Selma Beljord diffusion perfusion mri in ovarian lesions management and characterisation jfim ifupi milan 2018

1. S . B E L D J O R D - I . T H O M A S S I N - N A G G A R A - M . B A Z O T
DIFFUSION- AND PERFUSION-WEIGHTED
MRI IN OVARIAN LESIONS
1st Italian-French Update Imaging – IFUPI
Advanced Multiparametric Imaging - How to use in daily practice
MILAN March 23-24 2018

2. INTRODUCTION
• Ovarian tumors : leading indication for gynecologic
surgery +++
• Imaging techniques :
• Reducing the number of women unnecessarily undergoing
cancer surgery
• preserving fertility in young women (laparoscopy versus
laparotomy)
• Referring patients to a cancer centre with specialist
gynecological oncologist (better outcome)
• Misdiagnoses with frozen intra-operative histology
Bazot M et al Eur Radiol 2006

3. MRI : INDETERMINATE OR COMPLEX
ADNEXAL MASSES
Accuracy:
MRI > CT or US+Doppler
Cost effectiveness :
Risk of malignancy is small
Improvement of surgical
diagnoses
Earlier diagnosis of cancer
Kinkel et al. Radiology 2005
Mucinous benign cystadenoma

4. MRI PROTOCOL
• Axial T2 lombo-aortic
• Sagittale T2
• 3D T1 DIXON / VIBE / LAVA FLEX
• Axiale diffusion lombo-aortic
• Perfusion (3D echo gradient, 16s , 4:16)
• 3D T1 post-gadolinium

5. MRI : « THE 4 STEPS PRACTICAL
APPROACH »
• Step 1 : Is this an ovarian mass ? T2
• Step 2 : Is there fat or blood component ? T1/T1FS
• Step 3 : Is there solid tissue ? T1 post-gado
• Step 4 : Is there malignant tissue ? T2 + DWI + PWI

6. MRI : « THE 4 STEPS PRACTICAL
APPROACH »
• Step 1 : Is this an ovarian mass ? T2
• Step 2 : Is there fat or blood component ? T1/T1FS
• Step 3 : Is there solid tissue ? T1 post-gado
• Step 4 : Is there malignant tissue ? T2 + DWI + PWI

7. MRI : « THE 4 STEPS PRACTICAL
APPROACH »
• Step 1 : Is this an ovarian mass ? T2
• Step 2 : Is there fat or blood component ? T1/T1FS
• Step 3 : Is there solid tissue ? T1 post-gado
• Step 4 : Is there malignant tissue ? T2 + DWI + PWISECOND TISSUE PORTION CHARACTERIZATION

8. 1st : Looking for homolateral normal ovary
Para ovarian cyst
Ovarian fibromaEndometrial cysts
2nd : Looking for residual ovarian tissue: crescent sign
STEP 1 : LOCATION : IS THIS AN OVARIAN
MASS ? T2
3rd : Looking for lombo-ovarian pedicle
Peritoneal cyst

9. STEP 2 : IS THERE FAT OR BLOOD
COMPONENT? T1 / T1 FS
• Fat :
• Mature cystic
teratoma
• Blood :
• Endometrioma
• Hemorragic cyst
• Torsion
Mature cystic teratoma
Endometrioma
Hemorragic cyst
T2 T1 T1 FS
T2 T1 T1 gado
T2 T1 T1 gado
T2

10. MATURE VERSUS IMMATURE CYSTIC
TERATOMA
COLLOïDE

11. MATURE VERSUS IMMATURE CYSTIC
TERATOMA
BILATERAL MATURE CYSTIC TERATOMA
OF TYPE OVARIAN GOITER ON THE RIGHT

12. IMMATURE TERATOMA
MORPHOLOGICAL CHARACTERISTICS OF ROKITANSKY PROTUBERANCE

13. Adnexal torsion
Serous cystadenoma
Ovarian fibroma

14. Borderline mucinous tumor with adnexal torsion
T2 T1
T1 gadoT1 FS

15. STEP 3 : IS THERE SOLID TISSUE ?
T1 GADO ++
Solid portion
Mature cystic teratoma
T2 T1
T1FS
T1FSgado

16. STEP 3 : IS THERE SOLID TISSUE?
T1 GADO ++
Gadolinium injection is very useful for
adnexal mass characterization because
absence of enhancement is highly
predictive of benign disease

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

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

19. STEP 3 : IS THERE SOLID TISSUE?
T1 GADO ++
Solid Tissue enhances after gadolinium
injection
Presence of solid tissue in significantly
associated with malignancy
Solid Tissue includes :
- Solid papillary projection
- Irregular thickened septum (>3mm)
- Solid portion

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

21. STEP 3 : IS THERE SOLID TISSUE ?
T1 GADO ++
• Absence of solid tissue
• No wall enhancement or no internal enhancement
including purely cystic, endometriotic, fatty mass
• Others with internal enhancement : Bi or
multiloculate cyst with regular septa
• Presence of solid tissue >>> characterization
• T2 weighted sequence
• Diffusion weighted imaging (DWI)
• Perfusion weighted imaging (PWI)
BENIGN
PROBABLY BENIGN
(PPV<5%)

22. STEP 4 : IS THERE MALIGNANT TISSUE ? T2 /
DWI / PWI
Thomassin-Naggara I, et al. Radiology 2011

23. STEP 4 : IS THERE MALIGNANT TISSUE ?
T2 / DWI / PWI
T2 signal : Detection of fibrous component ++
Intermediate T2 signal Low T2 signal
T2T2
Siegelman ES et al... Radiology 1999
Outwater EK, et al.. J Magn Reson Imaging 1997
Sohaib et al. AJR 2003

24. STEP 4 : IS THERE MALIGNANT TISSUE ? T2 /
DWI / PWI
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
Qualitative analysis

25. STEP 4 : IS THERE 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 I, et al. Eur Radiol 2009

26. STEP 4 : IS THERE MALIGNANT TISSUE ?
T2 / PWI / DWI
PWI : Time Intensity curve and neoangiogenesis
Invasive malignant tumorBorderline tumorBenign tumor
Sensitivity 70%
Specificity 90.3%
Sensitivity 62.5%
Specificity 87%
Sensitivity 66%
Specificity 100%
Thomassin-Naggara I. et al. JMRI 2008

27. STEP 4 : IS THERE MALIGNANT TISSUE ?
T2 / DWI / PWI
PWI : Time Intensity curve and neoangiogenesis
Pericyte coverage index
VEGFR-2
Thomassin-Naggara et al.. Radiology 2008

28. T2 T1 gado
Characterization of solid tissueBilateral ovarian cystadenofibromas

29. TWO PURELY SOLID MASSES
Ovarian fibroma edematous
And uterine leiomyoma figo 7

30. Uterine leiomyoma Ovarian fibroma
Thomassin-Naggara et al. JCAT 2007
T2 T2

31. BORDERLINE CYSTADENOFIBROMA

32. T2 T1 gado b1000
T2
Borderline mucinous tumor with Brenner tumor

33. Unilaterality
Multilocularity
Vegetations
enhanced with gadolinium
But curve type 1
and no high b1000 signal
Benign mucinous tumor
TSE T2 b1000
EG T1 fat sat EG T1 fat sat gado

34. Subserous pediculated leiomyoma
T2
ADCDWI

35. Thomassin-Naggara I, et al. Radiology 2013
Accuracy 96% (316/329)

36. Menopausal asymptomatic
T2 T1
T1FS gadoT1 FS
DWI PWI

37. WHAT IS YOUR DIAGNOSIS?
A. ADNEXMR SCORE 1
B. ADNEXMR SCORE 2 Benign (PPV = 0)
C. ADNEXMR SCORE 3 Probably benign (PPV<5%)
D. ADNEXMR SCORE 4 Indeterminate
E. ADNEXMR SCORE 5 Probably malignant (PPV>95%)

38. Score 3
Ovarian fibroma

39. Menopausal woman with abdominopelvic enlargement
T2 DWI
T1 gado

40. Score 5
Ovarian
cystadenocarcinoma

42. Borderline mucinous tumor
with borderline Brenner tumor

43. ADNEXMR SCORING SYSTEM
Thomassin-Naggara I, 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.

44. TAKE HOME MESSAGES
T1-weighted MRI = essential for cystic component
T2-weighted MRI = essential for solid component
- Low signal intensity T2-w and diffusion : benign
- Intermediate signal intensity T2-w: suspicious
DWI valuable when low signal intensity on B1000
PWI with 3 valuable time-intensity curves