European Radiology

, Volume 20, Issue 1, pp 25–35 | Cite as

ESUR guidelines for MR imaging of the sonographically indeterminate adnexal mass: an algorithmic approach

  • John A. SpencerEmail author
  • Rosmarie Forstner
  • Teresa M. Cunha
  • Karen Kinkel
  • on behalf of the ESUR Female Imaging Sub-Committee


A significant proportion of adnexal masses detected by sonography are indeterminate. Either their organ of origin is uncertain or it is unclear whether their nature is benign or malignant. MR imaging of the sonographically indeterminate adnexal mass can resolve most of these uncertainties. Most indeterminate masses result from common benign conditions and women with such masses can avoid unnecessary or inappropriate surgery. For the minority of women whose masses are malignant, use of MR imaging rather than a ‘wait and watch’ strategy of repeat ultrasound (US) results in a more timely diagnosis. There are simple diagnostic steps in the MR imaging assessment which direct an algorithmic and problem-solving approach based on signal characteristics and morphology. MR imaging should provide a more timely diagnosis and, thereby, guide the management of the patient with reduced costs of investigation and treatment.


Ovary Ultrasound MR imaging Tumour Oncology 



We are grateful to the following members of the subcommittee who contributed to discussion of the guidelines and responded to a questionnaire about current practice in their institutions: B Hamm, C Lopez, K Togashi, C Balleguier, R Kubik-Huch, R Manfredi, C Nicolao, AC Tsili and M Bazot. JAS is also grateful to Mrs Sheila Boyes, Ms Fiona Lang and Dr Sunethra Ghattameneni for help with selection and preparation of images to illustrate this article and for helpful comments on the manuscript.


  1. 1.
    Royal College of Radiologists (RCR) (2007) Making the best use of clinical radiology services, 6th edn. RCR, LondonGoogle Scholar
  2. 2.
    Xiong T, Richardson M, Woodroffe R, Halligan S, Morton D, Lilford RJ (2005) Incidental lesions found on CT colonography: their nature and frequency. Br J Radiol 78:22–29CrossRefPubMedGoogle Scholar
  3. 3.
    Pickhardt PJ, Hanson ME, Vanness DJ et al (2008) Unsuspected extracolonic findings at screening CT colonography: clinical and economic impact. Radiology 249:151–159CrossRefPubMedGoogle Scholar
  4. 4.
    Katz DS, Scheer M, Lumerman JH, Mellinger BC, Stillman CA, Lane MJ (2000) Alternative or additional diagnoses on unenhanced helical computed tomography for suspected renal colic: experience with 1000 consecutive examinations. Urology 56:53–57CrossRefPubMedGoogle Scholar
  5. 5.
    Earle CC, Schrag D, Neville BA et al (2006) Effect of surgeon specialty on processes of care and outcomes for ovarian cancer patients. J Natl Cancer Inst 98:172–180PubMedCrossRefGoogle Scholar
  6. 6.
    Engelen MJ, Kos HE, Willemse PH et al (2006) Surgery by consultant gynecologic oncologists improves survival in patients with ovarian carcinoma. Cancer 106:589–598CrossRefPubMedGoogle Scholar
  7. 7.
    Vernooij F, Heintz P, Witteveen E, van der Graaf Y (2007) The outcomes of ovarian cancer treatment are better when provided by gynecologic oncologists and in specialized hospitals: a systematic review. Gynecol Oncol 105:801–812CrossRefPubMedGoogle Scholar
  8. 8.
    Sohaib SA, Mills TD, Sahdev A et al (2005) The role of magnetic resonance imaging and ultrasound in patients with adnexal masses. Clin Radiol 60:340–348CrossRefPubMedGoogle Scholar
  9. 9.
    Adusumilli S, Hussain HK, Caoili EM et al (2006) MRI of sonographically indeterminate adnexal masses. Am J Roentgenol 187:732–740CrossRefGoogle Scholar
  10. 10.
    Johnson W, Taylor MB, Carrington BM, Bonington SC, Swindell R (2007) The value of hyoscine butylbromide in pelvic MRI. Clin Radiol 62:1087–1093CrossRefPubMedGoogle Scholar
  11. 11.
    Nishimura K, Togashi K, Itoh K et al (1987) Endometrial cysts of the ovary: MR imaging. Radiology 162:315–318PubMedGoogle Scholar
  12. 12.
    Outwater EK, Dunton CJ (1995) Imaging of the ovary and adnexa: clinical issues and applications of MR imaging. Radiology 194:1–18PubMedGoogle Scholar
  13. 13.
    Kido A, Togashi K, Konishi I et al (1999) Dermoid cysts of the ovary with malignant transformation: MR appearance. Am J Roentgenol 172:445–449Google Scholar
  14. 14.
    Oh SN, Rha SE, Byun JY et al (2008) MRI features of ovarian fibromas: emphasis on their relationship to the ovary. Clin Radiol 63:529–535CrossRefPubMedGoogle Scholar
  15. 15.
    Jung SE, Rha SE, Lee JM et al (2005) CT and MRI findings of sex cord-stromal tumor of the ovary. Am J Roentgenol 185:207–215Google Scholar
  16. 16.
    Kim SH, Kim SH, Yang DM, Kim KA (2004) Unusual causes of tubo-ovarian abscess: CT and MR imaging findings. Radiographics 24:1575–1589CrossRefPubMedGoogle Scholar
  17. 17.
    Hricak H, Chen M, Coakley FV et al (2000) Complex adnexal masses: detection and characterization with MR imaging-multivariate analysis. Radiology 214:39–46PubMedGoogle Scholar
  18. 18.
    Guerra A, Cunha TM, Félix A (2008) Magnetic resonance evaluation of adnexal masses. Acta Radiol 49:700–709CrossRefPubMedGoogle Scholar
  19. 19.
    Thomassin-Naggara I, Bazot M, Daraï E, Callard P, Thomassin J, Cuenod CA (2008) Epithelial ovarian tumors: value of dynamic contrast-enhanced MR imaging and correlation with tumor angiogenesis. Radiology 248:148–159CrossRefPubMedGoogle Scholar
  20. 20.
    Department of Health (2000) Referral guidelines for suspected cancer. Stationery Office, LondonGoogle Scholar
  21. 21.
    Spencer JA, Forstner R, Hricak H (2008) Investigating women with suspected ovarian cancer. Gynecol Oncol 108:262–264CrossRefPubMedGoogle Scholar
  22. 22.
    Kinkel K, Lu Y, Mehdizade A, Pelte MF, Hricak H (2005) Indeterminate ovarian mass at US: incremental value of second imaging test for characterization-meta-analysis and Bayesian analysis. Radiology 236:85–94CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Radiology 2009

Authors and Affiliations

  • John A. Spencer
    • 1
    Email author
  • Rosmarie Forstner
    • 2
  • Teresa M. Cunha
    • 3
  • Karen Kinkel
    • 4
  • on behalf of the ESUR Female Imaging Sub-Committee
  1. 1.Department of RadiologySt. James’s University HospitalLeedsUK
  2. 2.Universitätsinstitut für RadiodiagnostikSalzburgAustria
  3. 3.Department of RadiologyHospital Pulido ValenteLisbonPortugal
  4. 4.Clinique des GrangettesGeneva University Hospital and Institut de RadiologieChêne-Bougeries/GenevaSwitzerland

Personalised recommendations