This document discusses the evaluation of adnexal masses using the International Ovarian Tumor Analysis (IOTA) classification system. It describes the IOTA terminology including simple descriptors for patterns like unilocular, solid, and cyst contents. The document also outlines the IOTA simple rules for predicting malignancy based on the presence of benign or malignant features. Examples are provided to demonstrate how to classify and diagnose masses using IOTA descriptors and rules. Resources for further learning about IOTA are also listed.

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

4. IOTA
Normal
ovaries
Premenopausal VS postmenopausal women

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

14. Unilocular-solid
IOTA

15. Multilocular
IOTA

16. Multilocular-solid
IOTA

17. Solid
IOTA

18. Cystic contents
IOTA

19. Mixed cystic contents
IOTA

20. Internal wall of the cyst
IOTA

21. IOTA
-projection >3 mm
Papillary

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

41. How to differentiate

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

58. Serous cystadenofibroma

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

76. THANK YOU
&
Jajakallah khair