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4/23/17
1
BMUSStudyDay
Gynaecology Ultrasound ImagingApril2017London
Dr SusanneJohnson FRCOGSouthampton, UK
Imagingoftheovaries:predictingtheriskofmalignancyin
adnexalmasses isimportant• Diagnoseovariancancerearlier
• Enablewomenwithmalignanciestohavesurgeryinadedicatedoncologycentre
• Triagewomenwithbenignpathologytobenigngynaecologyservicefor– conservativemanagement– minimallyinvasivesurgery
Thispresentationwillcover:• Standardisationofterminology– IOTA
• IOTASimpleDescriptors(patternrecognition)
• Predictionofmalignancy– IOTASimpleRules
• Workedexamples
• Quiz
• Latestdevelopments– RiskofMalignancyIndicators
Thereportreallymatters
• Istheadnexal massbenign ormalignant?
• Previously reports would state:– Simplecyst– Complexcyst
• Canwedobetter?
Howtoreportthisabnormality?
By the end of this presentation you will be able to report this!
Ovarianpathology
• Standardisationofterminology– IOTA
• IOTASimpleDescriptors(patternrecognition)
• Predictionofmalignancy– IOTASimpleRules
• Workedexamples
• Quiz
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Standardisation ofterminology
• IOTAgroup
• Termsanddefinitions ofadnexalpathology
• TRANSVAGINALULTRASOUND
TheoriginalIOTApaper
Adnexal massIsamassneartheuterus,whichisinconsistentwithnormalphysiology
IOTAcriteriatodescribeadnexalmasses
– Unilocular, unilocular-solid , multilocular, multilocular-solid or solid
– Cystcontents – anechoic, low level, ground glass, haemorrhagic ormixed
– Solid material orpapillary structures orwall irregularity (presenceandsize)
– Vascularity
– Shadows
– Ascites
Locularity
Unilocular
In black – a single cystic structure
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Unilocular-solid
In black – a single cystic structure WITH in pink– a solid component >3 mm
Multilocular
In black – more than one cystic structure
Multilocular-solid
In black– more than one cystic structure WITH in pink – a solid component >3 mm
Solid
In pink - solid lesion (>80% is solid, up to 20% can be cystic)
Cystcontents
Echogenicityofcysticcontents• Anechoic
– black• Lowlevel
– homogeneouslowlevelechoeslikemucin• Groundglass
– homogeneouslydispersedechoesasinendometriomas• Haemorrhagic
– internalfibrinthreadsorclotwithcob-webs• Mixed
– variableechogenicityasindermoids orabscess
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Echogenicityofcysticcontents
• Anechoic
• Lowlevel
• Groundglass
• Haemorrhagic
• Mixed
EchogenicityofcysticcontentsAnechoic
EchogenicityofcysticcontentsLowlevel
EchogenicityofcysticcontentsGroundglass
EchogenicityofcysticcontentsHaemorrhagic
EchogenicityofcysticcontentsMixed
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Solidmaterial/papillations
Solidmaterial/papillations
• Solid component – structure thathas echogenicity suggestive oftissueBUT
– thewhiteball of adermoid isnotsolidtissue– bloodclotormucin isnotsolidtissue
• Apapillary projection is aprotrusion >3mmin height fromthe cystwall (this also counts asasolid component)If<3mm= irregularity
• Irregular –means an irregular internal wall OR irregular outer contourofasolid lesion
Solidmaterial– papillations Solidmaterial– notapapillation
Vascularity
Vascularityscore• Colour Doppler• PRF0.3• Velocityscale3-6cm/sec• Balance220• AdjustDopplergaintojustbelowartefactlevel
• Noflow=1 (noneatall)• Minimalflow=2 (reallyhavetolookforit)• Moderateflow=3 (justthere)• Strongflowthroughout=4 (strong,inoneareaorallover)
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Vascularityscores1-41
2
3
4Shadows
Denseshadows Subtleshadow
Ascites
Ascites
Fluid outside PODie abovethelevelofthe uterine fundus
uterus
longitudinal view pelvis
TA view pelvis with ascites
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Ovarianpathology• Standardisationofterminology– IOTA
• IOTASimpleDescriptors(patternrecognition)
• Predictionofmalignancy– IOTASimpleRules
• Workedexamples
• Quiz
SimpleDescriptors
SimpleDescriptors
• Certain abnormalities arereallyobvious:– PATTERN RECOGNITION
• Endometrioma• Benign cysticteratoma - dermoid• Simplecystorcystadenoma• Functional cysteg haemorrhagic cyst• Malignant tumour with ascites
SimpleDescriptors– benigndescriptor
• Endometrioma– Unilocular lesionwithground-glassechogenicityinapremenopausalwoman
SimpleDescriptors– benigndescriptor
• Benign cysticteratoma (dermoid)Unilocular lesionwithmixedechogenicityandacousticshadowsinpremenopausalwoman
SimpleDescriptors– benigndescriptor
• SimplecystorcystadenomaUnilocular anechoiclesionwithregularwallsandmaximumdiameter
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SimpleDescriptors– benigndescriptor
• Functional cysteg haemorrhagic cystRemainingunilocular lesionswithregularwalls
(note– nosolidmaterialasthatwouldmakethelesion‘unilocular-solid’)
SimpleDescriptors– malignantdescriptor
• Malignant tumour with ascitesTumour withascitesandatleastmoderatecolourDopplerbloodflow(score3+)inapost-menopausalwoman
WhenSimpleDescriptorsdonotapply:
Ifthemassisnot instantly recognisableandSimpleDescriptors donotapply:
then applySimpleRules
Ovarianpathology• Standardisationofterminology– IOTA
• IOTASimpleDescriptors(patternrecognition)
• Predictionofmalignancy– IOTASimpleRules
• Workedexamples
• Quiz
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BMJ2010 SimpleRulesBENIGNFEATURESofamass
Bfeatures
• Unilocular cyst• Solid component largestdiameter
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IOTACRITERIAtodescribeadnexalmasses
– Unilocular,unilocular-solid, multilocular,multilocular-solidorsolid
– Cystcontents– anechoic,lowlevel,groundglass,haemorrhagic ormixed
– Solidmaterialorpapillarystructuresorwall irregularity(presenceandsize)
– Vascularity
– Shadows
– Ascites
SIMPLEDESCRIPTORS
• Unilocular cyst,acousticshadows, regularwalls,premenopausalwoman=Benign teratoma
• Unilocular cyst,groundglassechogenicity,regularwalls,premenopausalwoman=Endometrioma
• Unilocular anechoiccyst,regularwalls,maximumdiameter
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Example3Simple descriptorsunilocular, anechoic, regular walls,
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ButwhenSimpleDescriptorsdonotapply….
ThenapplySimple Rules
– threeworkedexamples:
SheetwithSimple Rules
Example 1
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Diagnosticpath• IOTAdescription
– Unilocular, unilocular-solid, multilocular, multilocular-solid or solid– Cyst contents – anechoic, low level,ground glass ,haemorrhagic ormixed
– Solid material or papillary s tructures or wallirregularity (presence and s ize)– Vascularity 1-4 4
– Shadows NO– Ascites NO(poss ibly)
• Simple Descriptors – donotapply– endometrioma / dermoid / s imple cyst/ haemorrhagic cyst/ malignancy
• Simplerules– Benign - unilocular, smooth multilocular tumor <100 mm, largest solid component diameter < 7mm,
acoustic shadows, no blood flow (color score 1)
– Malignant - Irregularsolid tumor,Irregular multilocular-solid tumor ≥100 mm, ≥ 4papillarys tructures , ascites , verystrongbloodflow (colorscore4)
– Uncertain
Example 2 Simple rules:MALIGNANTMetastasisfrombowel primary
Example 2
Example 3 Diagnosticpath• IOTAdescription
– Unilocular, unilocular-solid, multilocular, multilocular-solid or solid– Cyst contents – anechoic, low level,ground glass ,haemorrhagic ormixed
– Solid material or papillary s tructures or wallirregularity (presence and s ize)yes– Vascularity 1-4 2
– Shadows NO– Ascites NO
• Simple Descriptors – donotapply– endometrioma / dermoid / s imple cyst/ haemorrhagic cyst/ malignancy
• Simplerules– Benign - unilocular, smooth multilocular tumor <100 mm, largest solid component diameter < 7mm,
acoustic shadows, no blood flow (color score 1)
– Malignant - Irregular solidtumor, Irregular multilocular-solid tumor ≥100 mm, ≥4 papillarys tructures , ascites , very s trong blood flow (color score 4)
– Uncertain (NOBENIGN RULESAND NOMALIGNANT RULES=UNCERTAIN)
Example 3
Simple rules:UNCERTAINBorderlineovariantumour
Example 3
Ovarianpathology• Standardisationofterminology– IOTA
• IOTASimpleDescriptors(patternrecognition)
• Predictionofmalignancy– IOTASimpleRules
• Workedexamples
• Quiz
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QUIZ• Lookatthemassanddescribe itusingIOTAcriteria
• ApplySimpleDescriptors (pattern recognition)• ApplySimpleRules• Decide whether benign, uncertain ormalignant
• Suggesthistological diagnosis
Areyoureadytostartthequiz?
Refertoyourhandout
Q1 premenopausal,
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Q5
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ANSWERS
Q1Simple descriptor: (unilocular, regular walls, 4papillations andshadowing) =UncertainBorderline ovarian tumour
Q3Simple descriptor (unilocular, mixedechoes, shadows, premenopausal) =
dermoidSimple rules (unilocular, shadows, novascularity) =Benign
Dermoid
Q4Simple descriptors do notapply
Simple Rules (smooth multilocular
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Q6Simple descriptors do notapply
Simple Rules (irregular solid) =MalignantMetastatic colon cancer
Q7Simple descriptors do notapply
Simple Rules (Shadowing) =BenignFibroma
Q8Simple descriptor (unilocular, ground glass echoes, premenopausal) =
endometriomaSimple Rules (unilocular, novascularity) =Benign
Endometrioma
Q9Simple descriptors do notapply
Simple Rules (irregular solid andstrong blood flow) =Malignantserous ovariancarcinoma
Q10Simple descriptors (unilocular, mixedechoes, shadows, premenopausal) =
dermoidSimple Rules (shadowing andnocolour) =Benign
Mature teratoma (dermoid)
Conclusion• ApplyIOTAterminology andSimple Rulestoalladnexalmasses,keeparecord andchasethehistology – wereyouright?
• Simpleor complex VERSUS
• IOTAcriteria, SimpleDescriptors andSimpleRules – acomprehensive andinformativereport
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Tosumup• Carefulhistory• Systematicscan–don’tpanicwhentherearemanyseparate
abnormalities• UsetheIOTAcriteriatodescribethelesion• ApplySimpleDescriptors(patternrecognition)• ApplySimpleRules• (applyLRandADNEXmodels) AFTERTHEBREAK• Clearreport
– Benign /uncertain /malignant– Suggested histology
• Chasethehistology– wereyouright?
IFTHEREISTIME
LATESTDEVELOPMENTS
RISKOFMALIGNANCYINDICATORS
Riskofmalignancyindicators
• RMI
• LR2
• ADNEX
RMI– riskofmalignancyindex• RMI =U x M x Ca125
• Theultrasound result is scored 1point foreachof the followingcharacteristics: multilocular cysts, solid areas, metastases, ascites andbilateral lesions
– U= 0(foranultrasoundscoreof 0),U =1( foranultrasoundscoreof 1) ,U =3( foranultrasoundscoreof 2–5)
• Themenopausal status is scored as1 = pre-menopausal and3 = post-menopausal
– The classif icationof 'post-menopausal'isawomanwhohashadnoperiodformorethan1 year orawomanover50whohashadahysterectomy
• SerumCA125 ismeasured in IU/ml– andcanvary between 0andthousandsof units
CA125• CA125– bloodtest
• Proteincalledatumour markerorbiomarker • CAstandsforcancerantigen• Moreoftenpresentincancercells
• Canberaisedinmalignancybutalsoinendometriosis,fibroids,PID,pregnancy,pneumonia,cardiacdiseaseetc
IOTALR2Logisticregressionmodel2
• age• ascites• blood-flow inapapillary projection• maximum diameter solid material• irregular internal cystwall• acoustic shadowing
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2014- IOTA- ADNEX
• AssessmentofDifferent NEoplasias intheadneXa
• Age• SerumCa125• Typeofcentre (oncologycentres vothers)• Maximum size oflesion• Proportion ofsolid tissue• More than10cystlocules• Number ofpapillary projections• Acoustic shadows• Ascites
IOTA2014- ADNEX
ADNEXmodel BORDERLINEFIGO1
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RiskofMalignancyIndicatorsRMI LR2 ADNEXage age ageascites ascites ascites
blood flow papillation NUMBER PAPSsolid max solid max solid / ,max size
irregular internal wallshadowing shadowing
type centreCA125 CA125multilocular
metastases
>10 locules
Howdothetestsperform?
• SensitivityProbabilitythatatestisPOSITIVEifthediseaseispresentegCANCER
• SpecificityProbabilitythatatestisNEGATIVEifthediseaseisabsentegBENIGNpathology
Howdothetestsperform?Sensitivity Specificity
CA125>30 89 73RMI>250 70 90LR2>10% 97 71Simple RulesB/M 93 81ADNEX>10% 96.5 71.3
Simpl e r ule s – excl ud es un ce rtai n 2 2% c as es
Which ‘predictionofmalignancytest’touse
• SimpleRulesverygoodbut25%casesareuncertain
• CA125andRMInotuseful
• LR2verygoodtestbutnoteasytoapply
• ADNEXhighsensitivitybutlowerspecificity(ieovercallspathology)
Predictionofmalignancy
• Describe the massusingIOTAterminology
• UseSimpleDescriptors
• UseSimpleRules
• WhereSimple Rulesisuncertain:– applyLR2andADNEX
SOURCES• Websitewww.gynaecologyultrasound.co.uk
linksinto:• YouTubechannel
GynaecologyUltrasound
• IOTAwebsitewww.iotagroup.org
publishedpaperscoursesapps(malignancyriskcalculatorsSR,LR2andADNEX)conferencedates
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THANKYOU