11/20/2019

1

“Expert”evaluation of adnexal masses:

Does IOTA have a future in the USA

Ilan E Timor-Tritsch MD

Update on Gynecological Ultrasound

29th Annual OB/GYN Ultrasound Update for Clinical Practice Hollywood Beach Marriott, Florida, Dec. 5 - 8, 2019

No conflict of interest other

than presenting some of our

own publications

First of all: What is IOTA?

IOTA stands for

I = international

O= ovarian

T= tumor

A= analysis

An international group of clinicians who

became interested in inserting some logic

into evaluating adnexal masses

It standardizes the way adnexal

masses, mainly ovarian msses, are

evaluated using ultrasound, correlating

their visual appearances and physical

features with clinical and histological

findings

IOTA is a concept

The leader of the group

• Dr Dirk Timmerman from Loewen, Belgium

• This international group of clinicians come from a

number of mostly European countries.

• They come from differtent areas of interest and

specialities: gynecology, gynecologic oncology,

epidemiology, genetics, statistics and other fields

• Their main strength is that they see the patients,

scan them, take them to the operating room, study

their outcome summarizing all the above in scientific

publications.

• They educate and share their combined experience

Their base is an international

validating process

• Once a sonographic observation is made

and tested on an initial study group of

patients, their findings are retested using –

what they call – an “external validation”

process

• This is performed by a different group of

clinicians and scientists usually on a larger

scale and who have not participated in

developing the original thesis or observation

1 2

3 4

5 6

11/20/2019

2

The last phase is perfecting the

performance of the predictions

using advanced research creating

better prediction models

This group extended their work to include

the endometrium, the myometrium as

well the endometriosis, creating an

organized way to approach pathologies

in those areas

Before I answer the question

posted in the first slide…..

……let us see what can we see if

we look into the adnexa/e

In the next 30-35 minutes I will try to make

you understand and start using your basic

sonographic knwledge to be able to

evaluate the adnexa/e

Scanning for adnexal pathologies

• US should be the almost always the 1st line

imaging before CT & MRI

• You MUST arrive at a conclusion!

• Therefore use all available US tools:

– primarily transvaginal sonography (TVS),

combine it with

– transabdominal sonography (TAS)

– Use a variety of transducers for

frequency, depth, color and power

Doppler, employ 3D as needed….

Scanning for adnexal pathologies

• The question is: benign or malignant?

• Remember: not all masses are ovarian and not all ovarian masses are malignant!!

• Take a good history

– Talk to the patient! She may be your best source of information

– Do a bimanual pelvic exam before as well as after the scan to confirm US findings

– Ask for a menstrual history

Menstrual Hx.: Important!!

• In the reproductive years, physiologic as

well as pathologic processes are driven

by the menstrual cycle or by (therapeutic

or pathologic) hormonal stimulation.

• Know your patients’ first day of her cycle.

Gray scale Color Doppler Power Doppler

Is this an ovarian malignancy?

How about this?

7 8

9 10

11 12

11/20/2019

3

In the secretory phase of the cycle do not

attempt to make a diagnosis of ovarian

pathology in a new patient. Rather look for

the corpus luteum using color Doppler

Be careful and bring back the patient in the follicular

phase of one of her next cycles.

If irregular cycles are the case: ask her to call and

make appointment to suit her based upon her time of

bleeding

Before talking about screening

or diagnostic algorithms we

have to be familiar with

appearances of ovarian

masses

Know what to look for?

• Appearance:

• “Bizarre shapes”

• Mixed components

• Size

• Is it uni- or bilateral?

• Ascites

• Motion tenderness

• Vessels

• Mobility:sliding/fixed?

When these are

documented, the next

step is: LOOK AT THE

VASCULARITY.

Learn the building blocks to define a mass• General appearance

– Solid

• Hyperechoic (shadowing)

• Hypoechoic (nonshadowing)

– Cystic:

• Without solid component

• With solid component

– Unilocular, Multilocular

• Internal echo structure:

– Anechoic/hypoechoic

– Echogenic (solid/shadowing)

– Ground glass appearance (low-level echoes )

– Mixed echogenicity (shadowing)

– Reticular, etc

Learn the building blocks to define a mass

• Wall structure:

– Thickness

– Inner wall:

– Mural nodules

– Papillae

If inner wall papilla/e or nodules are seen,

apply power [not color!] Doppler with the

highest sensitivity to look for blood vessels.

Learn the building blocks to define a mass

13 14

15 16

17 18

11/20/2019

4

Second:

We should realize that scoring

systems existed even before

IOTA and they are able to

differentiate between benign and

malignant ovarian masses

What do scoring systems do?

• They translate macroscopic, pathologic features into sonographically recognizable features……

...which are based upon the same building blocks:

– Wall thickness

– Septations

– Echogenicity

– Papillary formations

– Solid components

– Blood supply (vascularity)

Some systems add: size, ascites, age, etc…

First of all: do not belittle your

experience (provided that you

obtained some by looking at many

adnexal masses!)

Several scientifically proven set of

articles suggest that subjective

evaluation of adnexal masses is

almost as good as the evaluation

based upon strict scoring systems

Scoring systems

The first scoring systems

Obstet Gynecol 1991 78;70

1991

2000 IOTA

2008

• Sassone M, Timor-Tritsch et al, AJOG 1991

• Kentucky. DePriest et al, Gynecol Oncol 1997

• 1993; Osmers, AJOG 1994

• Bromley et al, Obstet Gynecol 1994

• Lerner JP, Timor-Tritsch al, AJOG 1994

• Kurjak, UOG 1994

• Ferazzi, UOG 1998

• Timmerman, UOG 1999-2016

• The most tested for accuracy is

the IOTA system

One may use Morphology Scoring

Systems: they are out there.

However, they do not have to be applied to the letter.

Just understand their basic idea to differentiate a benign

tumor & from a suspicious or a malignant one

19 20

21 22

23 24

11/20/2019

5

Following are the first

“buds” or attempts to make

some sense and

organization of adnexal US

findings

Radiology: Volume 256: September 2010 n radiology.rsna.org

The clinical significance of papillary

formations in ovarian cysts

• Agreement in EUROPE

and the USA:

– Cysts with “Small “,

hyperechoic papilae

without blood vessels

are benign and can be

followed by periodic

imaging

Radiology: Volume 256: September 2010 n radiology.rsna.org

• Agreement in EUROPE

and the USA:

– Cysts containing papillae

with blood vessels are

suspicious for malignancy

and should be removed

Radiology: Volume 256: September 2010 n radiology.rsna.org

The clinical significance of papillary

formations in ovarian cysts

• Multi-disciplinary expert panel convened in 2014

– To examine the state of the science

– To formulate recommendations for clinical

assessment and management

• Aim of the recommendations was

– To promote conservative management for benign

disease

– Optimize referrals to gyn-oncologists in cases of

suspected malignancies

1st International Consensus Report on Adnexal

Masses: Management Recommendations

Second effort to reflect new attempts to improve

management of adnexal masses

Obstet Gynecol. 2016 Nov;128(5):e210-e226.

Practice Bulletin No. 174: Evaluation and Management of Adnexal

Masses.

American College of Obstetricians and Gynecologists’ Committee on

Practice Bulletins—Gynecology.

• Simple cysts up to 10 cm in diameter on TVUS performed by

experienced ultrasonographers are likely benign and may be safely

monitored using repeat imaging without surgical intervention, even in

postmenopausal patients.

• Consultation with or referral to a gynecologic oncologist is

recommended for women with an adnexal mass who meet one or

more of the following criteria:

• Postmenopausal with elevated CA 125 level, ultrasound findings suggestive of malignancy, ascites, a nodular or fixed pelvic mass, or evidence of abdominal or distant metastasis

• - Premenopausal with very elevated CA 125 level, ultrasound findings suggestive of malignancy, ascites, a nodular or

fixed pelvic mass, or evidence of abdominal or distant metastasis

• - Premenopausal or postmenopausal with an elevated score on a formal risk assessment test such as the multivariate index assay, risk of malignancy index, or the Risk of Ovarian Malignancy Algorithm or one of the ultrasound-based

scoring systems from the International Ovarian Tumor Analysis group

• * The evaluation of adnexal masses in adolescents is similar to that in premenopausal women. Management of adnexal masses in adolescents should prioritize ovarian conservation to preserve fertility.

• * Aspiration of an adnexal mass may be appropriate in cases of tubo-ovarian abscess (although antibiotic therapy is first-line treatment) and for the diagnosis of suspected advanced ovarian cancer for which neoadjuvant therapy is

planned. Otherwise, aspiration of cyst fluid for diagnosis is contraindicated when there is a suspicion for cancer.

• * Adnexal torsion in women who want to remain fertile should be managed by reduction of the torsion with concomitant ovarian cystectomy for identified ovarian pathology.

The New Consensus Panel

Recommendations published 2017

25 26

27 28

29 30

11/20/2019

6

1st International Consensus Report on Adnexal

Masses: Management Recommendations

• In North America, most sonographically confirmed

adnexal masses undergo subjective evaluation without

standardized terminology or risk stratification.

• In Europe, using standardized terminology that is

matched to the images and reported via evidence-

based risk algorithms is becoming increasingly

popular

• An experienced sonologist can correctly distinguish

between benign and malignant adnexal masses.

However, the majority of imaging is performed and

interpreted by practitioners with varying levels of

expertise and confidence.

The New Consensus Panel

Recommendations

• In the USA, it is estimated that 200,000 women undergo surgeries for pelvic masses– 13%-21% women are found to have ovarian cancer

– Number of surgeries per malignancy:• USA→ 9.1

• European IOTA oncology center trials→ 2.3

• Other centers →5.9

– OLD ACOG Practice Bulletin [“Management of Adnexal Masses”] states … “With the exception of simple cysts on a TVU finding, most pelvic masses in post-menopausal women will require surgical intervention.”

• Surgical exploration of benign lesions have potential consequences with complications ranging from 2-15%

• Surgical intervention for malignant lesions improves survival outcomes when surgery is performed by a gyn-oncologist

The recommendations of the 1st

International Concensus Panel were

based partly by the IOTA SIMPLE RULES

• The IOTA group developed a “Simple Rules”

approach to evaluating an ovarian lesion

sonographically

• The “Simple Rules” allows practitioners with varying

degrees of sonography expertise to quickly use

standardized terminology and arrive at similar

results – BENIGN or MALIGNANT

• The “Simple Rules” are comprised of 5 features that

are indicative of BENIGN lesions and 5 features that

are indicated of MALIGNANT lesions

I= international

O= ovarian

T= tumor

A= analysis

The simple rules by

the IOTA group

Benign features • B1 feature: unilocular cyst with

thin, few, or incomplete septations or wall nodularity of ≤3 mm. There may be internal echoes.

• B2: presence of a solid component of ≤ 7 mm in largest diameter.

• B3: acoustic shadowing • B4: smooth multilocular tumor

of with a largest diameter ≤10 cm • B5: no detectable Doppler flow

IOTA simple rules

Timmerman D et al

Malignant features• M1: irregular solid tumor. • M2: presence of ascites. • M3: at least 4 papillary

structures within a cystic lesion.

• M4: irregular multilocular solid tumor with a largest diameter of ≥10 cm

• M5: very high color content on color Doppler examination.

IOTA simple rules

Timmerman D et al

31 32

33 34

35 36

11/20/2019

7

IOTA color score

D. Timmerman, B. Van Calster, A. Testa, L. Savelli, D. Fischerova, W. Froyman, L. Wynants, C. Van Holsbeke, E. Epstein, D. Franchi, J. Kaijser, A. Czekierdowski, S. Guerriero, R. Fruscio, F. Leone, A. Rossi, C. Landolfo, I. Vergote, T. Bourne, L. Valentin. Risk assessment of adnexal masses based on the IOTA Simple Rules. AJOG 2016.

Courtesy of D. Fischerova

IOTA Simple Rules

• If one or more M-features apply in the absence of a B-feature, the mass is classified as malignant.

• If one or more B-features apply in the absence of an M-feature, the mass is classified as benign.

• If both M-features and B-features apply, the mass cannot be classified. If no feature applies, the mass cannot beclassified.

Timmerman D, Testa AC, Bourne T, et al. Simple ultrasound-based rules for the diagnosis of ovarian cancer. Ultrasound Obstet Gynecol 2008;31(6):681-690.

D. Timmerman, B. Van Calster, A. Testa, L. Savelli, D. Fischerova, W. Froyman, L. Wynants, C. Van Holsbeke, E. Epstein, D. Franchi, J. Kaijser, A. Czekierdowski, S. Guerriero, R. Fruscio, F. Leone, A. Rossi, C. Landolfo, I. Vergote, T. Bourne, L. Valentin. Risk assessment of adnexal masses based on the IOTA Simple Rules. AJOG 2016.

Simple Risk Assessment Stratification

Profile: The 3 Categories

“Indeterminate”: Defined as unable to unambiguously place into the

“Almost certainly Benign” or “Suspicious for Malignancy” category

Slide courtesy Dr Platt

Simple US rules to distinguish between benign

and malignant masses before surgery:

prospective validation by IOTA group

• Prospective study to assess the Dx performance of

the IOTA Simple Rules to predict benignity vs

malignancy in an adnexal mass

• 19 centers; 1,938 patients (1,396 benign, 373 1ry

invasive, 111 borderline malignant, 58 metastatic tumors)

• Patients with adnexal masses had TVUS

• Mass was classified: benign or malignant

• Histology of mass is gold standard

• Surgery based on histology and US results

Timmerman D, et al. Ultrasound Obstet Gynecol 2010;36: 226-34

• On external validation (997 patients from 12

centers), the area under the receiver-operating

characteristics curve (AUC) revealed:

– for a model using 12 predictors (LR1) was 0.956,

– for a reduced model of 6 predictors (LR2) was

0.949 and

– for subjective assessment was 0.949.

– Subjective assessment gave a positive likelihood

ratio of 11.0 and a negative likelihood ratio of 0.14.

Simple US rules to distinguish between benign

and malignant masses before surgery:

prospective validation by IOTA group

Timmerman D, et al. Ultrasound Obstet Gynecol 2010;36: 226-34

Let us take the IOTA

concept to a higher platform

Welcome to the

ADNEX Model

37 38

39 40

41 42

11/20/2019

8

Assessment of Different NEoplasias in

the adneXa (ADNEX) modelFor those who want to read

more and apply it……..

The ADNEX Model:

easy as 1, 2, 3!! Step 1: Fill in the information

ClicKKK

Step 2: Read the resulting score

43 44

45 46

47 48

11/20/2019

9

• RESULTS: Of 131 women, 63 (48.1%) had a benign ovarian tumor, 16 (12.2%) had a BOT, 17 (13.0%) had Stage I OC, 24 (18.3%) had Stage II-IV OC and 11 (8.4%) had metastasis.

• AUC was 0.92 (95% CI, 0.88-0.97) for basic discrimination between benign vs malignant tumors.

• Performance was high for the discrimination between benign vs Stage II-IV OC, BOT vs Stage II-IV OC and Stage I OC vs Stage II-IV OC, with AUCs of 0.99, 0.97 and 0.94, respectively.

• Performance was poor for the differentiation between BOT vs Stage I OC and between Stage I OC vs ovarian metastasis with AUCs of 0.64.

• CONCLUSION: The majority of adnexal masses were classified correctly

• The authors expect the model to aid in the management of women with an adnexal mass presenting to a Gyn Onc service

• RESULTS: Of 131 women, 63 (48.1%) benign; 16 BOT, 17 Stage I OC, 24 Stage II-IV OC and 11 metastatic tumor.

• The ROC curve (AUC) was 0.92 (95% CI, 0.88-0.97) for basic discrimination between benign vs malignant

• CONCLUSION: The majority of adnexal masses were classified correctly

• The authors expect the model to aid in the management of women with an adnexal mass presenting to a Gyn Onc service

• Evaluation of malignancy risks by these 2 tests highlighted a NPV of 100% (there was no case of false negative) and a PPV of 80%.

• DISCUSSION AND CONCLUSION: The IOTA classification and the ADNEX multimodal algorithm used as risks prediction models can improve the performance of pelvic US and discriminate between benign and malignant cysts in postmenopausal women, especially for undetermined lesions.

And finally the ACR listened

• They try to eliminate standard cut-and-

paste reports such as: “Complex

adnexal mass. Malignancy cannot be

ruled out. Additional imaging is

suggested (meaning MRI)”, that never

really helped patients & gynecologists

• The ACR created a task force and

published the resulting document

J Am Coll Radiol 2018;15:1415-1429. Copyright 2018 American College of Radiology

The ultimate objective will be to apply the lexicon to a risk stratification classification for consistent follow-up and management in clinical practice. This white paper describes the consensus process in the creation of a standardized lexicon for ovarian and adnexal lesions and the resultant lexicon.

• Ultrasound is the most commonly used imaging technique for the evaluation of ovarian and other adnexal lesions.

• The interpretation of sonographic findings is variable because of inconsistency in descriptor terminology used among reporting clinicians.

• The use of vague terms that are inconsistently applied can lead to significant differences in interpretation and subsequent management strategies.

• A committee was formed under the direction of the ACR initially to create a standardized lexicon for ovarian lesions.

• The ultimate objective will be to apply the lexicon to a risk stratification classification for consistent follow-up and management in clinical practice.

• This white paper describes the consensus processJ Am Coll Radiol 2018;15:1415-1429. Copyright 2018 American College of Radiology

49 50

51 52

53 54

11/20/2019

10

….and maybe the first attempt

to bring IOTA closer to the

American Ob/Gyn

readership….:

• Sensitivity of the Simple Rules and Assessment of Different NEoplasias

in the adneXa model (using a cut-off of 10% to predict malignancy) are

92% and 96.5%, respectively, and specificities are 96% and 71.3%,

respectively.

• These models are the best predictive tests for the preoperative classification

of adnexal tumors.

• Their intent is to help the specialist make management decisions when

faced with a patient with a persistent ovarian mass.

• The models are simple, are easy to use, and have been validated in

multiple reports but not in the United States.

• We suggest they should be validated and widely introduced into medical

practice in the United States.

American Journal of Obstetrics & Gynecology DECEMBER 2017

American Journal of Obstetrics & Gynecology APRIL 2016

• OBJECTIVE: The Authors sought to develop and validate a model to predict the risk of malignancy in adnexal masses using the ultrasound features in the Simple Rules.

• Quantification of the risk of malignancy based

on the Simple Rules has good diagnostic

performance both in oncology centers and other

centers.

• A simple classification based on these risk

estimates may form the basis of a clinical

management system.

• Patients with a high risk may benefit from

surgery by a gynecological oncologist, while

patients with a lower risk may be managed

locally.

Conclusion

What I do in my practice for

adnexal masses

• Perform TVS for all gynecologic patient

• Color (power) Doppler for all gyn patients

• Document masses/cysts using 3D tomographic

mode

• Describe masses in the terms of IOTA simple rules

• Add ADNEX if Ca125 available

• Call Gyn & or Gyn Onc personally explaining IOTA

• Follow the course of the workup, additional imaging,

surgery and pathology report

“Papillae” and “Nodules”

are discriminatory

sonographic markers of

ovarian masses

Let me add to the above my

experience of looking at additional

discriminative features of ovarian

masses

55 56

57 61

66 67

11/20/2019

11

What are nodules & papillae?

• The difference between them is:

– Nodules are hyperechoic, usually

shadowing, sub-centimeter,

avascular inner wall structures in

cysts & at times on septae

– Papillae are hypoechoic, usually

non-shadowing, irregularly shaped,

vascular inner wall structures in cysts (please remember→ papilla -singular, as in: “one

papilla”; papillae – plural, as in: “two, three papillae”)

Q: does the finding of

papillae in adnexal cysts

increase the risk of ovarian

cancer?

A: Depends on their

sonographic character

The questions are:

• How do we diagnose a nodule or a

papilla?

• How do we use color or power Doppler?

• Are there any other characteristic

features that help sorting them out?

• And if we sort them out, does it mean the

we will be able to say that we can predict

or rule out malignancy?

Papillary projections/nodules

within ovarian or other cysts

• Can sensitive markers of malignancy

• If found

– 1. Measure them – size matters

– 2. Their number matters

– 3. Determine surface, shape and echogenicity

– 4. Observe if they shadow or not

– 5. Look for blood vessels in it

– 6. Examine their signature tissue texture

How to measure the papilla?

Timmmerman D: The IOTA group UOG 2000;16:500

The kinds of papillary

projections

Timmmerman D: The IOTA group UOG 2000;16:500

Sorry Dierk! This is a typical

sketch of a chronic hydrosalpinx!

The others are OK.

68 69

70 71

72 73

11/20/2019

12

Three kinds of nodules/papillae• Hyperechoic nodule/e

• No vessels in nodule

• Papilla does shadow

• Hypoechoic papilla/e!

• Irregular borders

• Vessels in papilla

• Does not shadow

Usually benign

(cystadeno-fibroma) Usually borderline ovarian

tumor or frank epithelial Ca.

In pregnancy c. aproprate

history: Decidualized

endometrioma

• Hypoechoic papilla/e

• Smooth, rounded borders

• Vessels in papilla

• Does not shadow

Mascilini F. et al, UOG 2014;Goldstein & Timor-Tritsch JCU 2010

Timor-Tritsch JCU 2019 Timmerman et al, UOG 2008;

First: papillae in an

endometrioma

An example:

Imperative (MD &RDMS!!) : obtain good history, ask

patient, review chart, call referring doctor and or NP

• You scan a 31 y.o. patient at 12 weeks for NT in

the right adnexa this is the TVS finding:

Benign or malignant?

If benign: is it a CL? or an E-oma?

If malignant: is it an epithelial Ca or clear cell Ca

Diagnosis:

decidualized E-oma

Evolution of a decidualized

endometrioma across and

after the pregnancy

9w4d 10w4d

38w5d

2 months postparum

11w5d 19w5d

Watch the difference between a papilla in a

decidualized endometrioma and that of a BOT

Rounded surface of papilla Irregular surface of papilla

„DIAGNOSTIC POINTERS“

Decidualized Endometrioma vs Ovarian Cancer

• Shallow, rounded papillae versus large

irregular (cauliflower shaped) papillae

protruding from the inner surface

Decidualized Endometrioma Ovarian Cancer

74 75

76 77

78 79

11/20/2019

13

Nodules in a cyst

An example:

Several ovarian cysts w. nodules/papillae

What do they have in common?

They have

echogenic,

shadowing nodules

& no blood vessels

Ultrasound and histopathologic correlation of ovarian cystadenofibromas: diagnostic value of the “shadow sign”Timor-Tritsch, Yoon, Monteagudo, Ciaffarano, Brandon, Mittal, Wallach, Boyd, MD1 JUM 2019

What next?

Apply power Doppler!!

No blood vewssel in the nodule

The ultimate proof:

is comparing a series of ovarian cysts with

nodules/papillae with their histopathology

80 81

82 83

84 85

11/20/2019

14

10mm

CAF 13D renedering (teaching

value only!

a b c

Question:

Over time, do cystadenofibrmas (or,

for that matter: cystadenomas)

undergo changes in appearance and/or

size?

11.24.14 3.9.15 8.26.15 12.10.15

a

a’

c

c’

d

d’

b

b’

Answer: not really!

The answer: No, or very little

Bilateral “resilient” cystadenoma

Third: papillae in in a cyst

An example:

86 87

88 89

90 91

11/20/2019

15

Papilla with blood flow

Highly

suspicious for

malignancyHighly suspicious

for malignancy

What abaout paraovarian cysts

considered a-priori benign?

Let us analyze this case

Diagnosis?

Paraovarian cyst with papilla

Attention: paraovarian cysts may have

papillae. If they do, look for blood vessels. If

they have, it may be a reason to remove them

©AIUM

Borderline Ovarian Tumor/

Low Malignant Potential tumor

In a significant number of

cases, mostly in reproductive

age women, cysts with

vascular papillae are

overwhelmingly consistent

with BOT of low malignant

potential

92 93

94 95

96 97

11/20/2019

16

Why is it important to mention

this kind of ovarian tumor?

Only two “word slides”…..

General• Borderline Ovarian Tumors (BOT) or tumors of Low

Malignant Potential (LMP) are:

– epithelial tumors (serous=50%: mucinous= 46%)

– have a slow growth & low invasive potential

– are often diagnosed at an earlier stage than invasive Ca.

– have good prognosis, present as: Stage I=70%; Stage II=10%;

– tend to occur in younger women

– 5 y. survival rate is ≈95%

• Because of all the above, fertility sparing conservative treatments

have been proposed

• Some suggest endoscopic approach after surgical staging Darai E et al, Eur J Obstet Gynecol Reprod Biol 1996;66:141Candiani M et al, Clin Exp Obstet Gynecol 1999;26:39

Seracchioli R et al, Fertil Steril 2001;76:999Camatte S et al, BJOG 2001;109:376

We may be able to determine

the above by looking at the

sonographic characteristics of

borderline ovarian tumors

Exacoustos C et al, Sonographic

appearance of borderline ovarian tumors.

• The most frequent diagnostic feature on imaging BOT is the

presence of papillae within the cyst. However, neither papillae

nor other sonographic features constituted highly sensitive

sonographic markers of BOT. (Doppler was NOT used!)

Ultrasound Obstet Gynecol 2005; 25: 50–59.

48yo serous BOT 52 yo ovary c. benign cystadenofibroma

We looked at the detailed

morphology of the BOTs and

revealed some interesting features.

A new sonographic descriptor of Borderline

ovarian tumors of low malignant potential

• As we evaluated the sonographic appearance of the

67 histologically proven BOT with LMPs a unique

feature became increasingly evident.

• A number of the papillae, solid components of different

sizes demonstrated a microcystic texture

• These microcysts measured between 1 and 3mm

5mm

10mm

A B

I. Timor/L.Boyd/A. Monteagudo/R. Wallach/C. Brandon/ C.Foley: UOG 2019

98 99

102 104

106 107

11/20/2019

17

5-9 MHz transvaginal probe

One more observation

6-12 MHz transvaginal probeI. Timor/L.Boyd/A. Monteagudo/R. Wallach/C. Brandon/ C.Foley: UOG 2019

Examples of microcystic

papillary texture

I. Timor/L.Boyd/A. Monteagudo/R. Wallach/C. Brandon/ C.Foley: UOG 2019

A

5mm

B

C

10 mm

Here are the results regarding US

characteristics of BOT of LMP

108 109

110 111

112 113

11/20/2019

18

What did we learn?

• The microcystic structures seen on high

frequency transvaginal scans can be seen on

low power microscopy on the histologic slides

which confirm the observations

• This sonographic feature can be considered

as one of the US markers of BOT of LMP

• It may render increased significance to

establish the diagnosis if combined with other

common features of BOT such as vascularity

and presence of papillae

Now I will try to answer the

main question: Can IOTA be

adopted in the USA?

Does it have a future here?

The answer is Yes and No at

the same time

Yes, if our governing bodies

(ACOG, AIUM, SGO) would support:

1. Extensive education & sonographer training

the ‘front end’ of Gyn US in this country

2. Convincing “Gyn generalists”, who forever (as

a ”knee-jerk” reaction) sent and are still

sending their patients straight to MRI after a

“garden variety US” exam without even trying

to use an experienced “US site/person“

Yes, if our governing bodies

(ACOG, AIUM, SGO) would support:

3. Convincing Gyn oncologists to except and use

expert US as a 1st imaging test for their patients,

and rarely operate based upon screening US

4. Re-educating Rad’s to avoid term: “complex

mass & additional imaging suggested,” & not to

report a ”laundry list” of differential diagnoses

(a.k.a. hedging), irrelevant to Gyn’s & Onc’s alike

5. Rad’s to adopt the new “Adnexal Lexicon”

proposed by some bold ACR Rad’s leaders

Simple Rules, Not So Simple: The Use of IOTA Terminology and Simple

Rules in Inexperienced Hands in a Prospective Multicenter Cohort

StudyMeys E, et al. Ultraschall Med 2017; 38 (6): 633-641

• Results: 46 discrepancies were observed in the description of ovarian masses when non-experts utilized the IOTA terminology

– Tumor type was misclassified (n=22); poor I/O agreement between non-expert and expert % of agreement 52.0%

– Misinterpretation of simple rules by non-experts was observed (n=57), erroneous diagnosis in 15 pts (30%)

– Agreement for classifying the mass as benign or inconclusive was only moderate between non-expert and expert % of agreement 70.0%

– Level of agreement for simple rules varied greatly; % of agreement 66-94%

• Conclusion: Simple rules are a useful to distinguish between a benign and malignant ovarian masses, but not in the hands of untrained examiners. More training with both the terminology and simple rules is necessary before the simple rules can be introduced into guidelines and daily clinical practice.

No! Not in my academic and

clinical lifetime, since…….:

1. I have a bad experience with the long way clinical

advances are transformed from concepts to widely

accepted practices (it took around 20 years for “my baby”, the

transvaginal US probe, to be slowly, generally accepted and used)

2. Unlike in Europe, in the USA Gyn “generalists” & Gyn

oncologists DO NOT perform their own US scans &

surgery mostly done without lookining at US images.

3. In the USA almost all Gyn US is performed by Rad’s,

and despite my hope for a change in their practices

and their reporting…this will SURELY NOT HAPPEN

in my lifetime

114 115

116 117

118 119

11/20/2019

19

However, let us be optimistic!

There are things that can be done

• ACOG: Please re-discover Ultrasound, it is

alive and thriving. Create Gyn US courses!

• AIUM: Bring gynecologists and radiologists to sit

together developing educational CME programs,

webinars, courses talking the same (US) language

involve & teach Med students!

• Extend the teaching of Gyn US in residency

and Onc fellowship programs: THOSE ARE

THE TIMES TO LEARN THE VALUE OF US

Conclusions:

What are the chances of the Simple IOTA Rules to

take roots in the USA?

• Short term?: slim → Reasons:

– Too few Ob/Gyns & no Gyn Onc’s scan

– Almost all gynecologic scans done by Rad’s

– Neither of them are versed in the IOTA concept

– USA Oncologists favor MRI over US

• Long term 5-10 years?: not un-reasonable:

– Rad’s adopting new lexicon and O-RADS model

– Will take time to let go “complex cyst” and

“additional imaging is suggested”

– Will take years to “retool” (old customs die hard)

Benacerraf BR, Abuhamad AZ, Bromley B, Goldstein SR, Groszman Y, Shipp TD, Timor-Trisch IE. Consider ultrasound

first for imaging the female pelvis. Am J Obstet Gynecol 2015; 212: 450-5

--Sassone AM1, Timor-Tritsch IE, Artner A, Westhoff C, Warren WB Transvaginal sonographic characterization of

ovarian disease: evaluation of a new scoring system to predict ovarian malignancy. Obstet Gynecol. 1991 Jul;78(1):70-6.

--Timor-Tritsch IE, Goldstein SR: The simplicity of a simple cyst and the complexity of a complex mass. JUM Editorial 2005

--Timmerman D, Testa AC, Bourne T, et al. Simple ultrasound-based rules for the diagnosis of ovarian cancer.

Ultrasound Obstet Gynecol 2008;31(6):681-690--Testa AC et al. Ovarian cancer arising in endometrioid cysts: ultrasound findings. UOG 2011; 38: 99

--John R van Nagell Jr & John T Hoff: Transvaginal sonography in ovarian screening: current perspectives. International journal of womann’s health 2013

--Radiology: Volume 256: September 2010 n radiology

-- Sohaey R, Gardner TL, Woodward PJ, Peterson CM. Sonographic diagnosis of peritoneal inclusion cysts. J Ultrasound Med 1995; 14:913-917

--Sohaey R, Gardner TL, Woodward PJ, Peterson CM. Sonographic diagnosis of peritoneal inclusion cysts. J Ultrasound Med 1995; 14:913-917

-- Modesitt SC et al Risk of malignancy in unilocular ovarian cystic tumors less than 10 cm in diameter. Obstet Gynecol

2003;102:594–9-- Saunders BA, et al. Risk of malignancy in sonographically confirmed septated cystic ovarian tumors. Gynecol Oncol

2010;188:278–82--Fruscella E et al. Sonographic features of decidualized ovarian endometriosis suspicious for malignancy..UOG 2004;

24: 578

-- Mascilini F. et al, Imaging in gynecological disease. 10: Clinical and ultrasound characteristics of decidualizedendometriomas surgically removed during pregnancy. UOG 2014;44):354-60.

-- Monteagudo A et al. Ovarian steroid cell tumors: sonographic characteristics. UOG 1997;10:282.-- Jeong-Ah Kim et al. High-Resolution Sonographic Findings

of Ovarian Granulosa Cell Tumors JUM 2010; 29:187–19

--van Nagell JR Jr,, Miller, RW. Management of Asymptomatic Ovarian Tumors Obstet Gynecol 2016;127:848–58-- John R van Nagell Jr & John T Hoff: Transvaginal sonography in ovarian screening: current perspectives.

International journal of womann’s health 2013--

Key References

Glanc P et al. JUM 2017

Glanc P et al. JUM

120 121

122 123