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Ovarian tumor analysis
- 1. Adnexal mass evaluation (IOTA Terminology, Simple Descriptors and Simple Rules) A.S.M. SUFIAN HMO , Cumilla Medical College Hospital (Radiology & Imaging )
- 2. Ovarian pathology Classification system for ovarian pathology Standardization of terminology – IOTA IOTA Simple Descriptors (pattern recognition) Prediction of malignancy– IOTA Simple Rules Examples The International Ovarian Tumor Analysis (IOTA)
- 3. Ovarian cysts and tumors IOTA
- 5. The report reallymatters • Is it benign or malignant? • Simple cyst • Complex cyst • Can we do better?
- 6. By the end of this presentation you will be able to report this! How to report this abnormality?
- 7. Classification system for adnexal masses • Benign ovarian • Benign non-ovarian • Primary malignant ovarian • Secondary malignant ovarian
- 8. Classification system for adnexal masses BENIGN OVARIAN: ascites and • Polycystic ovaries • Functional cysts • Endometriomas • Serous cystadenoma • Mucinous cystadenoma • Mature teratoma • Fibroma (rare, can cause Meig’s syndrome: pleural effusion)
- 9. Classification system for adnexal masses BENIGN NON-OVARIAN: • Paratubal cyst • Hydrosalpinx • Tubo-ovarian abscess • Peritoneal pseudocysts • Appendicular abscess • Diverticular abscess • Pelvic kidney • Ectopic pregnancy
- 10. Classification system for adnexal masses PRIMARY MALIGNANT OVARIAN Epithelial carcinoma – Borderline – Serous cystadenocarcinoma (commonest ovarian cancer, 50% malignancies) – Mucinous cystadenocarcinoma (10% ovarian malignancies) • Borderline variant is pseudomyxoma peritonei -exclude appx primary – Endometrioid carcinoma (25% ovarian malignancies)(associated with endometrial ca in 20%) – Clear cell carcinoma Germ cell tumor – Malignant teratoma – Dysgerminoma • Sex-cord tumor – Granulosa cell tumor (secretes estrogen)
- 11. Classification system for adnexal masses SECONDARY MALIGNANT OVARIAN • 10% of ovarian malignancy Predominantly: • Breast • Gastrointestinal carcinoma (Krukenberg tumor)
- 12. IOTA definitions – Unilocular, Unilocular-solid, Multilocular, Multilocular-solid or Solid – Cyst contents– or hemorrhagic. anechoic, low level, ground glass, mixed – Solid material or papillary structures or wall irregularity (presence and size) – Vascularity – Shadows – Ascites
- 13. Unilocular IOTA
- 17. Solid IOTA
- 20. Internal wall of the cyst IOTA
- 22. IOTA Definitions • Solid component – Structure that has echogenicity suggestive of solid tissue. BUT the white ball of a Dermoid is not solid tissue and blood clot or mucin is not solid tissue • If protrusion >3 mm = papillary projection (count as Solid component) If < 3 mm = irregularity • Irregular – contour of means an irregular internal wallOR irregular outer • Ascites – fluid outside POD lesion a solid
- 23. Vascularity score • Colour Doppler or Power Doppler (more cm/sec Doppler gain to just below artefact sensitive) • PRF0.3 • Velocityscale 3-6 • Balance 220 • Adjust level Moderate flow • No flow =1 • Minimalflow =2 • = Strong 3 flow throughout = 4
- 24. Ovarian pathology • Classification systemfor ovarian pathology • Standardization of terminology – IOTA • IOTA Simple Descriptors (pattern recognition) • Prediction of malignancy – IOTA Simple Rules • Worked examples
- 25. Simple Descriptors • Certain abnormalities are really obvious: RECOGNITION - • Endometrioma • Benign cystic teratoma / Dermoid Cyst • Simple cyst or serous cystadenoma • Functional • Malignant Cyst. Eg. Hemorrhagic cyst. tumour with ascites PATTERN
- 27. BD, benign descriptor; MD, malignant descriptor. Simple Descriptors of an ovarian mass used to make a diagnosis
- 28. When Simple Descriptorsdo not apply: • If the mass is not instantly recognizable and Simple Descriptorsdo not applicable: –Then apply Simple Rules
- 29. Ovarian pathology • Classification systemfor ovarian pathology • Standardization of terminology – IOTA • IOTA Simple Descriptors (pattern recognition) • Prediction of malignancy – IOTA Simple Rules • Worked examples
- 30. • Simple ultrasound-based rules Morphologic Classification (n=1066) Type of tumor N Malign. % 1.Unilocular cyst 313 2 0.6 2.Unilocular solid 132 44 33 3.Multilocular cyst 196 20 10 4.Multilocular solid 284 116 41 5.Solid tumour 136 84 62
- 32. Simple Rules FEATURES of a benign mass (B-features) A mass is classified as benign if at least one B- feature is present and no M-features are present
- 33. FEATURES of a malignant mass (M features) A mass is classified as malignant if at least one M-feature is present and no B-features are present
- 34. Simple Rules Rule 1: If one or more M features are present in absence of B feature(s), the mass is classified as malignant. • Rule 2: If one or more B features are present in absence of M feature(s), the mass is classified as benign. • Rule 3: If both M features and B features are present, or if no B or M features are present, the result is inconclusive and a second stage test is recommended.
- 35. • examples–
- 36. premenopausal
- 37. Endometrioma unilocular, ground glass echogenicity,
- 38. Simple Descriptors Pattern recognition premenopausal
- 39. unilocular , Dermoid mixed echoes, shadows, premenopausal
- 42. <10 cm
- 43. Serous cystadenoma unilocular, regular walls, <10 cm
- 45. Stage 4 ovarian carcinoma with ascites Tumor with at least moderate blood flow, ascites, postmenopausal
- 46. Exampleswhere Simple descriptor don’t apply
- 47. <10cm
- 49. Example 1 Simplerules: BENIGN Mucinous cystadenoma
- 50. Example 2
- 52. Example 2 Simple rules:MALIGNANT Metastasis from bowel primary
- 53. E x a m p l e 3
- 54. • IOTA descrition – Unilocular, unilocular-solid, multilocular, multilocular-solid or solid – Cyst contents – anechoic, low level, ground glass, hemorrhagic or mixed – Uncertain (NO BENIGN RULES AND NO MALIGNANT RULES = UNCERTAIN
- 55. Example 3 Simple rules:UNCERTAIN Borderline ovariantumour
- 60. Ovarian Fibroma most commonly manifest as solid, hypoechoic masses with ultrasound beam attenuation. As such, they may appear similar to a pedunculated subserosal uterine fibroid
- 72. Resources apps (risk • IOTA – papers, courses, calculators), conferences hKp://www.iotagroup.org • ISUOG – papers, journal club slides • GE poster. • Internet slide and picture.
- 73. IOTA apps
- 74. IOTA apps
Editor's Notes
- Example
- Video
- Benign , fibroma
- video
- CT scan – Multilobulated solid masses with prominent fibrovascular septa. Post contrast imaging shows enhancement of the septae. Other- calcification may be present in a speckled pattern.
- video
- example
- Papillary serous cystadenocarcinoma