Diane DeFriend Derriford Hospital, Plymouth

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1 Diane DeFriend Derriford Hospital, Plymouth

2 Ultrasound US remains primary imaging modality for investigation of an adnexal mass Aim to characterise Benign Malignant Indeterminate 90% adnexal masses characterised by ultrasound alone

3 Adnexal Masses- Why do we need to characterise Benign Conservative Management Discharge / Follow up imaging Surgery Minimally invasive Fertility sparing Malignant Staging laparotomy / Cytoreductive surgery Specialist gynaecological oncology surgeon Cancer Centre

AIMS RECOGNISE FEATURES MALIGNANCY Avoid need for repeat

masses benign May avoid unnecessary surgery

imaging Different approaches to characterising adnexal

4 AIMS RECOGNISE FEATURES MALIGNANCY Avoid need for repeat surgery RECOGNISE COMMON BENIGN MASSES Most adnexal masses benign May avoid unnecessary surgery INDETERMINATE MASSES Role of follow up / alternative imaging Different approaches to characterising adnexal masses Experienced examiner Subjective pattern recognition approach superior

5 Benign Ovarian Lesions BIG FIVE

7 Corpus Luteum Crenellated cyst Low level echoes Circumferential flow Secretory endometrium

8 Benign Adnexal Masses Simple Cysts Virtually exclude malignancy Large cysts - ensure not missing small nodules serous cystadenoma occ present as simple cyst esp larger cysts / older women Most resolve 1-2 months - follow up pre-menopausal > 5cm Post-menopausal > 3cm

strands)-strong predictor Clot may simulate solid nodule concave

10 Haemorrhagic Cysts Varied appearance change blood products over time Typical appearances reticular pattern (fibrin strands)-strong predictor Clot may simulate solid nodule concave border absence flow Atypical premenopausal Should resolve 1-2 cycles Follow -up

12 Endometrioma Characteristic Well defined cyst Uni / multilocular Homogenous low level echoes - ground glass appearance Hyperechoic wall foci Atypical 15% mural irregularity Usually avascular clot Rarely flow endometrial tissue Diffuse echoes Dermoid Cyst Mucinous ovarian tumour Further imaging Characteristic - haemorrhage

13 MR T1 high signal Endometrioma FS more conspicuous excludes dermoid T2 low signal (SHADING) complete loss signal dependent layering

Polycystic Ovary 2003 Consensus report defined PCOS 2 of 3 criteria Oligo and/or anovulation Hyperandrogenism Polycystic ovary US Polycystic Ovary 12+ follicles

15 Polycystic Ovary 2003 Consensus report defined PCOS 2 of 3 criteria Oligo and/or anovulation Hyperandrogenism Polycystic ovary US Polycystic Ovary 12+ follicles 2-9mm and/or Ovarian volume >10cc Follicle distribution/stromal echogenicity not included? 25 follicles - Dewailly et al follicles, yrs - Lujan et al 2013

internal composition Often specific features

Nodule echogenic nodule / dense well defined

Fat-Fluid level Echogenic mass (sebaceous

17 Germ Cell Tumours Cystic/Solid Mature Teratoma (Dermoid Cyst ) Variable appearance internal composition Often specific features Dermoid plug Tip of iceberg sign Rokitansky Nodule echogenic nodule / dense well defined shadowing Dermoid mesh Floating Balls Fat-Fluid level Echogenic mass (sebaceous material / hair ) ill defined shadowing obscures posterior border

Mature Teratoma ( Dermoid Cyst) Dermoid Mesh Multiple

Uncommon / Pathognomonic Sebaceous material around

at least 2 characteristic features detected Further

18 Mature Teratoma ( Dermoid Cyst) Dermoid Mesh Multiple echogenic lines/dots Hair fibres Floating Balls Uncommon / Pathognomonic Sebaceous material around focus debris/hair Fat fluid Level non specific Often at least 2 characteristic features detected Further imaging Atypical - characteristic for fat Visualise other ovary

20 T2 T1 T1 FAT SAT

22 BIG FIVE Benign Ovarian Lesions Corpus Luteal Cysts Functional Cysts Haemorrhagic Cysts Endometriomas PCOS Dermoids

23 Benign Extra- Ovarian Lesions Hydrosalpinx Para-ovarian Cysts Peritoneal Inclusion cysts

24 Paraovarian cyst Broad ligament Paramesonephric, mesothelial, mesonephric remnants Usually simple

25 Hydrosalpinx Tubular Incomplete septations Indentations opposite sides of wall -waist sign Mural nodules cogwheel beads on a string Echoes - pyosalpinx

26 Peritoneal Inclusion Cyst Functioning ovary Adhesions surgery, endometriosis, PID Cystic mass + septa Shape conforms to adjacent pelvic structures NB normal ovary within/ periphery mass

27 Pseudocyst / Peritoneal Inclusion Cyst

28 Pitfalls

29 Pitfalls

30 Bladder - TVS

33 Classification of Ovarian Neoplasms EPITHELIAL TUMOURS 65-70% Serous Cystadenoma/Carcinoma Mucinous Cystadenoma/Carcinoma Endometrioid Clear Cell Brenner Tumour GERM CELL TUMOURS 15-20% SEX CORD STROMAL TUMOURS 5-10% Mature Teratoma (Dermoid) / Immature Teratoma Dysgerminoma Granulosa Cell Sertoli Leydig Fibroma Thecoma Metastases 5-10 %

35 Classification of Ovarian Neoplasms EPITHELIAL TUMOURS 65-70% Serous Cystadenoma / Carcinoma Mucinous Cystadenoma / Carcinoma Endometrioid Clear Cell Brenner Tumour 85% malignant ovarian neoplasm Serous / Mucinous Benign Peak years Malignant - Peak 6-7 th decade Cystic and Solid - varying amounts solid tissue +/-Differentiation

Epithelial Tumours - Cystic/Solid - Serous Predominantly cystic

projections single best predictor of epithelial neoplasm 60%

(cystadenocarcinoma) Malignant more projections / solid tissue

36 Epithelial Tumours - Cystic/Solid - Serous Predominantly cystic Largely echo-free fluid Unilocular/multilocular Papillary projections single best predictor of epithelial neoplasm 60% benign (cystadenoma) few/small papillary nodules 25% malignant (cystadenocarcinoma) Malignant more projections / solid tissue 15% borderline (resemble benign or malignant) Serous cystadenocarcinoma

37 Epithelial Tumours - Cystic/Solid - Mucinous Multilocular Cystadenoma Echogenic fluid mucin Benign thin septa Malignant thick enhancing septa / solid elements Mucinous Cystadenocarcinoma 20-25% ovarian tumours 80% benign 10% borderline 10% malignant

38 Serous Bilaterality Ca2 + common psammomatous Peritoneal carcinomatosis Mucinous Rarely bilateral Ca2+ rare linear Pseudomyoma peritonei

hyperplasia Clear Cell 5% all ovarian cancer Malignant Assoc

39 Epithelial - Cystic / Solid Endometrioid 10-15% all ovarian cancers Almost always malignant 15-30% assoc endometrial Ca / hyperplasia Clear Cell 5% all ovarian cancer Malignant Assoc with endometriosis Most common neoplasm assoc with endometriosis

40 Pitfalls

Decidualised Endometriotic Cyst Hypertrophy

Decidual change ectopic endometrium Vascularised

level echoes Major contributory factor to

45 Decidualised Endometriotic Cyst Hypertrophy stromal cells endometrium during pregnancy Decidual change ectopic endometrium Vascularised rounded papillary projections in cyst with low level echoes Major contributory factor to incorrect diagnosis in pregnant women Resoving at follow up - surgically proven

46 Classification of Ovarian Neoplasms EPITHELIAL TUMOURS 65-70% Serous Cystadenoma/Carcinoma Mucinous Cystadenoma/Carcinoma Endometrioid Clear Cell Brenner Tumour GERM CELL TUMOURS 15-20% SEX CORD STROMAL TUMOURS 5-10% Mature Teratoma (Dermoid) / Immature Teratoma Dysgerminoma Granulosa Cell Sertoli Leydig Fibroma Thecoma Metastases 5-10 %

47 Solid Masses - Regular Regular solid masses often benign Pedunculated fibroid Typically solid Picket fence shadowing Ovarian fibroma Solid mass Marked acoustic shadowing (18-52%)

Solid Masses Regular Fibroma SEX CORD STROMAL TUMOURS 5-10% Granulosa Cell Sertoli Leydig Fibroma Thecoma Almost always benign Middle age women

48 Solid Masses Regular Fibroma SEX CORD STROMAL TUMOURS 5-10% Granulosa Cell Sertoli Leydig Fibroma Thecoma Almost always benign Middle age women Heterogenous/homogen ous solid mass Marked acoustic shadowing (18-52%) Differential Pedunculated fibroids Brenner Tumour Brenner Tumour Rarely malignant

49 Solid Masses Regular Fibroma Further imaging Large fibroids / shadowing may limit TVS Atypical Characteristic for fibrous tissue Visualise ovaries / relationship to uterus

50 Solid Masses Regular MEIGS Syndrome Ascites Pleural Effusion Benign ovarian tumour - Fibroma

Metastases Rare Tumours Sex Cord Stromal Tumours Malignant teratoma Dysgerminoma

51 Solid masses - Malignant Irregular solid mass suggests malignancy Epithelial neoplasms cystic/solid rarely completely solid Solid/nearly solid malignancies Metastases Rare Tumours Sex Cord Stromal Tumours Malignant teratoma Dysgerminoma Bilateral solid masses raise concern for metastases further imaging? primary Krukenberg - gastric

Rare 3% ovarian malignancies Peri /postmenopusal Unilateral - 95% US

52 Sex Cord Stromal - Granulosa Cell Tumours SEX CORD STROMAL TUMOURS 5-10% Granulosa Cell Sertoli Leydig Fibroma Thecoma Hormone secreting - oestrogen Rare 3% ovarian malignancies Peri /postmenopusal Unilateral - 95% US appearances non specific Cystic/solid - Solid 1/3 endometrial hyperplasia Up to 25% endometrial Ca

53 Sex Cord Stromal - Fibrothecoma SEX CORD STROMAL TUMOURS 5-10% Granulosa Cell Sertoli Leydig Fibroma Thecoma

Most common < 30 years Usually solid Immature Teratoma Most common first two decades

54 Solid masses Malignant GERM CELL TUMOURS 15-20% Mature Teratoma (Dermoid) / Immature Teratoma Dysgerminoma Dysgerminoma 17 yr old Immature Teratoma 27 yr old Dysgerminoma Most common < 30 years Usually solid Immature Teratoma Most common first two decades Predominantly solid, cystic/solid Raised AFP/Beta-hCG/LDH in some malignant germ cell tumours

55 Features of Malignancy Solid Component within cystic mass Irregular solid mass / wall Thick Septations Presence of Flow Borderline Ascites Peritoneal nodules Metastases /Nodes

56 Solid Component Most important predictor of malignancy Malignant Several nodules solid tissue Echogenicity similar to cyst wall Often convex / irregular Flow Benign Solitary / small papillary nodule serous cystadenoma Hyperechoic with shadowing dermoid Clot concave border / avascular

57 Septations Septa in cystic mass suggest neoplasm Increased risk malignancy > 2-3mm flow Fibrin strands Thin weak reflectors Numerous Do not traverse entire cyst Adjacent cysts may mimic

Doppler Colour doppler qualitative Flow in solid

similar specificity Spectral doppler Confirm presence

58 Doppler Colour doppler qualitative Flow in solid component / septum Power doppler increased sensitivity / similar specificity Spectral doppler Confirm presence flow Malignant tumours Low resistance flow lower PI & RI s, higher velocity RI < 0.4; PI <1.0 prev cited as cut-off for malignancy Overlap with benign little role characterisation

59 Ascites Indirect indicator of malignancy Small amount fluid in Pouch of Douglas normal in premenopausal women >15mm AP diameter Pre-existing illness eg cirrhosis Echogenic fluid - ruptured cyst/torsion Meig s Syndrome ascites + pleural effusion + fibroma

60 Indeterminate Masses Ultrasound Typical benign lesions Sensitive malignancy Many benign lesions demonstrate features malignancy Solid areas / septations / flow Tubo-ovarian abscess Cystadenofibroma Borderline tumours

61 Risk of Malignancy Index U Score M score Feature RMI 1 Score Ultrasound features: Multilocular cyst Solid areas Bilateral lesions Ascites Intra-abdominal metastases Pre-menopausal 1 Post menopausal 3 CA125 0=none 1=one abnormality 3=2 or more abnormalities U/ml RMI score = ultrasound x menopausal x CA125 level in U/ml Sensitivity 85% Specificity 97%

62 Triage using RMI Risk RMI Women (%) Risk of cancer (%) Low <25 40 <3 Moderate High > High RMI score > referral to specialist centre (SIGN Guidelines 2012) Intermediate RMI score MRI often considered appropriate RMI heavily influenced by CA 125 CA 125 may be elevated by benign disease esp pre-menopausal RMI recommended by RCOG and systematic review 2009 Geomini P et al The Accuracy of Risk Scores in Predicting Ovarian Malignancy: A Systematic Review Obstetrics & Gynecology; Volume 113 : 2, (Part 1), February 2009, pp

63 Simple Rules Developed as part of the IOTA (International Ovarian Tumour Analysis) study Prospective, multicentre, European study patients with adnexal masses, 21 centres, 9 countries Simple rules based on clearly defined US features BENIGN - B RULES Unilocular cyst Presence solid components where largest solid component < 7mm Presence acoustic shadowing Smooth multilocular tumour with largest diameter <100mm No blood flow MALIGNANT - M RULES Irregular solid tumour Ascites At least four papillary structures Irregular multilocular solid tumour with largest diameter 100mm Very strong blood flow

64 Ultrasound in Obstetrics & Gynecology Volume 41, Issue 1, pages 9-20, 25 DEC 2012 DOI: /uog Slides Ligita Jokubkiene Jan 2013 UOG Journal club

65 A mass is unclassifiable if no M or B features or both

66 Simple Rules Could be applied in 77% 2 step strategy Simple Rules + subjective assessment by experienced examiner if unclassifiable ( MDT ) 90% sensitivity and 93% specificity to detect ovarian malignancy Equivalent to expert subjective assessment in all (sensitivity 90% /specificity 93%) misclassified fewer stage 1 malignancies than did RMI and measurement of CA125. UK - RCOG included simple rules in 2011 guideline for evaluating ovarian pathology in premenopausal women

68 Conclusion Clinical, Pre/Post Menopausal CA125 US Adnexal Mass Likely Malignant Adnexal Mass Indeterminate Adnexal mass Likely benign Staging Characterisation Follow up

2/24/19. Ovarian pathology: IOTA ADNEXAL MASSES. Content. IOTA terms for description of an adnexal mass. IOTA terms for description of an adnexal mass

2/24/19. Ovarian pathology: IOTA ADNEXAL MASSES. Content. IOTA terms for description of an adnexal mass. IOTA terms for description of an adnexal mass Content Ovarian pathology: IOTA ADNEXAL MASSES X SIMPLE COMPLEX Dr DESCRIBE WHAT YOU SEE FRANZCOG, MPH, DDU, COGU Sonologist Clinically useful Benign Malignant Communication between clinicians/research