Ovarian Cystic Adnexal Masses February 2015
Dr. Paul Riley FRANZCR FRCR MRCS MBChB BSc Med Sci Keystone Radiology Group 2013
Ovarian Cystic Adnexal Masses OBJECTIVES Common ovarian cyst presentations. Common ovarian cyst appearances. Distil the consensus findings of the IOTA trial from peer reviews. Ovarian cyst management pathway.
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Ovarian Cysts: Initial Considerations Often incidental. Often clinically insignificant or benign. Indication Menopausal status Age, LMP, OCP, HRT Laboratory findings, Hb, Ca-125 Transabdominal Ultrasound Transvaginal Ultrasound
Simple Ovarian cyst Ovarian cystadenoma
Beware of Mimics Hydrosalpinx Paraovarian Cysts Peritoneal Inclusion Cysts
IOTA: Improving Strategies For Diagnosing Ovarian Cancer Standardise terms and definitions. Centred around the study of persistent adnexal masses. 20 Different centres in different countries. Prospective trial (6 phases between 1999 2017) 1) Role of Ca125 in Dx 2) External validation. 3) Second stage tests incl. U/S, Doppler, new tumour markers. 4) Performance of IOTA against different levels of ultrasound experience. 5) Long Term behaviour of Ovarian masses managed expectantly. Phase 2 Standardize terms. Assessed demographic and ultrasound variables Phase 3 5 Malignant features or M-features 5 Benign Feature or B-features. Mass is classified as malignant if at least one M-feature and no B-features are present and vice versa No B or M features or both B and M features then unclassifiable.
Atypical lesions Clot misinterpreted as a solid nodule. Fibrin strands misinterpreted as septations. Endometriomas and haemorrhagic cysts can have irregular walls. Thin septations, mural calcifications. Indeterminate but likely benign. Interval ultrasound +/- MR. GI-RADS.
Recommendations based on IOTA Findings At least 75% of adnexal masses classified as benign or malignant. 25% specialist assessment +/or further imaging. Ca-125 not necessary in premenopausal women
Guidelines for Premenopausal Women Simple or haemorrhagic cysts <3cm. No follow up. May be omitted from report at the discretion of interpreting radiologist. Simple or haemorrhagic cysts >3cm and < 5cm. Do not require follow up but should be mentioned in the report. Simple cysts > 5cm and < 7cm. Should be followed up to ensure stability and/or resolution. Haemorrhagic cysts > 5cm and < 7cm. Should be followed up to ensure resolution in 6 12 weeks. Simple cysts >7cm. Further imaging (e.g. MRI) or surgical intervention.
Guidelines for Premenopausal or Postmenopausal Women Classic appearing Endometriomas; 6-12 week follow up. Potential for annual follow up. Classic appearing dermoids ; 6-12 month follow up. Classic appearing hydrosalpinx or PIC do not require F/U. Paraovarian cysts are followed up by the same criteria as ovarian cysts.
Guidelines for Women in Early Menopause Any classic appearing haemorrhagic cysts should be described and followed up in 6-12 weeks to ensure resolution.
Guidelines for Postmenopausal Women. Simple cysts < 1cm do note require F/U. May be omitted from report. Simple cysts >1cm and <7cm should be described in the report. Annual F/U. Simple cysts >7cm. Further imaging (e.g. MRI) or surgical intervention. Haemorrhagic cysts should not occur in anovulatory women. Therefore, should be considered neoplastic.
Conclusion Typical appearances of some ovarian cystic lesions IOTA Standardised descriptions Predictive models for benignity vs malignant Management principles
Conclusion Premenopausal women cysts >5cm 6-12 week F/U Postmenopausal women cysts >1cm. 6-12 month F/U Cysts >7cm. Further imaging (MRI) or surgical intervention. Atypical or indeterminate lesions Further imaging and/or specialist review. Classical benign and malignant features Thick septations, nodules (with blood flow) wall thickening have malignant risk and should be surgically evaluated. Dermoids and Endometriomas Annual F/U
References Faye C.L., Allison S.J. US of the Ovary and Adnexa. To Worry or not to Worry? Radiographics 2012; 32: 1621-1639 Levine D, Brown D et al Managment of Asymptomatic Ovarian and Other Adnexal Cysts Imaged at US. Radiology 2010 vol 256 3 943-954 Kaijser J, Bourne et al Key Findings from the International Ovarian Tumour Analysis (IOTA) Study AJUM 2012 15 (3) 82-86 Kaijser J, Bourne et al Improving Strategies for Diagnosing Ovarian Cancer a summary from IOTA Ultrasound Obstet Gynecol 2013 41 9-20
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