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2017-11-03 1 Understanding the IOTA (International Ovarian Tumor Analysis) terminology & Classification Using the IOTA simple rules to estimate the risk of malignancy in women with adnexal masses Elisabeth Epstein, Associate Professor Southern University Hospital, Karolinska Insitute Stockholm, Sweden Estimate the risk of malignancy in adnexal masses - Overview IOTA terminology & classification Predicting risk of malignancy using Pattern recognition Simple rules Case examples Terminology unilocular multiocular unilocularsolid multilocularsolid solid Sonolucent hemorragic mixed ground glass Low level Papillary projection Incomplete septa Aucoustic shadowing Assessment of vascularization Type of lesion Cyst contence Defintions Unilocular cyst Multilocular cyst Unilocular-solid cyst Multilocular-solid cyst Solid 0.3% 10% 33% 40% 62% Classification according to Granberg -89 Risk of maligancy, IOTA trial n=1066, 2005 Unilocular cyst – no septa or solid components Incomplete septae Should not regarded as real septae Sludge/amorphous material should not be regarded as papillary projection ”White ball” should not be classified as solid component Irregularities < 3mm in height, should not be regarded as papillary projection Unilocular solid – with solid component > 3mm Pyosalpinx with cog- wheel papilations > 3mm Papillation > 3 mm in height Solid component < 80%
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Page 1: 2017-11-03 Estimate the risk of malignancy in adnexal ...old.sfog.se/media/350651/adnexalmassesbaskurs2017.pdf · Malignant /Borderline. Difficult masses 2: Solid ovarian masses.

2017-11-03

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Understanding the IOTA (International OvarianTumor Analysis) terminology & Classification

Using the IOTA simple rules to estimate the risk of malignancy in women with adnexal masses

Elisabeth Epstein, Associate Professor

Southern University Hospital, Karolinska Insitute

Stockholm, Sweden

Estimate the risk of malignancy in adnexal masses - Overview

• IOTA terminology & classification

• Predicting risk of malignancy using

– Pattern recognition

– Simple rules

• Case examples

Terminology

unilocular multiocular unilocularsolid multilocularsolid solid

Sonolucent hemorragic mixed ground glass Low level

Papillary projection Incomplete septa Aucoustic shadowing Assessment of vascularization

Type of lesion

Cyst contence

Defintions

Unilocular cyst

Multilocular cyst

Unilocular-solid cyst

Multilocular-solid cyst

Solid

0.3%

10%

33%

40%

62%

Classification according to Granberg -89Risk of maligancy, IOTA trial n=1066, 2005

Unilocular cyst – no septa or solid components

Incomplete septaeShould not regardedas real septae

Sludge/amorphousmaterial should not be regarded as papillary projection

”White ball”should not be classified as solid component

Irregularities < 3mm in height, should not be regarded as papillary projection

Unilocular solid – with solid component > 3mm

Pyosalpinx with cog-wheel papilations >3mm

Papillation > 3 mm in heightSolid component < 80%

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Multilocular cyst – purely cystic lesion,with at least one septae

Solid – solid component comprise>80% of the lesion

Assessment of cyst wall – if anyirregularity is seen: classify as irregular

Irregular: Sludge is alsoregarded as an irregularity

Smooth/regular Smooth/regular Irregular: papillaryprojections

Incomplete septa

•Typical finding

in hydrosalpinx

Papillary projection –solid protrusion > 3mm in height

Irregular papillary projectionsSmooth papillary projectionSeen in decidualizedendometrioma

Diffrentiate solid components from papillaryprojections

But, all solid componentsPapillary projections

Are not papillary projectionsAre solid components

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Differentiate:“amorphous” wall deposits

from solid papilary projections

Amorphous wall deposits - endometrioma

Papilary projection – suspect malignancy/ BOT

”White ball” - dermoid

BOT with papilla

Cystic Content

SonolucentAnechoic

hemorragicground glassLow levelEchogenic

mixed

Acoustic shadows

Acoustic shadow infibroma Acoustic shadow

In dermoid

Acoustic shadowing frompapillations in cystadenoma

Colour score

Colour score 1No bloodflow

Colour score 2 Minimal bloodflow

Colour score 3Moderate bloodflow

Colour score 4Marked/high bloodflow

Prediction of malignancy using the IOTA terminology

• Subjective assessment using pattern recognition

• Simple rules

• (Mathematical models)

– LR1 (12 variables)

– LR2 (6 variables)

– Adnex model® (multimodal)

– Simple Rules RM (risk predicition model9®

Subjective assessment using “Pattern recognition” in discriminating benign from malignant lesions

Absence of solid components and irregularities suggests benignity.

Solid vascularized components and irregularities suggest malignancy.

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Accuracy of ultrasound in the diagnosis of malignancy using

saubjective ”pattern recognition”

sens spec

Malignancy vs Benignity 88-96%* 90-96%*

Correct specific diagnosis over all 40%

in benign tumours 68%*

Valentin et al 1999, Timmerman et al 1999, Timmerman 2006

Expert ultrasound examiners were “uncertain” in 8% of cases Valentin L et al, 2007: (n=1066):

Serous cystadenoma Mucinous cystadenoma

Mucinous BOTSerous BOT

Struma OvariiFibroma

Intraligamental fibroid

Example of difficult tumours:

• Fibroma

• Pedunculated/intraligamental

Fibroid

• Struma ovarii

• Borderline

• Cystadeno(fibr)oma

Difficult masses 1: With papillary projections

Benign< 3 papillary projectionsPapillary max diameter < 7 mmNo papillary flowShadowing

> 4 papillary projectionsPapillary diameter > 7 mmPapillary flow

Malignant /Borderline

Difficult masses 2: Solid ovarian masses

Fibroma -benignMalignancy

CancerMalignant granulosa cell tumor Benign Brenner tumor

Regular echogenicityshadowing, and sparsevascularization supports benign diagnosis. Irregularechogenicity/outline, no shadowing suggestmalignancy

Difficult masses 2: Solid pelvic masses – can also be extraovarian pathology

Pedunculated sarcoma Intraligamental fibroids

Mescenterialfibromatosis

Neurofibromatosis

Important to lookfor the ovary!

Tubal cancer

Difficult masses 3: Multilocular cysts with

a large number of locules

Mucinous cystadenoma

Techa lutein cyst – functional; pregnancy/molar/trofoblastic disease

Mucinous intestinal borderline

Size <10 cmSuggests benign diagnosis

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Benign or malignant?

Adnexal masses: Case 1

Woman 43 years old. Benign? Malignant? Diagnosis?

Adnexal masses. Case 2

Woman 63 years old, episodes with abundant fluor.Benign? Malignant? Diagnosis?

Adnexal masses: Case 3

Incidentally detected bilateral lesion, woman 80 years old.Diagnosis? Management?

Adnexal lesions: Case 4

Woman 29 years old, incidental finding. 5cm lesion.Diagnosis? Management?

Adnexal masses: Case 5

Woman 32 years, Pregnant GW 18+ abdominal painDifferential diagnosis?

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Predicition of malignancy in adnexal masses usingIOTA models: Simple rules®

Ovarian cancer Mucinous cystadenoma Dermoid

IOTA Simple Rules - Classifies 80% of all lesions

Simple Rules• Accuracy very high in masses that apply to the rules (80%) –

sensitivity 91% specificity 96%• Simple rules works well also in the hands of less experienced

examiners (Alcazar 2013), (Sayasneh 2013)• Work better than RMI both in the hands of experienced and

less experienced examiners (Ameye 2012, Sayasneh 2013)• IOTA Simple Rules is one of the best approaches to

preoperatively classify adnexal masses as benign or malignant (Kaijser 2014)

• Correct application of the Simple Rules requires knowledge and proper use of the ultrasound features. (Timmerman 2000)

• Recomended in the national Swedish guidelines in favor of RMI especially in pre-MP women

Benign (B) - features

B1 Unilocular

B3 Acousticshadowing

B2 Solid component < 7mm

B5 No bloodflowB4 Multilocular smooth, < 10 cm

Malignant (M) - features

M1 Irregular solid lesion

M5 Strong blood flow

M2 Ascites M3 > 4 papillaryprojections

M4 Multilocular solid, > 10 cm

Simple Rules - interpretetionMalignt (M) features

• M1—Irregular solid tumour

• M2—Presence of ascites

• M3—At least four papillary structures

• M4—Irregular multilocular solid tumourwith largest diameter ≥100mm

• M5—Very strong blood flow (colourscore 4)

Benign (B) features

• B1—Unilocular

• B2—Largest solid component diameter <7 mm

• B3—Presence of acoustic shadows

• B4—Smooth multilocular tumour with largest diameter <100 mm

• B5—No blood flow

At least one B-feature, No M-features = probably benignAt least one M-feature, No B-feature= probably malignantBoth M and B features or neither B nor M features = inconclusive

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What to do with the inconclusive cases?

• Treat all inconclusive cases as malignant

• Send all inconclusive cases for expert US assessment

– (SR + SA, sens 91% spec 91%)

Simple rules:Case examples

Case example 1:

Woman, 32 years old, Largest diameter 12cm, Examined in non-oncology centre:

Case example (1) – Simple Rules tick box

Ultrasound features predictive for amalignant tumor (M-features)

Features predictive for a benign tumor (B-features)

M1 Irregular solid tumor B1 Unilocular

M2 Presence of ascites B2 Presence of solid components wherethe largest solid component has a largestdiameter < 7 mm

M3 At least four papillary structures B3 Presence of acoustic shadows

M4 Irregular multilocular solid tumor with largest diameter ≥ 100 mm

B4 Smooth multilocular tumor withlargest diameter < 100 mm

M5 Very strong blood flow (color score 4) B5 No blood flow (color score 1)

No features present

Case 1 management & findings

• Refer to oncology center? • Refer for expert US examination? • Operate in regional centre?

Histology:Mucinous Cystadenoma

Expert US assessment: Impossible to say if it is a mucinous cystadenoma or mucinos intestinal borderline,Probablility of invasive malignancy low

Case example (2)

• Patient seen in oncological center

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Case example (2) – Simple Rules tick box

Ultrasound features predictive for amalignant tumor (M-features)

Features predictive for a benign tumor (B-features)

M1 Irregular solid tumor B1 Unilocular

M2 Presence of ascites B2 Presence of solid components wherethe largest solid component has a largestdiameter < 7 mm

M3 At least four papillary structures B3 Presence of acoustic shadows

M4 Irregular multilocular solid tumor with largest diameter ≥ 100 mm

B4 Smooth multilocular tumor withlargest diameter < 100 mm

M5 Very strong blood flow (color score 4) B5 No blood flow (color score 1)

Case 2 management & findings

• Operate in regional centre?• Follow-up if no symptoms or high co-morbidity?

Histology:Benign cystadenofibroma

Expert US assessment:Papillation with shadowing and without blood flow support benign diagnosis

Case example 3

Age 74, no ascites, maximum diameter 67mm, max size of solid component 49mm, examinedin oncology centre

Case example (3) – Simple Rules tick box

Ultrasound features predictive for amalignant tumor (M-features)

Features predictive for a benign tumor (B-features)

M1 Irregular solid tumor B1 Unilocular

M2 Presence of ascites B2 Presence of solid components wherethe largest solid component has a largestdiameter < 7 mm

M3 At least four papillary structures B3 Presence of acoustic shadows

M4 Irregular multilocular solid tumor with largest diameter ≥ 100 mm

B4 Smooth multilocular tumor withlargest diameter < 100 mm

M5 Very strong blood flow (color score 4) B5 No blood flow (color score 1)

Case 3 management & findings

• High risk of ovarian cancer • Should undergo surgery in oncology centre• Preoerative assessment of tumor extension indicated (CT, PET-CT; Ultrasound) – to assess if optimal debulkingcan be done. If not* – consider tru-cut biopsy – to establish diagnosis and to select Chemo.

Histology:Stage III ovarian cancer

*•Pulmonary metastasis, deep liver metastasis, •carcinosis on small intestine/•LN metastasis above renal arteries•Bulky tumor in lever hilum

Case example 4 Woman 32 years old. Unilateral lesion max diameter 97mm, seen in oncolony unit

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Case example (4) – Simple Rules tick box

Ultrasound features predictive for amalignant tumor (M-features)

Features predictive for a benign tumor (B-features)

M1 Irregular solid tumor B1 Unilocular

M2 Presence of ascites B2 Presence of solid components wherethe largest solid component has a largestdiameter < 7 mm

M3 At least four papillary structures B3 Presence of acoustic shadows

M4 Irregular multilocular solid tumor with largest diameter ≥ 100 mm

B4 Smooth multilocular tumor withlargest diameter < 100 mm

M5 Very strong blood flow (color score 4) B5 No blood flow (color score 1)

Case 4 managment and findings

• Expert US assessment: Features resembelling teratoma. Struma Ovarii? Malignancy can not be ruled out.

• Advisable to perform ooforectomy

• Pre surgical tumor markers & CT

Case example (5)

• Patient seen in oncological center, age 65• Smooth solid mass right ovary, measuring 68x68x65 mm• Free fluid in the pouch of Douglas, but no ascites present

Case example (2) – Simple Rules tick box

Ultrasound features predictive for amalignant tumor (M-features)

Features predictive for a benign tumor (B-features)

M1 Irregular solid tumor B1 Unilocular

M2 Presence of ascites B2 Presence of solid components wherethe largest solid component has a largestdiameter < 7 mm

M3 At least four papillary structures B3 Presence of acoustic shadows

M4 Irregular multilocular solid tumor with largest diameter ≥ 100 mm

B4 Smooth multilocular tumor withlargest diameter < 100 mm

M5 Very strong blood flow (color score 4) B5 No blood flow (color score 1)

Case example (5)

• Expert US assessment: fibroid?

• CT, tumor markers prior to surgery

Advice

• Experienced examiners: pattern recogntion doesthe job.

• Moderate experienced examiners: Simple rulesand Simple Rules RM help you in a largeproportion of cases. Consider referinginconclusive cases for expert US assessment

• It is crucial to understand the terms and defintions to be able to use the models!

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IOTA collaboration website

• http://www.iotagroup.org

• Educational material– IOTA Terminology

– ”Easy descriptors”

– Simple rules

• IOTA models software– LR2, simple rules

– ADNEX® model

• IOTA online lectures

How to make a report on an adnexal mass?

• Describe lesion(s) according to IOTA classification

– Unilocular, multilocular, etc…..

– Colourscore (1-4)

– Mobility?

• Assess probability of malignancy

– Certainly bening, probably benign, inconclusive, probablymalignant, certainly malignant

• Try to give a specific diagnosis

– Fibroma, endometrioma, borderline tumor, hydrosalpinx, peritonela cyst, etc….

• Give advise on managment

Thank you for your attention!


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