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Urology gynecology pwi dwi ovarian mri m bazot

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Urology gynecology pwi dwi ovarian mri m bazot

  1. 1. ! DIFFUSION- AND PERFUSIONWEIGHTED MRI IN OVARIAN LESIONS M.BAZOT- I. THOMASSIN-NAGGARA - E.DARAI
  2. 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. 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. 4. INDETERMINATE OR COMPLEX ADNEXAL MASSES ON US
  5. 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. 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. 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. 8. Serous cystadenoma Adnexal torsion Ovarian fibroma
  9. 9. STEP 3 : SOLID TISSUE ? POST CONTRAST T1 Solid tissue ? T2 T1FS T1 Mature cystic teratoma T1FSgado
  10. 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. 11. Absence of wall enhancement +++ T2 T1 gado T1 Peritoneal cyst
  12. 12. Absence of internal enhancement +++ T2 T1 gado T1 Purely cystic « Purely endometriotic » « Purely fatty »
  13. 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. 14. Thickened irregular septa Solid papillary projection Mixed or purely solid
  15. 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. 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. 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. 18. PERFUSION : ANALYSIS ---Ext iliac artery ROI ---Ovarian lesion --Myometrium DESCRIPTIVE CURVE TYPE SEMI QUANTITATIVE QUANTITATIVE
  19. 19. PERFUSION : ANALYSIS Regions of interest (ROI) - Outer myometrium - Solid tissue - Time intensity curves
  20. 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. 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. 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. 23. Bilateral ovarian cystadenofibromas Characterization of solid tissue T2 T1 gado
  24. 24. T2 T2 Uterine leiomyoma Thomassin-Naggara, Bazot et al. JCAT 2007 Ovarian fibroma
  25. 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. 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. 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. 28. T1 T2 T1 3 min after gadolinium injection
  29. 29. T2 Mucinous borderline with clear cell carcinoma DWI b 1000 DCE-MRI DWI- ADC
  30. 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. 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. 32. T2 Subserous leiomyoma DWI ADC
  33. 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. 34. Peritoneal implants Low ADC High signal intensity (b 1000) Immature teratoma
  35. 35. Unicentric N=497 Retrospective Accuracy 96% (316/329) Thomassin-Naggara, Bazot et al. Radiology 2013
  36. 36. ADNEXMR SCORING SYSTEM PPV >95% PPV =5-95% PPV = 0-2% PPV <5%
  37. 37. T2 T1 Menopausal asymptomatic DWI T1 FS PWI T1FS gado
  38. 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. 39. Score 3 Ovarian fibroma
  40. 40. T2 DWI Menopausal woman with abdominopelvic enlargement T1 gado
  41. 41. Score 5 Ovarian cystadenocarcinoma
  42. 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. 43. DCE-MRI type 2 Borderline serous ovarian tumor Axial T2 HISTOLOGICAL CLASSIFICATION
  44. 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. 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

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