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1/26/2018
1
Adnexal Masses: Borderline Ovarian Tumors of
Low Malignant Potential
Can we define them more reliably?Ilan E Timor-Tritsch MD
NYUSOM, Department of OB/Gyn
41st Annual Advanced Ob-Gyn Ultrasound Seminar
©AIUM
Disclosures
Ilan E. Timor-Tritsch
I have no relevant financial relationships
Description of the lecture
• In the tile of the lecture I ask if we can, or could
define adnexal masses more clearly, more accurately
• Unless my previous, more general, teaching lectures
on adnexal masses, this talk is entirely different
• I will try to share my attempt to present a deeper
insight of a restricted number of entities rather than
repeat discussing a large number of issues in a broad
manner
• This lecture is dedicated to sonographers and
sonologists who want to understand more about
some important selected entities
©AIUM
Learning ObjectivesAfter the presentation, attendees will be able….
• ….to understand, and more importantly, apply
the available scanning strategies, diagnostic
rules, US tools, simple maneuvers and
effectively use them, not only to characterize,
but also to fine-tune certain features of adnexal
findings leading to accurate clinical diagnoses.
• ….to apply some of the scanning techniques to
be able to recognize the sonographic features of
borderline ovarian tumors and their differential
diagnoses
1. Scanning strategies
Timor & Monteagudo
Scanning strategies that help
Timor & Monteagudo
1. Imperative (MD & RDMS!!) : obtain good history, ask
patient, review chart, call referring doctor and/or NP
2. Use primarily transvaginal scanning route. Always
add transabdominal, and, if needed, transrectal scan.
3. Use the highest frequency transvaginal US probe
4. LEARN AND USE 3D US TECHNIQUES
5. Be familiar with scoring syatems (e.g. IOTA)
6. Read the literature and follow new clinical information
and new technical developments with new applications
7. Attend relevant courses. Listen/watch webinars
8. If possible ask if you can shadow someone who can
teach you a new way to improve your skills
1/26/2018
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Scanning for adnexal pathologies
• US should be the almost always the 1st line
imaging before CT & MRI
• You MUST arrive at a conclusion!
• Therefore use all available US tools:
– primarily transvaginal sonography (TVS),
combine it with
– transabdominal sonography (TAS)
– Use a variety of transducers for
frequency, depth, color and power
Doppler, employ 3D as needed….
Scanning for adnexal pathologies
• Most of the time the question is: is it malignant or is it benign?
• Remember: not all masses are ovarian.
– Take a good history
– Talk to the patient! She may be your best source of information
– MD: Do a bimanual pelvic exam before as well as after the scan to confirm US findings
– Ask for a menstrual history
Menstrual Hx.: Important!!
• In the reproductive years, physiologic as
well as pathologic processes are driven
by the menstrual cycle or by (therapeutic
or pathologic) hormonal stimulation.
• Know your patients’ first day of her cycle.
Gray scale Color Doppler Power Doppler
Is this an ovarian malignancy?
How about this?
In the secretory phase of the cycle do not
attempt to make a diagnosis of ovarian
pathology in a new patient. Rather look for
the corpus luteum using color Doppler
Be careful, reschedule the patient in the follicular
phase of one of her next cycles.
If irregular cycles, ask her to call for appointment to
suit her based upon her time of bleeding
2. General and basic
information follow the
message of the talk
1/26/2018
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First:
We have to be familiar with
appearances of ovarian
masses
Know what to look for?
• Appearance:
• “Bizarre shapes”
• Mixed components
• Size
• Is it uni- or bilateral?
• Ascites
• Motion tenderness
• Vessels
• Mobility:sliding/fixed?
When these are
documented, the next
step is: LOOK AT THE
VASCULARITY.
Look for these or similar images• General appearance
– Solid
• Hyperechoic
• Hypoechoic
– Cystic:
• without solid component
• With solid component
– Unilocular, Multilocular
Look for details
• Internal echo structure:
– Anechoic/hypoechoic
– Echogenic (solid)
– Low-level echoes (ground glass appearance)
– Mixed echogenicity
– Reticular, etc
Examine inner wall structure
• Wall structure:
– Thickness
– Inner, mural
papillae
If inner wall papilla/e or nodules are seen,
apply power [not color!] Doppler with the
highest sensitivity to detect blood vessels.
Second:
We should be familiar of
scoring systems and how
to apply them to better
differentiate between
benign and malignant
ovarian masses
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What do scoring systems do?
• They translate macroscopic, pathologic features to sonographically recognizable features.
• All are based upon the same building blocks:
– Wall thickness
– Septations
– Echogenicity
– Papillary formations
– Solid components
– Blood supply (vascularity)
• Some systems add: size, ascites, age, etc…
Several scientifically proven set
of articles suggest that
subjective evaluation of adnexal
masses is almost as good as
the evaluation based upon strict
scoring systems
• Sassone M, Timor-Tritsch et al, AJOG 1991
• Kentucky. DePriest et al, Gynecol Oncol 1997
• 1993; Osmers, AJOG 1994
• Bromley et al, Obstet Gynecol 1994
• Lerner JP, Timor-Tritsch al, AJOG 1994
• Kurjak, UOG 1994
• Ferazzi, UOG 1998
• The most tested for accuracy is the IOTA system
(Timmerman, UOG 1999-2016)
One may use Morphology Scoring
Systems: they are out there.
However, they do not have to be applied to the letter.
Just understand their basic idea to differentiate a benign
tumor & from a suspicious or a malignant one
The IOTA scoring system
I= international
O= ovarian
T= tumor
A= analysis
The simple rules by the IOTA group
Benign features • B1 feature: unilocular cyst
with thin, few, or incomplete
septations or wall nodularity
of ≤3 mm. There may be
internal echoes.
• B2: presence of a solid
component of ≤ 7 mm in
largest diameter.
• B3: acoustic shadowing
• B4: smooth multilocular
tumor of with a largest
diameter ≤10 cm
• B5: no detectable Doppler flow
IOTA simple rules
Timmerman D et al
Malignant features
• M1: irregular solid tumor.
• M2: presence of ascites.
• M3: at least 4 papillary
• structures within a cystic
lesion.
• M4: irregular multilocular
solid tumor with a largest
diameter of ≥10 cm
• M5: very high color
contenton color Doppler
examination.
IOTA simple rules
Timmerman D et al
1/26/2018
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IOTA color score
D. Timmerman, B. Van Calster, A. Testa, L. Savelli, D. Fischerova, W. Froyman, L. Wynants, C. Van Holsbeke, E. Epstein, D. Franchi, J. Kaijser, A. Czekierdowski, S. Guerriero, R. Fruscio, F. Leone, A. Rossi, C. Landolfo, I. Vergote, T. Bourne, L. Valentin. Risk assessment of adnexal masses based on the IOTA Simple Rules. AJOG 2016.
Courtesy of D. Fischerova
3. My first subject : nodules
and papillae in ovaries
My plan
• I will devote the first part of this
talk to discuss internal wall
nodules and papillae in ovarian or
paraovarian cysts s well as some
new ways to assess ovarian cysts
• The second part of this talk will
share some technical skills to
improve the diagnosis
Be forewarned! Be informed!
Almost everybody I know uses the
terms “papilla” and “nodule”
interchangebly
So does the literature
I have different definition for them
My definition of nodule & papilla
Nodule• Hyperechoic, mostly
shadowing, sub-
centimeter, avascular
inner wall structure in
ovarian or paraovarian
cysts & at times on
septae
Papilla (plural: papillae)
• Hypoechoic, mostly non-
shadowing, subcentimeter,
irregularly shaped,
vascular inner wall
structure in ovarian or
paraovarian cysts
10 mm 10 mm
Does the finding of papillae
in adnexal cysts increase the
risk of ovarian cancer?
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The significance of papillary
formations in ovarian cysts
• Agreement in EUROPE
and the USA:
– Cysts with “Small “,
hyperechoic papilae
without blood vessels
are benign and can be
followed by periodic
imaging
Radiology: Volume 256: September 2010 n radiology.rsna.org
The significance of papillary
formations in ovarian masses
• Agreement in EUROPE
and the USA:
– Cysts containig papillae
with blood vessels are
suspicious for malignancy
and should be removed
Radiology: Volume 256: September 2010 n radiology.rsna.org
The questions are:
• How do we make distinguish between a
nodule and a papilla?
• Are they different histologically?
• How do we use color or power Doppler?
• Are there any characteristic US features
that help sorting them out?
• And if we sort them out, does it mean the
we will be able to predict or rule out
malignancy?
Papillary projections within
ovarian or other cysts
• Thought to be sensitive markers of
malignancy
• If found, more work has to be done
–1. Measure them
–2. Determine shape and echogenicity
–3. Look for vessels in it
–4. Examine their signature texture
How to measure the papilla?
Timmmerman D: The IOTA group UOG 2000;16:500
The kinds of papillary
projections
Timmmerman D: The IOTA group UOG 2000;16:500
Sorry Dierk! This is a typical
sketch of a chronic hydrosalpinx!
The others are OK.
1/26/2018
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Papillae: general appearance
On the wall
On the wall
with blood
vessel
On the septum
Three kinds of nodules/papillae• Hyperechoic nodule/e
• No vessels in nodule
• Nodule does shadow
• Hypoechoic papilla/e!
• Irregular borders
• Vessels in papilla
• Does not shadow
Nodule: usually benign
(cystadeno-fibroma)
Goldstein & Timor-Tritsch JCU 2010
Usually borderline ovarian
tumor or frank epithelial Ca.
In pregnancy c. aproprate
history: Decidualized
endometrioma
• Hypoechoic papilla/e
• Smooth, rounded borders
• Vessels in papilla
• Does not shadow
Mascilini F. et al, UOG 2014;Timor & Monteagudo Timmerman et al, UOG 2008;
3D tomography use helps to generate
serial sections on one picture saving
multiple single ones
Electronic scalpel removes part of cyst
Rotate
Both compartments have papillae
The 3D rendered cyst
!!What about
the other
compartment
?
3d rendering: teaching value
I present 3 kinds of
nodules/papillae and point
out the subtle features to
help in defining them and in
an attempt to get as close
as possible the correct
diagnosis
First: papillae in an
endometrioma
An example:
1/26/2018
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Imperative (MD &RDMS!!) : obtain good history, ask
patient, review chart, call referring doctor and or NP
• You scan a 31 y.o. patient at 12 weeks for NT in
the right adnexa this is the TVS finding:
Benign or malignant?
Benign: CL? or malignant? or “other”?
• Ask patient: have you had any
Hx. of pelvic disese? A: No
• Any problems getting pregnant?
A: No
• Any pelvic imaging (US,CT,
MRI) in the last years? A: US
for pregnancy 2 y ago: NL
• Your Diff. Dx: CL vs E-oma
vs ov. malignancy (BOT/LMP)?
Scenario #1
Call MD/Gyn Onc Rescan PRN
No change Probably removal @16w
• Ask patient: have you had any
Hx. of pelvic disese? A: Yes
• Any problems getting pregnant?
A: Yes, 4y infertility Rx
• Any pelvic imaging (US,CT,
MRI) in the last years? A: US-
one endometrioma ?side?
• Your Diff. Dx now: CL vs
most probably: decidualized
E-oma
Scenario #2
Call MD F/U and rescan as needed
Evolution of a decidualized
endometrioma across and
after the pregnancy
9w4d 10w4d
38w5d
2 month postparum
11w5d 19w5d
What is a decidualized
endometrioma?
It is a subset of
endometriomas with a
characteristic appearance
seen in pregnancy
Here is the science behind the lesions
Histology• Under the influence of progesterone during
pregnancy the uterine endometrium transforms
into decidua; vessels enter the decidual lining.
• The saallme is happening in the decidua lining
the inner wall of the endometrioma
Schwartz N, 2009
The point of the matter
• With decidualization the sonographic
appearance of endometriomas can become
more heterogenous with papillary
excresences and increased vascularization
Machida S, 2008; Sammour RN, 2005
1/26/2018
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The point of the matter
It is therefore of great importance to correctly differentiate
between a decidualized E-oma and ovarian malignancy
• And….. since a richly
vascularized ovarian
lesion is considered
malignant unless proven
otherwise
• And… since the proof is
usually surgical
exploration, that may lead
to pregnancy loss or
premature labor…….
Decidualized endometriomaA subset of endometrioma seen in pregnancy
--Fruscella E et al. Sonographic features of decidualized ovarian endometriosis suspicious for
malignancy.UOG 2004; 24: 578
--Mascilini F. et al, Imaging in gynecological disease. 10: Clinical and ultrasound
characteristics of decidualized endometriomassurgically removed during pregnancy. UOG
2014;44):354-60.Timor & Monteagudo
• Shallow, mostly smooth, rounded papillae protruding from a thick inner surface “lining”
• Moderate amount of vessels in papillae• As pregnancy progresses picture returns to the basic
character of the preexisting EOMa
Make everything possible to obtain reliable history,
previous US images, laparoscopy results etc.
A proven diagnosis of endometriosis by the above
saves surgery during pregnancy!!
Watch the difference between a papilla in a
decidualized endometrioma and that of a BOT
Rounded surface of papilla Irregular surface of papilla
„DIAGNOSTIC POINTERS“
Decidualized Endometrioma vs Ovarian Cancer
• Shallow, rounded papillae versus large
irregular (cauliflower shaped) papillae
protruding from the inner surface
Decidualized Endometrioma Ovarian Cancer
Second: nodules in a cyst
An example:
Several ovarian cysts with nodules
What do they have in common?
They have echogenic,
shadowing nodules
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What next?
Apply power Doppler!!
The ultimate proof:
following is a series of ovarian
cysts with nodules with their
histology
10mm
1/26/2018
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a
bc10m
m
10m
m
10mm
3D renedering (teaching
value only!
a b c
a
b c10mm
10
mm
10 mm
• All the above were histologically
proven benign cystadeno-fibromas
Question:
do they undergo changes in
appearance and/or size?
1/26/2018
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11.24.14 8.26.15 3.9.15 12.10.15
a
a’
c
c’
d
d’
b
b’
Answer: not really!
Is there another variety of
benign fibromas in the
ovary?
Ovarian fibroma
Benign ovarian tumor
Cystic Solid
Non-neoplastic ovarian cystsThese are by far the most common cysts.
Timor & Monteagudo
• Hyperechoic, shadowing mural papilla/e
• Avascular papillae
• Anechoic fluid
• Mostly unilocular
• 30% multilocular
• Thin wall, thin septae
• Slow rate of growth
Benign ovarian tumor
Sono markers:
Cystic
Ovarian fibroma
Goldstein, Timor & Monteagudo JCU 2009Timor & Monteagudo
Solid
• Hypoechoic mass with
strong acoustic
shadowing
• Myometrium-like stroma
• They tend to have minimal
vascularity interrogated
with color Doppler US
• Almost certaily benign
• Slow rate of growth
Sono markers:
Solid Fibroma Ovarii
Hypoechoic
Shadowing
Poor vessel content
Finally, the secret to the Dx.• Turn on POWER Doppler NOT Color Doppler (Power
Doppler is more sensitive)
• Use the smallest possible ROI for the Doppler search
• Use the lowest possible PRF, just before artifacts start
to appear.
PRF 0.3
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Third: papillae in in a cyst
An example:
Papilla with blood flow
Let us analyze this image
Diagnosis?
Paraovarian cyst with papilla
Attention: paraovarian cysts may have
papillae. If they do, look for blood vessels. If
they have, it may be a reason to remove them
Diagnosis
• Paraovarian/paratubal cyst (you were right)
• Low Malignant potential changes in
the papilla
• Remember: paraovarian cysts may
have LMP areas
1/26/2018
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Which leads me into the
borderline tumors of LMP
©AIUM
Borderline Ovarian Tumor/
Low Malignant Potential tumor
In a significant number of
cases, mostly in reproductive
age women, cysts with
vascular papillae are
borderline ovarian tumors of
low malignant potential
Why is it important to mention
this kind of ovarian tumor?
Only two “word slides”…..
General• Borderline Ovarian Tumors (BOT) or tumors of Low
Malignant Potential (LMP) are:
– epithelial tumors (serous=50%: mucinous= 46%)
– have a slow growth & low invasive potential
– are often diagnosed at an earlier stage than invasive Ca.
– have good prognosis, present as: Stage I=70%; Stage II=10%;
– tend to occur in younger women
– 5 y. survival rate is ≈95%
• Because of all the above, fertility sparing conservative treatments
have been proposed
• Some suggest endoscopic approach after surgical staging Darai E et al, Eur J Obstet Gynecol Reprod Biol 1996;66:141Candiani M et al, Clin Exp Obstet Gynecol 1999;26:39
Seracchioli R et al, Fertil Steril 2001;76:999Camatte S et al, BJOG 2001;109:376
• Conclusions
• Although the correlation of stage with survival was mixed,
performing staging procedures for low malignant potential
ovarian tumors is not supported by the best available
evidence. Guidelines in support of staging based their
recommendations on a few regional studies and conflict
with better-quality data that do not support staging
procedures. An international consensus statement is
needed to standardize the surgical management of low
malignant potential ovarian tumors.
1/26/2018
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• This study systematically reviews the literature for the accuracy
of TVUS, MRI and CT in the diagnostic of BOTs.
• Search in PubMed/Medline of articles in English from the last 5
years and included 14 studies for systematic review, 9 of them
meta-analysis.
• The pooled sensitivity and specificity was respectively
– 77.0% and 83.0% for TVUS (5 studies) and
– 85% and 74% for MRI (4 studies) in differentiating benign from
malignant BOTs.
• 4 CT studies have also shown a high accuracy in differentiating
BOTs from malignant ovarian cancers.
Exacoustos C,
et al
Preoperative
sonographic
features of
borderline
ovarian
tumors.
UOG
2005;25:50
Fertility preservation in women with borderline ovarian tumors
- how does it impact disease outcome? A cohort study.
• OBJECTIVE was to identify features impacting on recurrence and survival, and assess the
safety of a fertility-sparing approach.
• MATERIAL AND METHODS: A historical cohort study of consecutive borderline ovarian
tumors cases treated at a single institution over 30 years (1981-2011).
• Data on surgical approach (fertility-sparing or otherwise), disease stage, CA125 levels,
histological features, adjuvant treatment and follow-up data were collected.
• RESULTS: 213 patients were included.
• Of 132 women age 40 years and below at diagnosis,
• 112 (85%) had fertility-sparing procedure & 60 (46%) had conservation of an involved ovary.
• Fifty patients (24%) developed recurrences; fertility preservation (hazard ratio = 2.57; 95%
confidence interval 1.1-6; p = 0.029) and advanced stage (hazard ratio = 4.15; 95% confidence interval 2.3-7.6; p <
0.001) were independently associated with recurrence on multivariate analysis.
• Eleven (5%) patients died of their disease.
• Fertility preservation was not associated with compromised survival.
• CONCLUSIONS: Borderline ovarian tumors carry a good prognosis overall.
• Fertility preservation is associated with a higher risk of disease relapse; however, as
most relapses are localized and may be salvaged with surgical treatment, overall
survival is not compromised.
Helpman L1,2, Yaniv A2, Beiner ME1,2, Aviel-Ronen S1,2, Perri T1,2, Ben-Baruch G1,2, Hogen Ben-David L1, Jakobson-Setton A1, Korach J1,2. Acta Obstet Gynecol Scand. 2017 Nov;96(11):1300-1306
• Objectives: The aim is to determine if there are any US
features of papillations or of the cyst wall that can discriminate
between benign and malignant unilocular-solid cysts with
papillations but no other solid components.
• Methods: Patients with the above features identified from the
IOTA database of 7 centers.
• All had TVS between 1999 - 2012 by an experienced examiner
by the IOTA research protocol.
• Information on four US features of papillations had been
collected prospectively.
• Info on a further 7 US features was collected retrospectively.
• The histological diagnosis was the gold standard.
• Results: Of 204 masses included,
– 131 (64%) were benign,
– 42 (20.5%) were borderline tumors,
– 31 (15%) primary invasive and
– one (0.5%) was a metastasis. • Multivariate logistic regression analysis showed the following US features to
be independently associated with malignancy:
– the height of the largest papillation,
– blood flow in papillations,
– papillation confluence or papillation dissemination, and
– shadows behind papillations.
• Shadows decreased the odds of malignancy, the other features
increased them.
• Conclusion: We have identified US features that can help discriminate
between benign and malignant unilocular-solid cysts with papillations but no
other solid components.
• Our results need to be confirmed in prospective studies.
1/26/2018
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What are the sonographic
characteristics of BOTs?
Exacoustos C et al, Sonographic
appearance of borderline ovarian tumors.
• The most frequent diagnostic feature on imaging BOT is the
presence of papillae within the cyst. However, neither papillae
nor other sonographic features constituted highly sensitive
sonographic markers of BOT. (Doppler was NOT used!)
Ultrasound Obstet Gynecol 2005; 25: 50–59.
48yo serous BOT 52 yo ovary c. benign cystadenofibroma
Shape and
size
variations
1.5cm
18 cm
. Alfuhaid TR et al. Ultrasound Quartely 2003;19:13
Alfuhaid TR et al, Low malignant potential tumor of
the ovary: Sonographic features with
clinicopathologic correlation in 41 patients
Morphologic variations
. Alfuhaid TR et al. Ultrasound Quartely 2003;19:13
Septae, solid
component
Septae, mural
nodulesPsammomatous
calcifications
Endometrioma-
like
Mimick solid
tumors
Mural nodules
Blood vessels
in papillae
• Wide variety of morphologies
• Only 35.3% had a unique appearance—a cyst within the ovary
of small to medium size with vascular mural
Ascites &
peritoneal
seedings
Our NEW observation regarding US
characteristics of BOT of LMP
• Low-power microscopic, histology pictures were
obtained of 71 ovarian masses with proven BOT-LMP
• Before surgery TV-US performed by 5-9 mHz probes
• US images were juxtaposed and compared to the
microscopic pictures
• Histologic diagnosis of 10 ovaries was BOT, however
1-5% of their areas demonstrated features of epithelial
cancer, these were analyzed separately, therefore…
• ….61 US/histology pairs were analyzed for US
features of adnexal masses applying the IOTA
“simple rules”
I. Timor/L.Boyd/A. Monteagudo/R. Wallach/C. Brandon/ C.Foley: IRB approved -Unpublished
61 BOT c. LMP
with histologic
confirmation
Unilocular31 (50.8%)
Multilocular30 (49.1%)
Septae44 (72.1%)
Blood vessel
present41 (82.8%)
Solid component
>7mm52 (85.2%)
Papilla/e ≤7mm
31 (50.8%)
Microcysticappearance
51 (83.6%)
I. Timor/L.Boyd/A. Monteagudo/R. Wallach/C. Brandon/ C.Foley: IRB approved -Unpublished
New observation regarding US
characteristics of BOT of LMP
What are these “microcysts”?and how do they look?
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A new sonographic descriptor of Borderline
ovarian tumors of low malignant potential
• As we evaluated the sonographic appearance of the
61 histologically proven BOT with LMPs a unique
feature became increasingly evident.
• A number of the papillae, solid components of different
sizes demonstrated a microcystic texture
• These microcysts measured between 1 and 3mm
5mm
10mm
A B
5-9 MHz transvaginal probe
One more observation
6-12 MHz transvaginal probe
A
5mm
Do I have false positives? Yes I do!
Here is one:
It is not
hyperechoic
It has
microcystic
texture
With capillary
Doppler signature
It has a v small
blood vessel
Therefore my diagnosis
was: Borderline Ovarian
Tumor with Low Malignant
Potential
And since, by the rules
(papilla with blood vessel),
it was removed
laparoscopically
Histologic Dx: Benign
cystadenofibroma
It is not
hyperechoic
With capillary
Doppler
signature
It has a blood
vessel
It is not
hyperechoicBut has some
shadowing
Morale: 1. Pay MORE attention to the
sono characteristics
2. If in doubt rescan in 1-2 months
It has some
microcystic
texture
4. General and Technical
Aspects
1/26/2018
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Technical aspects: Here to help!
Again: the most efficient pelvic
evaluation is by using high
frequency transvaginal probes.
For structures 6-7 cm away use 5-8/5-9MHz probes
If they are small and only 4-7 cm away, it is
worth the trouble to plug in a higher
frequency probe (use 6-12MHz). You will be
rewarded by clearer images!
Use the “Sliding organs sign”
Generated by the intermittent pressure of the vaginal probe moving the cervix, ovaries, uterus back and forth to evaluate their movement relative to the pelvic floor and/or each other. Useful to diagnose or rule out pelvic adhesions.
Technical aspects
Timor-Tritsch IE UOG 2016
Sliding organs sign
Important in patients with infertility,
endometriosis or suspect for a frozen
pelvis
• * First described in: Transvaginal Sonography. (eds): Timor-Tritsch IE and Rottem S
Elsevier Science Publishing Co. New York 1988; Pages 24,35,52,55,72,84
Positive sliding organs sign
(normal):
Uterus and cul-de-sac
Positive sliding organs sign (normal):
Normal right ovary Normal left ovary
Timor-Tritsch IE and Rottem S Elsevier Science Publishing Co. New York 1988; Pages 24,35,52,55,72,84
At the same time also test for pain
(Endometriosis? Torsion?)
Test for pain with the
transvaginal probe
• Every fifth patient scanned by us is referred
for “pelvic pain” or a combination of pain and
something else
• Touch and press against the ovaries,
adnexae and cervix while watching the
patient’s face for a possible pain reaction and
asking her if “this is the pain” for which she
has the scan
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Record the mobility or fixed nature
of pelvic organs
• Add credibility to your report!
• Acquire and save “sweeps” of the adnexae
Timor & Monteagudo
The “jiggling” blood clot in a
hemorrhagic CL
Timor & Monteagudo
Most common mistake: calling it suspicious for malignancy.
Solution: scan patients between days 5-9 of their period!!
– Harder to find (no, or rare follicles as markers).
– Linger on the adnexae & look for hypoechoic, 1-3 cm structures
amidst constantly moving bowel.
Advise to find postmenopausal ovaries
Gray scale
Color
Doppler
Steroid cell tumorsSono characteristics:
Rare, found usually by their clinical presentation & laboratory tests
Male hairline
Small, intra-ovarian,
yellowish tumor
Monteagudo A et al. Ovarian steroid cell tumors: sonographic characteristics. UOG 1997;10:282.
Small size, homogeneous echogenicity
Rich vascular ring around its periphery
The normal and abnormal Fallopian tube
• A normal Fallopian tube is almost
impossible to detect sonographically,
unless it is surrounded by pelvic fluid, or,
fluid is injected in it (hydrosonography)
• However, tubal pathologies can be
detected and diagnosed by gray scale
and color Doppler transvaginal US
7. The Fallopian tube
• Primary fallopian tube cancer is the rarest
among female genital tract cancers.
• It accounts for 0.3% to 1.8% of these cancers.
• Papillary serous adeno-carcinoma represents
more than 90% of these cancers [2, 3].
• Other less common types include clear cell
carcinoma, endometroid cancer, germ cell
cancers, and sarcoma .
7.2. Tubal carcinoma
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20
Tubal carcinoma Tubal carcinoma : ultrasound
8. Additional sites to check
Look at the cul-de-sac
Postoperative peritoneal inclusion cysts in
loculated pelvic fluid
Sohaey R, Gardner TL, Woodward PJ, Peterson CM. Sonographic diagnosis of
peritoneal inclusion cysts. J Ultrasound Med 1995; 14:913-917
• The Dx should be suspected in
the right clinical setting.
• Dx depends on the presence
of filmy, ondulating strings of
adhesions within surrounding
loculated fluid confined to the
intra-peritoneal space.
Cul-de-sac/pelvic peritoneum
Tumor seedings
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The New Consensus
Panel Recommendations
Glanc P et al. JUM 2017
• The AIUM convened a group of experts as well
representatives of the involved and pertinent professional
gouverning bodies to hold a concensus conference on the
subject of imaging and managing adnexal masses.
• The content of the following slides show the results of the
agreed upon features of the adnexa/e
Adnexal Mass Consensus
Recommendations
1. Pelvic sonography should include the transvaginal
approach with Doppler imaging as indicated.
2. Simple ovarian cysts are not precursor lesions to
malignant ovarian cancer; however, it is crucial to
perform a high-quality examination to ensure the
absence of any solid/papillary structures before
designating it a simple cyst.
The risk of progression to malignancy is extremely
low; thus, a degree of follow-up is prudent.
Glanc P et al. JUM 2017
3. Real-time pattern recognition sonography in the
hands of an experienced imager is currently the most
accurate method of characterizing an ovarian mass.
4. Initial mass characterization could be performed either
by pattern recognition or via a risk model such as the
IOTA Simple Rules.
5. When an ovarian lesion is considered benign, the
patient may be followed conservatively, or if indicated,
surgery can be performed by a general gynecologist.
6. Serial sonography is a beneficial strategy, but
there are limited prospective data to support an exact
interval and duration.Glanc P et al. JUM 2017
Timor & Monteagudo
7. Fewer surgical interventions may well result in
an increase in sonographic surveillance.
8. When an ovarian lesion is considered
indeterminate on initial sonography, and after
appropriate clinical evaluation, a “second-step”
evaluation may include: referral to an expert
sonologist, serial sonography, application of
established risk prediction models, correlation with
serum biomarkers, correlation with MRI, or referral
to gynecologic oncologist for further evaluation.
Glanc P et al. JUM 2017
9. Summary and
conclusions
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22
Summary and conclusions
• Most of the time adnexal masses carry
defined sono characteristics and
pathognomonic features (markers)
• The major, refined sono-markers of
adnexal masses were described to enable
a better recognition of their possible
histology
• Where applicable, relevant articles from the
contemporary literature were quoted
Conclusions
• Most adnexal masses can be assessed
subjectively using:– Hi frequency TV-US probes (TA if large mass)
– An enhanced basic US knowledge
– Liberal use of power Doppler
– IOTA simple rules: Benign and malignant US markers
• For my friends in radiology:
– If you like to use the term : “complex mass”, please
describe it in terms of their sonographic character (based on the new consensus data or IOTA “simple rules”)
– You help the gyn by focusing on minimal # of Diff. Dx-ese
Conclusions• Avoid the word “cyst” referring to follicles or
corpora lutea: Define them!!
• Be attuned to the issues of nodules/papillae in
a cyst (size, shape, echogenicity, shadowing , blood vessels in it)
• Avoid the sentence: “…malignancy can not be
ruled out”! It sentences patients to surgery!!
• Use: ”My suspicion of the structure to be
malignant is: high, moderate, low, none or can
not classify” ADD: “I favor xyz..diagnosis”
• Ask for MRI or Gyn Onc only if really needed
Thank you for listening
Benacerraf BR, Abuhamad AZ, Bromley B, Goldstein SR, Groszman Y, Shipp TD, Timor-Trisch IE. Consider ultrasound first for imaging the female pelvis. Am J Obstet Gynecol 2015; 212: 450-5
--Sassone AM1, Timor-Tritsch IE, Artner A, Westhoff C, Warren WB Transvaginal sonographic characterization of
ovarian disease: evaluation of a new scoring system to predict ovarian malignancy. Obstet Gynecol. 1991 Jul;78(1):70-6.
--Timor-Tritsch IE, Goldstein SR: The simplicity of a simple cyst and the complexity of a complex mass. JUM Editorial 2005
--Timmerman D, Testa AC, Bourne T, et al. Simple ultrasound-based rules for the diagnosis of ovarian cancer.
Ultrasound Obstet Gynecol 2008;31(6):681-690--Testa AC et al. Ovarian cancer arising in endometrioid cysts: ultrasound findings. UOG 2011; 38: 99
--John R van Nagell Jr & John T Hoff: Transvaginal sonography in ovarian screening: current perspectives. International journal of womann’s health 2013
--Radiology: Volume 256: September 2010 n radiology
-- Sohaey R, Gardner TL, Woodward PJ, Peterson CM. Sonographic diagnosis of peritoneal inclusion cysts. J Ultrasound Med 1995; 14:913-917
--Sohaey R, Gardner TL, Woodward PJ, Peterson CM. Sonographic diagnosis of peritoneal inclusion cysts. J Ultrasound Med 1995; 14:913-917
-- Modesitt SC et al Risk of malignancy in unilocular ovarian cystic tumors less than 10 cm in diameter. Obstet Gynecol
2003;102:594–9-- Saunders BA, et al. Risk of malignancy in sonographically confirmed septated cystic ovarian tumors. Gynecol Oncol
2010;188:278–82--Fruscella E et al. Sonographic features of decidualized ovarian endometriosis suspicious for malignancy..UOG 2004;
24: 578
-- Mascilini F. et al, Imaging in gynecological disease. 10: Clinical and ultrasound characteristics of decidualizedendometriomas surgically removed during pregnancy. UOG 2014;44):354-60.
-- Monteagudo A et al. Ovarian steroid cell tumors: sonographic characteristics. UOG 1997;10:282.-- Jeong-Ah Kim et al. High-Resolution Sonographic Findings
of Ovarian Granulosa Cell Tumors JUM 2010; 29:187–19
--van Nagell JR Jr,, Miller, RW. Management of Asymptomatic Ovarian Tumors Obstet Gynecol 2016;127:848–58-- John R van Nagell Jr & John T Hoff: Transvaginal sonography in ovarian screening: current perspectives.
International journal of womann’s health 2013--
Key References
Glanc P et al. JUM 2017
Glanc P et al. JUM