From the Guidelines

MRI with and without IV contrast is indicated for cervical and ovarian complexes.

For cervical cancer, MRI pelvis without and with IV contrast is used to determine tumor size and extent of local invasion, with T2-weighted noncontrast sequences in the sagittal, axial oblique, and coronal oblique planes being the foundation of the anatomic assessment 1.
The addition of diffusion-weighted imaging (DWI) improves interobserver agreement and increases sensitivity and specificity for parametrial involvement 1.
For ovarian complexes, MRI pelvis without and with IV contrast is usually appropriate for characterization, especially when the initial pelvic US is indeterminate and there are no acute symptoms 1.
Contrast-enhanced MRI performs superiorly to US and noncontrast MRI in confirming the presence of internal enhancing soft tissue components and characterizing indeterminate lesions 1.
Noncontrast MRI may be used when the use of IV contrast is precluded, but its usefulness is limited in identifying enhancing solid tissue and its enhancement pattern 1.

Variant 4 recommends MRI pelvis without and with IV contrast as the next imaging study for characterization of an adnexal mass that is indeterminate on initial pelvic US with no acute symptoms 1.
Variant 7 and Variant 9 recommend MRI pelvis without and with IV contrast or without IV contrast as the next imaging study for characterization of an adnexal mass that is indeterminate on initial pelvic US with no acute symptoms in pregnant patients 1.

From the Research

MRI provides exquisite views of the pelvic anatomy and plays a key role in the workup of ovarian lesions, identifying features that distinguish benign and malignant lesions 2.
For cervical and ovarian complexes, the following MRI techniques are indicated:
- Morphological T1 and T2 sequences are recommended for pelvic MRI 3.
- In case of solid portion, perfusion and diffusion sequences are recommended 3.
- Dynamic contrast-enhanced MRI (DCE-MRI) and diffusion-weighted MRI (DW-MRI) are useful in characterizing ovarian masses and detecting small peritoneal implants in patients with ovarian cancer 4, 5.
- Contrast-enhanced MRI is useful in defining intratumoral architecture and tumor borders, and in determining malignancy in adnexal masses 4.
- DCE-MRI improves the accuracy of T2-weighted imaging in staging of endometrial cancer and helps differentiate tumor recurrence from radiation fibrosis in patients with cervical cancer 5.

Contrast-enhanced MRI is indicated for:
- Characterization of adnexal masses, particularly in cases where the diagnosis is uncertain 3, 4.
- Staging of endometrial cancer and cervical carcinoma 4, 5.
- Detection of small peritoneal implants in patients with ovarian cancer 5.
- Differentiation of tumor recurrence from radiation fibrosis in patients with cervical cancer 5.

MRI has high contrast resolution and lacks ionizing radiation exposure, making it an essential problem-solving tool for determining the site of origin of a pelvic mass, characterizing an adnexal mass, and detecting local invasion 6.