Apparent diffusion coefficient analysis of solid tissue helps distinguish borderline from invasive malignant adnexal masses rated O-RADS MRI 4.

PURPOSE: The purpose of this study was to evaluate the contribution of apparent diffusion coefficient (ADC) analysis of the solid tissue of adnexal masses to optimize tumor characterization and possibly refine the risk stratification of the O-RADS MRI 4 category. MATERIALS AND METHODS: The EURAD cohort was retrospectively analyzed to select all patients with an adnexal mass with solid tissue and feasible ADC measurements. Two radiologists independently measured the ADC values of solid tissue, excluding necrotic areas, surrounding structures, and magnetic susceptibility artifacts. Significant differences in diffusion quantitative parameters in the overall population and according to the morphological aspect of solid tissue were analyzed to identify its impact on ADC reliability. Receiver operating characteristics curve (ROC) was used to determine the optimum cutoff of the ADC for distinguishing invasive from non-invasive tumors in the O-RADS MRI score 4 population. RESULTS: The final study population included 180 women with a mean age of 57 ± 15.5 (standard deviation) years; age range: 19-95 years) with 93 benign, 23 borderline, and 137 malignant masses. The median ADC values of solid tissue was greater in borderline masses (1.310 × 10-3 mm2/s (Q1, Q3: 1.152, 1.560 × 10-3 mm2/s) than in benign masses (1.035 × 10-3 mm2/s; Q1, Q3: 0.900, 1.560 × 10-3 mm2/s) (P= 0.002) and in benign tumors compared by comparison with invasive masses (0.850 × 10-3 mm2/s; Q1, Q3: 0.750, 0.990 × 10-3 mm2/s) (P < 0.001). Solid tissue corresponded to irregular septa or papillary projection in 18.6% (47/253), to a mural nodule or a mixed mass in 46.2% (117/253), and to a purely solid mass in 35.2% (89/253) of adnexal masses. In mixed masses or masses with mural nodule subgroup, invasive masses had a significantly lower ADC (0.830 × 10-3 mm2/s (Q1, Q3: 0.738, 0.960) than borderline (1.385; Q1, Q3: 1.300, 1.930) (P= 0.0012) and benign masses (P= 0.04). An ADC cutoff of 1.08 × 10-3 mm2/s yielded 71.4% sensitivity and 100% specificity for identifying invasive lesions in the mixed or mural nodule subgroup with an AUC of 0.92 (95% confidence interval: 0.76-0.99). CONCLUSION: ADC analysis of solid tissue of adnexal masses could help distinguish invasive masses within the O-RADS MRI 4 category, especially in mixed masses or those with mural nodule.

Surgical and Percutaneous Image-guided Therapies of Abdominal Wall Endometriosis: a Systematic Review of Current Evidence.

OBJECTIVE: Despite various surgical and non-surgical strategies for abdominal wall endometriosis, the lack of definitive guidance on optimal treatment choice leads to clinical uncertainty. This review scrutinizes the safety and efficacy of abdominal wall endometriosis treatments to aid in decision-making. DATA SOURCES: We performed a systematic literature review of PubMed, Embase and Cochrane Library databases from 1947 until December 2023. METHODS OF STUDY SELECTION: A comprehensive literature search identified studies that assessed both surgical and nonsurgical interventions, including high-intensity focused ultrasound (HIFU), cryoablation, radiofrequency ablation (RFA), and microwave ablation (MWA). This review is registered in NIHR-PROSPERO (CRD 42023494969). Local tumor control (LTC), local pain relief (LPR) and adverse events (AE) were recorded. TABULATION, INTEGRATION, AND RESULTS: This review included 51 articles among 831 identified. All study designs were considered eligible for inclusion. A total of 2,674 patients are included: 2,219 patients (83%) undergoing surgery, and 455 (17%) undergoing percutaneous interventions (342 HIFU, 103 cryoablation, 1 RFA, 9 MWA). Follow-up length was 18 months in median, ranging from 1 to 235 months. Overall LTC rates ranged from 86% to 100%. Surgical interventions consistently demonstrated the highest rate of LTC with a median rate of 100%, and LPR with a median rate of 98.2% (95% confidence interval [CI]: 93.9-97.7). HIFU showed median LTC and LPR rates, respectively of 95.65% (95% CI, 87.7-99.9) and 76.1% (95% CI, 61.8-90.4); and cryoablation of 85.7% (95% CI, 66.0-99.9) and 79.2% (95% CI, 67.4-91.03). Minor AE were reported after surgery in 17.5% of patients (225/1284) including 15.9% (199/1284) of mesh implantation; 76.4% (239/313) after HIFU; and 8.7 % (9/103) after cryoablation. Severe AE were reported in 25 patients in the surgery group and 1 in the percutaneous group. CONCLUSION: The safety profile and efficacy of nonsurgical interventions support their clinical utility for management of abdominal wall endometriosis.

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.

Reasons why it is time to change imaging guidelines on endometriosis.

In light of the rising number of patients referred for magnetic resonance imaging (MRI) due to suspected endometriosis and the high expectations of these patients, there is a need for new imaging guidelines to optimally protocol and indicate MRI and transvaginal ultrasonography (TVUS) examinations. This is crucial for accurately addressing the inquiries of gynecologists, encompassing complete mapping and preoperative staging, and facilitating effective communication with patients. In this context, the development of a standardized lexicon, as well as dedicated imaging classifications, is recommended to aid in the comprehensive management of patients. CLINICAL RELEVANCE STATEMENT: The radiologist should use a standardized lexicon and provide a score along with details about the specific compartments affected by endometriosis disease. This helps in offering clearer guidance to the surgeon. KEY POINTS: • An optimal staging is based on the combination of clinical examination, transvaginal US, and MRI. • MRI is able to detect location that is hidden at the beginning of a laparoscopic surgery and thus the need for dedicated MR classifications to correctly stage the disease. • Deep pelvic endometriosis index (dPEI) classification is externally validated and highly correlated with operating time, hospital stay, and postoperative complications.

Endometriosis MR mimickers: T2-hypointense lesions.

Endometriosis is a common crippling disease in women of reproductive age. Magnetic resonance imaging (MRI) is considered the cornerstone radiological technique for both the diagnosis and management of endometriosis. While its sensitivity, especially in deep infiltrating endometriosis, is superior to that of ultrasonography, many sources of false-positive results exist, leading to a lack of specificity. Hypointense lesions or pseudo-lesions on T2-weighted images include anatomical variants, fibrous connective tissues, benign and malignant tumors, feces, surgical materials, and post treatment scars which may mimic deep pelvic infiltrating endometriosis. False positives can have a major impact on patient management, from diagnosis to medical or surgical treatment. This educational review aims to help the radiologist acknowledge MRI criteria, pitfalls, and the differential diagnosis of deep pelvic infiltrating endometriosis to reduce false-positive results. Critical relevance statement MRI in deep infiltrating endometriosis has a 23% false-positive rate, leading to misdiagnosis. T2-hypointense lesions primarily result from anatomical variations, fibrous connective tissue, benign and malignant tumors, feces, surgical material, and post-treatment scars. Key points • MRI in DIE has a 23% false-positive rate, leading to potential misdiagnosis.• Anatomical variations, fibrous connective tissues, neoplasms, and surgical alterations are the main sources of T2-hypointense mimickers.• Multisequence interpretation, morphologic assessment, and precise anatomic localization are crucial to prevent overdiagnosis.• Gadolinium injection is beneficial for assessing endometriosis differential diagnosis only in specific conditions.

O-RADS MRI scoring system has the potential to reduce the frequency of avoidable adnexal surgery.

OBJECTIVE: To assess the potential impact of the O-RADS MRI score on the decision-making process for the management of adnexal masses. METHODS: EURAD database (prospective, European observational, multicenter study) was queried to identify asymptomatic women without history of infertility included between March 1st and March 31st 2018, with available surgical pathology or clinical findings at 2-year clinical follow-up. Blinded to final diagnosis, we stratified patients into five categories according to the O-RADS MRI score (absent i.e. non adnexal, benign, probably benign, indeterminate, probably malignant). Prospective management was compared to theoretical management according to the score established as following: those with presumed benign masses (scored O-RADS MRI 2 or 3) (follow-up recommended) and those with presumed malignant masses (scored O-RADS MRI 4 or 5) (surgery recommended). RESULTS: The accuracy of the score for assessing the origin of the mass was of 97.2 % (564/580, CI95% 0.96-0.98) and was of 92.0 % (484/526) for categorizing lesions with a negative predictive value of 98.1 % (415/423, CI95% 0.96-0.99). Theoretical management using the score would have spared surgery in 229 patients (87.1 %, 229/263) with benign lesions and malignancy would have been missed in 6 borderline and 2 invasive cases. In patients with a presumed benign mass using O-RADS MRI score, recommending surgery for lesions >= 100 mm would miss only 4/77 (4.8 %) malignant adnexal tumors instead of 8 (50 % decrease). CONCLUSION: The use of O-RADS MRI scoring system could drastically reduce the number of asymptomatic patients undergoing avoidable surgery.

O-RADS MRI to classify adnexal tumors: from clinical problem to daily use.

Eighteen to 35% of adnexal masses remain non-classified following ultrasonography, leading to unnecessary surgeries and inappropriate management. This finding led to the conclusion that ultrasonography was insufficient to accurately assess adnexal masses and that a standardized MRI criteria could improve these patients' management. The aim of this work is to present the different steps from the identification of the clinical issue to the daily use of a score and its inclusion in the latest international guidelines. The different steps were the following: (1) preliminary work to formalize the issue, (2) physiopathological analysis and finding dynamic parameters relevant to increase MRI performances, (3) construction and internal validation of a score to predict the nature of the lesion, (4) external multicentric validation (the EURAD study) of the score named O-RADS MRI, and (5) communication and education work to spread its use and inclusion in guidelines. Future steps will include studies at patients' levels and a cost-efficiency analysis. Critical relevance statement We present translating radiological research into a clinical application based on a step-by-step structured and systematic approach methodology to validate MR imaging for the characterization of adnexal mass with the ultimate step of incorporation in the latest worldwide guidelines of the O-RADS MRI reporting system that allows to distinguish benign from malignant ovarian masses with a sensitivity and specificity higher than 90%. Key points • The initial diagnostic test accuracy studies show the limitation of a preoperative assessment of adnexal masses using solely ultrasonography.• The technical developments (DCE/DWI) were investigated with the value of dynamic MRI to accurately predict the nature of benign or malignant lesions to improve management.• The first developing score named ADNEX MR Score was constructed using multiple easily assessed criteria on MRI to classify indeterminate adnexal lesions following ultrasonography.• The multicentric adnexal study externally validated the score creating the O-RADS MR score and leading to its inclusion for daily use in international guidelines.

Endometriosis MR mimickers: T1-hyperintense lesions.

Endometriosis is a chronic and disabling gynecological disease that affects women of reproductive age. Magnetic resonance imaging (MRI) is considered the cornerstone radiological technique for both the diagnosis and management of endometriosis. While MRI offers higher sensitivity compared to ultrasonography, it is prone to false-positive results, leading to decreased specificity. False-positive findings can arise from various T1-hyperintense conditions on fat-suppressed T1-weighted images, resembling endometriotic cystic lesions in different anatomical compartments. These conditions include hemorrhage, hyperproteic content, MRI artifacts, feces, or melanin. Such false positives can have significant implications for patient care, ranging from incorrect diagnoses to unnecessary medical or surgical interventions and subsequent follow-up. To address these challenges, this educational review aims to provide radiologists with comprehensive knowledge about MRI criteria, potential pitfalls, and differential diagnoses, ultimately reducing false-positive results related to T1-hyperintense abnormalities.Critical relevance statementMRI has a 10% false-positive rate, leading to misdiagnosis. T1-hyperintense lesions, observed in the three phenotypes of pelvic endometriosis, can also be seen in various other causes, mainly caused by hemorrhages, high protein concentrations, and artifacts.Key points• MRI in endometriosis has a 10% false-positive rate, leading to potential misdiagnosis.• Pelvic endometriosis lesions can exhibit T1-hyperintensity across their three phenotypes.• A definitive diagnosis of a T1-hyperintense endometriotic lesion is crucial for patient management.• Hemorrhages, high protein concentrations, lipids, and artifacts are the main sources of T1-hyperintense mimickers.

French community grid for the evaluation of radiological artificial intelligence solutions (DRIM France Artificial Intelligence Initiative).

PURPOSE: The purpose of this study was to validate a national descriptive and analytical grid for artificial intelligence (AI) solutions in radiology. MATERIALS AND METHODS: The RAND-UCLA Appropriateness Method was chosen by expert radiologists from the DRIM France IA group for this statement paper. The study, initiated by the radiology community, involved seven steps including literature review, template development, panel selection, pre-panel meeting survey, data extraction and analysis, second and final panel meeting, and data reporting. RESULTS: The panel consisted of seven software vendors, three for bone fracture detection using conventional radiology and four for breast cancer detection using mammography. A consensus was reached on various aspects, including general target, main objective, certification marking, integration, expression of results, forensic aspects and cybersecurity, performance and scientific validation, description of the company and economic details, possible usage scenarios in the clinical workflow, database, specific objectives and targets of the AI tool. CONCLUSION: The study validates a descriptive and analytical grid for radiological AI solutions consisting of ten items, using breast cancer and bone fracture as an experimental guide. This grid would assist radiologists in selecting relevant and validated AI solutions. Further developments of the grid are needed to include other organs and tasks.

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.

European Society of Breast Imaging (EUSOBI) guidelines on the management of axillary lymphadenopathy after COVID-19 vaccination: 2023 revision.

Axillary lymphadenopathy is a common side effect of COVID-19 vaccination, leading to increased imaging-detected asymptomatic and symptomatic unilateral axillary lymphadenopathy. This has threatened to negatively impact the workflow of breast imaging services, leading to the release of ten recommendations by the European Society of Breast Imaging (EUSOBI) in August 2021. Considering the rapidly changing scenario and data scarcity, these initial recommendations kept a highly conservative approach. As of 2023, according to newly acquired evidence, EUSOBI proposes the following updates, in order to reduce unnecessary examinations and avoid delaying necessary examinations. First, recommendation n. 3 has been revised to state that breast examinations should not be delayed or rescheduled because of COVID-19 vaccination, as evidence from the first pandemic waves highlights how delayed or missed screening tests have a negative effect on breast cancer morbidity and mortality, and that there is a near-zero risk of subsequent malignant findings in asymptomatic patients who have unilateral lymphadenopathy and no suspicious breast findings. Second, recommendation n. 7 has been revised to simplify follow-up strategies: in patients without breast cancer history and no imaging findings suspicious for cancer, symptomatic and asymptomatic imaging-detected unilateral lymphadenopathy on the same side of recent COVID-19 vaccination (within 12 weeks) should be classified as a benign finding (BI-RADS 2) and no further work-up should be pursued. All other recommendations issued by EUSOBI in 2021 remain valid.

ENDOGRADE: A four level classification to rate surgical complexity in endometriosis.

OBJECTIVES: We studied a post operative classification of surgical complexity in endometriosis. STUDY DESIGN: Retrospective monocentric observational study was conducted between January 2001 to December 2019 and included 764 women with DE that underwent surgery. We retrospectively graded surgical complexity through operative reports according to the ENDOGRADE classification, that grades the surgical complexity of DE in four progressive levels. RESULTS: Operating time was longer for patients rated ENDOGRADE 3 (228±93 min) compared to patients rated ENDOGRADE 2 (120± 51 min) (p<10-3) and for patients rated ENDOGRADE 4 (301±99 min) compared to patients rated ENDOGRADE 3 (228±93 min), (p<10-3). Eighty percent (20/25) of peroperative complications were rated ENDOGRADE 3 or 4, 20% (5/25) were rated ENDOGRADE 1 or 2 (p = 0.01). Patients rated ENDOGRADE 2, 3 and 4 were 10.3 times (95CI=2.4-44.9, p = 2.10-3), 12.2 times (95CI=2.9-50.2, p = 5.10-4) and 38.3 times (95CI=9.1-162, p = 7.10-7) more likely to experience postoperative complications than those rated ENDOGRADE 1. According to multivariate analysis, only patients rated ENDOGRADE 2, 3, and 4 had a significantly higher risk of postoperative complications with an OR=16.0 (95CI=2.0-127.4, p = 9.10-3), OR=16.2 (95CI=1.6-159.7, p = 0.02) and OR=104.2 (95CI=24.6-440.5, p = 4.10-3), respectively. CONCLUSION: ENDOGRADE classification of surgical complexity in DE is correlated to operating time, per- and post-operative complications.

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.

Multicenter External Validation of the Deep Pelvic Endometriosis Index Magnetic Resonance Imaging Score.

Importance: Preoperative mapping of deep pelvic endometriosis (DPE) is crucial as surgery can be complex and the quality of preoperative information is key. Objective: To evaluate the Deep Pelvic Endometriosis Index (dPEI) magnetic resonance imaging (MRI) score in a multicenter cohort. Design, Setting, and Participants: In this cohort study, the surgical databases of 7 French referral centers were retrospectively queried for women who underwent surgery and preoperative MRI for DPE between January 1, 2019, and December 31, 2020. Data were analyzed in October 2022. Intervention: Magnetic resonance imaging scans were reviewed using a dedicated lexicon and classified according to the dPEI score. Main outcomes and measures: Operating time, hospital stay, Clavien-Dindo-graded postoperative complications, and presence of de novo voiding dysfunction. Results: The final cohort consisted of 605 women (mean age, 33.3; 95% CI, 32.7-33.8 years). A mild dPEI score was reported in 61.2% (370) of the women, moderate in 25.8% (156), and severe in 13.1% (79). Central endometriosis was described in 93.2% (564) of the women and lateral endometriosis in 31.2% (189). Lateral endometriosis was more frequent in severe (98.7%) vs moderate (48.7%) disease and in moderate vs mild (6.7%) disease according to the dPEI (P < .001). Median operating time (211 minutes) and hospital stay (6 days) were longer in severe DPE than in moderate DPE (operating time, 150 minutes; hospital stay 4 days; P < .001), and in moderate than in mild DPE (operating time; 110 minutes; hospital stay, 3 days; P < .001). Patients with severe disease were 3.6 times more likely to experience severe complications than patients with mild or moderate disease (odds ratio [OR], 3.6; 95% CI, 1.4-8.9; P = .004). They were also more likely to experience postoperative voiding dysfunction (OR, 3.5; 95% CI, 1.6-7.6; P = .001). Interobserver agreement between senior and junior readers was good (κ = 0.76; 95% CI, 0.65-0.86). Conclusions and Relevance: The findings of this study suggest the ability of the dPEI to predict operating time, hospital stay, postoperative complications, and de novo postoperative voiding dysfunction in a multicenter cohort. The dPEI may help clinicians to better anticipate the extent of DPE and improve clinical management and patient counseling.

Resolution of Pain after Percutaneous Image-Guided Cryoablation of Extraperitoneal Endometriosis.

PURPOSE: To retrospectively evaluate the relief of pain after percutaneous image-guided cryoablation of symptomatic extraperitoneal endometriosis (EE). MATERIAL AND METHODS: From 2017 to 2022, cryoablation of EE was performed at a single institution on a total of 47 lesions in 42 consecutive patients (median age, 37 years; interquartile range [IQR], 33-39.5 years). Patient and procedural characteristics were reviewed retrospectively. Tolerance and outcomes in terms of pain and patient satisfaction were evaluated. RESULTS: The median follow-up duration was 13.5 months (IQR, 1.1-37.7 months) after cryoablation. The median pain-free survival rate was 93.8% (95% confidence interval [CI], 77.3-98.4) at 6 months and 82.7% (95% CI, 58.8-93.5) after 12 months. Pain decreased from a median of 8/10 (IQR, 7-9) on the visual analog scale to 0/10 (IQR, 0-1) at the last follow-up (P < .0001). The median Patient Global Impression of Change score recorded at the last follow-up was 1/7 (IQR, 1-2). The efficacy rate of cryoablation to avoid secondary surgery was 92.8% (39/42) per patient and 93.6% (44/47) per nodule treated. Four patients (9.5%, 4/42) experienced an adverse event in the days following the procedure, and 1 patient (2%) experienced a severe adverse event. CONCLUSIONS: Percutaneous cryoablation is safe and effective in significantly reducing pain and obtaining local control of EE.

Impact of DWI and ADC values in Ovarian-Adnexal Reporting and Data System (O-RADS) MRI score.

PURPOSE: Introduce DWI and quantitative ADC evaluation in O-RADS MRI system and observe how diagnostic performance changes. Assess its validity and reproducibility between readers with different experience in female pelvic imaging. Finally, evaluate any correlation between ADC value and histotype in malignant lesions. MATERIALS AND METHODS: In total, 173 patients with 213 indeterminate adnexal masses (AMs) on ultrasound were subjected to MRI examination, from which 140 patients with 172 AMs were included in the final analysis. Standardised MRI sequences were used, including DWI and DCE sequences. Two readers, blinded to histopathological data, retrospectively classified AMs according to the O-RADS MRI scoring system. A quantitative analysis method was applied by placing a ROI on the ADC maps obtained from single-exponential DWI sequences. AMs considered benign (O-RADS MRI score 2) were excluded from the ADC analysis. RESULTS: Excellent inter-reader agreement was found in the classification of lesions according to the O-RADS MRI score (K = 0.936; 95% CI). Two ROC curves were created to determine the optimal cut-off value for the ADC variable between O-RADS MRI categories 3-4 and 4-5, respectively, 1.411 × 10-3 mm2/sec and 0.849 × 10-3 mm2/sec. Based on these ADC values, 3/45 and 22/62 AMs were upgraded, respectively, to score 4 and 5, while 4/62 AMs were downgraded to score 3. ADC values correlated significantly with the ovarian carcinoma histotype (p value < 0.001). CONCLUSION: Our study demonstrates the prognostic potential of DWI and ADC values in the O-RADS MRI classification for better radiological standardisation and characterisation of AMs.