IOTA classification Susanne Johnson FRCOG Southampton, UK - - PowerPoint PPT Presentation

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IOTA classification Susanne Johnson FRCOG Southampton, UK - - PowerPoint PPT Presentation

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London Cancer and Barts Health IOTA Simple Rules Meeting September 2018 Prediction of malignancy in adnexal masses IOTA classification Susanne Johnson FRCOG Southampton, UK GynaecologyUltrasound.com IOTA classification Simple Rules

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London Cancer and Barts Health IOTA Simple Rules Meeting September 2018

Prediction of malignancy in adnexal masses

IOTA classification

Susanne Johnson FRCOG Southampton, UK

GynaecologyUltrasound.com

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  • IOTA classification
  • Simple Rules
  • ADNEX
  • Worked Examples
  • Quiz later this morning

GynaecologyUltrasound.com

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Imaging of the ovaries: predicting the risk of malignancy in adnexal masses is important

  • Diagnose ovarian cancer earlier
  • Enable women with malignancies to have surgery in a dedicated oncology

centre

  • Triage women with benign pathology to benign gynaecology service for

– conservative management – minimally invasive surgery

GynaecologyUltrasound.com

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IOTA classification

  • Standardisationof terminology – IOTA
  • Prediction of malignancy – IOTA Simple Rules
  • IOTA Risk of Malignancy Model: ADNEX

GynaecologyUltrasound.com

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The original IOTA paper

GynaecologyUltrasound.com

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IOTA criteria to describe adnexal masses

– Unilocular, unilocular-solid, multilocular, multilocular-solid or solid – Cyst contents – anechoic, low level, ground glass, haemorrhagic or mixed – Solid material or papillary structures or wall irregularity (presence and size) – Vascularity – Shadows – Ascites

GynaecologyUltrasound.com

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Unilocular Unilocular-solid Multilocular Multilocular-solid Solid

Locularity

GynaecologyUltrasound.com

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Echogenicity of cystic contents

  • Anechoic
  • Low level
  • Ground glass
  • Haemorrhagic
  • Mixed

GynaecologyUltrasound.com

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Solid material / papillations

  • Solid component – structure that has echogenicity suggestive of tissue

– at least 3 mm

  • BUT

– the white ball of a dermoid is not solid tissue – blood clot or mucin is not solid tissue

  • A papillary projection is a protrusion >3 mm in height from the cyst wall

(this also counts as a solid component) If < 3 mm = irregularity

  • Irregular – means an irregular internal wall OR irregular outer contour of a

solid lesion

GynaecologyUltrasound.com

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Solid material

Solid material – Papillations (indent the cyst wall) Solid material – Not a papillation (no indentation)

GynaecologyUltrasound.com

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Vascularity score

  • Colour Doppler
  • PRF 0.3 – 0.6
  • Velocity scale 3-6 cm/sec
  • Adjust Doppler gain to just below artefact level
  • No flow = 1

(none at all at PRF 0.3)

  • Minimal flow = 2

(really have to look for it)

  • Moderate flow = 3

(just there)

  • Strong flow throughout = 4

(strong, in one area or all over)

GynaecologyUltrasound.com

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Vascularity scores 1- 4

1 2 3 4

GynaecologyUltrasound.com

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Shadows - dense

GynaecologyUltrasound.com

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Shadows - subtle

GynaecologyUltrasound.com

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Ascites

Fluid outside POD ie above the level of the uterine fundus

GynaecologyUltrasound.com

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  • Standardisationof terminology – IOTA
  • Prediction of malignancy – IOTA Simple Rules
  • IOTA Risk of Malignancy Models: LR2 and ADNEX

GynaecologyUltrasound.com

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Simple descriptors

  • Pattern recognition
  • 50% adnexal masses – usually ‘instantly’ recognisable

eg

  • Endometrioma
  • Dermoid
  • Simple cyst/cystadenoma
  • Physiological cysts eg haemorrhagic cyst
  • Malignant tumour with ascites
  • But if the mass does not fit one of these categories – then use Simple Rules

GynaecologyUltrasound.com

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GynaecologyUltrasound.com

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GynaecologyUltrasound.com

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BMJ 2010

GynaecologyUltrasound.com

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Simple Rules – BENIGN features

Solid component <7 mm Unilocular Shadowing Smooth multilocular <100 mm No vascularity (1+) Simple Rule : The mass is classified as BENIGN if

  • ne or more B features

are present in absence of M feature(s)

GynaecologyUltrasound.com

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Simple Rules – MALIGNANT features

Irregular solid tumour At least 4 papillary structures Irregular multilocular-solid >100 mm Very strong bloodflow (4+) Ascites

Simple Rule: The mass is classified as MALIGNANT if one or more M features are present in absence of B feature(s)

GynaecologyUltrasound.com

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Simple Rules

  • Rule 1: The mass is classified as MALIGNANT if one
  • r more M features are present in absence of B

feature(s)

  • Rule 2: The mass is classified as BENIGN if one or

more B features are present in absence of M feature(s)

  • Rule 3: The result is INCONCLUSIVE if both M

features and B features are present, or if no M or B features are present

GynaecologyUltrasound.com

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Sheet with Simple Rules

GynaecologyUltrasound.com

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IOTA website: www.iotagroup.org

GynaecologyUltrasound.com

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Worked examples

GynaecologyUltrasound.com

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MAX 90 mm

Example 1

GynaecologyUltrasound.com

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Worked example 1

  • IOTA descriptors

– Unilocular, unilocular solid, multilocular, multilocular solid or solid – Cyst contents – anechoic, low level, ground glass, haemorrhagicor mixed – Solid material or papillary structures or wall irregularity (presence and size) NO – Vascularity 1-4 2 – Shadows NO – Ascites NO

  • Simple rules

– Benign - unilocular, smooth multilocular tumor < 100 mm, largest solid component diameter < 7mm, acoustic shadows, no blood flow (color score 1) – Malignant - Irregular solid tumor, Irregular multilocular solid tumor ≥ 100 mm, ≥ 4 papillary structures, ascites, very strong blood flow (color score 4) – Uncertain

Simple rules: BENIGN

GynaecologyUltrasound.com

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Simple rules: BENIGN

Mucinous cystadenoma

GynaecologyUltrasound.com

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Example 2

GynaecologyUltrasound.com

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Worked example 2

  • IOTA descriptors

– Unilocular, unilocular solid, multilocular, multilocular solid or solid – Cyst contents – anechoic, low level, ground glass, haemorrhagicor mixed – Solid material or papillary structures or wall irregularity (presence and size) – Vascularity 1-4 4 – Shadows NO – Ascites NO

  • Simple rules

– Benign - unilocular, smooth multilocular tumor < 100 mm, largest solid component diameter < 7mm, acoustic shadows, no blood flow (color score 1) – Malignant - Irregular solid tumor, Irregular multilocular solid tumor ≥ 100 mm, ≥ 4 papillary structures, ascites, very strong blood flow (color score 4) – Uncertain

Simple rules: MALIGNANT

GynaecologyUltrasound.com

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Simple rules: MALIGNANT

Metastasis from bowel primary

GynaecologyUltrasound.com

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Example 3

GynaecologyUltrasound.com

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Worked example 3

  • IOTA descriptors

– Unilocular, unilocular solid, multilocular, multilocular solid or solid – Cyst contents – anechoic, low level, ground glass, haemorrhagicor mixed – Solid material or papillary structures or wall irregularity (presence and size) – Vascularity 1-4 1-2 – Shadows NO – Ascites NO

  • Simple rules

– Benign - unilocular, smooth multilocular tumor < 100 mm, largest solid component diameter < 7mm, acoustic shadows, no blood flow (color score 1) – Malignant - Irregular solid tumor, Irregular multilocular solid tumor ≥ 100 mm, ≥ 4 papillary structures, ascites, very strong blood flow (color score 4) – Uncertain (NO BENIGN RULES AND NO MALIGNANT RULES = UNCERTAIN)

Simple rules: UNCERTAIN

GynaecologyUltrasound.com

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Simple rules: UNCERTAIN

Borderline ovarian tumour

GynaecologyUltrasound.com

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How good are Simple Rules?

  • When ‘Benign’ or ‘Malignant’
  • Sensitivity 92 %
  • Specificity 96 %
  • Timmerman et al 2010
  • But they are ‘Uncertain’ in 25% cases
  • Which second stage test to use?

GynaecologyUltrasound.com

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Ultrasound Second stage tests when Simple Rules are Inconclusive:

  • RMI
  • LR2
  • Simple Risk Rules SRR with traffic light system for varying levels of risk
  • Subjective opinion by expert
  • ADNEX

GynaecologyUltrasound.com

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  • Standardisationof terminology – IOTA
  • Prediction of malignancy – IOTA Simple Rules
  • IOTA Risk of Malignancy Model: ADNEX

GynaecologyUltrasound.com

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And: Age, Oncology Centre, Ca125 level (optional)

GynaecologyUltrasound.com

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Example

Age 49 Some pelvic pain Ovarian cystectomy 10 years ago ?side Normal CA125

GynaecologyUltrasound.com

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ADNEX model

www.IOTAgroup.org/adnexmodel desktop or phone

GynaecologyUltrasound.com

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Results

  • Choose a ‘cut-off’ for distinguishing between Benign and Malignant

Eg 10%,15%, 20% or 25%

  • Patient specific increase in risk compared to baseline
  • Distinguish between different types of malignancy eg BOT, early stage v late stage

and metastatic

GynaecologyUltrasound.com

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Simple Rules:

Simple Rules: no Benign features / no Malignant features = UNCERTAIN Subjective Opinion – mucinous Borderline Ovarian Tumour (BOT)

GynaecologyUltrasound.com

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Laparoscopic BSO for likely malignancy

FIGO 1 BORDERLINE mucinous ovarian tumour

Surgery - Sameer Umranikar at PAH, Southampton

GynaecologyUltrasound.com

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How do the tests perform?

Sensitivity Specificity RMI >250 70 90 Simple Rules when conclusive B / M * Subjective Assessment (all masses) 92 90 96 93 ** ADNEX >10% cut-off 97 71 ***

* Simple rules – excludes uncertain 23% cases

Sensitivity Probability that a test is POSITIVE if the disease is present eg CANCER Specificity Probability that a test is NEGATIVE if the disease is absent eg BENIGN pathology

**Timmerman et al 2010 *** Van Calster B 2014

GynaecologyUltrasound.com

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  • RMI was least accurate
  • ADNEX: 0ptimum cut-off 26.1% with sensitivity 0.9 and specificity 0.76
  • Only Subjective Appearance by expert was superior to ADNEX

GynaecologyUltrasound.com

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Which ‘prediction of malignancy test’ to use

  • CA125 and RMI not useful
  • Simple Rules very good but ± 25% cases are ‘Uncertain’
  • ADNEX – very good test

–(almost) as good as having an expert in your clinic

GynaecologyUltrasound.com

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Prediction of malignancy

  • Describe the mass using IOTA terminology
  • Use Simple Descriptors

applicable in 50% masses

  • Use Simple Rules

applicable in 75% of masses

  • Where Simple Rules are Uncertain:

–Apply ADNEX

GynaecologyUltrasound.com

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GynaecologyUltrasound.com

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FURTHER SOURCES

www.IOTAgroup.org

  • List of their published papers
  • Courses with IOTA-accreditation exams
  • Download Apps (malignancy risk calculators SR, LR2 and ADNEX)
  • Conference dates

GynaecologyUltrasound.com

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IOTA website: www.iotagroup.org

GynaecologyUltrasound.com

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GynaecologyUltrasound.com

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GynaecologyUltrasound.com

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GynaecologyUltrasound.com

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@GynaecologyUS www.facebook.com/GynaecologyUltrasound

GynaecologyUltrasound.com

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THANK YOU

GynaecologyUltrasound.com

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GynaecologyUltrasound.com

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QUIZ

GynaecologyUltrasound.com

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QUIZ

Use the sheet with the Simple Rules

  • Look at the mass and describe it using IOTA criteria
  • Apply Simple Descriptors/pattern recognition
  • Apply Simple Rules
  • Decide whether benign, uncertain or malignant
  • Suggest histological diagnosis

GynaecologyUltrasound.com

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Q1

premenopausal<10 cm

GynaecologyUltrasound.com

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Q2

<10 cm, smooth multilocular cyst with no solid material

GynaecologyUltrasound.com

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Q3

GynaecologyUltrasound.com

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Q4

GynaecologyUltrasound.com

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Q5

GynaecologyUltrasound.com

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Q 6

<10 cm

GynaecologyUltrasound.com

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Q7 <10 cm

GynaecologyUltrasound.com

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Q8

GynaecologyUltrasound.com

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Q9

GynaecologyUltrasound.com

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Q10

GynaecologyUltrasound.com

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Q11

premenopausal One week later …

GynaecologyUltrasound.com

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Q12

GynaecologyUltrasound.com

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Q13

GynaecologyUltrasound.com

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Q14

GynaecologyUltrasound.com

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Q15

GynaecologyUltrasound.com

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Q16

GynaecologyUltrasound.com

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Q17

GynaecologyUltrasound.com

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Q18

GynaecologyUltrasound.com

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Q19

GynaecologyUltrasound.com

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Q20

GynaecologyUltrasound.com

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ANSWERS

GynaecologyUltrasound.com

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Q1 – Simple descriptors

Serous cystadenoma

GynaecologyUltrasound.com

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Q2 –Simple rules B4 and B5

smooth multilocular <10 cm, no blood flow Mucinous cystadenoma

GynaecologyUltrasound.com

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Q3 – Simple rules M1

irregular solid Stage 3 ovarian cancer

GynaecologyUltrasound.com

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Q4 – Simple descriptor

Dermoid

GynaecologyUltrasound.com

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Q5 Simple Rules

Uncertain ( no B, no M) Borderline ovarian tumour

GynaecologyUltrasound.com

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Q 6 Simple Rules B4

smooth multilocular <10 cm Mucinous cystadenoma

GynaecologyUltrasound.com

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Q7 Simple Rules B4

smooth multilocular <10 cm Serous cystadenoma

GynaecologyUltrasound.com

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Q8 Simple Rules M1 and M5

irregular solid, very strong blood flow Metastatic colon cancer

GynaecologyUltrasound.com

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Q9 Simple Rules B3

Shadowing Fibroma

GynaecologyUltrasound.com

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Q10 - Simple descriptor

Endometrioma

GynaecologyUltrasound.com

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Q11 Simple Rules B1

Unilocular (no solid material as this is clot) physiological cyst

One week later …

GynaecologyUltrasound.com

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Q12 Simple Rules M1 and M5

irregular solid and strong blood flow Stage 4 serous ovarian carcinoma

GynaecologyUltrasound.com

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Q13 Simple Rules

B3 shadows and probably B5 no colour Mature teratoma ( dermoid)

GynaecologyUltrasound.com

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Q14 Simple rules B1

Unilocular Endometrioma

GynaecologyUltrasound.com

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Q15 Simple rules M1 and M5

Malignant – irregular solid and strong vascularity Borderline serous cystadenoma

GynaecologyUltrasound.com

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Q16 Simple Rules B4

smooth multilocular <10 cm Mucinous cystadenoma

GynaecologyUltrasound.com

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Q17 Simple Rules M5

strong blood flow Stage 4 MMMT - ovary

GynaecologyUltrasound.com

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Q18 Simple Rules Uncertain

irregular solid with shadowing and some strong vascularity Secondary malignancy - Bilateral Krukenberg from GI primary

GynaecologyUltrasound.com

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Q19 Simple Rules B4

smooth multilocular <10 cm Serous cystadenoma

GynaecologyUltrasound.com

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Q20 Simple Rules M1 and M5

M1 irregular solid and M5 strong vascularity

  • varian serous adenocarcinoma

GynaecologyUltrasound.com

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THANK YOU

GynaecologyUltrasound.com