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IOTATerminology,SimpleDescriptorsandSimpleRules
SusanneJohnson
PrincessAnneHospital
Southampton
Ovarianpathology
• ClassificaGonsystemforovarianpathology
• StandardisaGonofterminology–IOTA
• IOTASimpleDescriptors(paKernrecogniGon)
• PredicGonofmalignancy–IOTASimpleRules
• Workedexamples
• Quiz
Ovariancystsandtumours
IOTA
Premenopausalvspostmenopausal women
Normalovaries
BenignovariantumorsBorderlineovariantumors
Invasiveovariancancer
Invasive ovarian cancer IOTA
ThereportreallymaKers
• Isitbenignormalignant?
• Simplecyst
• Complexcyst
• CanwedobeKer?
Howtoreportthisabnormality?
By the end of this presentation you will be able to report this!
Ovarianpathology
• ClassificaGonsystemforovarianpathology• StandardisaGonofterminology-IOTA
• PredicGonofmalignancy–IOTASimpleRules
• Workedexamples
• PaKernrecogniGon• Quiz
ClassificaGonsystemforadnexalmasses
• Benignovarian
• Benignnon-ovarian
• Primarymalignantovarian
• Secondarymalignantovarian
ClassificaGonsystemforadnexalmasses
BENIGNOVARIAN:• PolycysGcovaries• FuncGonalcysts• Endometriomas• Serouscystadenoma
• Mucinouscystadenoma• Matureteratoma
• Fibroma(rare,cancauseMeig’ssyndrome:ascitesandpleuraleffusion)
• Thecoma(veryrare,cansecreteoestrogenandprogesterone)
ClassificaGonsystemforadnexalmasses
BENIGNNON-OVARIAN:• Paratubalcyst• Hydrosalpinges• Tubo-ovarianabscess• Peritonealpseudocysts• Appendicealabscess• DiverGcularabscess• Pelvickidney
ClassificaGonsystemforadnexalmasses
PRIMARYMALIGNANTOVARIAN• Epithelialcarcinoma
– Borderline– Serouscystadenocarcinoma(commonestovariancancer,50%malignancies)– Mucinouscystadenocarcinoma(10%ovarianmalignancies)
• Borderlinevariantispseudomyxomaperitonei–excludeappxprimary– Endometrioidcarcinoma(25%ovarianmalignancies)(associatedwithendometrialcain20%)– Clearcellcarcinoma(<10%ovarianmalignancies)
• Germcelltumour– Malignantteratoma– Dysgerminoma
• Sex-cordtumour– Granulosacelltumour(secretesoestrogen)
ClassificaGonsystemforadnexalmasses
SECONDARYMALIGNANTOVARIAN
• 10%ofovarianmalignancy
Predominantly:
• breast• gastrointesGnalcarcinoma(Krukenbergtumour)
Ovarianpathology
• ClassificaGonsystemforovarianpathology
• StandardisaGonofterminology–IOTA
• IOTASimpleDescriptors(paKernrecogniGon)
• PredicGonofmalignancy–IOTASimpleRules
• Workedexamples
• Quiz
StandardisaGonofterminology
• IOTAgroup
• TermsanddefiniGonsofadnexalpathology
• TRANSVAGINALULTRASOUND
IOTAdefiniGons– Unilocular,unilocular-solid,mulGlocular,mulGlocular-solidorsolid
– Cystcontents–anechoic,lowlevel,groundglass,haemorrhagicormixed
– Solidmaterialorpapillarystructuresorwallirregularity(presenceandsize)
– Vascularity
– Shadows
– Ascites
Unilocular
IOTA
Unilocular-solid
IOTA
MulGlocular
IOTA
MulGlocular-solid
IOTA
Solid
IOTA
CysGccontents
IOTA
MixedcysGccontents
IOTA
Internalwallofthecyst
IOTA
PapillaryprojecGon>3mm
IOTA
IOTAdefiniGons
• Solidcomponent–structurethathasechogenicitysuggesGveofGssueBUTthewhiteballofadermoidisnotsolidGssueandbloodclotormucinisnotsolidGssue
• Ifprotrusion>3mm=papillaryprojecGon(countassolidcomponent)
If<3mm=irregularity
• Irregular–meansanirregularinternalwallORirregularoutercontourofasolidlesion
• Ascites–fluidoutsidePOD
Vascularityscore• ColourDopplerorPowerDoppler(moresensiGve)
• PRF0.3• Velocityscale3-6cm/sec• Balance220• AdjustDopplergaintojustbelowartefactlevel
• Noflow=1• Minimalflow=2• Moderateflow=3• Strongflowthroughout=4
Ovarianpathology
• ClassificaGonsystemforovarianpathology
• StandardisaGonofterminology–IOTA
• IOTASimpleDescriptors(paKernrecogniGon)
• PredicGonofmalignancy–IOTASimpleRules
• Workedexamples
• Quiz
SimpleDescriptors
• CertainabnormaliGesarereallyobvious:– PATTERNRECOGNITION
• Endometrioma
• BenigncysGcteratoma-dermoid
• Simplecystorcystadenoma
• FuncGonalcysteghaemorrhagiccyst
• Malignanttumourwithascites
Simple Descriptors of an ovarian mass used to make a diagnosis
BD, benign descriptor; MD, malignant descriptor.
WhenSimpleDescriptorsdonotapply:
• Ifthemassisnotinstantlyrecognisable
• andSimpleDescriptorsdonotapply:
– ThenapplySimpleRules
Ovarianpathology
• ClassificaGonsystemforovarianpathology
• StandardisaGonofterminology–IOTA
• IOTASimpleDescriptors(paKernrecogniGon)
• PredicGonofmalignancy–IOTASimpleRules
• Workedexamples
• Quiz
Benignormalignant?PotenGaltests
• ClinicalexaminaGon• ColourDopplerImaging:PIorRI?• Morphologicscoringsystems(80+)• SerumCA125,othermarkers(HE4…)• Riskofmalignancyindex(RMI)
• Computermodels(logisGcregression+other)
• SubjecGveassessment(paKernrecogniGon)
• Simpleultrasound-basedrules
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 tumo ur 136 84 62
IOTA
BMJ2010
Simple Rules FEATURES of a benign mass (B-features)
AmassisclassifiedasbenignifatleastoneB-featureispresentandnoM-featuresare
present
Simple Rules FEATURES of a malignant mass (M-
features) Amassisclassifiedas
malignantifatleastoneM-featureispresentand
noB-featuresarepresent
SimpleRules
• Rule1:IfoneormoreMfeaturesarepresentinabsenceofBfeature(s),themassisclassifiedasmalignant.
• Rule2:IfoneormoreBfeaturesarepresentinabsenceofMfeature(s),themassisclassifiedasbenign.
• Rule3:IfbothMfeaturesandBfeaturesarepresent,orifnoBorMfeaturesarepresent,theresultisinconclusiveandasecondstagetestisrecommended.
Ovarianpathology
• ClassificaGonsystemforovarianpathology
• StandardisaGonofterminology–IOTA
• IOTASimpleDescriptors(paKernrecogniGon)
• PredicGonofmalignancy–IOTASimpleRules
• Workedexamples
• Quiz
Workedexamples–asagroupUsethesheetwiththeSimpleRules
• LookatthemassanddescribeitusingIOTAcriteria
• SimpleDescriptors/paKernrecogniGon–isitobvious?
• Ifnot-applySimpleRules
• Decidewhetherbenign,uncertainormalignant
• Suggesthistologicaldiagnosis
Simpledescriptors/PaKernrecogniGon
premenopausal
Endometriomaunilocular,groundglassechogenicity,premenopausal
Simpledescriptors/PaKernrecogniGon
premenopausal
Dermoidunilocular,mixedechoes,shadows,premenopausal
Simpledescriptors/PaKernrecogniGon
<10cm
Serouscystadenomaunilocular,regularwalls,<10cm
Simpledescriptors/PaKernrecogniGon
postmenopausal
Stage4ovariancarcinomawithascites
tumourwithatleastmoderatebloodflow,ascites,postmenopausal
ExampleswhereSimpleDescriptors/easypaKern
recogniGondonotapply….
• ApplySimpleRules
– threeworkedexamples:
Example 1 <10cm
DiagnosGcsieve• IOTAdescripGon
– Unilocular,unilocular-solid,mulGlocular,mulGlocular-solidorsolid– Cystcontents–anechoic,lowlevel,groundglass,haemorrhagicormixed– Solidmaterialorpapillarystructuresorwallirregularity(presenceandsize) NO– Vascularity1-4 2
– Shadows NO– Ascites NO
• SimpleDescriptors–donotapply– endometrioma/dermoid/simplecyst/haemorrhagiccyst/malignancy
• Simplerules– Benign-unilocular,smoothmulGloculartumor<100mm,largestsolidcomponentdiameter<7mm,
acousGcshadows,nobloodflow(colorscore1)
– Malignant-Irregularsolidtumor,IrregularmulGlocular-solidtumor≥100mm,≥4papillarystructures,ascites,verystrongbloodflow(colorscore4)
– Uncertain
Example 1
Simplerules:BENIGNMucinouscystadenoma
Example 1
Example 2
DiagnosGcsieve• IOTAdescripGon
– Unilocular,unilocular-solid,mulGlocular,mulGlocular-solidorsolid– Cystcontents–anechoic,lowlevel,groundglass,haemorrhagicormixed– Solidmaterialorpapillarystructuresorwallirregularity(presenceandsize)– Vascularity1-4 4
– Shadows NO– Ascites NO
• SimpleDescriptors–donotapply– endometrioma/dermoid/simplecyst/haemorrhagiccyst/malignancy
• Simplerules– Benign-unilocular,smoothmulGloculartumor<100mm,largestsolidcomponentdiameter<7mm,
acousGcshadows,nobloodflow(colorscore1)
– Malignant-Irregularsolidtumor,IrregularmulGlocular-solidtumor≥100mm,≥4papillarystructures,ascites,verystrongbloodflow(colorscore4)
– Uncertain
Example 2
Simplerules:MALIGNANTMetastasisfrombowelprimary
Example 2
Example 3
DiagnosGcsieve• IOTAdescripGon
– Unilocular,unilocular-solid,mulGlocular,mulGlocular-solidorsolid– Cystcontents–anechoic,lowlevel,groundglass,haemorrhagicormixed– Solidmaterialorpapillarystructuresorwallirregularity(presenceandsize)– Vascularity1-4 1-2
– Shadows NO– Ascites NO
• SimpleDescriptors–donotapply– endometrioma/dermoid/simplecyst/haemorrhagiccyst/malignancy
• Simplerules– Benign-unilocular,smoothmulGloculartumor<100mm,largestsolidcomponentdiameter<7mm,
acousGcshadows,nobloodflow(colorscore1)
– Malignant-Irregularsolidtumor,IrregularmulGlocular-solidtumor≥100mm,≥4papillarystructures,ascites,verystrongbloodflow(colorscore4)
– Uncertain (NOBENIGNRULESANDNOMALIGNANTRULES=UNCERTAIN)
Example 3
Simplerules:UNCERTAINBorderlineovariantumour
Example 3
Ovarianpathology
• ClassificaGonsystemforovarianpathology
• StandardisaGonofterminology–IOTA
• IOTASimpleDescriptors(paKernrecogniGon)
• PredicGonofmalignancy–IOTASimpleRules
• Workedexamples
• Quiz
QUIZUsethesheetwiththeSimpleRules
• LookatthemassanddescribeitusingIOTAdefiniGons
• ApplySimpleDescriptors(paKernrecogniGon)
• ApplySimpleRules
• Decidewhetherbenign,uncertainormalignant
• Suggesthistologicaldiagnosis
SheetwithSimpleRules
• Therewillbe10imagesforthequizwithworkedanswers
Conclusion
• ApplyIOTAterminologyandSimpleRulestoalladnexalmasses,keeparecordandchasethehistology– wereyouright?
• SimpleorcomplexVERSUS
• IOTAcriteria,SimpleDescriptorsandSimpleRules–acomprehensiveandinformaGvereport
Tosumup
• Carefulhistory• SystemaGcscan–don’tpanicwhentherearemanyseparate
abnormaliGes
• UsetheIOTAclassificaGontodescribethelesion• ApplySimpleDescriptors(paKernrecogniGon)• ApplySimpleRules
• (applyothermodelsegLR2,ADNEX)• Clearreport
– Benign/uncertain/malignant
– Suggestedhistology
• Chasethehistology–wereyouright?
Resources
• IOTA–papers,courses,apps(riskcalculators),conferences
hKp://www.iotagroup.org
• ISUOG–papers,journalclubslides
• GEposter
IOTAwebsite
IOTAapps
IOTAapps
IOTAwebsitehKp://www.iotagroup.org
GEPoster
THANKYOU