1. !
DIFFUSION- AND PERFUSIONWEIGHTED MRI IN OVARIAN LESIONS
M.BAZOT- I. THOMASSIN-NAGGARA - E.DARAI

2. INTRODUCTION
Common indication of consultation / potential surgery
Ultrasonography : first-line imaging technique
- Expertise
- “Indeterminate lesions”
MRI : second-line imaging technique
Conventional and Functional MR imaging (PWI-DWI)
- Characterization
- (Extension et follow-up)

3. Indeterminate ovarian mass at US: Incremental value of
second imaging test for characterization - Meta-analysis
and Bayesian analysis. Kinkel et al. Radiology 2005
Indeterminate mass at US: MRI > CT or US + Doppler

4. INDETERMINATE OR COMPLEX ADNEXAL MASSES ON US

5. « 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)

6. STEP 1 : LOCATION : OVARIAN OR NOT?
T2
1st: Looking for normal ovaries
Para ovarian cyst
Peritoneal cyst
2nd: Looking for residual ovarian tissue
Endometrial cysts
Ovarian fibroma

7. STEP 2 : FAT OR BLOOD COMPONENT?
T1 / T1 FAT SATURATION
Fat :
Dermoid cyst
Blood :
Endometrioma
Hemorragic cyst
Torsion
Togashi et al. Radiology 1989
T2
T1
T1 FS
Mature cystic teratoma
Endometrioma
Hemorragic cyst

8. Serous cystadenoma
Adnexal torsion
Ovarian fibroma

9. STEP 3 : SOLID TISSUE ?
POST CONTRAST T1
Solid tissue ?
T2
T1FS
T1
Mature cystic teratoma
T1FSgado

10. STEP 3 : SOLID TISSUE ?
POST CONTRAST T1
Gadolinium injection is very useful for
adnexal mass characterization
Absence of enhancement is highly
predictive of benign disease

11. Absence of wall enhancement +++
T2
T1 gado
T1
Peritoneal cyst

12. Absence of internal enhancement +++
T2
T1 gado
T1
Purely cystic
« Purely endometriotic »
« Purely fatty »

13. 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

14. Thickened irregular septa
Solid papillary projection
Mixed or purely solid

15. STEP 3 : SOLID TISSUE ?
POST CONTRAST T1
Absence of solid tissue = BENIGN
No wall enhancement or no internal enhancement
including purely cystic, endometriotic, fatty mass
Presence of solid tissue = SUSPICIOUS
T2 weighted sequence
Perfusion weighted imaging (PWI)
Diffusion weighted imaging (DWI)

16. STEP 4 : MALIGNANT TISSUE ?
T2 / PWI / DWI
T2 signal : Initial characterization of solid tissue
T2
Intermediate T2 signal
Edema
Cellular
Invasive
T2
Low T2 signal
Fibrous
Muscle

17. PERFUSION : ACQUISITION
Gadolinium injection
0.02 ml/kg / 2ml/sec
T1 gradient echo using 2D or 3D
Repetitive acquisition
Acquisition d'une série d'images

18. PERFUSION : ANALYSIS
---Ext iliac
artery
ROI
---Ovarian
lesion
--Myometrium
DESCRIPTIVE
CURVE TYPE
SEMI QUANTITATIVE
QUANTITATIVE

19. PERFUSION : ANALYSIS
Regions of interest (ROI)
- Outer myometrium
- Solid tissue
- Time intensity curves

20. Can dynamic contrast-enhanced MRI predict the nature of ovarian tumors?
Thomassin-Naggara, Bazot et al. Radiology 2008
MALIGNANT
3
2
1
Type 1 : weak enhancement
BENIGN
Type 2 : moderate enhancement with pic followed by a plateau
Type 3 : intense enhancement earlier than myometrium

21. STEP 4 : MALIGNANT TISSUE ?
T2 / PWI / DWI
PWI : Time Intensity curve and neoangiogenesis
Benign ovarian tumors Borderline ovarian tumors Invasive ovarian tumors
Sensitivity
70%
Sensitivity
62.5%
Sensitivity
66%
Specificity
90.3%
Specificity
87%
Specificity
100%
Thomassin-Naggara, Bazot et al. JMRI 2008

22. 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

23. Bilateral ovarian cystadenofibromas
Characterization of solid tissue
T2
T1 gado

24. T2
T2
Uterine leiomyoma
Thomassin-Naggara, Bazot et al. JCAT 2007
Ovarian fibroma

25. DIFFUSION WEIGHTED IMAGING
Echo Planar Imaging
T2
At least two b values: 0-1000 mm2/s
Fat saturation techniques
Qualitative analysis +++
- Low or high signal intensity on b1000
b1000
- Comparison with T2 (or fusion)
Quantitative analysis
- ADC values
ADC

26. STEP 4 : MALIGNANT TISSUE ?
T2 / PWI / DWI
DWI : Signal
Invasive
malignant
tumor always
T2
Ovarian
cystadenocarcinoma
displays high
b1000 signal ….
T2
Ovarian fibroma
…But some
benign tumors
may also
display high
DWI
b1000 signal
DWI

27. STEP 4 : MALIGNANT TISSUE ?
T2 / PWI / DWI
DWI : Signal
In contrast, the absence of high b1000
signal is highly predictive of benignity
(PLR = 10.1)
Cystadenofibroma
T2
T1FS gado
Thomassin-Naggara, Bazot et al. Eur Radiol 2009
DWI

28. T1
T2
T1 3 min after gadolinium injection

29. T2
Mucinous borderline with clear cell carcinoma
DWI b 1000
DCE-MRI
DWI- ADC

30. STEP 4 : MALIGNANT TISSUE ?
T2 / DWI / PWI
TP (No.)
TN (No.)
FP (No.)
FN (No.)
Sensitivity (%)
Specificity (%)
VPP (%)
VPN (%)
Accuracy (%)
Diagnostic confidence (%)
ConvMRI
(n=87)
44
19
18
6
88
51.3
70.9
76
72.4
ConvMRI +DWI
(n=73)
45
23
6
1
97.8
79.3
88.2
95.8
90.6
ConvMRI+DCE
(n=65)
45
15
4
1
97.8
78.9
91.8
93.7
92.3
ConvMRI +DWI+DCE
(n=57)
41
13
3
0
100
81.2
93.1
100
94.7
-
15
25
22.8
Thomassin-Naggara, Bazot et al. Radiology 2011

31. Benign seromucinous tumors
Bilaterality
Multilocularity
Vegetations
enhanced with gadolinium
But curve type 1
and no high b1000 signal
TSE T2
EG T1 fat sat
b1000
EG T1 fat sat gado

32. T2
Subserous leiomyoma
DWI
ADC

33. Combination of T2 + DWI
T2
> DWI or (T2 + T1G) alone
Peritoneal Implants
DWI
High signal intensity b 1000
Bilateral ovarian cancer
Low ADC
Sala et al. Radiology 2012

34. Peritoneal implants
Low ADC
High signal intensity (b 1000)
Immature teratoma

35. Unicentric
N=497
Retrospective
Accuracy 96% (316/329)
Thomassin-Naggara, Bazot et al. Radiology 2013

36. ADNEXMR SCORING SYSTEM
PPV >95%
PPV =5-95%
PPV = 0-2%
PPV <5%

37. T2
T1
Menopausal asymptomatic
DWI
T1 FS
PWI
T1FS gado

38. WHAT IS YOUR DIAGNOSIS?
A. ADNEXMR SCORE 1
B. ADNEXMR SCORE 2
Benign (PPV < 2%)
C. ADNEXMR SCORE 3
Probably benign (PPV<5%)
D. ADNEXMR SCORE 4
Indeterminate
E. ADNEXMR SCORE 5
Probably malignant (PPV>95%)

39. Score 3
Ovarian fibroma

40. T2
DWI
Menopausal woman with abdominopelvic enlargement
T1 gado

41. Score 5
Ovarian
cystadenocarcinoma

42. ADNEXMR SCORING SYSTEM
ADNEXMR SCORE >4 predicts malignancy
with a sensitivity 93.5% and a specificity of 96.6%
Cancer center
ADNEXMR SCORE <3 predicts benignity
with a sensivity 96,6% and a specificity of 93,5%
Follow up
Conservative
surgery
ADNEXMR SCORING system relays radiologist’s suspicions to clinician
and would help to standardize MR imaging reporting with the
potential aim of improving patient management.
Thomassin-Naggara, Bazot et al. Radiology 2013

43. DCE-MRI type 2
Borderline serous ovarian tumor
Axial T2
HISTOLOGICAL CLASSIFICATION

44. TAKE HOME MESSAGES
Conventional MRI +++
- T1 for cystic component
- T2 for solid component
- Low T2 : benign
- Intermediate T2 : suspicious
DWI ++
- Low signal on b1000 : benign
- High signal for peritoneal implants
PWI +++
- Type 1: benign
- Type 2: overlap (mainly borderline)
- Type 3: invasive

45. CLINICAL TRIAL SIFEM-2013 : EUROPEAN MULTICENTRIC VALIDATION
March 2013-July 2017
UK : A.Rockall
A.Sahdev
M.Lewinski
S.Freeman
M.Hall-Craggs
Italy : G.Masseli
G.Reistano
R.Manfredi
Austria : R.Forstner
Portugal : TM Cunha
AG.Guerra
Belgium : A.Thille
Switzerland :
K.Kinkel
R.Kubik
H.Thoeny
Serbia: S.Stojanovic
Coordonnator :
I.Thomassin-Naggara
(Paris)
Croatia:
I.Giordana
France : M.Bazot
A.Jalaguier
S.Taieb
C.Balleyguier
O.Lucidarme
L.Fournier
I.Millet
N.Perrot
S.Bendavid
E.Poncelet
V.Juhan
C.Malhaire