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Urology gynecology pwi dwi ovarian mri m bazot
 

Urology gynecology pwi dwi ovarian mri m bazot

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    Urology gynecology pwi dwi ovarian mri m bazot Urology gynecology pwi dwi ovarian mri m bazot Presentation Transcript

    • ! DIFFUSION- AND PERFUSIONWEIGHTED MRI IN OVARIAN LESIONS M.BAZOT- I. THOMASSIN-NAGGARA - E.DARAI
    • 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)
    • 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)
    • 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
    • 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
    • Serous cystadenoma Adnexal torsion Ovarian fibroma
    • STEP 3 : SOLID TISSUE ? POST CONTRAST T1 Solid tissue ? T2 T1FS T1 Mature cystic teratoma 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
    • Absence of wall enhancement +++ T2 T1 gado T1 Peritoneal cyst
    • Absence of internal enhancement +++ T2 T1 gado T1 Purely cystic « Purely endometriotic » « Purely fatty »
    • 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 T2 Intermediate T2 signal Edema Cellular Invasive T2 Low T2 signal Fibrous Muscle
    • 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 ---Ext iliac artery ROI ---Ovarian lesion --Myometrium DESCRIPTIVE CURVE TYPE SEMI QUANTITATIVE QUANTITATIVE
    • PERFUSION : ANALYSIS Regions of interest (ROI) - Outer myometrium - Solid tissue - Time intensity curves
    • 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
    • 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
    • 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
    • Bilateral ovarian cystadenofibromas Characterization of solid tissue T2 T1 gado
    • T2 T2 Uterine leiomyoma Thomassin-Naggara, Bazot et al. JCAT 2007 Ovarian fibroma
    • 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
    • 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
    • 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
    • T1 T2 T1 3 min after gadolinium injection
    • T2 Mucinous borderline with clear cell carcinoma DWI b 1000 DCE-MRI DWI- ADC
    • 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
    • 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
    • T2 Subserous leiomyoma DWI ADC
    • 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
    • Peritoneal implants Low ADC High signal intensity (b 1000) Immature teratoma
    • Unicentric N=497 Retrospective Accuracy 96% (316/329) Thomassin-Naggara, Bazot et al. Radiology 2013
    • ADNEXMR SCORING SYSTEM PPV >95% PPV =5-95% PPV = 0-2% PPV <5%
    • T2 T1 Menopausal asymptomatic DWI T1 FS PWI T1FS gado
    • 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
    • T2 DWI Menopausal woman with abdominopelvic enlargement T1 gado
    • Score 5 Ovarian cystadenocarcinoma
    • 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
    • DCE-MRI type 2 Borderline serous ovarian tumor 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
    • 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