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SRU Consensus on Management of Ovarian Cysts
with Case Studies
Therese M. Weber, MDFebruary 26, 2013
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Disclosures
Dr. Weber has no disclosures and no conflict of interest related to this presentation.
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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.
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Ultrasound
Imaging modality of choice for the female pelvis
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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
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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).
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Radiology 2010;256:943-954
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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
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Normal reproductive CL cyst
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Normal postmenopausal ovary
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Clinically inconsequentialPostmenopausalSimple cyst< 1 cm
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Levine D et al. Radiology 2010;256:943-954
©2010 by Radiological Society of North America
Cysts with Benign Characteristics
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Key issues
SizePatient Age, Menstrual status
Use Doppler to ensure NO solid elements
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Simple Cyst
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Simple Cyst
Ultrasound criteria must be confirmed.
AnechoicSmooth, thin wallsNo solid component or septationPosterior acoustic enhancement
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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
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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.
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Hemorrhagic Cyst
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Hemorrhagic Cyst
Reticular pattern of internal echoes+/- Solid appearing area with concave marginsNo internal flow
Use Doppler to ensure no solid elements
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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
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Endometrioma
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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.
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Dermoid
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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.
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Hydrosalpinx
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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
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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.
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Cysts with indeterminate, probably benign characteristics
Levine D et al. Radiology 2010;256:943-954
©2010 by Radiological Society of North America
Worrisome forMalignancy
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Findings suggestiveof, but not classicfor hemorrhagiccyst, endometiomaor dermoid
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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
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Thin-walled cyst with single septation or focalcalcification in the wall of a cyst
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Multiple thin sepatations< 3 mm
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Nodule (non-hyperechoic)Without flow
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Cysts with characteristics worrisome for malignancy
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Thick (> 3 mm)irregular septation
Any age: Considersurgical evaluation
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Nodule with blood flow
Any age: Consider surgical evaluation
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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
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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
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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
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Ovarian Neoplasms
Surface epithelial-stromal tumors: 65-75%
Germ cell tumors: 15-20%
Sex cord-stromal tumors: 5-10%
Metastatic tumors: 5-10%
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Ultrasound Criteria Suggesting Malignancy
GrowthSolid or predominantly solidDiameter > 5 cmIrregular cystic spaces suggesting necrosisMural or septal thickness > 3 mm
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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.
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Metastatic Disease to Ovary
Compared with primary ovarian carcinoma, ovarian metastases are more likely to be hyperechoic and solid.
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Summary
US plays the primary role in imaging the ovary and adnexa, and is the most cost-effective modality for the female pelvis.
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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.
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Summary
Reviewed recent SRU Consensus Guidelines for management of ovarian cysts.Applied these guidelines to multiple cases.Questions/comments
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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.
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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.
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References
Van Nagell JR, et al. Ovarian cancer screening with annual transvaginal sonography. Cancer 2007;109:1887-1896.
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