MR diagnostics of adnexal masses Poster No.: C-1499 Congress: ECR 2017 Type: Educational Exhibit Authors: O. Nikolic, J. Ostojic, M. Basta Nikolic, A. Spasic, D. Donat, S. Stojanovic; Novi Sad/RS Keywords: Pelvis, MR, Imaging sequences, Neoplasia, Metastases, Cancer DOI: 10.1594/ecr2017/C-1499 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 48
Learning objectives This lecture will cover: 1. MRI indications, 2. patient preparation, 3. protocol and 4. categorization of adnexal masses. Variety of selected cases will be discussed. Background Based on US examination all adnexal masses can be divided into three cathegories: 1. benign 2. malignant 3. indeterminate. Indeterminate adnexal mass is the complex one which even after including color doppler cannot be placed into either cathegory or for which the site of origin cannnot be established. For women with indeterminate adnexal masses MR imaging is the method of choice. In these women MRI imaging can reduce the number of unnecessary surgery for benign lesions and the risk of missing malignant lesions. Page 2 of 48
Findings and procedure details For evaluation of adnexal masses we used the following MRI protocol: T2W Sag pelvis T2W, T1W covering the mass in the same ortogonal plane (ax, cor or oblique) with identical slice thickness. DWI Ax T1W DCE Option 1: mass has high signal on T1W Ax FSE, then T1W FS Option 2: if doubts whether mass belongs to ovary or uterus (axial plane of the ovary FSE T1WFS, axial plane of the ovary FSE T2W, axial plane of the ovary 3DT1WFS). According to signal characteristics obtained by this protocol adnexal masses were categorized as: 1. T1 bright, 2. T2 solid or 3. Cystic-solid masses. Selected cases from all three cathegories are presented. 1. T1 bright bilateral ovarian masses. Bilateral teratomas. Torsion of the left ovary. Page 3 of 48
Fig. 1: T1W: bilateral T1 bright mass (arrows) Page 4 of 48
Fig. 2: T1FS: fat saturation in both masses diagnostic for dermoid cysts (arrows) Page 5 of 48
Fig. 3: T2W: whirlpool sign on the left which is diagnostic for torsion of the ovary (arrow) 2. T1 bright left ovarian mass. Endometrioma of the left ovary Page 6 of 48
Fig. 4: T1 bright left adnexal mass without fat saturation. Page 7 of 48
Fig. 5: T2W: fluid-fluid level in the left adnexal mass. 3. T2 solid left ovarian mass. Atypical ovarian fibroma. Page 8 of 48
Fig. 6: T2W: left ovarian T2 solid mass. Page 9 of 48
Fig. 7: DWI: diffusion restriction atypical for fibroma. Page 10 of 48
Fig. 8: Considering that the lesion has high DWI signal with high b values contrast enhanced T1FS imaging was performed. Page 11 of 48
Fig. 9: Perfusion DCE base image: ROI placed on 1. myometrium, 2. left ovarian mass. Page 12 of 48
Fig. 10: Perfusion DCE curves: 1. myometrial curve, 2. indeterminate type curves. 4. Cystic-solid masses of both ovaries. Struma ovarii. Page 13 of 48
Fig. 11: T2W: bilateral ovarian cystic-solid lesions. Page 14 of 48
Fig. 12: T1FSC+: prominent peripheral enchancement of both ovarian lesions. Page 15 of 48
Fig. 13: Perfusion DCE base image: ROI placed on 1. myometrium, 2. mass on the right, 3. mass on the left. Page 16 of 48
Fig. 14: Perfusion DCE curves: 1. myometrial curve, 2. and 3. indeterminate type curves. 5. Cystic-solid mass on the right. Mucinous cystadenoma (indeterminate). Page 17 of 48
Fig. 15: T2: cystic-solid mass of the right ovary. Page 18 of 48
Fig. 16: T1FSC+: enchancement of the solid component of right ovarian mass. Page 19 of 48
Fig. 17: DWI: diffusion restriction in the solid component of right ovarian mass. Page 20 of 48
Fig. 18: Perfusion DCE base image: ROI placed on 2. myometrium, 3. mass on the right. Page 21 of 48
Fig. 19: Perfusion DCE curves: 2. myometrial curve, 3. indeterminate type curve. 6. Cystic-solid masses bilaterally. Krukenberg tumor. Page 22 of 48
Fig. 20: T2: bilateral cistic-solid ovarian masses. Ascites. Page 23 of 48
Fig. 21: T1FSC+: peripheral and septal enhancement of both ovarian lesions; prominent enhancement of solid component on the right. Page 24 of 48
Fig. 22: DWI: diffusion restriction in the solid component of both ovarian mass. Page 25 of 48
Fig. 23: Perfusion DCE base image: ROI placed on 3. mass on the right, 4. myometrium, 5. mass on the left. Page 26 of 48
Fig. 24: Perfusion DCE curves: 3. and 5. malignant type curves, 4. myometrial curve. 7. Cystic lesion of the left ovary. Serous cystadenoma. Page 27 of 48
Fig. 25: T2: cystic lesion of the left ovary. Page 28 of 48
Fig. 26: T1FSC+: peripheral and septal enhancement. Page 29 of 48
Fig. 27: Perfusion DCE base image: ROI placed on 1. myometrium, 2. mass on the left. Page 30 of 48
Fig. 28: Perfusion DCE curves: 1. myometrial curve, 2. benign type curve. Images for this section: Page 31 of 48
Fig. 15: T2: cystic-solid mass of the right ovary. Radiology, Clinical Center Vojvodina - Novi Sad/RS Page 32 of 48
Fig. 16: T1FSC+: enchancement of the solid component of right ovarian mass. Radiology, Clinical Center Vojvodina - Novi Sad/RS Page 33 of 48
Fig. 17: DWI: diffusion restriction in the solid component of right ovarian mass. Radiology, Clinical Center Vojvodina - Novi Sad/RS Page 34 of 48
Fig. 18: Perfusion DCE base image: ROI placed on 2. myometrium, 3. mass on the right. Radiology, Clinical Center Vojvodina - Novi Sad/RS Page 35 of 48
Fig. 19: Perfusion DCE curves: 2. myometrial curve, 3. indeterminate type curve. Radiology, Clinical Center Vojvodina - Novi Sad/RS Page 36 of 48
Fig. 9: Perfusion DCE base image: ROI placed on 1. myometrium, 2. left ovarian mass. Radiology, Clinical Center Vojvodina - Novi Sad/RS Page 37 of 48
Fig. 10: Perfusion DCE curves: 1. myometrial curve, 2. indeterminate type curves. Radiology, Clinical Center Vojvodina - Novi Sad/RS Page 38 of 48
Fig. 20: T2: bilateral cistic-solid ovarian masses. Ascites. Radiology, Clinical Center Vojvodina - Novi Sad/RS Page 39 of 48
Fig. 21: T1FSC+: peripheral and septal enhancement of both ovarian lesions; prominent enhancement of solid component on the right. Radiology, Clinical Center Vojvodina - Novi Sad/RS Page 40 of 48
Fig. 22: DWI: diffusion restriction in the solid component of both ovarian mass. Radiology, Clinical Center Vojvodina - Novi Sad/RS Page 41 of 48
Fig. 23: Perfusion DCE base image: ROI placed on 3. mass on the right, 4. myometrium, 5. mass on the left. Radiology, Clinical Center Vojvodina - Novi Sad/RS Page 42 of 48
Fig. 24: Perfusion DCE curves: 3. and 5. malignant type curves, 4. myometrial curve. Radiology, Clinical Center Vojvodina - Novi Sad/RS Page 43 of 48
Fig. 25: T2: cystic lesion of the left ovary. Radiology, Clinical Center Vojvodina - Novi Sad/RS Page 44 of 48
Fig. 26: T1FSC+: peripheral and septal enhancement. Radiology, Clinical Center Vojvodina - Novi Sad/RS Page 45 of 48
Fig. 27: Perfusion DCE base image: ROI placed on 1. myometrium, 2. mass on the left. Radiology, Clinical Center Vojvodina - Novi Sad/RS Page 46 of 48
Fig. 28: Perfusion DCE curves: 1. myometrial curve, 2. benign type curve. Radiology, Clinical Center Vojvodina - Novi Sad/RS Page 47 of 48
Conclusion MRI allows identification of blood products within adnexal masses that may mimic solid tumors at US. T1WFS images may reveal small amounts of fat, which allows the diagnosis of mature hematoma. T1WCE imaging best depicts features of malignancy. Perfusion curve types are useful tool for analysis of epithelial ovarian tumors. Personal information References 1. 2. 3. 4. 5. 6. 7. 8. Spencer JA, Forstner R, Cunha TM, Kinkel K. ESUR guidelines for MR imaging of the sonographically indeterminate adnexal mass: an algorithimic approach. Eur Radiol 2010; 20: 25-35. Spencer JA, Ghattamaneni S. MR imaging of the sonographically indeterminate adnexal mass. Radiology 2010; 256: 677-94. Thomassin-Nagarra I et al. Characterization of complex adnexal masses: value of adding perfusion and diffusion-weighted MR imaging to conventional MR imaging. Radiology 2011; 258; 3: 793-803. AIUM, ACR, ACOG, SPR, SRU. AIUM practice guideline for the performance of ultrasound of the female pelvis. J Ultrasound Med 2014; 33:1122-1130. Adusumilli et al. MRI of sonographically indeterminate adnexal masses. AJR 2006;187:732-40. Sohaib SAA, Sahdev A, Trappen PV, Jacobs IJ, Reznek RH. Characterization of adnexal mass lesions on MR imaging. AJR 2003; 180: 1297-304. Brown DL, Dudiak KM, Laing FC. Adnexal masses: US characterization and reporting. Radiology 2010; 254: 342-54. Thomassin-Naggara I, Darai E, Cuenod CA, Rouzier R, Callard P, Bazot M. Dynamic contrast-enhanced magnetic resonance imaging: a useful tool for characterizing ovaran epithelial tumors. Journal of magnetic resonance imaging 2008; 28:111-120. Page 48 of 48