urology gynecology pwi dwi ovarian mri m bazot
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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
!
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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
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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
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INDETERMINATE OR COMPLEX ADNEXAL MASSES ON US
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« 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)
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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
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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
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Adnexal torsion
Serous cystadenoma
Ovarian fibroma
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STEP 3 : SOLID TISSUE ? POST CONTRAST T1
Solid tissue ?
Mature cystic teratoma
T2 T1
T1FS T1FSgado
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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
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Peritoneal cyst
Absence of wall enhancement +++
T2 T1 T1 gado
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Purely cystic
« Purely endometriotic »
« Purely fatty »
Absence of internal enhancement +++
T2 T1 T1 gado
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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
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Thickened irregular septa Solid papillary projection Mixed or purely solid
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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)
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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
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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
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PERFUSION : ANALYSIS
DESCRIPTIVE QUANTITATIVE
SEMI QUANTITATIVE CURVE TYPE
ROI
---Myometrium
---Ovarian lesion
---Ext iliac artery
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Regions of interest (ROI)
- Outer myometrium
- Solid tissue
- Time intensity curves
PERFUSION : ANALYSIS
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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
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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
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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
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T2 T1 gado
Characterization of solid tissue Bilateral ovarian cystadenofibromas
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Uterine leiomyoma Ovarian fibroma
Thomassin-Naggara, Bazot et al. JCAT 2007
T2 T2
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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
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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
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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
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T2 T1 3 min after gadolinium injection
T1
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DWI b 1000
DCE-MRI
Mucinous borderline with clear cell carcinoma
T2
DWI- ADC
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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
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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
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Subserous leiomyoma T2
ADC DWI
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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
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Immature teratoma
High signal intensity (b 1000)
Low ADC Peritoneal implants
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Thomassin-Naggara, Bazot et al. Radiology 2013
Unicentric N=497 Retrospective
Accuracy 96% (316/329)
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PPV = 0-2% PPV <5%
PPV >95%
PPV =5-95%
ADNEXMR SCORING SYSTEM
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Menopausal asymptomatic
T2 T1
T1FS gado T1 FS
DWI PWI
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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%)
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Score 3 Ovarian fibroma
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Menopausal woman with abdominopelvic enlargement
T2 DWI
T1 gado
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Score 5 Ovarian
cystadenocarcinoma
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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.
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Borderline serous ovarian tumor
DCE-MRI type 2
Axial T2
HISTOLOGICAL CLASSIFICATION
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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
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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