O-RADS MRI classification of indeterminate adnexal lesions: time-intensity curve analysis is better than visual assessment

Background The MRI Ovarian-Adnexal Reporting and Data System (O-RADS) enables risk stratification of sonographically indeterminate adnexal lesions, partly based on time-intensity curve (TIC) analysis, which may not be universally available. Purpose To compare the diagnostic accuracy of visual assessment with that of TIC assessment of dynamic contrast-enhanced MRI scans to categorize adnexal lesions as benign or malignant and to evaluate the influence on the O-RADS MRI score. Materials and Methods The European Adnex MR Study Group, or EURAD, database, a prospective multicenter study of women undergoing MRI for indeterminate adnexal lesions between March 2013 and March 2018, was queried retrospectively. Women undergoing surgery for an adnexal lesion with solid tissue were included. Solid tissue enhancement relative to outer myometrium was assessed visually and with TIC. Contrast material washout was recorded. Lesions were categorized according to the O-RADS MRI score with visual and TIC assessment. Per-lesion diagnostic accuracy was calculated. Results A total of 320 lesions (207 malignant, 113 benign) in 244 women (mean age, 55.3 years ± 15.8 [standard deviation]) were analyzed. Sensitivity for malignancy was 96% (198 of 207) and 76% (157 of 207) for TIC and visual assessment, respectively. TIC was more accurate than visual assessment (86% [95% CI: 81, 90] vs 78% [95% CI: 73, 82]; P < .001) for benign lesions, predominantly because of higher specificity (95% [95% CI: 92, 98] vs 76% [95% CI: 68, 81]). A total of 21% (38 of 177) of invasive lesions were rated as low risk visually. Contrast material washout and high-risk enhancement (defined as earlier enhancement than in the myometrium) were highly specific for malignancy for both TIC (97% [95% CI: 91, 99] and 94% [95% CI: 90, 97], respectively) and visual assessment (97% [95% CI: 92, 99] and 93% [95% CI: 88, 97], respectively). O-RADS MRI score was more accurate with TIC than with visual assessment (area under the receiver operating characteristic curve, 0.87 [95% CI: 0.83, 0.90] vs 0.73 [95% CI: 0.68, 0.78]; P < .001). Conclusion Time-intensity curve analysis was more accurate than visual assessment for achieving optimal diagnostic accuracy with the Ovarian-Adnexal Reporting and Data System MRI score. Clinical trial registration no. NCT01738789 © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Vargas and Woo in this issue