ReviewCancer imaging : the official publication of the International Cancer Imaging Society2026
Magnetic resonance biomarkers in detection and characterisation of ovarian cancer: is magnetic resonance spectroscopy ready for clinical use?
Review in Cancer imaging : the official publication of the International Cancer Imaging Society, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Ovarian cancer is a major cause of cancer-related mortality in women, largely due to late-stage diagnosis and challenges in preoperative characterisation of adnexal masses. Multiparametric MRI, incorporating diffusion-weighted (DW) and dynamic contrast-enhanced (DCE) imaging, has improved lesion characterisation and led to the development of the Ovarian-Adnexal Reporting and Data System (O-RADS) MRI for standardised malignancy risk stratification. Despite its demonstrated clinical value, O-RADS MRI relies on qualitative assessment and lacks metabolic information. Magnetic resonance spectroscopy (MRS) provides non-invasive insight into tissue biochemical composition. It offers potential for differentiating benign and malignant ovarian lesions that are indeterminate on ultrasound or MRI. This review discusses current functional MRI biomarkers within the O-RADS framework and evaluates the emerging role of MRS as potential biomarker for ovarian cancer characterisation. Quantitative metrics derived from DWI, including apparent diffusion coefficient (ADC) and histogram analyses, and semi-quantitative and quantitative DCE parameters, have demonstrated utility in differentiating benign, borderline, and malignant lesions. Variability in acquisition protocols, post-processing, and region-of-interest selection, along with motion artifacts and magnetic field inhomogeneities, limits routine clinical implementation. Advanced diffusion models and whole-lesion histogram approaches improve lesion characterization, particularly in indeterminate O-RADS MRI 4 masses, but no single parameter reliably discriminates all lesion types. Early MRS studies identified metabolites such as choline (Cho), lactate (Lac), lipids (Lip), and N-acetylaspartate (NAA) as potential malignancy indicators, with Cho/Cr ratio frequently investigated. Diagnostic performance has been inconsistent due to small cohorts, variable metabolite thresholds, and heterogeneity in acquisition and analysis protocols. Technical limitations, including low signal-to-noise ratio, motion artifacts, field inhomogeneities, and voxel mislocalisation, further limit clinical adoption. Standardized MRS acquisition, voxel localization, shimming, denoising, and post-processing are needed. Community-endorsed consensus guidelines, similar to those in brain MRS, could improve reproducibility, comparability, and reliability. Currently, MRS remains investigational but may serve as a complementary biomarker for O-RADS MRI 4 lesions. Harmonised protocols and consensus guidelines are required to support its clinical translation.
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