O-RADS MRI risk stratification system: pearls and pitfalls.

In 2021, the American College of Radiology (ACR) Ovarian-Adnexal Reporting and Data System (O-RADS) MRI Committee developed a risk stratification system and lexicon for assessing adnexal lesions using MRI. Like the BI-RADS classification, O-RADS MRI provides a standardized language for communication between radiologists and clinicians. It is essential for radiologists to be familiar with the O-RADS algorithmic approach to avoid misclassifications. Training, like that offered by International Ovarian Tumor Analysis (IOTA), is essential to ensure accurate and consistent application of the O-RADS MRI system. Tools such as the O-RADS MRI calculator aim to ensure an algorithmic approach. This review highlights the key teaching points, pearls, and pitfalls when using the O-RADS MRI risk stratification system.Critical relevance statement This article highlights the pearls and pitfalls of using the O-RADS MRI scoring system in clinical practice.Key points• Solid tissue is described as displaying post- contrast enhancement.• Endosalpingeal folds, fimbriated end of the tube, smooth wall, or septa are not solid tissue.• Low-risk TIC has no shoulder or plateau. An intermediate-risk TIC has a shoulder and plateau, though the shoulder is less steep compared to outer myometrium.

O-RADS scoring system for adnexal lesions: Diagnostic performance on TVUS performed by an expert sonographer and MRI.

RATIONALE AND OBJECTIVE: To determine the diagnostic performance of transvaginal ultrasound (TVUS) performed by an US specialist and MRI based on the O-RADS scoring system. MATERIALS AND METHODS: Between March 5th 2013 and December 31st 2021, 227 patients, referred to our center, underwent TVUS and pelvic MRI for characterization of an adnexal lesion proven by surgery or two years of negative follow-up. All lesions were classified according to O-RADS US and O-RADS MRI risk scoring systems. Imaging data were then correlated with histopathological diagnosis or negative follow-up for 2 years. RESULTS: The prevalence of malignancy was 11.1%. Sensitivity of O-RADS US / O-RADS MRI were respectively of 83.3%/83.3% and specificity was 73.2%/92.9% (p < 0.001). O-RADS MRI was more accurate than O-RADS US even when performed by an US specialist (p < 0.001). When MRI was used after US, 51 lesions were reclassified correctly by MRI and only 4 lesions incorrectly reclassified. Most of the lesions (49/51) rated O-RADS US 4 or 5 and reclassified correctly by MRI were benign, mainly including cystadenomas or cystadenofibromas. Only 4 lesions were misclassified by MRI but correctly classified by ultrasound. CONCLUSION: Our study suggests that MR imaging has equally high sensitivity but higher specificity than TVUS for the characterization of adnexal lesions based on O-RADS scoring system. MRI should be the recommended second-line technique when a mass is discovered during TVUS and is rated O-RADS 4 and 5 over than TVUS by an US specialist.

Added Value of FDG PET/MRI in Gynecologic Oncology: A Pictorial Review.

Fluorine 18-fluorodeoxyglucose (FDG) PET and MRI independently play a valuable role in the management of patients with gynecologic malignancies, particularly endometrial and cervical cancer. The PET/MRI hybrid imaging technique combines the metabolic information obtained from PET with the excellent soft-tissue resolution and anatomic details provided by MRI in a single examination. MRI is the modality of choice for assessment of local tumor extent in the pelvis, whereas PET is used to assess for local-regional spread and distant metastases. The authors discuss the added value of FDG PET/MRI in imaging gynecologic malignancies of the pelvis, with a focus on the role of FDG PET/MRI in diagnosis, staging, assessing treatment response, and characterizing complications. PET/MRI allows better localization and demarcation of the extent of disease, characterization of lesions and involvement of adjacent organs and lymph nodes, and improved differentiation of benign from malignant tissues, as well as detection of the presence of distant metastasis. It also has the advantages of decreased radiation dose and a higher signal-to-noise ratio of a prolonged PET examination of the pelvis contemporaneous with MRI. The authors provide a brief technical overview of PET/MRI, highlight how simultaneously performed PET/MRI can improve stand-alone MRI and PET/CT in gynecologic malignancies, provide an image-rich review to illustrate practical and clinically relevant applications of this imaging technique, and review common pitfalls encountered in clinical practice. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Distribution of prostate specific membrane antigen (PSMA) on PET-MRI in patients with and without ovarian cancer.

OBJECTIVES: Ovarian cancer is the most lethal cancer and future research needs to focus on the early detection and exploration of new therapeutic agents. The objectives of this proof-of-concept study are to assess the feasibility of PSMA 18F-DCFPyl PET/MR imaging for detecting ovarian cancer and to evaluate the PSMA distribution in patients with and without ovarian cancer. METHODS: This prospective pilot proof-of-concept study in patients with and without ovarian cancers occurred between October 2017 and January 2020. Patients were recruited from gynecologic oncology or hereditary ovarian cancer clinics, and underwent surgical removal of the uterus and ovaries for gynecologic indications. PSMA 18F-DCFPyl PET/MRI was obtained prior to standard of care surgery. RESULTS: Fourteen patients were scanned: four patients with normal ovaries, six patients with benign ovarian lesions, and four patients with malignant ovarian lesions. Tracer uptake in normal ovaries (SUVmax = 2.8 ± 0.4) was greater than blood pool (SUVmax = 1.8 ± 0.5, p < 0.0001). Tracer uptake in benign ovarian lesions (2.2 ± 1.0) did not differ significantly from blood pool (p = 0.331). Tracer uptake in ovarian cancer (SUVmax = 7.8 ± 3.8) was greater than blood pool (p < 0.0001), normal ovaries (p = 0.0014), and benign ovarian lesions (p = 0.005). CONCLUSION: PET/MR imaging detected PSMA uptake in ovarian cancer, with little to no uptake in benign ovarian findings. These results are encouraging and further studies in a larger patient cohort would be useful to help determine the extent and heterogeneity of PSMA uptake in ovarian cancer patients.

Practical Tips for Reporting Adnexal Lesions Using O-RADS MRI.

The Ovarian-Adnexal Reporting and Data System (O-RADS) MRI risk stratification system provides a standardized lexicon and evidence-based risk score for evaluation of adnexal lesions. The goals of the lexicon and risk score are to improve report quality and communication between radiologists and clinicians, reduce variability in the reporting language, and optimize management of adnexal lesions. The O-RADS MRI risk score is based on the presence or absence of specific imaging features, including the lipid content, enhancing solid tissue, number of loculi, and fluid type. The probability of malignancy ranges from less than 0.5% when there are benign features to approximately 90% when there is solid tissue with a high-risk time-intensity curve. This information can aid in optimizing management of patients with adnexal lesions. The authors present an algorithmic approach to the O-RADS MRI risk stratification system and highlight key teaching points and common pitfalls. © RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Gynecologic oncology tumor board: the central role of the radiologist.

This manuscript is a collaborative, multi-institutional effort by members of the Society of Abdominal Radiology Uterine and Ovarian Cancer Disease Focus Panel and the European Society of Urogenital Radiology Women Pelvic Imaging working group. The manuscript reviews the key role radiologists play at tumor board and highlights key imaging findings that guide management decisions in patients with the most common gynecologic malignancies including ovarian cancer, cervical cancer, and endometrial cancer.

Adnexal Lesion Imaging: Past, Present, and Future.

Currently, imaging is part of the standard of care for patients with adnexal lesions prior to definitive management. Imaging can identify a physiologic finding or classic benign lesion that can be followed up conservatively. When one of these entities is not present, imaging is used to determine the probability of ovarian cancer prior to surgical consultation. Since the inclusion of imaging in the evaluation of adnexal lesions in the 1970s, the rate of surgery for benign lesions has decreased. More recently, data-driven Ovarian-Adnexal Reporting and Data System (O-RADS) scoring systems for US and MRI with standardized lexicons have been developed to allow for assignment of a cancer risk score, with the goal of further decreasing unnecessary interventions while expediting the care of patients with ovarian cancer. US is used as the initial modality for the assessment of adnexal lesions, while MRI is used when there is a clinical need for increased specificity and positive predictive value for the diagnosis of cancer. This article will review how the treatment of adnexal lesions has changed due to imaging over the decades; the current data supporting the use of US, CT, and MRI to determine the likelihood of cancer; and future directions of adnexal imaging for the early detection of ovarian cancer.

MR Imaging in Cervical Cancer: Initial Staging and Treatment.

Cervical cancer remains a significant contributor to morbidity and mortality for women globally despite medical advances in preventative medicine and treatment. The 2018 Internal Federation of Gynecology and Obstetrics committee modified their original 2009 staging scheme to incorporate advanced imaging modalities, where available, to increase the accuracy of staging and to guide evolving treatments. Having a robust understanding of the newest staging iteration, its consequences on treatment pathways, and common imaging pitfalls will aid the radiologist in generating valuable and practical reports to optimize treatment strategies.

PET/MRI in Gynecologic Malignancy.

Patients with gynecologic malignancies often require a multimodality imaging approach for initial staging, treatment response assessment, and surveillance. MRI imaging and PET are two well-established and widely accepted modalities in this setting. Although PET and MRI imaging are often acquired separately on two platforms (a PET/computed tomography [CT] and an MRI imaging scanner), hybrid PET/MRI scanners offer the potential for comprehensive disease assessment in one visit. Gynecologic malignancies have been one of the most successful areas for implementation of PET/MRI. This article provides an overview of the role of this platform in the care of patients with gynecologic malignancies.

Ferumoxytol-enhanced MR demonstration of changes to internal placental structure in placenta accreta spectrum: Preliminary findings.

INTRODUCTION: The goal of this pilot study is to determine if ferumoxytol-enhanced MR might provide a new approach to the diagnosis of placenta accreta spectrum (PAS), and if so, to identify signs of PAS. METHODS: Ten pregnant women were referred for MRI evaluation for PAS. MR studies consisted of pre-contrast SSFSE, SSFP, DWI, and ferumoxytol-enhanced sequences. Post-contrast images were rendered as MIP and MinIP images to separately display the maternal and fetal circulations respectively. Two readers examined the images for architectural changes to placentone (fetal cotyledon) that might distinguish PAS cases from normal. Attention was given to the size and morphology of the placentone, villous tree, and vascularity. In addition, the images were examined for evidence of fibrin/fibrinoid, intervillous thrombus, basal and chorionic plate bulges. Interobserver agreement was characterized with kappa coefficients and levels of confidence for feature identification was recorded on a 10-point scale. RESULTS: At delivery, there were five normal placentas and five with PAS (one accreta, two increta, two percreta). The ten changes of placental architecture in PAS included: focal/regional expansion of placentone(s); lateral displacement and compression of the villous tree; disruption of a regular pattern of normal placentones; bulging of the basal plate; bulging of the chorionic plate; transplacental stem villi; linear/nodular bands at basal plate; non-tapering villous branches; intervillous hemorrhage; and dilated subplacental vessels. All these changes were more common in PAS; the first five achieved statistical significance in this small sample. The interobserver agreement and confidence for the identification of these features was good to excellent except for dilated subplacental vessels. DISCUSSION: Ferumoxytol-enhanced MR imaging appears to depict derangements of the internal architecture of placentas with PAS, thereby suggesting a promising new strategy to diagnose PAS.

Placenta accreta spectrum: the pattern and character of intraplacental blood flow by color and spectral Doppler.

PURPOSE: To characterize intraplacental blood flow patterns in placenta accreta spectrum (PAS) with color and spectral Doppler imaging. METHODS: Thirty-two patients at risk for PAS underwent ultrasound imaging with both color and spectral Doppler. The placenta was inspected for areas of vascularity by color Doppler, particularly within the lower uterine segment. Spectral Doppler waveforms were obtained from these vessels and categorized as either intraplacental or subplacental (myometrial), venous or arterial, fetal or maternal (based on heart rate). Arterial waveforms were measured for heart rate, peak systolic velocity, end diastolic velocity, and resistive index. Statistical comparisons were made between cases with and without PAS using Fisher exact tests (categorical variables) and Mann-Whitney U tests (numerical indices). Interobserver agreement was characterized with kappa coefficients. RESULTS: At delivery, there were 19 cases with PAS and 13 without PAS. On ultrasound studies, clustered intraplacental vascularity was found in the lower uterine segment in 66% of cases (95% of PAS cases and 23% cases without PAS; p < 0.0001). Maternal arterial waveforms were found within the vascular cluster in 84% of PAS cases and 15% of cases without PAS (p < 0.0001). A traversing fetal artery was found within the vascular cluster in 56% of cases (84% PAS cases and 15% cases without PAS; p = 0.001). Venous waveforms were found in 84% of PAS cases and 15% of cases without PAS. Interobserver agreement was good to excellent. CONCLUSION: Intraplacental blood flow pattern in PAS is characterized by an intraplacental vascular cluster containing low-resistance maternal arterial flow and transplacental fetal arteries.

O-RADS MRI After Initial Ultrasound for Adnexal Lesions: AJR Expert Panel Narrative Review.

The Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound (US) and MRI risk stratification systems were developed by an international group of experts in adnexal imaging to aid radiologists in assessing adnexal lesions. The goal of imaging is to appropriately triage patients with adnexal lesions. US is the first-line imaging modality for assessment, whereas MRI can be used as a problem-solving tool. Both US and MRI can accurately characterize benign lesions such as simple cysts, endometriomas, hemorrhagic cysts, and dermoid cysts, avoiding unnecessary or inappropriate surgery. In patients with a lesion that does not meet criteria for one of these benign diagnoses, MRI can further characterize the lesion with an improved specificity for cancer and the ability to provide a probable histologic subtype in the presence of certain MRI features. This allows personalized treatment, including avoiding overly extensive surgery or allowing fertility-sparing procedures for suspected benign, borderline, or low-grade tumors. When MRI findings indicate a risk of an invasive cancer, patients can be expeditiously referred to a gynecologic oncologic surgeon. This narrative review provides expert opinion on the utility of multiparametric MRI when using the O-RADS US and MRI management systems.

Surgical outcomes of adnexal masses classified by IOTA ultrasound simple rules.

IOTA (International Ovarian Tumor Analysis) Simple Rules classifies adnexal masses as benign, malignant, or indeterminate based on sonographic features. We seek to determine if IOTA inappropriately directed women to surgery, or more aggressive surgery, than their final diagnosis warranted. This is a retrospective study of sonographically detected adnexal masses with known clinical outcomes from two institutions (n = 528). Surgically managed patients (n = 172) were categorized based on pathology and compared using Chi-square and t-test for categorical and continuous variables respectively. A logistic regression was used to predict characteristics that predicted surgery or imaging follow up of indeterminate masses. Of the 528 masses imaged, 29% (n = 155) underwent surgery for benign pathology. Only 1.9% (n = 10) underwent surgery after classification as malignant by IOTA for what was ultimately a benign mass. Surgical complications occurred in 10 cases (5.8%), all benign. Fifteen (3.2%) patients went into surgically induced menopause for benign masses, one of which was inaccurately classified by IOTA as malignant. Of the 41 IOTA indeterminate masses, the presence of soft tissue nodules on ultrasound was the only statistically significant predictor of the patient being triaged directly to surgery (OR 1.79, p = 0.04). Our findings support that the IOTA ultrasound classification system can provide clinical guidance without incurring unnecessary surgeries or surgical complications.

Update on MRI in Evaluation and Treatment of Endometrial Cancer.

Endometrial cancer is the second most common gynecologic cancer worldwide and the most common gynecologic cancer in the United States, with an increasing incidence in high-income countries. Although the International Federation of Gynecology and Obstetrics (FIGO) staging system for endometrial cancer is a surgical staging system, contemporary published evidence-based data and expert opinions recommend MRI for treatment planning as it provides critical diagnostic information on tumor size and depth, extent of myometrial and cervical invasion, extrauterine extent, and lymph node status, all of which are essential in choosing the most appropriate therapy. Multiparametric MRI using a combination of T2-weighted sequences, diffusion-weighted imaging, and multiphase contrast-enhanced imaging is the mainstay for imaging assessment of endometrial cancer. Identification of important prognostic factors at MRI improves both treatment selection and posttreatment follow-up. MRI also plays a crucial role for fertility-preserving strategies and in patients who are not surgical candidates by helping guide therapy and identify procedural complications. This review is a product of the Society of Abdominal Radiology Uterine and Ovarian Cancer Disease-Focused Panel and reflects a multidisciplinary international collaborative effort to summarize updated information highlighting the role of MRI for endometrial cancer depiction and delineation, treatment planning, and follow-up. The article includes information regarding dedicated MRI protocols, tips for MRI reporting, imaging pitfalls, and strategies for image quality optimization. The roles of MRI-guided radiation therapy, hybrid PET/MRI, and advanced MRI techniques that are applicable to endometrial cancer imaging are also discussed. Online supplemental material is available for this article. ©RSNA, 2022.

Contemporary image-guided cervical cancer brachytherapy: Consensus imaging recommendations from the Society of Abdominal Radiology and the American Brachytherapy Society.

PURPOSE: To present recommendations for the use of imaging for evaluation and procedural guidance of brachytherapy for cervical cancer patients. METHODS: An expert panel comprised of members of the Society of Abdominal Radiology Uterine and Ovarian Cancer Disease Focused Panel and the American Brachytherapy Society jointly assessed the existing literature and provide data-driven guidance on imaging protocol development, interpretation, and reporting. RESULTS: Image-guidance during applicator implantation reduces rates of uterine perforation by the tandem. Postimplant images may be acquired with radiography, computed tomography (CT), or magnetic resonance imaging (MRI), and CT or MRI are preferred due to a decrease in severe complications. Pre-brachytherapy T2-weighted MRI may be used as a reference for contouring the high-risk clinical target volume (HR-CTV) when CT is used for treatment planning. Reference CT and MRI protocols are provided for reference. CONCLUSIONS: Image-guided brachytherapy in locally advanced cervical cancer is essential for optimal patient management. Various imaging modalities, including orthogonal radiographs, ultrasound, computed tomography, and magnetic resonance imaging, remain integral to the successful execution of image-guided brachytherapy.

Diagnostic Performance of the Ovarian-Adnexal Reporting and Data System (O-RADS) Ultrasound Risk Score in Women in the United States.

Importance: The American College of Radiology (ACR) Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound (US) risk scoring system has been studied in a selected population of women referred for suspected or known adnexal lesions. This population has a higher frequency of malignant neoplasms than women presenting to radiology departments for pelvic ultrasonography for a variety of indications, potentially impacting the diagnostic performance of the risk scoring system. Objective: To evaluate the risk of malignant neoplasm and diagnostic performance of O-RADS US risk scoring system in a multi-institutional, nonselected cohort. Design, Setting, and Participants: This multi-institutional cohort study included a population of nonselected women in the United States who presented to radiology departments for routine pelvic ultrasonography between 2011 and 2014, with pathology confirmation imaging follow up or 2 years of clinical follow up. Exposure: Analysis of 1014 adnexal lesions using the O-RADS US risk stratification system. Main Outcomes and Measures: Frequency of ovarian cancer and diagnostic performance of the O-RADS US risk stratification system. Results: This study included 913 women with 1014 adnexal lesions. The mean (SD) age of the patients was 42.4 (13.9 years), and 674 of 913 (73.8%) were premenopausal. The overall frequency of malignant neoplasm was 8.4% (85 of 1014 adnexal lesions). The frequency of malignant neoplasm for O-RADS US 2 was 0.5% (3 of 657 lesions; <1% expected); O-RADS US 3, 4.5% (5 of 112 lesions; <10% expected); O-RADS US 4, 11.6% (18 of 155; 10%-50% expected); and O-RADS 5, 65.6% (59 of 90 lesions; >50% expected). O-RADS US 4 was the optimum cutoff for diagnosing cancer with sensitivity of 90.6% (95% CI, 82.3%-95.9%), specificity of 81.9% (95% CI, 79.3%-84.3%), positive predictive value of 31.4% (95% CI, 25.7%-37.7%) and negative predictive value of 99.0% (95% CI, 98.0%-99.6%). Conclusions and Relevance: In this cohort study of a nonselected patient population, the O-RADS US risk stratification system performed within the expected range as published by the ACR O-RADS US committee. The frequency of malignant neoplasm was at the lower end of the published range, partially because of the lower prevalence of cancer in a nonselected population. However, a high negative predictive value was maintained, and when a lesion can be classified as an O-RADS US 2, the risk of cancer is low, which is reassuring for both clinician and patient.

ACR Appropriateness Criteria® Newly Diagnosed Palpable Scrotal Abnormality.

Palpable scrotal abnormalities are caused by a variety of disorders, ranging from indolent benign conditions to aggressive tumors, and infectious and vascular processes. In these patients the diagnostic workup typically begins with a complete clinical, history, and physical examinations, including analysis of risk factors. If imaging is required, ultrasound examination is the diagnostic modality of choice. In few select patients with very large scrotal masses, MRI may be appropriate. However, the use of gadolinium-based contrast should be evaluated critically depending on specific patient factors. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Pelvic Floor Dysfunction in Females.

Pelvic floor disorders including pelvic organ prolapse (POP), urinary dysfunction, defecatory dysfunction, and complications after pelvic floor surgery are relatively common in the female population. Imaging tests are obtained when the initial clinical evaluation is thought to be incomplete or inconclusive or demonstrates findings that are discordant with patients' symptoms. An integrated imaging approach is optimal to evaluate the complex anatomy and dynamic functionality of the pelvic floor. Fluoroscopic cystocolpoproctography (CCP) and MR defecography are considered the initial imaging tests of choice for evaluation of POP. Fluoroscopic voiding cystourethrography is considered the initial imaging test for patients with urinary dysfunction. Fluoroscopic CCP and MR defecography are considered the initial imaging test for patients with defecatory dysfunction, whereas ultrasound pelvis transrectal is a complementary test in patients requiring evaluation for anal sphincter defects. MRI pelvis without and with intravenous contrast, MRI pelvis with dynamic maneuvers, and MR defecography are considered the initial imaging tests in patients with suspected complications of prior pelvic floor surgical repair. Transperineal ultrasound is emerging as an important imaging tool, in particular for screening of pelvic floor dysfunction and for evaluation of midurethral slings, vaginal mesh, and complications related to prior pelvic floor surgical repair. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Gender and racial diversity among plenary session speakers at the Society of Abdominal Radiology Annual Meetings: a five-year assessment.

PURPOSE: To evaluate the gender and racial diversity of plenary session speakers in the annual meetings of Society of Abdominal Radiology (SAR) over 2016 to 2020. MATERIALS AND METHODS: The brochures of the SAR annual meetings were reviewed for plenary session speakers and titles. Publicly available institutional profiles and social media were reviewed by the investigator in order to infer gender and race. Gender assessments were men, women, transgender men, transgender women or gender non-binary. Race was classified as White, Black or African American, American Indians and Alaskan Natives, Asian, Native Hawaiian and Pacific Islander and Multiracial. Statistical analysis was performed using chi square and T-tests. RESULTS: Based on self-reported data, the SAR has 64% male and 36% female members. Over 2016-2020, plenary session speakers were more likely to be men [69.6% (183/263)] than women [30.4% (80/263)] (p-value = 0.0007). No speakers could be reliably identified as transgender, gender non-binary or gender expansive. In 2016, there were 24% women plenary speakers. This proportion was 28% in 2017, 33% in 2018 and 36% in 2019, and 30% in 2020. When assessing racial distribution, white speakers accounted for the majority of plenary speakers, ranging from 61 to 78%. Asians speakers accounted for 22 to 35%. There were no Black and African American, American Indian & Alaskan Native, Native Hawaiian & Pacific Islander plenary speakers (0%). Multiracial speakers were represented from 2018 to 2020, accounting for 2-4% speakers (p-value < 0.0001). CONCLUSIONS: Plenary speakers at SAR Annual Meetings from 2016-2020 were more likely to be men, but with the proportion of women presenters increasing over time. White speakers represented the majority of plenary session speakers, followed by Asians. No plenary session speakers were identified as Black or African American or Native Americans.