Diane DeFriend Derriford Hospital, Plymouth Ultrasound US – remains primary imaging modality for investigation of an adnexal mass
Aim to characterise
Benign
Malignant
Indeterminate
≈ 90% adnexal masses characterised by ultrasound alone Adnexal Masses- Why do we need to characterise Benign
• Conservative Management • Discharge / Follow up imaging • Surgery • Minimally invasive • Fertility sparing
Malignant
• Staging laparotomy / Cytoreductive surgery • Specialist gynaecological oncology surgeon • Cancer Centre AIMS
RECOGNISE FEATURES MALIGNANCY Avoid need for repeat surgery
RECOGNISE COMMON BENIGN MASSES Most adnexal masses benign May avoid unnecessary surgery
INDETERMINATE MASSES Role of follow up / alternative imaging
Different approaches to characterising adnexal masses Experienced examiner Subjective ‘pattern recognition’ approach superior Benign Ovarian Lesions
BIG FIVE
Corpus Luteum
Crenellated cyst
Low level echoes
Circumferential flow
Secretory endometrium Benign Adnexal Masses Simple Cysts
Virtually exclude malignancy
Large cysts - ensure not missing small nodules
serous cystadenoma – occ present as simple cyst esp larger cysts / older women
Most resolve 1-2 months - follow up pre-menopausal > 5cm Post-menopausal > 3cm
Haemorrhagic Cysts
Varied appearance change blood products over time
Typical appearances reticular pattern (fibrin strands)-strong predictor Clot – may simulate solid nodule concave border absence flow
Atypical – premenopausal Should resolve 1-2 cycles Follow -up
Endometrioma Characteristic Atypical Well defined cyst • ≈ 15% mural irregularity • Usually avascular – clot Uni / multilocular • Rarely flow – endometrial Homogenous low level echoes tissue - ‘ground glass’ appearance • Diffuse echoes Hyperechoic wall foci • Dermoid Cyst • Mucinous ovarian tumour • Further imaging • Characteristic - haemorrhage Endometrioma MR T1 high signal
FS – more conspicuous excludes dermoid
T2 low signal (SHADING) complete loss signal dependent layering
Polycystic Ovary
2003 Consensus report defined PCOS 2 of 3 criteria Oligo and/or anovulation Hyperandrogenism Polycystic ovary – US
Polycystic Ovary 12+ follicles 2-9mm and/or ? ≥ 25 follicles - Dewailly et al Ovarian volume >10cc 2014 Follicle distribution/stromal echogenicity not included 26 follicles , 18-35 yrs - Lujan et al 2013
Germ Cell Tumours – Cystic/Solid Mature Teratoma (Dermoid Cyst )
Variable appearance – internal composition
Often specific features Dermoid plug Rokitansky Nodule – echogenic nodule / dense well Tip of iceberg sign defined shadowing
Dermoid mesh
Floating Balls
Fat-Fluid level Echogenic mass (sebaceous material / hair ) ill defined shadowing obscures posterior border Mature Teratoma ( Dermoid Cyst)
Dermoid Mesh Multiple echogenic lines/dots Hair fibres
Floating Balls Uncommon / Pathognomonic Sebaceous material around focus debris/hair
Fat fluid Level – non specific
Often at least 2 characteristic features detected
Further imaging Atypical - characteristic for fat Visualise other ovary
T2 T1 T1 FAT SAT
Benign Ovarian Lesions BIG FIVE
Corpus Luteal Cysts Functional Cysts
Haemorrhagic Cysts
Endometriomas
PCOS
Dermoids Benign Extra- Ovarian Lesions
Hydrosalpinx
Para-ovarian Cysts
Peritoneal Inclusion cysts Paraovarian cyst
Broad ligament
Paramesonephric, mesothelial , mesonephric remnants
Usually simple Hydrosalpinx Tubular
Incomplete septations
Indentations opposite sides of wall -waist sign
Mural nodules – cogwheel beads on a string
Echoes - pyosalpinx Peritoneal Inclusion Cyst
Functioning ovary Adhesions – surgery, endometriosis, PID Cystic mass + septa Shape – conforms to adjacent pelvic structures NB – normal ovary within/ periphery mass Pseudocyst / Peritoneal Inclusion Cyst Pitfalls Pitfalls Bladder - TVS
Classification of Ovarian Neoplasms
• Serous Cystadenoma/Carcinoma EPITHELIAL • Mucinous Cystadenoma/Carcinoma TUMOURS • Endometrioid • Clear Cell 65-70% • Brenner Tumour
GERM CELL • Mature Teratoma (Dermoid) / Immature Teratoma TUMOURS • Dysgerminoma 15-20%
SEX CORD STROMAL • Granulosa Cell TUMOURS • Sertoli Leydig 5-10% • Fibroma Thecoma
Metastases 5-10 %
Classification of Ovarian Neoplasms
• Serous Cystadenoma / Carcinoma EPITHELIAL • Mucinous Cystadenoma / Carcinoma • Endometrioid TUMOURS • Clear Cell 65-70% • Brenner Tumour
85% malignant ovarian neoplasm
Serous / Mucinous
Benign – Peak 30-40 years Malignant - Peak 6-7th decade
Cystic and Solid - varying amounts solid tissue
+/-Differentiation Epithelial Tumours - Cystic/Solid - Serous
Predominantly cystic Largely echo-free fluid Unilocular/multilocular Papillary projections single best predictor of epithelial neoplasm
60% benign (cystadenoma) few/small papillary nodules 25% malignant (cystadenocarcinoma) Malignant – more projections / solid tissue 15% borderline (resemble benign or malignant) Serous cystadenocarcinoma Epithelial Tumours - Cystic/Solid - Mucinous
Multilocular Cystadenoma
Echogenic fluid – mucin
Benign – thin septa
Mucinous Cystadenocarcinoma Malignant – thick enhancing septa / solid elements
20-25% ovarian tumours 80% benign 10% borderline 10% malignant Serous Mucinous
Bilaterality Rarely bilateral Ca2+ common psammomatous Ca2+ rare linear Peritoneal carcinomatosis Pseudomyoma peritonei Epithelial - Cystic / Solid Endometrioid Clear Cell 10-15% all ovarian cancers 5% all ovarian cancer
Almost always malignant Malignant
15-30% assoc endometrial Ca / hyperplasia Assoc with endometriosis
Most common neoplasm assoc with endometriosis Pitfalls
Decidualised Endometriotic Cyst
Hypertrophy stromal cells endometrium during pregnancy
Decidual change ectopic endometrium
Vascularised rounded papillary projections in cyst with low level echoes
Major contributory factor to incorrect diagnosis in pregnant women
Resoving at follow up - surgically proven Classification of Ovarian Neoplasms
• Serous Cystadenoma/Carcinoma EPITHELIAL • Mucinous Cystadenoma/Carcinoma TUMOURS • Endometrioid • Clear Cell 65-70% • Brenner Tumour
GERM CELL • Mature Teratoma (Dermoid) / Immature Teratoma TUMOURS • Dysgerminoma 15-20%
SEX CORD STROMAL • Granulosa Cell TUMOURS • Sertoli Leydig 5-10% • Fibroma Thecoma
Metastases 5-10 % Solid Masses - Regular
Regular solid masses often benign
• Pedunculated fibroid • Typically solid • “Picket fence” shadowing
• Ovarian fibroma • Solid mass • Marked acoustic shadowing (18-52%) Solid Masses – Regular Fibroma
SEX CORD • Granulosa Cell STROMAL • Sertoli Leydig TUMOURS • Fibroma Thecoma 5-10% Almost always benign
Middle age women
Heterogenous/homogen ous solid mass
Marked acoustic shadowing (18-52%)
Differential Pedunculated fibroids Brenner Tumour Brenner Tumour Rarely malignant Solid Masses – Regular Fibroma Further imaging
• Large fibroids / shadowing – may limit TVS
• Atypical – Characteristic for fibrous tissue
• Visualise ovaries / relationship to uterus Solid Masses – Regular
MEIGS’ Syndrome
Ascites
Pleural Effusion
Benign ovarian tumour - Fibroma Solid masses - Malignant • Irregular solid mass suggests malignancy
• Epithelial neoplasms – cystic/solid rarely completely solid
• Solid/nearly solid malignancies • Metastases • Rare Tumours • Sex Cord Stromal Tumours • Malignant teratoma • Dysgerminoma
• Bilateral solid masses – • raise concern for metastases – • further imaging ? primary Krukenberg - gastric Sex Cord Stromal - Granulosa Cell Tumours
SEX CORD STROMAL • Granulosa Cell TUMOURS • Sertoli Leydig • Fibroma Thecoma 5-10% Hormone secreting - oestrogen Rare 3% ovarian malignancies Peri /postmenopusal Unilateral - 95%
US appearances non specific Cystic/solid - Solid
1/3 endometrial hyperplasia Up to 25% endometrial Ca Sex Cord Stromal - Fibrothecoma
SEX CORD • Granulosa Cell STROMAL • Sertoli Leydig TUMOURS • Fibroma Thecoma 5-10% •Mature Teratoma Solid masses – Malignant GERM CELL (Dermoid) / Immature TUMOURS Teratoma 15-20% •Dysgerminoma
Dysgerminoma 17 yr old Immature Teratoma 27 yr old
Dysgerminoma Immature Teratoma Most common < 30 years Most common – first two decades Usually solid Predominantly solid, cystic/solid
Raised AFP/Beta-hCG/LDH in some malignant germ cell tumours Features of Malignancy • Solid Component • within cystic mass • Irregular solid mass / wall
• Thick Septations
Borderline • Presence of Flow
• Ascites
• Peritoneal nodules
• Metastases /Nodes Solid Component Most important predictor of malignancy
Malignant Benign
• Several nodules solid • Solitary / small tissue papillary nodule – serous cystadenoma • Echogenicity similar to cyst wall • Hyperechoic with shadowing – dermoid • Often convex / irregular • Clot – concave border / avascular • Flow Septations Septa in cystic mass suggest neoplasm Increased risk malignancy > 2-3mm flow
Fibrin strands Thin weak reflectors Numerous Do not traverse entire cyst
Adjacent cysts may mimic Doppler Colour doppler –qualitative Flow in solid component / septum
Power doppler – increased sensitivity / similar specificity
Spectral doppler Confirm presence flow
Malignant tumours Low resistance flow lower PI & RI’s, higher velocity RI < 0.4; PI <1.0 prev cited as cut-off for malignancy Overlap with benign – little role characterisation Ascites
Indirect indicator of malignancy
Small amount fluid in Pouch of Douglas normal in premenopausal women >15mm AP diameter
Pre-existing illness eg cirrhosis
Echogenic fluid - ruptured cyst/torsion
Meig’s Syndrome – ascites + pleural effusion + fibroma Indeterminate Masses Ultrasound Typical benign lesions Sensitive – malignancy
Many benign lesions demonstrate features malignancy Solid areas / septations / flow Tubo-ovarian abscess Cystadenofibroma
Borderline tumours Risk of Malignancy Index Feature RMI 1 Score Ultrasound features: 0=none •Multilocular cyst 1=one abnormality •Solid areas 3=2 or more abnormalities U •Bilateral lesions Score •Ascites •Intra-abdominal metastases
M •Pre-menopausal 1 score •Post menopausal 3 CA125 U/ml
RMI score = ultrasound x menopausal x CA125 level in U/ml
Sensitivity 85% Specificity 97% Triage using RMI
Risk RMI Women (%) Risk of cancer (%) Low <25 40 <3 Moderate 25-200 30 20 High >200 30 75
High RMI score > 200 - referral to specialist centre (SIGN Guidelines 2012)
Intermediate RMI score 25-200 – MRI often considered appropriate
RMI – heavily influenced by CA 125
CA 125 – may be elevated by benign disease esp pre-menopausal
RMI – recommended by RCOG and systematic review 2009 Geomini P et al The Accuracy of Risk Scores in Predicting Ovarian Malignancy: A Systematic Review Obstetrics & Gynecology; Volume 113 : 2, (Part 1), February 2009, pp 384-394 Simple Rules Developed as part of the IOTA (International Ovarian Tumour Analysis) study
Prospective, multicentre, European study patients with adnexal masses, 21 centres, 9 countries 1999-2017
Simple rules based on clearly defined US features
BENIGN - B RULES MALIGNANT - M RULES
• Unilocular cyst • Irregular solid tumour • Presence solid components where • Ascites largest solid component < 7mm • At least four papillary • Presence acoustic shadowing structures • Smooth multilocular tumour with • Irregular multilocular solid largest diameter <100mm tumour with largest diameter • No blood flow ≥ 100mm • Very strong blood flow Ultrasound in Obstetrics & Gynecology Volume 41, Issue 1, pages 9-20, 25 DEC 2012 DOI: 10.1002/uog.12323 Slides – Ligita Jokubkiene Jan 2013 UOG Journal club A mass is unclassifiable if no M or B features or both Simple Rules
Could be applied in 77%
2 step strategy – Simple Rules + subjective assessment by experienced examiner if unclassifiable ( MDT )
90% sensitivity and 93% specificity to detect ovarian malignancy
Equivalent to expert subjective assessment in all (sensitivity 90% /specificity 93%)
misclassified fewer stage 1 malignancies than did RMI and measurement of CA125.
UK - RCOG included simple rules in 2011 guideline for evaluating ovarian pathology in premenopausal women
Conclusion
Clinical , Pre/Post Menopausal CA125 US
Adnexal Mass Adnexal Mass Adnexal mass Likely Malignant Indeterminate Likely benign
Staging Characterisation Follow up