SRU Consensus on Management of Ovarian Cysts with Case Studiesradreference.info/ewExternalFiles/SRU...

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SRU Consensus on Management of Ovarian Cysts

with Case Studies

Therese M. Weber, MDFebruary 26, 2013

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Disclosures

Dr. Weber has no disclosures and no conflict of interest related to this presentation.

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Objectives

1. Review recent SRU Consensus Guidelines for management of ovarian cysts.

2. Apply these guidelines to multiple case examples.

3. Provide a more concise and uniform approach to management of ovarian cysts.

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Ultrasound

Imaging modality of choice for the female pelvis

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UPDATE

Society of Radiologists in Ultrasound (SRU) Consensus Conference on Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged on Ultrasound

October 2009

Previous: Carotid and Thyroid

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UPDATE

SRU Consensus Conference on Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged on Ultrasound

Goal: Produce a summary of the most important issues regarding management of ovarian and other adnexal cysts (F/U vs surgery).

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Radiology 2010;256:943-954

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Normal Ovary

Levine D et al. Radiology 2010;256:943-954

©2010 by Radiological Society of North AmericaDownloaded from sar2013.conferencespot.org

Normal reproductive ovary

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Normal reproductive CL cyst

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Normal postmenopausal ovary

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Clinically inconsequentialPostmenopausalSimple cyst< 1 cm

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Levine D et al. Radiology 2010;256:943-954

©2010 by Radiological Society of North America

Cysts with Benign Characteristics

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Key issues

SizePatient Age, Menstrual status

Use Doppler to ensure NO solid elements

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Simple Cyst

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Simple Cyst

Ultrasound criteria must be confirmed.

AnechoicSmooth, thin wallsNo solid component or septationPosterior acoustic enhancement

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Simple Cyst

Reproductive age:< 5 cm. No follow-up needed.> 5 and < 7cm. Yearly follow-up.

Postmenopausal:> 1 and < 7 cm. Yearly follow-up.

Any age: > 7 cm. Further imaging/surg eval

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Simple cysts

For cysts < 3 cm in reproductive age women, it is at the discretion of the interpreting physician whether to describe the cysts in the imaging report.

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Hemorrhagic Cyst

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Hemorrhagic Cyst

Reticular pattern of internal echoes+/- Solid appearing area with concave marginsNo internal flow

Use Doppler to ensure no solid elements

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Hemorrhagic Cyst

Reproductive age:< 5 cm. No follow-up needed.> 5 cm. 6-12 wk follow-up to ensure

resolution.

Early PM: Follow-up to ensure resolution

Late PM: Consider surgical evaluation

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Endometrioma

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Endometrioma

Homogeneous low level internal echoesNo solid component+/- Tiny echogenic foci in wall

Any age: Initial follow-up 6-12 wks, then yearly if not surgically removed.

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Dermoid

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Dermoid

Focal or diffuse hyperechoic componentHyperechoic lines and dotsArea of acoustic shadowingNo internal flow

Any age: If not surgically removed, follow-up yearly to ensure stability.

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Hydrosalpinx

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Hydrosalpinx

Tubular shaped cystic mass+/- Short round projections “beads on a string”+/- Waist sign (i.e. indentations on opposite sides.+/- Seen separate from the ovary

Any age: Follow-up as clinically indicated.Downloaded from sar2013.conferencespot.org

Peritoneal Inclusion Cyst

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Peritoneal Inclusion Cyst

Follow the contour of adjacent pelvic organsOvary at the edge of the mass or suspended within the mass+/- Septations

Any age: Follow-up as clinically indicated.

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Cysts with indeterminate, probably benign characteristics

Levine D et al. Radiology 2010;256:943-954

©2010 by Radiological Society of North America

Worrisome forMalignancy

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Findings suggestiveof, but not classicfor hemorrhagiccyst, endometiomaor dermoid

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Cysts with indeterminate characteristics

Reproductive age: 6-12 wk follow-up to ensure resolution. If lesion is unchanged, then hemorrhagic cyst is unlikely, and continued follow-up with either US or MR should be considered. If these studies do not confirm endometrioma or dermoid, surgical evaluation should be considered.

PM: Consider surgical evaluation

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Thin-walled cyst with single septation or focalcalcification in the wall of a cyst

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Multiple thin sepatations< 3 mm

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Nodule (non-hyperechoic)Without flow

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Cysts with characteristics worrisome for malignancy

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Thick (> 3 mm)irregular septation

Any age: Considersurgical evaluation

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Nodule with blood flow

Any age: Consider surgical evaluation

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Ovarian Cancer

3rd in incidence of cancers of female reproductive tract (behind cervical and endometrial)

Accounts for about 50% of all deaths from cancer of the female reproductive tract

About 20% of all ovarian tumors are malignant

Malignant tumors more common 40 – 65 y/o

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Ovarian Carcinoma

Mortality and incidence rates are higher for white women than for any other racial or ethnic group.

U.S. Cancer Statistics Working Group

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Ovarian Carcinoma

Leading cause of death from gynecologic malignancy in U.S. due to late diagnosis

80% of cases occur in women >50 years of age

Overall 5-year survival rate is only 38%

CA-125

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Ovarian Neoplasms

Surface epithelial-stromal tumors: 65-75%

Germ cell tumors: 15-20%

Sex cord-stromal tumors: 5-10%

Metastatic tumors: 5-10%

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Ultrasound Criteria Suggesting Malignancy

GrowthSolid or predominantly solidDiameter > 5 cmIrregular cystic spaces suggesting necrosisMural or septal thickness > 3 mm

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Metastatic Disease to Ovary

Most common origins of ovarian metastases are breast, GI tract, and endometrial carcinoma.

Lymphoma and leukemia may involve the ovary and are frequently bilateral.

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Metastatic Disease to Ovary

Compared with primary ovarian carcinoma, ovarian metastases are more likely to be hyperechoic and solid.

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Summary

US plays the primary role in imaging the ovary and adnexa, and is the most cost-effective modality for the female pelvis.

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Summary

CT plays an important role in staging & recurrence, as well as evaluation of metastatic disease.

MR imaging allows an accurate diagnosis in problem cases, may assist in surgical planning, and may avoid unnecessary surgery in some cases.

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Summary

Reviewed recent SRU Consensus Guidelines for management of ovarian cysts.Applied these guidelines to multiple cases.Questions/comments

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References

Levine D, et al. Management of asymptomatic ovarian and other adnexal cysts imaged at US. Radiology 2010;256:943-954.

Javitt MC. Risk assessment for ovarian carcinoma: hope or hype? AJR 2010;194:308.

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References

Partridge, E, et al. Results from Four Rounds of Ovarian Cancer Screening in a Randomized Trial. Obstetrics & Gynecology. 2009;113: 775-782.

Sokalska, A, et al. Diagnostic accuracy of transvaginal ultrasound examination for assigning a specific diagnosis to adnexal masses. Ultrasound Obstet Gynecol. 2009;34:462-470.

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References

Van Nagell JR, et al. Ovarian cancer screening with annual transvaginal sonography. Cancer 2007;109:1887-1896.

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