and 46 in test group); in the study group, the lower cut-off value (LC), upper cut-off value (UC), CEUS cut-off value according to maximum YI, and then these cut-offs were validated in test group.There was no statistical significance in 3 RMI models (P = .35), and RMI1 model was established randomly for following study. When the RMI1 cut-off value was 149, the YI was maximal (0.53), and the sensitivity, specificity, positive/negative predictive value, and accuracy were 71.0%, 81.7%, 77.1%, 75.6%, and 76.2%, respectively. The LC was 15 (sensitivity was 98.0%), the UC was 3000 (specificity was 98.0%), and the CEUS cut-off value was 7 (maximal YI was 0.81). In the test group (46 cases), combining RMI1 LC (15) and UC (3000) with CEUS cut-off value (7), the sensitivity, specificity, positive/negative predictive value, and accuracy were up to 85.7%, 92.0%, 90.0%, 88.5%, and 89.1%, respectively.CEUS can help RMI to make a more effective differential diagnosis of the adnexal mass. Further validation by additional multicenter prospective trials is required.

Magnetic Resonance Imaging of Gynecological Malignancies: Role in Personalized Management

Gynecological malignancies are a leading cause of mortality and morbidity in women and pose a significant health problem around the world. Currently used staging systems for management of gynecological malignancies have unresolved issues, the most important being recommendations on the use of imaging. Although not mandatory as per the International Federation of Gynecology and Obstetrics recommendations, preoperative cross-sectional imaging is strongly recommended for adequate and optimal management of patients with gynecological malignancies. Standardized disease-specific magnetic resonance imaging protocols help assess disease spread accurately and avoid pitfalls. Multiparametric imaging holds promise as a roadmap to personalized management in gynecological malignancies. In this review, we will highlight the role of magnetic resonance imaging in cervical, endometrial, and ovarian carcinomas.

Diagnostic Value of the Risk of Malignancy Index (RMI) for Detection of Pelvic Malignancies Compared with Pathology

Introduction

Pelvic masses are among most the common causes of patient admission into gynecology clinics and one of the most common reasons for referral to gynecologic oncology departments due to the risk of uterine or ovarian malignancies. The aim of this study is to compare the four indices of the risk of malignancy index (RMI 1–4), as a combination of menstrual status, radiological findings, and serum CA125 concentration, for discrimination of benign from malignant pelvic masses.

Methods

This retrospective descriptive and analytic study was conducted on 200 patients with pelvic mass, post-surgery, and who were referred to the oncology department in Shahid Sadoughi hospital of Yazd (Iran) between June 2007 and September 2011. Data regarding demographics, pathology reports, paraclinical and clinical tests were analyzed. The four RMI indices were separately used for determination of benign vs. malignant masses using the optimized cutoff points, ROC curve, sensitivity, specificity, predictive value of positive and negative, and accuracy. Finally, p value for each index was calculated, and a final discrimination power was measured by using SPSS version 17 software.

Results

The calculated p values in the four RMI indices in ultrasound findings indicated statistical significance, and the RMI 2 showed the highest level of accuracy or diagnostic performance. RMI 2 had a cutoff point of 90, an under-chart area 86.7, 79.36% sensitivity, 78.95% specificity, 58.44%, positive predictive value, 90.08% negative predictive value, and 78.93% accuracy, and a p value of 0.004. However, this relationship was found not to be meaningful using CT scan images.

Conclusions

Using RMI 2 for differentiation of malignant from benign pelvic masses is a reliable method with ultrasound findings.

Criteria for selection of laparoscopy for women with adnexal mass

Objectives:

We compared the indication of laparoscopy for treatment of adnexal masses based on the risk scores and tumor diameters with the indication based on gynecology-oncologists' experience.

Methods:

This was a prospective study of 174 women who underwent surgery for adnexal tumors (116 laparotomies, 58 laparoscopies). The surgeries begun and completed by laparoscopy, with benign pathologic diagnosis, were considered successful. Laparoscopic surgeries that required conversion to laparotomy, led to a malignant diagnosis, or facilitated cyst rupture were considered failures. Two groups were defined for laparoscopy indication: (1) absence of American College of Obstetrics and Gynecology (ACOG) guideline for referral of high-risk adnexal masses criteria (ACOG negative) associated with 3 different tumor sizes (10, 12, and 14 cm); and (2) Index of Risk of Malignancy (IRM) with cutoffs at 100, 200, and 300, associated with the same 3 tumor sizes. Both groups were compared with the indication based on the surgeon's experience to verify whether the selection based on strict rules would improve the rate of successful laparoscopy.

Results:

ACOG-negative and tumors ≤10 cm and IRM with a cutoff at 300 points and tumors ≤10cm resulted in the same best performance (78% success = 38/49 laparoscopies). However, compared with the results of the gynecology-oncologists' experience, those were not statistically significant.

Discussion:

The selection of patients with adnexal mass to laparoscopy by the use of the ACOG guideline or IRM associated with tumor diameter had similar performance as the experience of gynecology-oncologists. Both methods are reproducible and easy to apply to all women with adnexal masses and could be used by general gynecologists to select women for laparoscopic surgery; however, referral to a gynecology-oncologist is advisable when there is any doubt.

Risk of Malignancy Index (RMI) in Evaluation of Adnexal Mass

BACKGROUND

The discrimination between benign and malignant adnexal masses is central to decisions regarding clinical management and surgical planning in such patients.

PURPOSE OF STUDY

To determine if the RMI (RMI 2) can distinguish between benign and malignant adnexal masses.

METHODS

A prospective cohort study was conducted of 58 women with an adnexal mass referred to a teaching hospital for diagnosis and management.

RESULTS

RMI > 200 had a sensitivity of 70.5 % (95 % CI 46.87-86.72), a specificity of 87.8 % (95 % CI 74.46-94.68), a positive predictive value of 70.5%, and negative predictive value of 87.8 %. ROC showed that cut off value of 25 achieved a sensitivity and specificity of 82.35 and 43.9 %, respectively, and a cut off value of 1,000 gave a sensitivity and specificity of 58.81 and 97.56 %, respectively. The association between RMI and disease status was not statistically significant for mucinous tumors.

CONCLUSION

RMI is a reliable tool in differentiating benign from malignant adnexal masses. It is simple, easy to use and cost effective. However it's predictive accuracy was less for mucinous as compared to serous epithelial ovarian cancers. The study is limited by its small sample size.

If the Mountain Does Not Come to Mohammad: The Significance of Guest Operations for Early Stage Ovarian Cancer

Background: In women with early ovarian cancer (EOC), comprehensive surgical staging is known to enhance ovarian cancer outcomes and requires specific surgical competence. Given that centralization of care remains a topic of continuing debate, a system of "guest operations" was introduced in the midwestern part of The Netherlands. During a guest operation a gynecologic oncologist participates in oncology surgery performed in the community hospital. Objective: This study was conducted to examine the effects of the presence of a gynecologic oncologist on the quality of staging, treatment, and survival in patients with EOC. Materials and Methods: All patients with a pathologically confirmed diagnosis of EOC between January 2000 and December 2009 were selected from a regional cancer registry. Surgical accuracy was checked on the basis of each patient's file, operative notes, and pathology report. Results: A total of 130 patients were included, of whom 15 were treated in the Leiden University Medical Center (LUMC) and 115 in eight regional community hospitals. If a gynecologic oncologist attended the operation, surgical staging was more often adequately performed, 81.1% versus 32.1% when a gynecologic oncologist was not present (p<0.001). Adherence to protocol was observed in 76.9% of operations when a gynecologic oncologist had been present, compared to 49.5% of patients who were treated by a general gynecologist alone (p=0.004). The 5-year disease-free survival was borderline significantly in favor of optimally staged patients, 75.1% in those who were not staged optimally versus 90.9% who were staged optimally (p=0.058). Conclusions: Guest operations deserve a distinguished place among the treatment modalities available to patients with EOC, because surgery by the most specialized and experienced surgeons contributes to better care. (J GYNECOL SURG 30:265).

Current diagnostic approach to patients with adnexal masses: which tools are relevant in routine praxis?

OBJECTIVE

The aim of the study was to investigate which anamnestic, laboratory and ultrasound parameters used in routine practice could predict the nature of adnexal mass, thus enabling referral to relevant specialist.

METHODS

Study involved the women treated for adnexal tumors throughout a period of 2 years. On admission, detailed anamnestic and laboratory data were obtained, expert ultrasound scan was performed, and power Doppler index (PDI), risk of malignancy index (RMI) and body mass index (BMI) were calculated for all patients. Obtained data were related to histopathological findings, and statistically analyzed.

RESULTS

The study included 689 women (112 malignant, 544 benignant, and 33 borderline tumors). Malignant and borderline tumors were more frequent in postmenopausal women (P=0.000). Women who had benignant tumors had the lowest BMI (P=0.000). There were significant (P<0.05) differences among tumor types regarding erythrocyte sedimentation rate, CA125 and carcinoembryonic antigen (CEA) levels. Among ultrasound findings, larger tumor diameter and ascites were more frequent in malignant tumors (P=0.000). Women with malignant tumors had highest values of RMI and PDI (P=0.000).

CONCLUSIONS

Anamnestic data, ultrasound parameters and laboratory analyses were all found to be good discriminating factors among malignant, benignant and borderline tumors.

From bench to bedside: discovery of ovarian cancer biomarkers using high-throughput technologies in the past decade

Ovarian cancer is the most lethal gynecological malignancy and survival of this disease has remained relatively unchanged over the past 30 years. A contributing factor to this has been the lack of reliable biomarkers for the clinical management of ovarian cancer. Rapid advances in high-throughput technologies over the past decade has allowed for new and exciting opportunities for biomarker discovery in the field of ovarian cancer, especially with respect to serum biomarkers that can be used for various clinical applications. This review highlights the major genomic and proteomic studies dedicated to ovarian cancer biomarker discovery over the past decade. An emphasis will be placed on the HE4, Risk of Malignancy Algorithm (ROMA) and OVA1™ serum-based tests/algorithms that have recently been approved by the US FDA as ovarian cancer biomarkers.

Differential diagnosis of a pelvic mass: improved algorithms and novel biomarkers

More than 200,000 women undergo exploratory surgery for a pelvic mass in the United States each year and 13%-21% of pelvic lesions are found to be malignant. Individual reports and meta-analysis indicate better outcomes when cancer surgery is performed by gynecologic oncologists. Despite the advantages provided by more thorough staging and cytoreductive surgery, only 30%-50% of women with ovarian cancer are referred to surgeons with specialized training in the United States. Imaging, menopausal status and biomarkers can aid in distinguishing malignant from benign pelvic masses to inform decisions regarding appropriate referral. The risk of malignancy index (RMI) uses ultrasound, menopausal status and CA125 and has been utilized in the United Kingdom for two decades, providing sensitivity that has ranged from 71%-88% and specificity it from 97%-74% for identifying patients with malignant disease. Criteria have been established by the Society of Gynecology Oncology and American College of Obstetrics and Gynecology for referral to a gynecologic oncologist, but these have lower sensitivity and specificity than the RMI. Recently, two new algorithms have been developed to identify women at sufficiently high risk to prompt referral to a specialized surgeon. The OVA1 multivariate index incorporates imaging, menopausal status, CA125 and four other proteomic biomarkers. Use of OVA1 provides 85%-96% sensitivity at 28%-40% specificity depending upon menopausal status. The negative predictive value for women judged to be at low risk is 94%-96%. The risk of malignancy algorithm (ROMA) includes CA125, human epididymal protein 4 and menopausal status, but not imaging results. The ROMA has yielded 93%-94% sensitivity at 75% specificity with a negative predictive value of 93%-98%. In a direct comparison, ROMA has achieved greater sensitivity (94%) than the RMI (75%) at 75% specificity. OVA1 has not been compared directly to ROMA, but is likely to be as sensitive, but substantially less specific. Both algorithms have high negative predictive values 94%-98%. Although a difference in specificity should not affect patient outcomes, it could affect distribution of medical resources.

Differential diagnosis of adnexal masses: sequential use of the risk of malignancy index and HistoScanning, a novel computer-aided diagnostic tool

OBJECTIVE

To assess the value of ovarian Histo-Scanning(™) , a novel computerized technique for interpreting ultrasound data, in combination with the risk of malignancy index (RMI) in improving triage for women with adnexal masses.

METHODS

RMI indices were assessed in 199 women enrolled in a prospective study to investigate the use of HistoScanning. Ultrasound scores were obtained by blinded analysis of archived images. The following sequential test was developed: HistoScanning was modeled as a second-line test for RMI between a lower cut-off and an upper cut-off. The optimal combination of these cut-offs that together maximized the Youden index (Sensitivity + Specificity - 1) was determined.

RESULTS

Using RMI at the standard cut-off value of 250 resulted in a sensitivity of 74% and a specificity of 86%. When RMI was combined with HistoScanning, the highest accuracy was achieved by using HistoScanning as a sequential second-line test for patients with RMI values between 105 and 2100. At these cut-off values, sequential use of RMI and HistoScanning resulted in mean sensitivity and specificity estimates of 88% and 95%, respectively.

CONCLUSIONS

Our data suggest that HistoScanning may have the potential to improve the diagnostic accuracy of RMI, which could result in better triage for women with adnexal masses. Further prospective validation is warranted.

Screening for ovarian cancer in the general population

Advances in screening and early detection of ovarian cancer over the past decade have included novel interpretation of serum CA125, discovery of human epididymis protein 4, which has the potential to add to CA125, and the growing understanding of the flaws of previous biomarker studies. No mortality effect was found in the ovarian screening arm of the Prostate Lung Colorectal and Ovarian Cancer Screening Trial.(87) Concerns, however, have been raised about trial design, and the results from the UK Collaborative Trial of Ovarian Cancer Screening in the general population(38) and other ongoing studies in the high-risk population are awaited for a definitive conclusion. Future work needs to take into account the new insights into ovarian cancer subtypes and the growing evidence that a significant proportion of ovarian cancers might originate in premalignant lesions in the distal fallopian tube.

Accuracy of 64-multidetector computed tomography in diagnosis of adnexal tumors

BACKGROUND

Adnexal cancers are in fifth place among the tumors with the highest mortality in the female population. The aim of the present study was to evaluate the accuracy of Multi-detector computed tomography (MDCT) on a 64-multislice CT scanner in the detection and differentiation of adnexal masses stages.

METHODS

During the present prospective study, 95 women with a primary diagnosis of ovarian mass in base of clinical examination and ultrasonographic findings underwent preoperative evaluation by a 64-slice MDCT with a section thickness of 0.6 mm, 50% overlap and reconstructed images. Afterward, results of MDCT were compared with surgical and histopathological findings, and the sensitivity, specificity, positive and negative predictive value and accuracy were determined.

RESULTS

The mean age of patients was 48.63 ± 13.93 years. MDCT diagnosed 25 (26.3%) masses to be benign and 70 (73.7%) to be malignant (sensitivity, specificity, positive and negative predictive value and accuracy were 92.8%, 88.0%, 95.5%, 81.4% and 91.5% respectively). The sensitivity and specificity of MDCT in determining local extension was 72.2% and 93.4% respectively. And the sensitivity and specificity of MDCT in determining peritoneal seeding and liver extension was 81.8% and 93% respectively. Estimated stage was significantly agreed with the surgical (Cohen's Kappa (κ) = 0.891) and histopathological findings (κ = 0.858).

CONCLUSION

MDCT is a highly sensitive and specific diagnostic method in evaluation of adnexal masses and successfully stage the tumor in consistent with surgery and histopathology.

Evaluation of the Risk of Malignancy Index in daily clinical management of adnexal masses

OBJECTIVE

To verify the effectiveness of the Risk of Malignancy Index in the discrimination between non-invasive (benign and borderline) lesions and invasive malignant adnexal masses in daily clinical practice.

METHODS

This prospective observational study was conducted in a multicentre cooperation of 11 hospitals. A total of 548 women with adnexal masses were included. Ultrasound characteristics, menopausal status and serum CA 125 level were registered preoperatively, and combined into the RMI afterwards. Final diagnosis was based on routine histopathologic examination. The decision to have patients operated by or with a gynecologic oncologist was based on the clinical impression of the gynecologist in the local hospital, based on physical examination, testing of serum samples, and ultrasound examination. This was compared with the hypothetical situation in which the RMI would have been applied as method of selection.

RESULTS

An RMI of 200 achieved a sensitivity of 81% and specificity of 85% in the detection of ovarian cancer. Positive and negative predictive values were 48% and 96% respectively. In current practice, 64% of ovarian cancer patients were operated by a gynecologic oncologist. This percentage would have increased to 80% if the RMI with a cutoff value of 200 would have been used as method of selection.

CONCLUSIONS

In our study population, introduction of the RMI would improve the management of adnexal masses, with a higher percentage of ovarian cancer patients that are operated by a gynecologic oncologist. At the same time, referral of patients with non-invasive (benign and borderline) lesions would be reduced.

MR imaging in ovarian cancer

Magnetic resonance (MR) imaging is increasingly being used in patients with gynaecological disorders due to its high contrast resolution compared to computed tomography (CT) and ultrasound. In women presenting with an adnexal mass, ultrasound remains the primary imaging modality in the detection and characterisation of such lesions. However, in recent years overwhelming evidence has accumulated for the use of MR imaging in patients with indeterminate adnexal masses particularly in younger women and where disease markers are unhelpful. In staging ovarian cancer and for evaluating therapeutic response MR imaging is as accurate as CT but CT remains the imaging modality of choice because it is more widely available and quicker. This article reviews that evidence and outlines a place for the use of MR imaging in ovarian cancer.