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

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1 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 Monash Health Position: bilateral? Side? Size of solid component Size of lesion Papillary projections Type of tumour Colour score Number of locules / Incomplete septum Ascites Echogenicity Presence of metastases Accoustic shadows Consensus statement on how to describe adnexal masses 5 Types of tumour Malignancy rate Granberg et al 1989 Lesion Part of an ovary or Adnexal mass inconsistent with normal physiology X Unilocular 0.3% 2% Multilocular 16% Haemorrhagic cyst Struma ovarii Multilocular solid Unilocular solid 40% Solid (solid tissue comprise 80% of tumour) 73% 1

2 5 types of cyst contents Solid component A structure that has echogenicity suggestive of tissue (myometrium, ovarian stroma) NOT white ball in a dermoid cyst NOT blood clot, or mucous Concave Push on the lesion Colour Doppler Anechoic Low level Ground glass Haemorrhagic Mixed Papillary projection Protrusion of solid tissue into a cyst cavity 3mm (height) Protrusions < 3mm (height) = irregularities Papillary projections = solid component Septum Thin strand of tissue that runs from one internal cyst surface to another Incomplete septum does not reach the opposite wall of the cystic structure in some scanning planes (seen in diseased tubes) Papillary projection Irregularity Solid component but not PP; base >7mm Septum Incomplete septum Shadowing Ascites Fluid outside pouch of Douglas 2

3 How do we use IOTA: practical applications IOTA colour score Adjust settings: maximize detection of flow without artifacts (3-6cm/s; PRF khz) Score 1 (none) Score 3 (moderate) Easy descriptors Pattern recognition IOTA Simple rules ADNEX LR 1/LR 2 Score 2 (minimal) Score 4 (strong) IOTA: Easy descriptors Unilocular cyst, ground glass echogenicity, +/- wall nodularity, premenopausal woman ENDOMETRIOMA Unilocular cyst, mixed Echogenicity (white ball, dot-dash), shadowing, Premenopausal DERMOID CYST Unilocular cyst, anechoic cyst fluid, regular walls,< 10 cm SIMPLE CYST OR CYSTADENOMA Mass At least moderate blood flow Postmenopausal Ascites MALIGNANT Mass > 50 years CA125 > 100 IU/mL MALIGNANT ENDOMETRIOMA Unilocular cyst, ground glass echogenicity, +/- wall nodularity, premenopausal woman All other unilocular cysts with regular walls BENIGN CYST Wall nodularity (blood clot/fibrin) (Not papillary projection) HAEMORRHAGIC CYST Reticular pattern Retracting clot DERMOID CYST Unilocular cyst Mixed echogenicity (white ball, dot-dash), shadowing, Premenopausal 3

4 Serpiginous HYDRO (PYO/HEMATO) SALPINX Incomplete septae BORDERLINE TUMOURS Papillary projections is characteristic Serous cystadenofibroma Cog wheeling Beads on a string Serous borderline Mucinous borderline - intestinal type Conforms to shape of peritoneal cavity Prior pelvic surgery Ovary suspended in edge of cyst PERITONEAL PSEUDOCYST Anasplastic carcinoma in mucinous borderline SOLID PELVIC TUMOURS SOLID PELVIC TUMOURS Myoma (uterine) Fibroma Thecoma Brenner tumour Leydig cell tumour Malignancies Ovarian malignancy Irregular contour Irregular echogenicity Inc vascularity Myoma Round, oval lobulated; Stripy shadows Min vascularity Broad ligament fibroid Dysgerminoma + yolk sac tumour Granulosa cell tumour Fibroma May mimic pedunculated fibroid Neuroendocrine tumour of ovary 4

5 IOTA: Simple Rules IOTA: ADNEX model Timmermen et al UOG 2008 CONCLUSION 1. Describe the mass instead of using the term complex 2. Be familiar with easy descriptors and pattern recognition 3. If uncertain, use Simple Rules +/- ADNEX THANK YOU May be confused with malignancy due to vascularity Pus and old blood look similar TUBO-OVARIAN ABSCESS 5