Adnexal cysts.pptx

adenexal lesions

1. Benign-appearing Incidental Adnexal Cysts at US, CT, and MRI Peter S. Wang, MD Otto G. Schoeck , MD Mindy M. Horrow, MD From the Department of Diagnostic Radiology, Einstein Healthcare Network, 5501 Old York Rd, Philadelphia, PA 19141-3098.

2. Disclosures Disclosures of Conflicts of Interest.— P.S.W. Payment for spectral CT presentation from Philips. M.M.H. Editorial board member of RadioGraphics .

3. Learning Objectives 1. Describe the appearance of physiologic ovarian lesions. 2. Explain the basis for the conclusion that a simple adnexal cyst does not increase risk of cancer regardless of menopausal status. 3. Discuss the condensed American College of Radiology (ACR) Ovarian-Adnexal Reporting and Data System (O-RADS) lexicon, consisting of terms useful in assigning risk categories. 4. Describe the updated recommendations of the Society of Radiologists in Ultrasound (SRU) 2019 Consensus for simple cysts based on size and menopausal status with parallel recommendations from tO -RADS and ACR 2019 Consensus on incidental CT and MRI lesions. 5. Recognize whether US after CT/MRI is to further characterize or provide follow-up with time.

4. Outline Introduction Historical background of US of adnexal cysts Review of recent major outcomes studies of adnexal cysts O-RADS SRU Update ACR Update How we put it all together

5. Three major consensus papers on adnexal cystic lesions published in 2019–2020 What are they and how can we integrate them for meaningful use in daily practice? SRU Consensus Update on Adnexal Cysts (2019 - US) Management of Incidental Adnexal Findings at CT and MRI (2020) O-RADS US Consensus Guideline (2020 - US) Management of Incidental Adnexal Findings on CT and MRI: A White Paper of the ACR Incidental Findings Committee. J Am Coll Radiol . 2020 Feb;17(2):248-254. Simple Adnexal Cysts: SRU Consensus Conference Update on Follow-up and Reporting. Radiology. 2019 Nov;293(2):359-371. O-RADS US Risk Stratification and Management System: A Consensus Guideline from the ACR Ovarian-Adnexal Reporting and Data System Committee. Radiology. 2020 Jan;294(1):168-185.  Use standardized reporting terminology Base recommendations on current evidence-based data and institutional practice patterns Minimize unnecessary follow-up imaging studies Apply to nonpregnant women of average risk for ovarian cancer

6. SRU Consensus establishes size thresholds for benign-appearing cysts that do not require follow-up. Limitations: No standardized terminology/definitions No risk stratification for malignancy No management recommendations for high risk lesions Overall reduction in US utilization due to fewer recommendations for follow-up of benign appearing cysts -Ghosh E, et al. Several studies demonstrate no increased risk of malignancy in women with simple adnexal cysts, unrelated to size or menopausal status. Smith-Bindman R, et al. Greenlee RT, et al. Sharma A, et al. IOTA (International Ovarian Tumor Analysis) Standardized terminology and definitions, widely used in Europe Limitations: ​ 20% of masses require additional tests for categorization Timeline of Imaging-based Recommendations for Adnexal Cysts O-RADS for US: Ovarian-Adnexal Reporting and Data System Standardized lexicon of descriptors and definitions Limitations: complexity and number of terms O-RADS Updated US Lexicon Linked to Risk Stratification Benefit: simplified lexicon to use when calculating risk of malignancy (based on IOTA model) ACR white paper on incidental adnexal cysts at CT and MR Limitations: Recommendations not aligned with US Revision ACR white paper on incidental adnexal cysts on CT and MR Benefit: aligned with SRU consensus 2010 2013 2015 2019 2020 2018 SRU Update on Simple Adnexal Cysts Benefit : evidence and consensus-based guidelines with management recommendations We will discuss these updates 1 ORADS 2 SRU 3 ACR CT/MR Toggle for More Info (On/Off) Toggle for More Info (On/Off)

7. O-RADS: Six Categories of Risk Stratification O-RADS Score Risk Management Incomplete evaluation Repeat study or alternate study 1 Normal ovary None 2 Almost certainly benign (<1%) Variable, depends on size, morphology, and menopausal status 3 Low risk of malignancy (1 to <10%) US specialist or MRI; Management by gynecologist​ 4 Intermediate risk (10 to <50%) US specialist of MRI; Management by gynecologist with GYN-oncologist consultation or solely by GYN-oncologist 5 High risk ( ≥50%) GYN-oncologist Based on retrospective analysis of IOTA phase 1 – 3 data US features of adnexal lesions placed in prespecified risk categories based on IOTA data Clinical management scheme based on expert opinion of gynecologists, gynecologic oncologists, and radiologists Based on average-risk asymptomatic patients without increased risk factors for ovarian cancer Major Categories Physiologic: follicle, corpus luteum Lesion Unilocular Unilocular with ≥3 mm solid Multilocular, no solid Solid or solid appearing ≥80 % Size: Maximum diameter Cystic Lesions: Inner margin or walls including solid component Papillary projection or nodule Height ≥3 mm Give # of papillary projections Smooth: inner margin of solid component not a papillary projection Irregular: Solid components <3 mm Incomplete septations Contour of solid component Cystic content: anechoic, hyperechoic Vascularity: Color Score 1 – 4 General Information Key Cystic Descriptors O-RADS Score Risk Management Incomplete evaluation Repeat study or alternate study 1 Normal ovary None 2 Almost certainly benign (<1%) Variable; depends on size, morphology, and menopausal status 3 Low risk of malignancy (1% to <10%) US specialist or MRI ; management by a gynecologist​ 4 Intermediate risk (10% to <50%) US specialist of MRI ; management by a gynecologist  with gynecologic oncologist consultation or solely by a gynecologic oncologist 5 High risk ( ≥50%) Gynecologic oncologist We will discuss cystic lesions O-RADS 1–3

8. O-RADS 1: Normal Ovarian Findings During Menstrual Cycle Day 1 : Early follicular phase Day 7: Mid Follicular Phase Day 14: Preovulatory Day 14 +: Postovulatory with Corpus L uteum Multiple small follicles Single follicle becomes dominant Dominant follicle Anechoic cyst along the wall of the dominant follicle represents a normal cumulus oophorus Avid enhancement of the corpus luteum wall on CT and MR images correlates with hypervascularity on color Doppler US A corpus luteum is a thick walled cyst ≤3 cm that may have crenulated inner margins, internal echoes, and intense peripheral color Doppler flow A follicle is a simple cyst ≤3 cm in premenopausal women Anechoic fluid has no internal echoes or structures of any kind CT+C MR+C Note.—+C = contrast enhanced.

9. O-RADS 2 Simple cysts , nonsimple unilocular cysts with smooth walls (<10 cm) Not visualized at follow-up Follow-up in 1 year if >3 cm and <10 cm Decreased size Follow-up recommended in 8–12 weeks if >5 cm and <10 cm Reproductive Postmenopausal (<1% risk of malignancy) Almost certainly benign

10. Hemorrhagic Cysts O-RADS 2 Classic lesions <10 cm:U se of Specific D escriptors R ecommended Hemorrhagic cyst with retracting clot (avascular, echogenic, angular , straight, and concave components) Reproductive Hemorrhagic cyst with lacy reticular echoes (<1% risk of malignancy) If ≤ 5cm – no additional management If >5 cm and <10cm – follow-up in 8–12 weeks ( if it persists or enlarges , refer to a US specialist, gynecologist, MRI) US specialist, MRI, gynecologist If ≥10 cm: O-RADS 3 US specialist , MRI, and management by a gynecologist Postmenopausal Dermoids Hyperechoic with posterior shadowing Hyperechoic lines and dots Floating spherical structures Reproductive Optional initial follow-up 8–12 weeks based on confidence of diagnosis If not removed, consider annual US follow-up; US specialist or MRI if larger or changed morphology Postmenopausal US specialist, MRI, gynecologist If confident diagnosis and not removed, consider annual US If enlarged or changed morphology →MRI If ≥10 cm = O-RADS 3 US specialist , MRI, and management by a gynecologist Endometriomas Optional initial follow-up in 8 – 12 weeks based on confidence of diagnosis if patient is of reproductive age → US specialist if postmenopausal → gynecologist and/or MRI If not removed, consider annual US follow-up US specialist or MRI if enlarged or changed morphology or if ≥10 cm Ground-glass , homogeneous low-level echoes

11. Simple paratubal / paraovarian cysts in two different patients Hydrosalpinx Extraovarian cysts Elongated tubular fluid-filled structure separate from ovary Peritoneal Inclusion Cyst Cystlike structure in a reproductive-age woman with history of abdominal/pelvis surgery O-RADS 2 More Examples of Classic Lesions <10 cm (<1% risk of malignancy) “Cyst” e ncases ovaries, contains thin adhesions (“spider web”), conforms to peritoneal space without exerting mass effect ​ O FT O C C O O UT UT O Note.— C = cyst, FT = fallopian tube, O = ovary, RO = right ovary, UT = uterus.

12. Larger , Almost Certainly Benign Cystic Lesion O-RADS 3 (1% to <10 % risk of malignancy) Reproductive Age Multilocular cyst <10cm, smooth inner wall, color score (none-moderate) Given the patient’s age, sonographic follow-up is recommended (alternatively , follow-up MRI and gynecologic management may be considered). 2005: 3 cm Likely an epithelial ovarian neoplasm such as serous or mucinous cystadenoma Benign neoplasms can enlarge over time. Postmenopausal Initially O-RADS 2 → O-RADS 3 at follow-up 2010: 4.6 cm 2020: 5.9 cm, more complex FOLLOW UP FOLLOW UP Reproductive Age 2019 2020 Mucinous cystadenoma Multilocular cyst <10 cm , smooth inner wall, color score (none-moderate), gynecologist recommends follow-up 6.8-cm multilocular cyst US specialist or MRI, management by a gynecologist Follow-up MR images show a multiloculated cyst without solid component or enhancement. MRI performed for characterization FOLLOW UP

13. SRU Consensus on Asymptomatic Adnexal Cysts (presumption of a technically adequate study) 2010 ≤5 cm : No follow-up >5 cm and ≤7 cm: yearly follow-up >7 cm: further imaging (MRI) or surgical consultation 2020 Simple Cysts > 1 cm and ≤7 cm : yearly, or less frequently after stability is established >7 cm : further imaging (MRI) or surgical consultation Reproductive age Postmenopausal Reproductive Postmenopausal Characteristic Adnexal Masses Hemorrhagic cyst follow-up only if >5 cm with US 2–3 months Clinical management and possible US follow-up: Paraovarian cyst, peritoneal inclusion cyst, hydrosalpinx, ovarian fibroma Possible imaging follow-up: Endometrioma and dermoid Suspected malignancy: US or MRI to characterize ≤3 cm: normal >3 –≤ 5 cm: describe, no follow-up >5 cm: describe Excellent visualization and ≤7 cm , no follow-up Standard visualization or >7 cm , follow First follow-up may vary from 2 – 12 months depending upon balance between need to characterize and assess growth ≤1 cm : describe if desired, no follow-up >1 –≤3 cm : describe, no follow up >3 cm, describe Excellent visualization and ≤5 cm, no follow up Standard visualization or >5 cm, follow-up First follow-up may vary from 3–12 months depending on balance between need to characterize and assess growth Problems: How long to follow? Is MRI necessary just because the cyst is >7cm ? Refer to paper for guidelines for further follow-up beyond initial reexamination

14. SRU Definitions Round or oval anechoic fluid collection with smooth thin walls, no solid component or septation, and no internal flow by using Color Doppler Three orthogonal measurements should be obtained without pressure on the US probe. The largest single diameter is used. Color Doppler helps identify solid components. Simple cysts will often demonstrate posterior acoustic enhancement. However, smaller cysts may not show this. Contains simple cysts less than or equal to 1 cm in postmenopausal women and 3 cm in premenopausal women If a simple cyst is less than or equal to 3 cm in reproductive-age women, in addition to labeling the ovary as normal , the use of the term follicle instead of simple cyst may decrease patient anxiety. Round or oval anechoic follicles with thin smooth walls and no internal vascularity Diffusely thickened wall, peripheral blood flow, size less than or equal to 3cm, +/- internal echoes and crenulated appearance Atrophic without follicles Reproductive Postmenopausal Corpus luteal cyst The Simple Cyst The Normal Ovary “Follicle” instead of “Cyst” Most simple cysts less than 3 cm in size are physiologic follicles.

15. Reproductive Simple Cysts When is follow-up recommended based on the 2019 SRU Consensus? Follow-up US shows ↓ size Conclusion: Non-neoplastic cyst ; no further follow-up needed SRU 2019 consensus for simple >7 cm: Follow up in 2 – 12 months 6 m os Kidney TX O-RADS 3 Risk Stratification based on size 9 yrs O-RADS 2 Risk Stratification SRU 2019 consensus for simple cyst <7 cm: No follow-up necessary Follow-up US shows no change in size (<10–15 % average linear dimension) 2010 SRU consensus recommended follow-up Patient who underwent kidney transplant Note.—Mos = months, yrs = years.

16. Postmenopausal Cysts that No Longer Require Imaging Follow-up Postmenopausal patient with 1.3-cm simple cyst 2013 2020 Previously required at least one follow-up as above Now no further imaging recommended under SRU 2019 guidelines No significant change: simple cyst O-RADS 2: No further management is suggested in cysts up to 3 cm Cysts reported in 14% of initial US examinations and are usually transient. Simple cysts >1 cm should be described but not followed unless they are >3 – 5 cm . The higher threshold is for exceptionally well-visualized cysts. 3-2018 10-2019 Dist 2.95 cm Dist 2.49 Dist 2.66 cm Dist 2.07 cm Repeat exam requested for other reasons

17. ACR White Paper on Incidental Adnexal Cysts at CT and MRI: Key Concepts Use US evidence of the natural history of adnexal cysts to interpret and make recommendations for CT and MRI studies Simple adnexal cysts have minimal risk of malignancy Larger cysts could be mischaracterized Enlarging cyst is more likely a benign neoplasm (cystadenoma) Guidelines for size based on SRU consensus 1 Distinguish between follow-up US in a specified time to look for resolution or to evaluate rate of growth and diagnostic US to more completely characterize a lesion that is either concerning because of size and menopausal status or not optimally visualized at CT/MRI If confident diagnosis can be made of an adnexal mass based on its characteristics, further management should be based on that diagnosis, for example: Paraovarian cyst, hydrosalpinx, peritoneal inclusion cyst, cystic teratoma, endometrioma, fibroma, carcinoma 3 2

18. General Considerations for ACR White Paper Mass must be >1 cm ( if smaller, it is difficult to adequately characterize at CT /MRI) Asymptomatic Do not follow the algorithm if the patient becomes symptomatic, since symptoms may require immediate imaging (hemorrhage, rupture, torsion). Nonpregnant No risk factors for ovarian malignancy Reporting Considerations Mass characteristics −10 to +20 HU or fluid signal Features that lead to another specific diagnosis Size Only report largest diameter Technical considerations “Limited assessment ” is dependent on signal-to-noise ratio, artifacts, lack of intravenous contrast material, incomplete coverage Menopausal status If not known, assume >50 years of age = postmenopausal Inclusion Criteria Stable size for ≥2 years because malignancy is excluded Exclusion Criteria

19. ACR : Incidental Adnexal Cysts at CT and MRI— Then and Now 2013 “benign appearing cyst” Premenopausal ≤5 cm no FU , >5 cm FU US in 6 – 12 weeks Early postmenopausal ≤3 cm no FU , >3cm and ≤5cm FU US in 6 – 12 months > 5-cm DX US Late post-menopausal ≤3 cm no FU , >3 cm DX US 2020 simple appearing <10 cm Premenopausal ≤3 cm no FU, >3 cm and ≤5 cm FU US in 6 – 12 weeks, >5cm DX US Early postmenopausal ≤3 cm no FU, >3cm DX US Late postmenopausal ≤1 cm no FU >1cm DX US Benign Appearing Probably Benign Premenopausal Postmenopausal US or MR to characterize Characteristic Adnexal Masses DX uncertain or simple ≥10 cm Hemorrhagic cyst FU only if >5 cm with US 2 – 3 months Clinical management : Paraovarian cyst, peritoneal inclusion cyst, hydrosalpinx, ovarian fibroma Possible imaging FU: Endometrioma and dermoid Suspected malignancy: US or MRI to characterize ≤5 cm no FU >5 cm Limited → US characterization Not fully characterized at MRI → US FU 6 – 12 months Fully characterized at MRI → US FU in 6 – 12 months only if >7 cm ≤3 cm, no FU >3 cm Limited → US characterization Fully characterized at MRI/ CT → US follow-up in 6 – 12 months Not fully characterized by MR → US FU 6 – 12 months Fully characterized at MRI, US FU in 6 – 12 months only if >5 cm Note.— DX = diagnosis, FU = follow-up.

20. Incidental Lesions at CT /MRI not Requiring any Follow-up Postmenopausal 4-cm simple appearing cyst 6 months later US; simple, stable Postmenopausal <2 cm simple appearing cysts Postmenopausal 20 years: 2- cm simple-appearing cyst 6-month follow-up Based on 2010 SRU STOP STOP Simple cyst, no further follow-up 43-year-old with renal MRI for APCKD and nonsimple LOV cyst 5.2 cm 1 month later: Resolving hemorrhagic cyst Incidental Lesions at CT/ MR Requiring Follow-up Imaging FOLLOW UP FOLLOW UP Note.— APCKD = adult polycystic kidney disease, LOV = left ovary.

21. Incidental Lesions at CT and MRI Requiring Imaging for Further Characterization Postmenopausal , 5 cm Postmenopausal : single pelvic image from venous run-off with images every 5 cm, measures 42 HU Could only tolerate TA US, which showed solid and cystic components Solid and cystic components and slight enhancement; pathology: sex cord stromal tumor Characterize with US Characterize with US Postmenopausal MRI of LS spine Partially visualized 5.5-cm cyst Simple cyst at US Pathology: benign cystadenoma Characterize with US Pathology: benign cystadenoma MRI Not simple appearing >20 HU and limited coverage Limited coverage Note.— LS = lumbrosacral, TA = transabdominal.

22. Characteristic Lesions on CT Images: Peritoneal inclusion cyst Bilateral hydrosalpinges Bilateral endometriomas Clinical Management and/ or Follow-up R ecommended Dermoids 30 – 32 HU Hysterosalpingograph (HSG) in same patient O

23. Characteristic Lesions on MR Images: Bilateral Endometriomas Clinical Management and/ or Follow-up Recommended Bilateral Dermoids T1 T1 FS T2 Hemorrhagic Cyst T1 hyperintense No fat suppression (FS) Layering T2 hypointense material typical of blood products in a hemorrhagic cyst T1 T1 FS T2 T1 hyperintense T2 hyperintense Signal drop out → macroscopic fat T1 T1 FS T2 T1 hyperintense No fat suppression “T2 shading”

24. Adnexal Cysts 2020: Putting it All Together SRU Consensus Update (2019 - US) Goal : Define characteristics of benign adnexal cysts to reduce surgical evaluation and imaging follow-up Assess ultrasound quality Standardize wording for reports, impressions, and recommendations Conclusion : Recommend limiting follow-up US for postmenopausal women with simple cysts greater than 2–5 cm and premenopausal women with simple cysts greater than 5–7cm Management of Incidental Adnexal Findings: White Paper (2020 - CT and MRI) Goal : Develop consensus for characterizing incidental cysts, weigh the risks and benefits of follow-up, develop common reporting terms Conclusion : An algorithm to guide management based on simple-appearing cysts, reasonably diagnostic imaging features, or uncertain diagnosis O-RADS US Consensus Guideline (2020 - US) Goal : Provide standard lexicon and risk categorization​ ​ O-RADS 1 : (Premenopausal only): normal ovary with 0% likelihood of malignancy​ ​ O-RADS 2 : Almost certainly benign with <1% likelihood of malignancy​ ​ O-RADS 3 : low risk, 1% to <10 % risk malignancy, mostly benign lesions >10 cm Management of Incidental Adnexal Findings on CT and MRI: A White Paper of the ACR Incidental Findings Committee. J Am Coll Radiol . 2020 Feb;17(2):248-254. Simple Adnexal Cysts: SRU Consensus Conference Update on Follow-up and Reporting. Radiology. 2019 Nov;293(2):359-371. O-RADS US Risk Stratification and Management System: A Consensus Guideline from the ACR Ovarian-Adnexal Reporting and Data System Committee. Radiology. 2020 Jan;294(1):168-185. 

25. The Simple Cyst SRU = ACR White Paper ≈ O-RADS 2 Post-menopausal Follow-up if >3 cm (5 cm if excellent visualization) Reproductive Follow-up if >5 cm (7cm if excellent visualization) Almost certainly benign Our Approach If there is a simple cyst at US or a simple-appearing cyst at CT /MRI (O-RADS 2), use the SRU ( ACR white paper ) size criteria for follow-up based on menopausal status. If O-RADS 3 or above, use O-RADS for follow-up and risk stratification. Use any other studies the patient may have undergone for other reasons to compare size and appearance, adjusting recommendations accordingly. All lesions require careful measurements, cine clips in two orthogonal planes, and evaluation with sensitive color Doppler settings.

26. Postmenopausal Patients: What to Recommend? Paraovarian Cyst Previously required follow-up (as below); now just report as benign with no follow-up necessary Stable compared to US 5 years earlier, no further follow-up necessary Incidental 3-cm adnexal cyst ( ) Further characterized at US as simple; surgically proven cystadenoma Incidental 7-cm adnexal cyst ( ) Simple extraovarian cyst clearly not arising from the ovary 6 months later Incidental 2-cm cysts ( ) at MRI and CT (2 different patients) Previously required follow-up, now just report as benign with no follow-up necessary

27. Following the Simple Cyst Before Updated Guidelines 18-year-old patient with incidental 5.7 cm x 7.5 cm simple right ovarian cyst US was recommended for follow-up First follow-up 7.7 cm x 6.0 cm simple cyst US was recommended in 2–3 menstrual cycles to ensure resolution 2012 2014 2016 2018 2020 Updated SRU Consensus O-Rads and ACR White Paper Slight increase in size Slight decrease in size Slight increase in size Slight decrease in size Updated guidelines should limit unnecessary follow-up for a lesion that is certainly benign. Total of 10 follow-up US examinations were performed The apparent slight change in size over time was likely due to differences in transducer pressure. With new guidelines, no follow-up would have been recommended after the first follow-up US in 2012 $ saved = $1,115.73 Other savings: Patient anxiety Time off work/lost income

28. Slow-growing Ovarian Cyst Postmenopausal Beginning at Age 60 CT 2012 US 2017 2015 MR for further characterization because of increasing size T2 hyperintense with single thin enhancing septation US 2020 Presumed epithelial neoplasm, benign/low grade. Patient declined surgery. Noncontrast study with decreased signal to noise → US characterization 3.9 cm “simple cyst” US characterization 2012 CT 2015 Size increased to 6.1 cm Size increased to 7.3 cm, thin septation noticed only on cine clip Size increased to 8.7 cm, increasing complexity with color score 2 T2 +C In this case, thin septa were missed until cine clips were included and confirmed at MRI. High-quality US is required when recommending no further evaluation of simple cysts. SRU updated consensus recommends: Certified sonographers with oversight by a trained physician Scanning equipment includes transvaginal sonography capabilities with color Doppler imaging that allows adequate visualization of the internal contents of cysts Up-to-date quality-assurance programs Higher size thresholds is justified by the SRU consensus when there is superior visualization, confidence in diagnosis, and documentation including cine clips.

29. Conclusion 1. Limiting follow-up for simple adnexal cysts is appropriate as they do not increase cancer risk. 2. A prerequisite for applying the three major consensus papers (SRU, O-RADS, and ACR) is a quality study. 3. We have proposed a framework for use of all three articles in daily practice. ORADS SRU ACR CT/MR