SCBT MR ADNEXAL INCIDENTALOMAS. Susan M. Ascher, MD Georgetown University School of Medicine Washington, DC
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1 SCBT MR ADNEXAL INCIDENTALOMAS Susan M. Ascher, MD Georgetown University School of Medicine Washington, DC
2 Managing incidentalomas can feel like
3
4
5 Low attenuation adnexal mass blah blah blah follow up US is recommend as clinically indicated.
6 GOALS: WHEN NOT TO PROMPTLY RE- IMAGE WITH ULTRASOUND Normal gyn structure Dx non-neo cyst vs benign neoplasm CT/MRI is characteristic Lesion is clearly myo Patel MD, Dubinsky TJ, Ultrasound Quarterly 2007; 23:
7 GOALS OF WHITE PAPER Practical framework for categorizing incidental adnexal findings Guidance for versus F/U US at specified interval versus Manage as appropriate to Dx
8
9 Adnexal Incidentalomas CT/MRI: THE RULES Nonpregnant & postmenarchal No known or suspected adnexal disorder Abdominal Pain common ER request No knowledge/access to prior imaging Postmenopausal 50 Early Late > 55 Exclusions: Normal findings
10 ASSIGNS CT/MRI FINDINGS INTO CATEGORIES Benign-appearing Cyst Probably Benign Cyst Adnexal Mass w/ Characteristic Features Other
11 ASSIGNS RECOMMENDATIONS: Category, Size & Meno Status No follow up Follow up US at specified intervals: Resolve or size over time Manage as is appropriate for dx
12 Benign-appearing Cyst* Round/oval Unilocular of uniform fluid signal/attenuation Regular/imperceptible wall Without solid areas or mural nodules < 10 cm in max diameter *If premeno may have layering hemorrhage
13 PREMENOPAUSAL 5 cm
14 POSTMENOPAUSAL 3 cm 3 cm < Early 5 cm Early > 5 cm Late > 3 cm
15 Probably Benign Cyst (PBC) Angulated margins Not round or oval Portion poorly imaged SNR (technical factors or no IV contrast)
16 PREMENOPAUSAL 3 cm 3 cm < PBC 5 cm > 5 cm
17 POSTMENOPAUSAL 3 cm-early 1 cm-late
18
19 1-3-5 RULE PRE POST
20 ANOTHER WAY Benign Cyst Probably Benign Cyst Pre F/U US 6-12 wk 3 < PBC 5 cm: F/U US 6-12 wk Early Post Late Post 3 < cyst 5 cm: F/U US 6-12 mo > 3 cm: > 3 cm: > 1 cm:
21 OTHER IMAGING FEATURES Solid component Mural nodule Septations Higher than fluid attenuation/signal T1-W FS Layering hemorrhage if post meno
22 SPECIFIC DIAGNOSIS? Yea Manage Nay DERMOID T1-W T1-W FS
23 CT & MRI DIAGNOSES WITH A HIGH DEGREE OF CERTAINTY
24 CASES Category: Size: Menstrual Status: PRE EARLY MENO POST REC: 5.2 cm BENIGN FU PROMPT 6-12 WK US Pre Early Post Late Post Benign Cyst F/U US 6-12 wk 3 < cyst 5 cm: F/U US 6-12 mo > 3 cm: Prob Benign Cyst 3 < PBC 5 cm: F/U US 6-12 wk > 3 cm: > 1 cm:
25 OVARIAN CASES CANCER Category: OTHER Size: IRRELEVANT Menstrual Status: IRRELEVANT Rec: SURGERY Pre Early Post Late Post Benign Cyst F/U US 6-12 wk 3 < cyst 5 cm: F/U US 6-12 mo > 3 cm: Prob Benign Cyst 3 < PBC 5 cm: F/U US 6-12 wk > 3 cm: > 1 cm:
26 CASES Category: BENIGN Size: 3.5 cm Menstrual Status: EARLY LATE POST Rec: F/U PROMPT US 6-12 US MO Pre Early Post Late Post Benign Cyst F/U US 6-12 wk 3 < cyst 5 cm: F/U US 6-12 mo > 3 cm: Prob Benign Cyst 3 < PBC 5 cm: F/U US 6-12 wk > 3 cm: > 1 cm:
27 HEMORRHAGIC CASES CYST Courtesy of M. Patel, MD Mayo Clinic, Arizona Category: BENIGN Size: 5 cm Menstrual Status: PRE EARLY MENO POST Rec: NO F/U F/U 6-12 WKS* Benign Cyst Prob Benign Cyst Pre Early Post Late Post F/U US 6-12 wk 3 < PBC 5 cm: F/U US 6-12 wk 3 < cyst 5 cm: F/U US 6-12 mo > 3 cm: * > 3 cm: > 1 cm:
28 BILATERAL CASES TOA S Category: OTHER Size: IRRELEVANT Menstrual Status: PRE MENO REC: ANTIBIOTICS Pre Early Post Late Post Benign Cyst F/U US 6-12 wk 3 < cyst 5 cm: F/U US 6-12 mo > 3 cm: Prob Benign Cyst 3 < PBC 5 cm: F/U US 6-12 wk > 3 cm: > 1 cm:
29 BILATERAL TOA S
30 CASES: PERITONEAL INCLUSION CYST Category: OTHER Size: IRRELEVANT Menstrual Status: PRE MENO Rec: TX AS NEEDED Benign Cyst Prob Benign Cyst Pre Early Post Late Post F/U US 6-12 wk 3 < PBC 5 cm: F/U US 6-12 wk 3 < cyst 5 cm: F/U US 6-12 mo > 3 cm: * > 3 cm: > 1 cm:
31
32 HYDROSALPINX CASES Category: OTHER Size: IRRELEVANT Menstrual Status: PRE MENO Rec: MANAGE Pre Early Post Late Post Benign Cyst F/U US 6-12 wk 3 < cyst 5 cm: F/U US 6-12 mo > 3 cm: Prob Benign Cyst 3 < PBC 5 cm: F/U US 6-12 wk > 3 cm: > 1 cm:
33 SO, HOW ARE WE DOING No data for acr white paper, but Rosenkrantz AB, Keirans AS. Radiology 2014; 271:
34 CONCLUSIONS 1. Categorize lesion 2. Make recommendation
35 CONCLUSIONS Normal structure Do nothing! Benign or Benign-appearing cyst: Size (1-3-5 cm) Menstrual Status (pre or post) No F/U, Interval F/U or Characteristic Manage Appropriately Still not sure
36 Thank you
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