M . B A Z O T - I . T H O M A S S I N - N A G G A R A - E . D A R A I

DIFFUSION- AND PERFUSION-WEIGHTED MRI IN OVARIAN LESIONS

!

Common indication of consultation / potential surgery Ultrasonography : first-line imaging technique

- Expertise - “Indeterminate lesions”

MRI : second-line imaging technique Conventional and Functional MR imaging (PWI-DWI)

- Characterization - (Extension et follow-up)

INTRODUCTION

Indeterminate ovarian mass at US: Incremental value of second imaging test for characterization - Meta-analysis

and Bayesian analysis. Kinkel et al. Radiology 2005

Indeterminate mass at US: MRI > CT or US + Doppler

INDETERMINATE OR COMPLEX ADNEXAL MASSES ON US

« PRACTICAL MRI ANALYSIS »

Conventional MRI sequences: T2 + T1/T1 Fat Sat +/- T1 post gadolinium

- Ovarian mass ? T2

- Fat or blood component ? T1/T1FS

- Solid tissue ? T1 post-gadolinium

Functional MRI sequences: DWI + PWI

- Malignant solid tissue ? PWI + DWI (in addition to T2 and T1-w)

1st: Looking for normal ovaries Para ovarian cyst Peritoneal cyst

Ovarian fibroma Endometrial cysts

2nd: Looking for residual ovarian tissue

STEP 1 : LOCATION : OVARIAN OR NOT? T2

STEP 2 : FAT OR BLOOD COMPONENT? T1 / T1 FAT SATURATION

Fat : Dermoid cyst

Blood :

Endometrioma Hemorragic cyst Torsion

Mature cystic teratoma

Endometrioma

Hemorragic cyst

T2 T1 T1 FS T2

Togashi et al. Radiology 1989

Adnexal torsion

Serous cystadenoma

Ovarian fibroma

STEP 3 : SOLID TISSUE ? POST CONTRAST T1

Solid tissue ?

Mature cystic teratoma

T2 T1

T1FS T1FSgado

STEP 3 : SOLID TISSUE ? POST CONTRAST T1

Gadolinium injection is very useful for

adnexal mass characterization

Absence of enhancement is highly

predictive of benign disease

Peritoneal cyst

Absence of wall enhancement +++

T2 T1 T1 gado

Purely cystic

« Purely endometriotic »

« Purely fatty »

Absence of internal enhancement +++

T2 T1 T1 gado

STEP 3 : SOLID TISSUE ? POST CONTRAST T1

Solid tissue enhances after gadolinium injection Solid tissue includes:

- Irregular thickened septum (>3mm) - Papillary projection - Solid portion

Solid tissue significantly associated with malignancy

Thickened irregular septa Solid papillary projection Mixed or purely solid

STEP 3 : SOLID TISSUE ? POST CONTRAST T1

Absence of solid tissue = BENIGN

No wall enhancement or no internal enhancement

including purely cystic, endometriotic, fatty mass

Presence of solid tissue = SUSPICIOUS

T2 weighted sequence

Perfusion weighted imaging (PWI)

Diffusion weighted imaging (DWI)

STEP 4 : MALIGNANT TISSUE ? T2 / PWI / DWI

T2 signal : Initial characterization of solid tissue

Intermediate T2 signal Edema Cellular Invasive

Low T2 signal Fibrous Muscle

T2 T2

PERFUSION : ACQUISITION

Gadolinium injection

0.02 ml/kg / 2ml/sec

T1 gradient echo using 2D or 3D

Repetitive acquisition

Acquisition d'une série d'images

PERFUSION : ANALYSIS

DESCRIPTIVE QUANTITATIVE

SEMI QUANTITATIVE CURVE TYPE

ROI

---Myometrium

---Ovarian lesion

---Ext iliac artery

Regions of interest (ROI)

- Outer myometrium

- Solid tissue

- Time intensity curves

PERFUSION : ANALYSIS

Can dynamic contrast-enhanced MRI predict the nature of ovarian tumors? Thomassin-Naggara, Bazot et al. Radiology 2008

MALIGNANT

BENIGN Type 1 : weak enhancement

Type 2 : moderate enhancement with pic followed by a plateau

Type 3 : intense enhancement earlier than myometrium

1

2

3

STEP 4 : MALIGNANT TISSUE ? T2 / PWI / DWI

PWI : Time Intensity curve and neoangiogenesis

Invasive ovarian tumors Borderline ovarian tumors Benign ovarian tumors

Sensitivity 70%

Specificity 90.3%

Sensitivity 62.5%

Specificity 87%

Sensitivity 66%

Specificity 100%

Thomassin-Naggara, Bazot et al. JMRI 2008

STEP 4 : MALIGNANT TISSUE ? T2 / PWI / DWI

PWI : Time Intensity curve and neoangiogenesis

Pericyte coverage index

VEGFR-2

Thomassin-Naggara, Bazot et al. Radiology 2008

T2 T1 gado

Characterization of solid tissue Bilateral ovarian cystadenofibromas

Uterine leiomyoma Ovarian fibroma

Thomassin-Naggara, Bazot et al. JCAT 2007

T2 T2

DIFFUSION WEIGHTED IMAGING

Echo Planar Imaging

At least two b values: 0-1000 mm2/s

Fat saturation techniques

Qualitative analysis +++

- Low or high signal intensity on b1000

- Comparison with T2 (or fusion)

Quantitative analysis

- ADC values

T2

b1000

ADC

STEP 4 : MALIGNANT TISSUE ? T2 / PWI / DWI

T2

DWI

Ovarian cystadenocarcinoma

Invasive

malignant

tumor always

displays high

b1000 signal …. Ovarian fibroma

…But some

benign tumors

may also

display high

b1000 signal

T2

DWI

DWI : Signal

STEP 4 : MALIGNANT TISSUE ? T2 / PWI / DWI

T2

In contrast, the absence of high b1000

signal is highly predictive of benignity

(PLR = 10.1)

Cystadenofibroma

T1FS gado DWI

DWI : Signal

Thomassin-Naggara, Bazot et al. Eur Radiol 2009

T2 T1 3 min after gadolinium injection

T1

DWI b 1000

DCE-MRI

Mucinous borderline with clear cell carcinoma

T2

DWI- ADC

STEP 4 : MALIGNANT TISSUE ? T2 / DWI / PWI

ConvMRI (n=87)

ConvMRI +DWI (n=73)

ConvMRI+DCE (n=65)

ConvMRI +DWI+DCE (n=57)

TP (No.) 44 45 45 41 TN (No.) 19 23 15 13 FP (No.) 18 6 4 3 FN (No.) 6 1 1 0 Sensitivity (%) 88 97.8 97.8 100 Specificity (%) 51.3 79.3 78.9 81.2 VPP (%) 70.9 88.2 91.8 93.1 VPN (%) 76 95.8 93.7 100 Accuracy (%) Diagnostic confidence (%)

72.4 -

90.6

15

92.3

25

94.7

22.8

Thomassin-Naggara, Bazot et al. Radiology 2011

Bilaterality Multilocularity Vegetations

enhanced with gadolinium

But curve type 1 and no high b1000 signal

Benign seromucinous tumors

TSE T2 b1000

EG T1 fat sat EG T1 fat sat gado

Subserous leiomyoma T2

ADC DWI

High signal intensity b 1000

Low ADC

Peritoneal Implants

Bilateral ovarian cancer

Combination of T2 + DWI

> DWI or (T2 + T1G) alone T2

DWI

Sala et al. Radiology 2012

Immature teratoma

High signal intensity (b 1000)

Low ADC Peritoneal implants

Thomassin-Naggara, Bazot et al. Radiology 2013

Unicentric N=497 Retrospective

Accuracy 96% (316/329)

PPV = 0-2% PPV <5%

PPV >95%

PPV =5-95%

ADNEXMR SCORING SYSTEM

Menopausal asymptomatic

T2 T1

T1FS gado T1 FS

DWI PWI

WHAT IS YOUR DIAGNOSIS?

A.  ADNEXMR SCORE 1

B.  ADNEXMR SCORE 2 Benign (PPV < 2%)

C.  ADNEXMR SCORE 3 Probably benign (PPV<5%)

D.  ADNEXMR SCORE 4 Indeterminate

E.  ADNEXMR SCORE 5 Probably malignant (PPV>95%)

Score 3 Ovarian fibroma

Menopausal woman with abdominopelvic enlargement

T2 DWI

T1 gado

Score 5 Ovarian

cystadenocarcinoma

ADNEXMR SCORING SYSTEM

Thomassin-Naggara, Bazot et al. Radiology 2013

ADNEXMR SCORE >4 predicts malignancy with a sensitivity 93.5% and a specificity of 96.6%

ADNEXMR SCORE <3 predicts benignity with a sensivity 96,6% and a specificity of 93,5%

Cancer center

Follow up Conservative surgery

ADNEXMR SCORING system relays radiologist’s suspicions to clinician and would help to standardize MR imaging reporting with the

potential aim of improving patient management.

Borderline serous ovarian tumor

DCE-MRI type 2

Axial T2

HISTOLOGICAL CLASSIFICATION

TAKE HOME MESSAGES

Conventional MRI +++ - T1 for cystic component - T2 for solid component - Low T2 : benign - Intermediate T2 : suspicious

DWI ++ - Low signal on b1000 : benign - High signal for peritoneal implants

PWI +++

- Type 1: benign - Type 2: overlap (mainly borderline) - Type 3: invasive

Coordonnator : I.Thomassin-Naggara

(Paris)

UK : A.Rockall A.Sahdev

M.Lewinski S.Freeman

M.Hall-Craggs

Switzerland : K.Kinkel R.Kubik

H.Thoeny

Belgium : A.Thille

Italy : G.Masseli G.Reistano R.Manfredi

France : M.Bazot A.Jalaguier

S.Taieb C.Balleyguier O.Lucidarme L.Fournier

I.Millet N.Perrot

S.Bendavid E.Poncelet

V.Juhan C.Malhaire

Serbia: S.Stojanovic

Austria : R.Forstner

Portugal : TM Cunha AG.Guerra

Croatia: I.Giordana

CLINICAL TRIAL SIFEM-2013 : EUROPEAN MULTICENTRIC VALIDATION March 2013-July 2017