Do you order pelvic Magnetic Resonance Imaging (MRI) with or without contrast to evaluate ovarian cysts?

From the Guidelines

Pelvic MRI without contrast is the preferred initial imaging modality for evaluating ovarian cysts, particularly for characterizing endometriomas and other benign lesions, as it provides sufficient diagnostic information without the need for contrast. When evaluating ovarian cysts, the primary goal is to accurately characterize the lesion and determine its potential for malignancy, while also considering the patient's overall health and any potential contraindications to certain imaging modalities. According to the most recent and highest quality study 1, MRI can accurately characterize benign lesions, and classical benign lesions such as simple cysts, endometriomas, and dermoid cysts have characteristic appearances on MRI and can be confidently diagnosed as almost certainly benign. The use of contrast (gadolinium) is not routinely necessary for the assessment of endometriosis 2, and its administration may not provide significant additional diagnostic value in cases of simple, clearly benign-appearing cysts. However, in cases where there is a high suspicion of malignancy or complex cysts are present, the use of contrast may be beneficial in highlighting solid components, septations, and mural nodules that may indicate malignancy. Key considerations in determining the need for contrast include:

• The presence of complex cysts or suspicious features on ultrasound
• The patient's renal function and potential contraindications to gadolinium
• The specific clinical concern and the need for detailed characterization of the cyst. In general, a non-contrast MRI may be sufficient for simple, clearly benign-appearing cysts, while a contrast-enhanced MRI may be necessary for more complex or suspicious lesions 1.

From the Research

Evaluation of Ovarian Cysts using Pelvic MRI

• The use of pelvic Magnetic Resonance Imaging (MRI) with or without contrast to evaluate ovarian cysts is a topic of interest in radiology 3, 4.
• A study published in the Journal of Magnetic Resonance Imaging discusses the clinical and imaging features of ovarian cystic lesions, including the use of MRI techniques for evaluation 3.
• However, the study does not specifically address the use of contrast agents in MRI for evaluating ovarian cysts.
• Another study published in Abdominal Radiology discusses the added value of gadolinium-based contrast agents for MRI evaluation of adnexal torsion in girls, suggesting that contrast administration should be individualized 4.

Role of Contrast Agents in MRI Evaluation

• The study found that post-contrast sequences did not provide additional benefit in evaluating acutely torsed ovaries but helped in excluding torsion in patients with adnexal lesions 4.
• This suggests that the use of contrast agents in MRI evaluation of ovarian cysts may be beneficial in certain cases, but more research is needed to determine the specific indications.
• Other studies have discussed the use of ultrasound and CT scans for evaluating ovarian torsion, but do not provide direct evidence for the use of MRI with or without contrast for evaluating ovarian cysts 5, 6, 7.

Imaging Modalities for Evaluating Ovarian Cysts

• Ultrasound is often the first-line imaging modality for evaluating ovarian cystic lesions, with MRI used as a problem-solving tool in cases with equivocal or non-diagnostic ultrasound findings 5, 7.
• CT scans are not typically used for evaluating ovarian torsion due to radiation concerns, but may be used in emergency settings for acute abdominal pain 6.