X Multilocular Unilocular 0.3% Unilocular solid 2% 16% - PDF document

15/04/2019 Content Ovarian pathology: IOTA ADNEXAL MASSES X SIMPLE COMPLEX Usmi Chauhan DESCRIBE WHAT YOU SEE Clinical Sonographer • Clinically useful Monash Health • Benign • Malignant • Communication between clinicians/research IOTA terms for description of an adnexal mass Position: bilateral? Side? Size of solid component Size of lesion Papillary projections Type of Colour score tumour Number of locules /incomplete septum Ascites Echogenicity Presence of metastases Acoustic shadows Consensus statement on how to describe adnexal masses IOTA terms for description of an adnexal mass IOTA terms for description of an adnexal mass ‘5 types of tumour’ Malignancy rate Granberg et al 1989 ‘Lesion’ • Part of an ovary or adnexal mass inconsistent with normal physiology X Multilocular Unilocular 0.3% Unilocular solid 2% 16% Haemorrhagic cyst Struma ovarii 40% Multilocular solid Solid (solid tissue comprise ≥ 80% 73% of tumour) 1

15/04/2019 IOTA terms for description of an adnexal mass IOTA terms for description of an adnexal mass ‘5 types of cyst contents’ ‘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 Ground glass Anechoic Low level Haemorrhagic Mixed IOTA terms for description of an adnexal mass IOTA terms for description of an adnexal mass ‘Papillary projection’ ‘Septum’ • • Protrusion of solid tissue into a cyst cavity ≥ 3mm (height) Thin strand of tissue that runs from one internal cyst surface to another • Protrusions < 3mm (height) = irregularities Incomplete septum • does not reach the opposite wall of the cystic structure in some scanning • Papillary projections = solid component planes (seen in diseased tubes) Papillary projection Irregularity Septum Incomplete septum Solid component but not PP IOTA terms for description of an adnexal mass IOTA terms for description of an adnexal mass ‘Shadowing’ ‘Ascites’ • Fluid outside pouch of Douglas 2

15/04/2019 IOTA terms for description of an adnexal mass How do we use IOTA: practical applications ‘IOTA colour score’ • Adjust settings: maximize detection of flow without artifacts (3-6cm/s; PRF 0.3-0.6 kHz) IOTA Score 1 Score 3 (none) (moderate) Easy Pattern Simple ADNEX LR 1/LR 2 descriptors recognition rules Score 4 Score 2 (strong) (minimal) IOTA: Easy descriptors IOTA: Easy descriptors Unilocular cyst, Mass ground glass At least moderate echogenicity, +/- wall blood flow nodularity. Postmenopausal Premenopausal woman Ascites ENDOMETRIOMA MALIGNANT Unilocular cyst, mixed echogenicity (white ball, Mass SIMPLE CYST OR CYSTADENOMA > 50 years dot-dash), shadowing, CA125 > 100 IU/mL Premenopausal • Unilocular cyst DERMOID CYST MALIGNANT • Anechoic cyst fluid • Regular walls Unilocular cyst, • anechoic cyst fluid, < 10 cm regular walls,< 10 cm SIMPLE CYST OR CYSTADENOMA All other unilocular cysts with regular walls BENIGN IOTA: Pattern recognition IOTA: Pattern recognition ENDOMETRIOMA • Unilocular cyst • Ground glass echogenicity • +/- wall nodularity • premenopausal woman DERMOID CYST • Unilocular cyst • Mixed echogenicity (white ball, dot-dash) • Shadowing • Premenopausal Wall nodularity (blood clot/fibrin) (Not papillary projection) 3

15/04/2019 IOTA: Pattern recognition IOTA: Pattern recognition HAEMORRHAGIC CYST Reticular pattern Retracting clot MALIGNANT MALIGNANT • • Mass with at least moderate blood flow Mass And/or • • Postmenopausal > 50 years • Ascites • CA125 > 100 IU/mL IOTA: Pattern recognition IOTA: Pattern recognition Incomplete septae Serpiginous HYDRO (PYO/HEMATO) SALPINX • Conforms to shape of peritoneal cavity Ovary suspended in edge of cyst • Prior pelvic surgery PERITONEAL PSEUDOCYST Cog wheeling Beads on a string Solid Pelvic Tumours Solid Pelvic Tumours • Myoma (uterine) • Fibroma • Thecoma Ovarian malignancy • Brenner tumour Irregular contour Irregular echogenicity • Leydig cell tumour Increased vascularity • Malignancies Broad ligament fibroid Peduculated fibroid Dysgerminoma + yolk sac tumour • Round, oval lobulated; • Stripy shadows Granulosa cell tumour • Min vascularity Fibroma • May mimic pedunculated fibroid Neuroendocrine tumour of ovary 4

15/04/2019 IOTA: Simple Rules IOTA: Simple Rules B-rules M-rules Unilocular cysts. Irregular solid tumour. Presence of solid component Ascites. where the largest solid component <7 mm. Acoustic shadowing. At least four papillary structures. Smooth multi-locular tumour Irregular multilocular solid with a largest diameter <10 cm. tumour with largest diameter ≥ 10 cm. No blood flow. Very strong blood flow. Timmermen et al UOG 2008 IOTA: ADNEX model https://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 THANK YOU THANK YOU 3. If uncertain, use Simple Rules +/- ADNEX 5