Improving risk stratification of indeterminate adnexal masses on MRI: What imaging features help predict malignancy in O-RADS MRI 4 lesions?

Purpose: Ovarian-Adnexal Reporting and Data System (O-RADS) MRI uses a 5-point scale to establish malignancy risk in sonographicallyindeterminate adnexal masses. The management of O-RADS MRI score 4 lesions is challenging, as the prevalence of malignancy is widely variable (5-90%). We assessed imaging features that may substratify O-RADS MRI 4 lesions into malignant and benign subgroups.Method: Retrospective single-institution study of women with ORADS MRI score of 4 adnexal masses between April 2021August 2022. Imaging findings were assessed independently by 2 radiologists according to the ORADS lexicon white paper. MRI and clinical findings were compared between malignant and benign adnexal masses, and inter-reader agreement was calculated.Results: Seventy-four women (median age 52 years, IQR 36-61) were included. On pathology, 41 (55.4%) adnexal masses were malignant. Patients with malignant masses were younger (p = 0.02) with higher CA-125 levels (p = 0.03). Size of solid tissue was greater in malignant masses (p = 0.01-0.04). Papillary projections and larger solid portion were more common in malignant lesions; irregular septations and predominantly solid composition were more frequent in benign lesions (p < 0.01). Solid tissue of malignant lesions was more often hyperintense on T2-weighted and diffusion-weighted imaging (p <= 0.03). Other imaging findings were not significantly different (p =0.090.77). Inter-reader agreement was excellent-good for most features (ICC = 0. 662-0.950; k = 0. 650-0.860).Conclusion: Various MRI and clinical features differed between malignant and benign O-RADS MRI score 4 adnexal masses. O-RADS MRI 4 lesions may be sub-stratified (high vs low risk) based on solid tissue characteristics and CA-125 levels.