sru consensus on management of ovarian cysts with case studiesradreference.info/ewexternalfiles/sru...

Downloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.orgDownloaded from sar2013.conferencespot.org

SRU Consensus on Management of Ovarian Cysts

with Case Studies

Therese M. Weber, MDFebruary 26, 2013

Downloaded from sar2013.conferencespot.org

Disclosures

Dr. Weber has no disclosures and no conflict of interest related to this presentation.


Objectives

1. Review recent SRU Consensus Guidelines for management of ovarian cysts.

2. Apply these guidelines to multiple case examples.

3. Provide a more concise and uniform approach to management of ovarian cysts.


Ultrasound

Imaging modality of choice for the female pelvis


UPDATE

Society of Radiologists in Ultrasound (SRU) Consensus Conference on Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged on Ultrasound

October 2009

Previous: Carotid and Thyroid


UPDATE

SRU Consensus Conference on Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged on Ultrasound

Goal: Produce a summary of the most important issues regarding management of ovarian and other adnexal cysts (F/U vs surgery).


Radiology 2010;256:943-954


Normal Ovary

Levine D et al. Radiology 2010;256:943-954

©2010 by Radiological Society of North AmericaDownloaded from sar2013.conferencespot.org

Normal reproductive ovary


Normal reproductive CL cyst


Normal postmenopausal ovary


Clinically inconsequentialPostmenopausalSimple cyst< 1 cm



©2010 by Radiological Society of North America

Cysts with Benign Characteristics


Key issues

SizePatient Age, Menstrual status

Use Doppler to ensure NO solid elements


Simple Cyst


Simple Cyst

Ultrasound criteria must be confirmed.

AnechoicSmooth, thin wallsNo solid component or septationPosterior acoustic enhancement


Simple Cyst

Reproductive age:< 5 cm. No follow-up needed.> 5 and < 7cm. Yearly follow-up.

Postmenopausal:> 1 and < 7 cm. Yearly follow-up.

Any age: > 7 cm. Further imaging/surg eval


Simple cysts

For cysts < 3 cm in reproductive age women, it is at the discretion of the interpreting physician whether to describe the cysts in the imaging report.


Hemorrhagic Cyst


Hemorrhagic Cyst

Reticular pattern of internal echoes+/- Solid appearing area with concave marginsNo internal flow

Use Doppler to ensure no solid elements


Hemorrhagic Cyst

Reproductive age:< 5 cm. No follow-up needed.> 5 cm. 6-12 wk follow-up to ensure

resolution.

Early PM: Follow-up to ensure resolution

Late PM: Consider surgical evaluation


Endometrioma


Endometrioma

Homogeneous low level internal echoesNo solid component+/- Tiny echogenic foci in wall

Any age: Initial follow-up 6-12 wks, then yearly if not surgically removed.


Dermoid


Dermoid

Focal or diffuse hyperechoic componentHyperechoic lines and dotsArea of acoustic shadowingNo internal flow

Any age: If not surgically removed, follow-up yearly to ensure stability.


Hydrosalpinx


Hydrosalpinx

Tubular shaped cystic mass+/- Short round projections “beads on a string”+/- Waist sign (i.e. indentations on opposite sides.+/- Seen separate from the ovary

Any age: Follow-up as clinically indicated.Downloaded from sar2013.conferencespot.org

Peritoneal Inclusion Cyst


Peritoneal Inclusion Cyst

Follow the contour of adjacent pelvic organsOvary at the edge of the mass or suspended within the mass+/- Septations

Any age: Follow-up as clinically indicated.


Cysts with indeterminate, probably benign characteristics


©2010 by Radiological Society of North America

Worrisome forMalignancy


Findings suggestiveof, but not classicfor hemorrhagiccyst, endometiomaor dermoid


Cysts with indeterminate characteristics

Reproductive age: 6-12 wk follow-up to ensure resolution. If lesion is unchanged, then hemorrhagic cyst is unlikely, and continued follow-up with either US or MR should be considered. If these studies do not confirm endometrioma or dermoid, surgical evaluation should be considered.

PM: Consider surgical evaluation


Thin-walled cyst with single septation or focalcalcification in the wall of a cyst


Multiple thin sepatations< 3 mm


Nodule (non-hyperechoic)Without flow


Cysts with characteristics worrisome for malignancy


Thick (> 3 mm)irregular septation

Any age: Considersurgical evaluation


Nodule with blood flow

Any age: Consider surgical evaluation


Ovarian Cancer

3rd in incidence of cancers of female reproductive tract (behind cervical and endometrial)

Accounts for about 50% of all deaths from cancer of the female reproductive tract

About 20% of all ovarian tumors are malignant

Malignant tumors more common 40 – 65 y/o


Ovarian Carcinoma

Mortality and incidence rates are higher for white women than for any other racial or ethnic group.

U.S. Cancer Statistics Working Group


Ovarian Carcinoma

Leading cause of death from gynecologic malignancy in U.S. due to late diagnosis

80% of cases occur in women >50 years of age

Overall 5-year survival rate is only 38%

CA-125


Ovarian Neoplasms

Surface epithelial-stromal tumors: 65-75%

Germ cell tumors: 15-20%

Sex cord-stromal tumors: 5-10%

Metastatic tumors: 5-10%


Ultrasound Criteria Suggesting Malignancy

GrowthSolid or predominantly solidDiameter > 5 cmIrregular cystic spaces suggesting necrosisMural or septal thickness > 3 mm


Metastatic Disease to Ovary

Most common origins of ovarian metastases are breast, GI tract, and endometrial carcinoma.

Lymphoma and leukemia may involve the ovary and are frequently bilateral.


Metastatic Disease to Ovary

Compared with primary ovarian carcinoma, ovarian metastases are more likely to be hyperechoic and solid.


Summary

US plays the primary role in imaging the ovary and adnexa, and is the most cost-effective modality for the female pelvis.


Summary

CT plays an important role in staging & recurrence, as well as evaluation of metastatic disease.

MR imaging allows an accurate diagnosis in problem cases, may assist in surgical planning, and may avoid unnecessary surgery in some cases.


Summary

Reviewed recent SRU Consensus Guidelines for management of ovarian cysts.Applied these guidelines to multiple cases.Questions/comments


References

Levine D, et al. Management of asymptomatic ovarian and other adnexal cysts imaged at US. Radiology 2010;256:943-954.

Javitt MC. Risk assessment for ovarian carcinoma: hope or hype? AJR 2010;194:308.


References

Partridge, E, et al. Results from Four Rounds of Ovarian Cancer Screening in a Randomized Trial. Obstetrics & Gynecology. 2009;113: 775-782.

Sokalska, A, et al. Diagnostic accuracy of transvaginal ultrasound examination for assigning a specific diagnosis to adnexal masses. Ultrasound Obstet Gynecol. 2009;34:462-470.


References

Van Nagell JR, et al. Ovarian cancer screening with annual transvaginal sonography. Cancer 2007;109:1887-1896.


sru consensus on management of ovarian cysts with case studiesradreference.info/ewexternalfiles/sru...

Documents