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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