Endometriosis is a common gynaecological condition of unknown aetiology that primarily affects women of reproductive age. The accepted first-line imaging modality is pelvic ultrasound. However, magnetic resonance imaging (MRI) is increasingly performed as an additional investigation in complex cases and for surgical planning. There is currently no international consensus regarding patient preparation, MRI protocols or reporting criteria. Our aim was to develop clinical guidelines for MRI evaluation of pelvic endometriosis based on literature evidence and consensus expert opinion. This work was performed by a group of radiologists from the European Society of Urogenital Radiology (ESUR), experts in gynaecological imaging and a gynaecologist expert in methodology. The group discussed indications for MRI, technical requirements, patient preparation, MRI protocols and criteria for the diagnosis of pelvic endometriosis on MRI. The expert panel proposed a final recommendation for each criterion using Oxford Centre for Evidence Based Medicine (OCEBM) 2011 levels of evidence. Key Points • This report provides guidelines for MRI in endometriosis. • Minimal and optimal MRI acquisition protocols are provided. • Recommendations are proposed for patient preparation, best MRI sequences and reporting criteria.

Adnexal masses are common, resulting in a significant clinical workload related to diagnostic imaging, surgery, and pathology.^1,2 Most adnexal masses are benign, and most masses can be accurately categorized as benign or malignant on ultrasonography.^3,4 However, between 18% and 31% of adnexal masses remain indeterminate following ultrasonography using International Ovarian Tumor Analysis (IOTA) Simple Rules or other ultrasonography scoring systems.^3,4 Moreover, this prevalence may be an underestimation, given that many studies only report the cases with available surgical reference standards.⁴ There are very limited data on patients who undergo only imaging and clinical follow-up. In a prospective external validation of the IOTA Simple Rules⁵ among 666 women, 362 women (54.4%) underwent surgery, 309 of whom (85.4%) had benign masses. The authors reported that, among 304 patients (45.6%) who underwent expectant management, 71 patients (23.4%) experienced disappearance of the mass, and 233 (76.6%) had a persistent mass on imaging follow-up that was considered benign after 1 year of follow-up.

The Ovarian-Adnexal Reporting and Data System MRI risk score is a stratification system for assigning malignancy probability to adnexal lesions and can improve communication between radiologists an... MRI plays an important role as a secondary test or problem-solving modality in the evaluation of adnexal lesions depicted at US. MRI has increased specificity compared with US, decreasing the numbe...

To retrospectively evaluate the diagnostic performance of dynamic contrast material-enhanced magnetic resonance (MR) imaging for the characterization of ovarian epithelial tumors, by using histologic findings as the reference standard, and to correlate dynamic contrast-enhanced MR imaging findings with angiogenesis biomarkers. Ethics committee approval was obtained, with waiver of informed consent. Patients consented to having their data used for future retrospective research. Forty-one women (age range, 22-73 years) with 48 epithelial ovarian tumors underwent dynamic contrast-enhanced MR imaging before surgical excision. In case of bilateral tumors (n = 7), only the most complex tumor was analyzed. Thus, 41 tumors (12 benign, 13 borderline, and 16 invasive) were examined with dynamic contrast-enhanced MR imaging and immunohistochemical methods. Dynamic contrast-enhanced MR imaging parameters (enhancement amplitude [EA], time of half rising [T(max)], and maximal slope [MS]) were analyzed according to histopathologic findings, microvessel density, pericyte coverage index (PCI), and vascular endothelial growth factor receptor 2 (VEGFR-2) expression. Statistical analyses were performed by using Kruskal-Wallis, Fisher exact, and Spearman tests and receiver operating curve analysis. EA was higher for invasive tumors than for benign (P < .001) and borderline (P < .05) tumors. T(max) was longer for benign tumors than for borderline (P < .05) and invasive (P < .01) tumors. MS was steeper for invasive tumors than for benign (P < .001) and borderline (P < .001) tumors. PCI was lower in invasive tumors than in borderline (P < .05) and benign (P < .05) tumors. Microvessels showed stronger immunohistochemical VEGFR-2 expression in invasive tumors than in benign or borderline tumors (P < .05). MS correlated with a lower PCI (r = -0.34, P = .04) and stronger VEGFR-2 expression by using both epithelial (r = 0.41, P < .01) and endothelial (r = 0.66, P < .001) cells. The early enhancement patterns of ovarian epithelial tumors on dynamic contrast-enhanced MR images can help distinguish among benign, borderline, and invasive tumors and were found to correlate with tumoral angiogenic status.

We summarise here the information to be provided to women and referring physicians about percutaneous breast biopsy and lesion localisation under imaging guidance. After explaining why a preoperative diagnosis with a percutaneous biopsy is preferred to surgical biopsy, we illustrate the criteria used by radiologists for choosing the most appropriate combination of device type for sampling and imaging technique for guidance. Then, we describe the commonly used devices, from fine-needle sampling to tissue biopsy with larger needles, namely core needle biopsy and vacuum-assisted biopsy, and how mammography, digital breast tomosynthesis, ultrasound, or magnetic resonance imaging work for targeting the lesion for sampling or localisation. The differences among the techniques available for localisation (carbon marking, metallic wire, radiotracer injection, radioactive seed, and magnetic seed localisation) are illustrated. Type and rate of possible complications are described and the issue of concomitant antiplatelet or anticoagulant therapy is also addressed. The importance of pathological-radiological correlation is highlighted: when evaluating the results of any needle sampling, the radiologist must check the concordance between the cytology/pathology report of the sample and the radiological appearance of the biopsied lesion. We recommend that special attention is paid to a proper and tactful approach when communicating to the woman the need for tissue sampling as well as the possibility of cancer diagnosis, repeat tissue sampling, and or even surgery when tissue sampling shows a lesion with uncertain malignant potential (also referred to as “high-risk” or B3 lesions). Finally, seven frequently asked questions are answered.

Our study has demonstrated the added value of using diffusion- and perfusion-weighted MR imaging in combination with conventional MR imaging to improve the characterization of complex adnexal masses; With use of a recursive partitioning model, MR imaging criteria led to the correct assessment of the nature of adnexal masses with a high degree of accuracy. PurposeTo retrospectively determine the value of adding perfusion-weighted (PW) and diffusion-weighted (DW) sequences to a conventional magnetic resonance (MR) imaging protocol to differentiate benign from malignant tumors.Materials and MethodsThe institutional ethics committee approved this retrospective study and waived the requirement to obtain informed consent. MR images in 87 women (age range, 25–87 years) who underwent imaging before surgery for complex adnexal masses—excluding endometriomas and cystic teratomas—were analyzed. Conventional morphologic, perfusion, and diffusion MR criteria of malignancy were recorded. Three independent observers reviewed images in four steps: conventional MR images alone, conventional MR images and PW images combined, conventional MR images and DW images combined, and conventional, PW, and DW MR images combined. Receiver operating characteristic curve analysis was performed to compare the results of the readings. A recursive partitioning model was built to establish ...