Ovarian tumor analysis

according to IOTA .

1. Adnexal mass evaluation ( IOTA Terminology , Simple Descriptor s an d Simpl e Rules ) A.S.M . SUFIAN HMO , Cumilla M edical C ollege H ospital ( R adiology & Imaging )

2. Ovarian pathology Classification system for ovarian pathology Standardization of terminology – IOTA IOTA Simple Descriptors (pattern recognition) Prediction of malignancy– IOTA Simple Rules Examples The International Ovarian Tumor Analysis (IOTA)

3. Ovarian cysts and tumors IOTA

4. IOTA N o rm a l ovaries Benign ovari a n tumors B ord erline ovarian tumors Invasive ovarian cancer Premenopausal VS postmenopausal women

5. The report really matters Is it benign or malignant? Simple cyst Complex cyst Can we do be tt er?

6. By the end of this presentation you will be able to report this! Ho w to report this abnormality?

7. Classifica ti on system for adnexal masses Benign ovarian Benign non-ovarian Primary malignant ovarian Secondary malignant ovarian

8. Classifica ti on system for adnexal masses BENIGN OVARIAN : ascites and Polycys ti c ovaries Func ti onal cysts Endometriomas Serous cystadenoma Mucinous cystadenoma Mature teratoma Fibroma (rare, can cause Meig’s syndrome : pleural effusion )

9. Classifica ti on system for adnexal masses BENIGN NON-OVARIAN : Paratubal cyst Hydrosalpin x Tubo-ovarian abscess Peri t one a l pse u docys t s Appendicular abscess Diver ti cular abscess Pelvic kidney Ectopic pregnancy

10. Classifica ti on system for adnexal masses PRI M ARY MALIGNANT OVAR I AN Epithelial carcinoma – Borderline – Serous cystadenocarcinoma (commonest ovarian cancer, 50% malignancies) – Mucinous cystadenocarcinoma (10% ovarian malignancies) • Borderline variant is pseudomyxoma peritonei -exclude appx primary – Endometrioid carcinoma (25% ovarian malignancies)(associated with endometrial ca in 20%) – Clear cell carcinoma Germ cell tumor – Malignant teratoma – Dysgerminoma • Sex-cord tumor – Granulosa cell tumor (secretes estrogen)

11. Classifica ti on system for adnexal masses SECONDAR Y MALIGNANT OVAR I AN 10% of ovarian malignancy Predominantly: B reast Gastrointestinal carcinoma ( Krukenberg tumor)

12. IOTA defini ti ons – Unilo c ular , U nilo c ula r -sol i d , M ul ti l ocu l ar , M ul ti l ocu l a r - s ol i d or S olid – Cyst contents – or he m o r rh a gic . anechoi c , low le v el, g r ou n d glass, mixed Soli d material o r pa pi l lar y structure s o r wal l irre g ul a rity (presence and size) Vascularity Shadows Ascites

13. Unilocular IOTA

14. Unilocular-solid IOTA

15. Mul ti locular IOTA

16. Mul ti locular -solid IOTA

17. Solid IOTA

18. Cys ti c contents IOTA

19. Mixed cy sti c contents IOTA

20. Internal wall of the cyst IOTA

21. IOTA -projectio n >3 mm Papillary

22. IOTA D efini ti ons Solid component – S tructur e tha t ha s echogeni c i t y sugges ti v e of solid tissue. BU T the whi t e bal l o f a D er m oi d i s no t sol i d ti ss u e and blood clot or mucin is not solid ti ssue If protrusion >3 mm = papillary projec ti on (count as S olid component) If < 3 mm = irregularity Irregular – contour of means an irre g ul a r int e rnal wall O R irre g ul a r outer Ascites – flu i d outside POD lesion a sol i d

23. Vascularity score Colou r Dopp l er or Power Dopp l er (more cm/sec Dopp l er gain t o just below artefact sensi ti ve ) PRF 0.3 V e l o ci t y scal e 3 - 6 Balance 220 Adjust level Moderate flow No flow =1 Minimal flo w = 2 • = Strong 3 flo w through o u t = 4

24. Ovarian pathology Classifica ti on system for ovarian pathology Standardization of terminology – IOTA IOTA Simpl e Descriptor s ( pa tt ern recogni ti on ) Predic ti on of malignancy – IOTA Simple Rules Worked examples

25. Simpl e Descriptors Cert a i n a b norma l i ti es are really obvious: RECOGNITION - Endometrioma Be n ig n cys ti c teratoma / D er m oid Cyst Simple cyst or serous cystadenoma Func ti onal Malignant C yst . E g . Hemorrhagic cyst . tumour with ascites   PATTERN

26. BD, benign descriptor; MD, malignant descriptor. Simple Descriptors of an ovarian mass used to make a diagnosis

27. When Simpl e Descriptor s d o not apply : I f the ma s s i s no t in s tantl y recognizable and Simple Descriptors do not app licable : –  The n apply Simple Rules

28. Ovarian pathology Classification system for ovarian pathology Standardization of terminology – IOTA IOTA Simpl e Descriptor s (pattern recognition) Prediction of malignancy – IOTA Simple Rules Worked examples

29. Simple ultrasound-based rules Morphologic Classification (n=1066) Type of tumor N Malign. % 1.Unilocular cyst 313 2 0.6 2.Unilocular solid 132 44 33 3.Multilocular cyst 196 20 10 4.Multilocular solid 284 116 41 5.Solid tumour 136 84 62

30. Simple Rules FEATURES of a benign mass (B-features ) A mass is classified as benign if at least one B-feature is present and no M-features are present \

31. FEATURES of a malignant mass (M featur e s) A mass is classified as malignant if at least one M-feature is present and no B-features are present

32. Simple Rules Rule 1: If one or more M features are present in absence of B feature(s), the mass is classified as malignant. • Rule 2: If one or more B features are present in absence of M feature(s), the mass is classified as benign. • Rule 3: If both M features and B features are present, or if no B or M features are present, the result is inconclusive and a second stage test is recommended.

33. example s –

34. premenopausal

35. Endometrioma unilocular , ground glass echogenicity,

36. Simple Descriptors Pattern recognition premenopausal

37. unilocular , Dermoid mixed echoes, shadows, premenopausal

38. How to differentiate

39. < 10 cm

40. Serous cystadenoma unilocular, regular walls , <10 cm

41. Stag e 4 ovaria n carcinoma with ascites Tumor wit h at least mode r ate bloo d fl o w, asci t es, postmenopausal

42. Examples where Simple descriptor don’t apply

43. <10cm

44. Example 1 Simpl e rules: BENIGN Mucinous cystadenoma

45. Example 2

46. Example 2 Simple rules: MALIGNANT Metastasi s fro m bo w el prim a r y

47. Example 3

48. • IOTA descrition – Unilo c ular , unilo c ula r -sol i d , multi l ocu l ar , multi l ocu l a r - s ol i d or solid – Cyst contents – anechoic, low level, ground glass, hemorrhagic or mixed – Uncertain (NO BENIGN RULES AND NO MALIGNANT RULES = UNCERTAIN

49. Example 3 Simple rules: UNCERTAIN B o rd e rli n e ovaria n tumour

50. Serous cystadenofibroma

51. Ovarian Fibroma most commonly manifest as solid, hypoechoic masses with ultrasound beam attenuation. As such, they may appear similar to a pedunculated subserosal uterine fibroid

52. Resources apps (risk IOTA – papers, courses, calculators), conferences hKp://www.iotagroup .org IS U O G – p a pers , jo u rnal club slides GE poster . Internet slide and picture.

53. IOTA apps

54. IOTA apps

55. THAN K YOU & Jajakallah khair