Pattern Recognition or Adnexal MR Scoring System: Which Is More Accurate in Evaluating Adnexal Lesions?

PURPOSE: This study aims to compare the accuracy of the ADNEX MR scoring system and pattern recognition system to evaluate adnexal lesions indeterminate on the US exam. METHODS: In this cross-sectional retrospective study, pelvic DCE-MRI of 245 patients with 340 adnexal masses was studied based on the ADNEX MR scoring system and pattern recognition system. RESULTS: ADNEX MR scoring system with a sensitivity of 96.6% and specificity of 91% has an accuracy of 92.9%. The pattern recognition system's sensitivity, specificity, and accuracy are 95.8%, 93.3%, and 94.7%, respectively. PPV and NPV for the ADNEX MR scoring system were 85.1 and 98.1, respectively. PPV and NPV for the pattern recognition system were 89.7% and 97.7%, respectively. The area under the ROC curve for the ADNEX MR scoring system and pattern recognition system is 0.938 (95% CI, 0.909-0.967) and 0.950 (95% CI, 0.922-0.977). Pairwise comparison of these AUCs showed no significant difference (p = 0.052). CONCLUSION: The pattern recognition system is less sensitive than the ADNEX MR scoring system, yet more specific.

Adnexal Mass Imaging: Contemporary Guidelines for Clinical Practice.

Several recent guidelines have been published to improve accuracy and consistency of adnexal mass imaging interpretation and to guide management. Guidance from the American College of Radiology (ACR) Appropriateness Criteria establishes preferred adnexal imaging modalities and follow-up. Moreover, the ACR Ovarian-Adnexal Reporting Data System establishes a comprehensive, unified set of evidence-based guidelines for classification of adnexal masses by both ultrasound and MR imaging, communicating risk of malignancy to further guide management.

Ovarian-Adnexal Reporting and Data Systems MR Imaging: Nuts and Bolts.

MR imaging plays a key role in the characterization of adnexal lesions of indeterminate malignant potential found at ultrasound. Recently, the Ovarian-Adnexal Reporting and Data Systems (O-RADS) MRI lexicon and scoring system was developed to aid in standardization of reporting and interpretation of adnexal lesions, allowing for risk stratification based on MR imaging findings. This in turn can help improve communication between radiologists and referring providers, and potentially aid the selection of optimal treatment options. This article provides a detailed review of the lexicon and the scoring rubric of the O-RADS MRI risk stratification system.

Imaging of Metastatic Disease to the Ovary/Adnexa.

Ovarian metastases tend to arise in young women, either in patients with known cancer or as the first presentation of a previously occult extraovarian malignancy. Although imaging cannot always differentiate between secondary and primary ovarian neoplasms, and pathologic confirmation is generally required, it is important to recognize suggestive imaging features on pelvic MR imaging. Ovarian metastases are commonly described as bilateral, solid, heterogenous, and hypervascular. Features vary based on the tumor origin and histology. Knowledge of these features, plus the appropriate clinical context, can help guide radiologists to include metastases in their differential diagnosis for atypical adnexal masses.

O-RADS MRI: A Systematic Review and Meta-Analysis of Diagnostic Performance and Category-wise Malignancy Rates.

Background US-indeterminate adnexal lesions remain an important indication for gynecologic surgery. MRI can serve as a problem-solving tool through the use of the Ovarian-Adnexal Imaging Reporting and Data System (O-RADS) MRI lexicon, which is based on the ADNEX MR scoring system. Purpose To perform a systematic review and meta-analysis of the diagnostic performance of pelvic MRI interpreted using the ADNEX or O-RADS MRI stratification systems to characterize US-indeterminate adnexal lesions and of the category-wise malignancy rates. Materials and Methods A systematic literature search from May 2013 (publication of the ADNEX MR score) to September 2022 was performed. Studies reporting the use of pelvic MRI interpreted with the ADNEX or O-RADS MRI systems to characterize US-indeterminate adnexal lesions, with pathologic examination and/or follow-up as the reference standard, were included. Summary estimates of diagnostic performance were obtained with the bivariate random-effects model, while category-wise summary malignancy rates of O-RADS MRI 2, 3, 4, and 5 lesions were obtained with a random-effects model. Effects of covariates on heterogeneity and diagnostic performance were investigated through meta-regression. Results Thirteen study parts from 12 studies (3731 women, 4520 adnexal lesions) met the inclusion criteria. Diagnostic performance meta-analysis for 4012 lesions found a 92% summary sensitivity (95% CI: 88, 95) and a 91% summary specificity (95% CI: 89, 93). The meta-analysis of malignancy rates for 3641 lesions showed summary malignancy rates of 0.1% (95% CI: 0, 1) among O-RADS MRI 2 lesions, 6% (95% CI: 3, 9) among O-RADS MRI 3 lesions, 60% (95% CI: 52, 67) among O-RADS MRI 4 lesions, and 96% (95% CI: 92, 99) among O-RADS MRI 5 lesions. Conclusion Pelvic MRI interpreted with the Ovarian-Adnexal Reporting and Data System (O-RADS) MRI lexicon had high diagnostic performance for the characterization of US-indeterminate adnexal lesions. Summary estimates of malignancy rates in the O-RADS MRI 4 and O-RADS MRI 5 categories were higher than predicted ones. © RSNA, 2022 Supplemental material is available for this article. See also the editorial by Lee and Kang in this issue.

Diagnostic Accuracies of the Ultrasound and Magnetic Resonance Imaging ADNEX Scoring Systems For Ovarian Adnexal Mass: Systematic Review and Meta-Analysis.

We conducted a meta-analysis of IOTA (international ovarian tumor analysis) ADNEX (Assessment of Different NEoplasias in the adneXa) as ultrasound system and MRI (magnetic resonance imaging) ADNEX scoring systems as MR system to assess their diagnostic test accuracy for differentiating benign from malignant adnexal masses of the ovary. We performed an electronic search for relevant publications in the English language up to February 2021 using PubMed, CENTRAL (Cochrane Central Register of Controlled Trials), Web of Science, and Google scholar databases and search engines. We computed the pooled sensitivity, pooled specificity, and summary receiver operating characteristics curve (SROC) using the statistical software STATA (Version 13, College Station, TX, StataCorp LP). Based on 11 studies using IOTA-ADNEX, we observed pooled sensitivity, specificity, area under curve, and diagnostic odds ratio were 96% (95% CI, 94% to 97%), 79% (95% CI, 70% to 86 %), 97% (95% CI, 95% to 98%), and 88 (95% CI, 43 to 180). Based on five studies using MR-ADNEX scoring system the pooled sensitivity, specificity, area under curve and diagnostic odds ratio were 91 % (95% CI, 87% to 94 %), 95% (95% CI, 92% to 97 %), 98% (95% CI, 96% to 99%), and 189 (95% CI, 90 to 396) respectively. Our meta-analysis results demonstrate that the MR-ADNEX scoring system had higher specificity however bit lower sensitivity compared to the IOTA-ADNEX scoring system for discriminating benign from malignant ovarian tumors.

Two-Step Strategy for Optimizing the Preoperative Classification of Adnexal Masses in a University Hospital, Using International Ovarian Tumor Analysis Models: Simple Rules and Assessment of Different NEoplasias in the adneXa Model.

OBJECTIVES: To evaluate the performance of a two-step strategy compared with the International Ovarian Tumor Analysis (IOTA) - Assessment of Different NEoplasias in the adneXa (ADNEX) model for preoperative classification of adnexal masses. METHODS: An ambispective diagnostic accuracy study based on ultrasound data collected at one university hospital between 2012 and 2018. Two ultrasonographers classified the adnexal masses using IOTA Simple Rules (first step). Not classifiable masses were evaluated using the IOTA ADNEX model (second step). Also, all masses were classified using the IOTA ADNEX model. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR-), and receiver operating characteristic (ROC) curve were estimated. A P value of <.05 was used to determine statistical significance. RESULTS: The study included 548 patients and 606 masses. Patients' median age was 41 years with an interquartile range between 32 and 51 years. In the first step, 89 (14%) masses were not classifiable. In the second step, 55 (61.8%) masses were classified as malignant. Furthermore, for the totality of 606 masses, the IOTA ADNEX model estimated the probability that 126 (20.8%) masses were malignant. The two-step strategy had a sensitivity, specificity, PPV, NPV, LR+, LR-, and ROC curve of 86.8%, 91.01%, 51.9%, 98.4%, 9.7, 0.1, and 0.889, respectively; compared to IOTA ADNEX model that had values of 91.8%, 87.16%, 44.4%, 99%, 7.1, 0.09, and 0.895, respectively. CONCLUSION: The two-step strategy shows a similar diagnostic performance when compared to the IOTA ADNEX model. The IOTA ADNEX model involves only one step and can be more practical, and thus would be recommended to use.

Estimating the risk of malignancy of adnexal masses: validation of the ADNEX model in the hands of nonexpert ultrasonographers in a gynaecological oncology centre in China.

BACKGROUND: This study aims to validate the diagnostic accuracy of the International Ovarian Tumor Analysis (IOTA) the Assessment of Different NEoplasias in the adneXa (ADNEX) model in the preoperative diagnosis of adnexal masses in the hands of nonexpert ultrasonographers in a gynaecological oncology centre in China. METHODS: This was a single oncology centre, retrospective diagnostic accuracy study of 620 patients. All patients underwent surgery, and the histopathological diagnosis was used as a reference standard. The masses were divided into five types according to the ADNEX model: benign ovarian tumours, borderline ovarian tumours (BOTs), stage I ovarian cancer (OC), stage II-IV OC and ovarian metastasis. Receiver operating characteristic (ROC) curve analysis was used to evaluate the ability of the ADNEX model to classify tumours into different histological types with and without cancer antigen 125 (CA 125) results. RESULTS: Of the 620 women, 402 (64.8%) had a benign ovarian tumour and 218 (35.2%) had a malignant ovarian tumour, including 86 (13.9%) with BOT, 75 (12.1%) with stage I OC, 53 (8.5%) with stage II-IV OC and 4 (0.6%) with ovarian metastasis. The AUC of the model to differentiate benign and malignant adnexal masses was 0.97 (95% CI, 0.96-0.98). Performance was excellent for the discrimination between benign and stage II-IV OC and between benign and ovarian metastasis, with AUCs of 0.99 (95% CI, 0.99-1.00) and 0.99 (95% CI, 0.98-1.00), respectively. The model was less effective at distinguishing between BOT and stage I OC and between BOT and ovarian metastasis, with AUCs of 0.54 (95% CI, 0.45-0.64) and 0.66 (95% CI, 0.56-0.77), respectively. When including CA125 in the model, the performance in discriminating between stage II-IV OC and stage I OC and between stage II-IV OC ovarian metastasis was improved (AUC increased from 0.88 to 0.94, P = 0.01, and from 0.86 to 0.97, p = 0.01). CONCLUSIONS: The IOTA ADNEX model has excellent performance in differentiating benign and malignant adnexal masses in the hands of nonexpert ultrasonographers with limited experience in China. In classifying different subtypes of ovarian cancers, the model has difficulty differentiating BOTs from stage I OC and BOTs from ovarian metastases.

Validation of American College of Radiology Ovarian-Adnexal Reporting and Data System Ultrasound (O-RADS US): Analysis on 1054 adnexal masses.

OBJECTIVE: To assess the diagnostic performance and inter-observer agreement of the American College of Radiology (ACR) Ovarian-Adnexal Reporting and Data System Ultrasound (O-RADS US). METHODS: From January 2016 to December 2018 a total of 1054 adnexal lesions in 1035 patients with pathologic results from two hospitals were retrospectively included. Each lesion was assigned to an O-RADS US category according to the criteria. Kappa (κ) statistics were applied to assess inter-observer agreement between a less experienced and an expert radiologist. RESULTS: Of the 1054 adnexal lesions, 750 were benign and 304 were malignant. The malignancy rates of O-RADS 5, O-RADS 4, O-RADS 3, and O-RADS 2 lesions were 89.57%, 34.46%, 1.10%, and 0.45% respectively. Area under the receiver operating characteristic curve was 0.960 (95% CI, 0.947-0.971). The optimal cutoff value for predicting malignancy was >O-RADS 3 with a sensitivity and specificity of 98.7% (95% CI, 0.964-0.996) and 83.2% (95% CI, 0.802-0.858) respectively. When sub-classifying multilocular cysts and smooth solid lesions in O-RADS 4 lesions as O-RADS 4a lesions and the rest cystic lesions with solid components as O-RADS 4b lesions, the malignancy rate were 17.02% and 42.57% respectively, which showed better risk stratification (P < 0.001). The inter-observer agreement between a less-experienced and an expert radiologist of O-RADS categorization was good (κ = 0.714). CONCLUSIONS: The ACR O-RADS US provides effective malignancy risk stratification for adnexal lesions with high reliability for radiologists with different experience. Sub-grouping of O-RADS 4 lesions into two groups facilitated better stratification of the intermediate risk.

Preoperative Evaluation of the ADNEX Model for the Prediction of the Ovarian Cancer Risk of Adnexal Masses at Siriraj Hospital.

INTRODUCTION: Distinguishing benign adnexal masses from malignant tumors plays an important role in preoperative planning and improving patients' survival rates. The International Ovarian Tumor Analysis (IOTA) group developed a model termed the Assessment of Different NEoplasias in the adneXa (ADNEX). OBJECTIVE: Our objective was to evaluate the performance of the ADNEX model in distinguishing between benign and malignant tumors at a cutoff value of 10%. METHODS: This was a prospective diagnostic study. 357 patients with an adnexal mass who were scheduled for surgery at Siriraj Hospital were included from May 1, 2018, to May 30, 2019. All patients were undergoing ultrasonography, and serum CA125 was measured. Data were calculated by the ADNEX model via an IOTA ADNEX calculator. RESULTS: Of the 357 patients, 296 had benign tumors and 61 had malignant tumors. The area under the receiver operating characteristic curve for using the ADNEX model was 0.975 (95% confidence interval, 0.953-0.988). At a 10% cutoff, the sensitivity was 98.4% and specificity was 87.2%. The best cutoff value was at 16.6% in our population. CONCLUSIONS: The performance of the ADNEX model in differentiating benign and malignant tumors was excellent.

Magnetic resonance scoring system for assessment of adnexal masses: added value of diffusion-weighted imaging including apparent diffusion coefficient map.

OBJECTIVES: To validate prospectively the ADNEX magnetic resonance (MR) scoring system to assess adnexal masses and to evaluate a new, modified ADNEX MR scoring system that incorporates diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) mapping. METHODS: Between January 2015 and September 2018, 323 consecutive women with adnexal masses diagnosed on transvaginal ultrasound (TVS) underwent standardized MR imaging (MRI) including diffusion and dynamic contrast-enhanced sequences. Of these, 131 underwent subsequent surgery. For interpretation of the MRI examinations, we applied the five-category ADNEX MR scoring system, along with a modified scoring system including DWI with ADC mapping. For both scoring systems, a score was given for all adnexal masses. Histological diagnosis was considered as the gold standard and lesions were classified as benign or malignant. The difference between the predictive values for diagnosing malignancy of the classical and modified scoring systems was assessed on the basis of the areas under the receiver-operating-characteristics (AUC) curves. The sensitivity and specificity for diagnosing malignancy of each score were also calculated. RESULTS: Among the 131 women with adnexal mass(es) diagnosed on TVS who underwent MRI and subsequent surgery, the surgery revealed 161 adnexal masses in 126 women; five women had no mass. Histological examination confirmed 161 adnexal masses, of which all had been detected on MRI: 32 malignant tumors, 15 borderline tumors, which were classified as part of the malignant group (n = 47), and 114 benign lesions. The AUC for prediction of a malignant lesion was 0.938 (95% CI, 0.902-0.975) using the classical ADNEX MR scoring system and 0.974 (95% CI, 0.953-0.996) using the modified scoring system. Pairwise comparison of these AUCs revealed a significant difference (P = 0.0032). The sensitivity and specificity for diagnosing malignancy with an ADNEX MR score of 4 or more were 95.5% and 86.6%, respectively, using the classic scoring system, and 95.7% and 93.3%, respectively, using the modified scoring system. CONCLUSION: DWI with ADC mapping could be integrated into the ADNEX MR scoring system to improve specificity, thereby potentially optimizing clinical management by avoiding unnecessary surgery. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Acute abdomen or life-threatening heterotopic pregnancy with tubal rupture: where does imaging play a role?

Heterotopic pregnancy (HP) is a rare, potentially life-threatening complication of an intrauterine pregnancy with a simultaneous ectopic pregnancy. There is a higher incidence with assisted reproduction techniques (ART) and radiology can be pivotal in its diagnosis. A 28-year-old woman underwent ART and at 7 weeks' gestation presented with acute right iliac fossa pain. Transvaginal ultrasound (US) imaging confirmed a viable intrauterine pregnancy. The patients' pain persisted however, and transabdominal US demonstrated a complex, heterogeneous right adnexal mass. Subsequent magnetic resonance imaging (MRI) confirmed an HP with a ruptured ectopic and haemoperitoneum. Emergency laparoscopic surgery and right salpingo-oopherectomy were performed without complication. We highlight the importance of considering HP as a diagnosis in the acute gravid abdomen, especially when initial investigations have confirmed a viable intrauterine pregnancy. Furthermore, this case highlights MRI as a useful modality in complex cases due to its high soft tissue contrast resolution using non-ionising radiation.

Caution with bilateral salpingectomy and consideration of tubal stump ectopic in IVF.

We report a 35-year-old female patient with a history of bilateral salpingectomy from ectopic pregnancies presenting with a positive serum beta-human chorionic gonadotropin (bhCG) result following in vitro fertilisation (IVF) treatment. Apart from per vaginal spotting, she remained asymptomatic. Initial ultrasound showed an empty uterus with a cystic mass on the right side of the uterus. Serum beta-hCG was trended. A follow-up pelvic ultrasound 1 week later showed a live pregnancy in the right adnexa. A diagnostic laparoscopy was performed, which revealed an unruptured right stump ectopic pregnancy that was successfully removed. As a stump ectopic pregnancy can be a potentially life-threatening occurrence, we emphasise caution with salpingectomy and the consideration of tubal stump ectopic pregnancies following IVF treatment.

Guideline No. 404: initial investigation and management of benign ovarian masses

To provide recommendations for a systematic approach to the initial investigation and management of a benign ovarian mass and facilitate patient referral to a gynaecologic oncologist for management.

Advances in MR Imaging of the Female Pelvis.

This article focuses on advanced MR imaging techniques of the female pelvis and clinical applications for benign and malignant disease. General and abbreviated protocols for female pelvic MR imaging are reviewed. Diffusion-weighted imaging, dynamic contrast-enhanced MR imaging, and susceptibility-weighted imaging are discussed in the context of adnexal mass characterization using the ADNEx-MR scoring system, evaluation of endometriosis, local staging of cervical and endometrial cancers, assessment of nodal and peritoneal metastasis, and potential detection of leiomyosarcoma. MR defecography is also discussed regarding evaluation of multicompartmental pelvic floor disorders.

Imaging of Benign Adnexal Disease.

This article provides an overview of the imaging evaluation of benign ovarian and adnexal masses in premenopausal and postmenopausal women and lesions discovered during pregnancy. Current imaging techniques are discussed, including pitfalls and differential diagnosis when necessary, as well as management. It also reviews the now well-established American College of Radiology (ACR)/Society of Radiologists in Ultrasound consensus guidelines and covers the more recently introduced Ovarian-Adnexal Reporting and Data System by the ACR and the recently published ADNEx Scoring System.

Imaging in gynecological disease (20): clinical and ultrasound characteristics of adnexal torsion.

OBJECTIVES: To describe the clinical and ultrasound characteristics of adnexal torsion. METHODS: This was a retrospective study. From the operative records of the eight participating gynecological ultrasound centers, we identified patients with a surgically confirmed diagnosis of adnexal torsion, defined as surgical evidence of ovarian pedicle, paraovarian cyst and/or Fallopian tube twisted on its own axis, who had undergone preoperative ultrasound examination by an experienced examiner, between 2008 and 2018. Only cases with at least two available ultrasound images and/or videoclips (one grayscale and one with Doppler evaluation) were included. Clinical, ultrasound, surgical and histological information was retrieved from each patient's medical record and entered into an Excel file by the principal investigator at each center. In addition, two authors reviewed all available ultrasound images and videoclips of the twisted adnexa, with regard to the presence of four predefined ultrasound features reported to be characteristic of adnexal torsion: (1) ovarian stromal edema with or without peripherally displaced antral follicles, (2) the follicular ring sign, (3) the whirlpool sign and (4) absence of vascularization in the twisted organ. RESULTS: A total of 315 cases of adnexal torsion were identified. The median age of the patients was 30 (range, 1-88) years. Most patients were premenopausal (284/314; 90.4%) and presented with acute or subacute pelvic pain (305/315; 96.8%). The surgical approach was laparoscopic in 239/312 (76.6%) patients and conservative surgery (untwisting with or without excision of a lesion) was performed in 149/315 (47.3%) cases. According to the original ultrasound reports, the median largest diameter of the twisted organ was 83 (range, 30-349) mm. Free fluid in the pouch of Douglas was detected in 196/275 (71.3%) patients. Ovarian stromal edema with or without peripherally displaced antral follicles was reported in the original ultrasound report in 167/241 (69.3%) patients, the whirlpool sign in 178/226 (78.8%) patients, absent color Doppler signals in the twisted organ in 119/269 (44.2%) patients and the follicular ring sign in 51/134 (38.1%) patients. On retrospective review of images and videoclips, ovarian stromal edema with or without peripherally displaced antral follicles (201/254; 79.1%) and the whirlpool sign (139/153; 90.8%) were the most commonly detected features of adnexal torsion. CONCLUSION: Most patients with surgically confirmed adnexal torsion are of reproductive age and present with acute or subacute pain. Common ultrasound signs are an enlarged adnexa, the whirlpool sign, ovarian stromal edema with or without peripherally displaced antral follicles and free fluid in the pelvis. The follicular ring sign and absence of Doppler signals in the twisted organ are slightly less common signs. Recognizing ultrasound signs of adnexal torsion is important so that the correct treatment, i.e. surgery without delay, can be offered. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.