Selected gynecologic MRI mimics and pitfalls: practical problem-solving pearls

Pelvic magnetic resonance imaging (MRI) plays an important role in the evaluation of suspected gynecologic malignancies, providing high soft tissue contrast and multiparametric capabilities, including diffusion-weighted imaging and dynamic contrast enhancement, aiding in diagnosis and management strategies. However, a variety of benign entities and non-neoplastic conditions may demonstrate overlapping imaging features with malignant tumors on MRI, creating potential diagnostic pitfalls and delaying treatment or prompting unnecessary interventions. These include endometriosis, atypical leiomyoma variants, ovarian fibromatosis, and treatment- or procedure-related changes, among others. Furthermore, rare malignant entities may mimic more common malignant entities or occasionally have features that overlap with benign entities, both of which can have important implications in determining the appropriate management plan. This pictorial essay highlights key MRI findings of selected gynecologic conditions that represent common and uncommon diagnostic pitfalls. Emphasis is placed on imaging patterns, multiparametric MRI features, and correlation with clinical presentation. By illustrating characteristic findings and highlighting distinguishing features, this review aims to enhance radiologists' confidence in differentiating benign mimics from true malignancy.