1/26/2018

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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

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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

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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.

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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:

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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

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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

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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?

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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

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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.

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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.

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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

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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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21

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