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Ovarian pathology: IOTA
Usmi Chauhan
Clinical Sonographer
Monash Health
Content
• Clinically useful• Benign • Malignant
• Communication between clinicians/research
DESCRIBE WHAT YOU SEE
ADNEXAL MASSES
SIMPLE COMPLEX
X
Consensus statement on how to describe adnexal masses
IOTA terms for description of an adnexal mass
Position: bilateral? Side?
Size of lesion
Type of tumour Number of locules /incomplete septum
Echogenicity
Acoustic shadows
Size of solid component
Papillary projections
Colour score
Ascites
Presence of metastases
IOTA terms for description of an adnexal mass
‘Lesion’ • Part of an ovary or adnexal mass inconsistentwith normal physiology
Struma ovarii Haemorrhagic cyst
X IOTA terms for description of an adnexal mass
‘5 types of tumour’
Solid (solid tissue comprise ≥ 80% of tumour)
Unilocular Unilocular solid Multilocular
Multilocular solid
Malignancy rate Granberg et al 1989
0.3% 2% 16%
73%40%
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IOTA terms for description of an adnexal mass
‘5 types of cyst contents’
Mixed
Anechoic Low level Ground glass
Haemorrhagic
IOTA terms for description of an adnexal mass
‘Solid component’• A structure that has echogenicity suggestive of tissue (ovarian stroma)• NOT ‘white ball’ in a dermoid cyst• NOT blood clot, or mucous
• Concave • Probe pressure• Colour Doppler
IOTA terms for description of an adnexal mass
‘Papillary projection’ • Protrusion of solid tissue into a cyst cavity ≥ 3mm (height)
• Protrusions < 3mm (height) = irregularities
• Papillary projections = solid component
Solid component but not PP IrregularityPapillary projection
IOTA terms for description of an adnexal mass
‘Septum’ • Thin strand of tissue that runs from one internal cyst surface to another
Incomplete septum • does not reach the opposite wall of the cystic structure in some scanning
planes (seen in diseased tubes)
Septum Incomplete septum
IOTA terms for description of an adnexal mass
‘Shadowing’
IOTA terms for description of an adnexal mass
‘Ascites’• Fluid outside pouch of Douglas
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IOTA terms for description of an adnexal mass
‘IOTA colour score’• Adjust settings: maximize detection of flow without artifacts (3-6cm/s; PRF 0.3-0.6 kHz)
Score 1(none)
Score 2(minimal)
Score 3 (moderate)
Score 4 (strong)
How do we use IOTA: practical applications
IOTA
Easy descriptors
Pattern recognition
Simple rules
ADNEX LR 1/LR 2
IOTA: Easy descriptorsUnilocular cyst,ground glass echogenicity, +/- wall nodularity.Premenopausal womanENDOMETRIOMA
Unilocular cyst, mixedechogenicity (white ball, dot-dash), shadowing,PremenopausalDERMOID CYST
Unilocular cyst,anechoic cyst fluid,regular walls,< 10 cmSIMPLE CYST OR CYSTADENOMA
All other unilocular cysts with regular wallsBENIGN
Mass> 50 yearsCA125 > 100 IU/mLMALIGNANT
MassAt least moderateblood flowPostmenopausalAscitesMALIGNANT
IOTA: Easy descriptors
SIMPLE CYST OR CYSTADENOMA
• Unilocular cyst• Anechoic cyst fluid• Regular walls• < 10 cm
IOTA: Pattern recognition
ENDOMETRIOMA
Wall nodularity (blood clot/fibrin)(Not papillary projection)
• Unilocular cyst• Ground glass
echogenicity• +/- wall nodularity• premenopausal woman
IOTA: Pattern recognition
DERMOID CYST
• Unilocular cyst• Mixed echogenicity
(white ball, dot-dash)• Shadowing• Premenopausal
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IOTA: Pattern recognition
HAEMORRHAGIC CYST
Reticular pattern Retracting clot
IOTA: Pattern recognition
MALIGNANT• Mass with at least moderate blood flow• Postmenopausal• Ascites
MALIGNANT• Mass• > 50 years• CA125 > 100 IU/mL
And/or
IOTA: Pattern recognition
HYDRO (PYO/HEMATO) SALPINXSerpiginous Incomplete septae
Cog wheeling Beads on a string
PERITONEAL PSEUDOCYST
IOTA: Pattern recognition
• Conforms to shape of peritoneal cavity• Prior pelvic surgery
Ovary suspended in edge of cyst
Solid Pelvic Tumours
• Myoma (uterine) • Fibroma• Thecoma • Brenner tumour • Leydig cell tumour • Malignancies
Peduculated fibroid
Fibroma
• Round, oval lobulated;
• Stripy shadows
• Min vascularity
• May mimic pedunculated fibroid
Broad ligament fibroid
Ovarian malignancyIrregular contourIrregular echogenicityIncreased vascularity
Dysgerminoma + yolk sac tumour
Solid Pelvic Tumours
Neuroendocrine tumour of ovary
Granulosa cell tumour
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IOTA: Simple Rules
Timmermen et al UOG 2008
IOTA: Simple Rules
B-rules M-rules
Unilocular cysts. Irregular solid tumour.
Presence of solid component where the largest solid component <7 mm.
Ascites.
Acoustic shadowing. At least four papillary structures.
Smooth multi-locular tumour with a largest diameter <10 cm.
Irregular multilocular solid tumour with largest diameter ≥ 10 cm.
No blood flow. Very strong blood flow.
IOTA: ADNEX modelhttps://www.iotagroup.org/sites/default/files/adnexmodel/IOTA%20-%20ADNEX%20model.html
CONCLUSION
1. Describe the mass instead of using the term ‘complex’
2. Be familiar with easy descriptors and pattern recognition
3. If uncertain, use Simple Rules +/- ADNEX
THANK YOU
THANK YOU