Does IOTA have a future in the USA than presenting some of ... · specialities: gynecology,...
Transcript of Does IOTA have a future in the USA than presenting some of ... · specialities: gynecology,...
11/20/2019
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“Expert”evaluation of adnexal masses:
Does IOTA have a future in the USA
Ilan E Timor-Tritsch MD
Update on Gynecological Ultrasound
29th Annual OB/GYN Ultrasound Update for Clinical Practice Hollywood Beach Marriott, Florida, Dec. 5 - 8, 2019
No conflict of interest other
than presenting some of our
own publications
First of all: What is IOTA?
IOTA stands for
I = international
O= ovarian
T= tumor
A= analysis
An international group of clinicians who
became interested in inserting some logic
into evaluating adnexal masses
It standardizes the way adnexal
masses, mainly ovarian msses, are
evaluated using ultrasound, correlating
their visual appearances and physical
features with clinical and histological
findings
IOTA is a concept
The leader of the group
• Dr Dirk Timmerman from Loewen, Belgium
• This international group of clinicians come from a
number of mostly European countries.
• They come from differtent areas of interest and
specialities: gynecology, gynecologic oncology,
epidemiology, genetics, statistics and other fields
• Their main strength is that they see the patients,
scan them, take them to the operating room, study
their outcome summarizing all the above in scientific
publications.
• They educate and share their combined experience
Their base is an international
validating process
• Once a sonographic observation is made
and tested on an initial study group of
patients, their findings are retested using –
what they call – an “external validation”
process
• This is performed by a different group of
clinicians and scientists usually on a larger
scale and who have not participated in
developing the original thesis or observation
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The last phase is perfecting the
performance of the predictions
using advanced research creating
better prediction models
This group extended their work to include
the endometrium, the myometrium as
well the endometriosis, creating an
organized way to approach pathologies
in those areas
Before I answer the question
posted in the first slide…..
……let us see what can we see if
we look into the adnexa/e
In the next 30-35 minutes I will try to make
you understand and start using your basic
sonographic knwledge to be able to
evaluate the adnexa/e
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
• The question is: benign or malignant?
• Remember: not all masses are ovarian and not all ovarian masses are malignant!!
• Take a good history
– Talk to the patient! She may be your best source of information
– 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?
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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 and bring back the patient in the follicular
phase of one of her next cycles.
If irregular cycles are the case: ask her to call and
make appointment to suit her based upon her time of
bleeding
Before talking about screening
or diagnostic algorithms 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.
Learn the building blocks to define a mass• General appearance
– Solid
• Hyperechoic (shadowing)
• Hypoechoic (nonshadowing)
– Cystic:
• Without solid component
• With solid component
– Unilocular, Multilocular
• Internal echo structure:
– Anechoic/hypoechoic
– Echogenic (solid/shadowing)
– Ground glass appearance (low-level echoes )
– Mixed echogenicity (shadowing)
– Reticular, etc
Learn the building blocks to define a mass
• Wall structure:
– Thickness
– Inner wall:
– Mural nodules
– Papillae
If inner wall papilla/e or nodules are seen,
apply power [not color!] Doppler with the
highest sensitivity to look for blood vessels.
Learn the building blocks to define a mass
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Second:
We should realize that scoring
systems existed even before
IOTA and they are able to
differentiate between benign and
malignant ovarian masses
What do scoring systems do?
• They translate macroscopic, pathologic features into sonographically recognizable features……
...which 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…
First of all: do not belittle your
experience (provided that you
obtained some by looking at many
adnexal masses!)
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
Scoring systems
The first scoring systems
Obstet Gynecol 1991 78;70
1991
2000 IOTA
2008
• 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
• Timmerman, UOG 1999-2016
• The most tested for accuracy is
the IOTA system
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
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Following are the first
“buds” or attempts to make
some sense and
organization of adnexal US
findings
Radiology: Volume 256: September 2010 n radiology.rsna.org
The clinical 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
• Agreement in EUROPE
and the USA:
– Cysts containing papillae
with blood vessels are
suspicious for malignancy
and should be removed
Radiology: Volume 256: September 2010 n radiology.rsna.org
The clinical significance of papillary
formations in ovarian cysts
• Multi-disciplinary expert panel convened in 2014
– To examine the state of the science
– To formulate recommendations for clinical
assessment and management
• Aim of the recommendations was
– To promote conservative management for benign
disease
– Optimize referrals to gyn-oncologists in cases of
suspected malignancies
1st International Consensus Report on Adnexal
Masses: Management Recommendations
Second effort to reflect new attempts to improve
management of adnexal masses
Obstet Gynecol. 2016 Nov;128(5):e210-e226.
Practice Bulletin No. 174: Evaluation and Management of Adnexal
Masses.
American College of Obstetricians and Gynecologists’ Committee on
Practice Bulletins—Gynecology.
• Simple cysts up to 10 cm in diameter on TVUS performed by
experienced ultrasonographers are likely benign and may be safely
monitored using repeat imaging without surgical intervention, even in
postmenopausal patients.
• Consultation with or referral to a gynecologic oncologist is
recommended for women with an adnexal mass who meet one or
more of the following criteria:
• Postmenopausal with elevated CA 125 level, ultrasound findings suggestive of malignancy, ascites, a nodular or fixed pelvic mass, or evidence of abdominal or distant metastasis
• - Premenopausal with very elevated CA 125 level, ultrasound findings suggestive of malignancy, ascites, a nodular or
fixed pelvic mass, or evidence of abdominal or distant metastasis
• - Premenopausal or postmenopausal with an elevated score on a formal risk assessment test such as the multivariate index assay, risk of malignancy index, or the Risk of Ovarian Malignancy Algorithm or one of the ultrasound-based
scoring systems from the International Ovarian Tumor Analysis group
• * The evaluation of adnexal masses in adolescents is similar to that in premenopausal women. Management of adnexal masses in adolescents should prioritize ovarian conservation to preserve fertility.
• * Aspiration of an adnexal mass may be appropriate in cases of tubo-ovarian abscess (although antibiotic therapy is first-line treatment) and for the diagnosis of suspected advanced ovarian cancer for which neoadjuvant therapy is
planned. Otherwise, aspiration of cyst fluid for diagnosis is contraindicated when there is a suspicion for cancer.
• * Adnexal torsion in women who want to remain fertile should be managed by reduction of the torsion with concomitant ovarian cystectomy for identified ovarian pathology.
The New Consensus Panel
Recommendations published 2017
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1st International Consensus Report on Adnexal
Masses: Management Recommendations
• In North America, most sonographically confirmed
adnexal masses undergo subjective evaluation without
standardized terminology or risk stratification.
• In Europe, using standardized terminology that is
matched to the images and reported via evidence-
based risk algorithms is becoming increasingly
popular
• An experienced sonologist can correctly distinguish
between benign and malignant adnexal masses.
However, the majority of imaging is performed and
interpreted by practitioners with varying levels of
expertise and confidence.
The New Consensus Panel
Recommendations
• In the USA, it is estimated that 200,000 women undergo surgeries for pelvic masses– 13%-21% women are found to have ovarian cancer
– Number of surgeries per malignancy:• USA→ 9.1
• European IOTA oncology center trials→ 2.3
• Other centers →5.9
– OLD ACOG Practice Bulletin [“Management of Adnexal Masses”] states … “With the exception of simple cysts on a TVU finding, most pelvic masses in post-menopausal women will require surgical intervention.”
• Surgical exploration of benign lesions have potential consequences with complications ranging from 2-15%
• Surgical intervention for malignant lesions improves survival outcomes when surgery is performed by a gyn-oncologist
The recommendations of the 1st
International Concensus Panel were
based partly by the IOTA SIMPLE RULES
• The IOTA group developed a “Simple Rules”
approach to evaluating an ovarian lesion
sonographically
• The “Simple Rules” allows practitioners with varying
degrees of sonography expertise to quickly use
standardized terminology and arrive at similar
results – BENIGN or MALIGNANT
• The “Simple Rules” are comprised of 5 features that
are indicative of BENIGN lesions and 5 features that
are indicated of MALIGNANT lesions
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 content on 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
IOTA Simple Rules
• If one or more M-features apply in the absence of a B-feature, the mass is classified as malignant.
• If one or more B-features apply in the absence of an M-feature, the mass is classified as benign.
• If both M-features and B-features apply, the mass cannot be classified. If no feature applies, the mass cannot beclassified.
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.
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.
Simple Risk Assessment Stratification
Profile: The 3 Categories
“Indeterminate”: Defined as unable to unambiguously place into the
“Almost certainly Benign” or “Suspicious for Malignancy” category
Slide courtesy Dr Platt
Simple US rules to distinguish between benign
and malignant masses before surgery:
prospective validation by IOTA group
• Prospective study to assess the Dx performance of
the IOTA Simple Rules to predict benignity vs
malignancy in an adnexal mass
• 19 centers; 1,938 patients (1,396 benign, 373 1ry
invasive, 111 borderline malignant, 58 metastatic tumors)
• Patients with adnexal masses had TVUS
• Mass was classified: benign or malignant
• Histology of mass is gold standard
• Surgery based on histology and US results
Timmerman D, et al. Ultrasound Obstet Gynecol 2010;36: 226-34
• On external validation (997 patients from 12
centers), the area under the receiver-operating
characteristics curve (AUC) revealed:
– for a model using 12 predictors (LR1) was 0.956,
– for a reduced model of 6 predictors (LR2) was
0.949 and
– for subjective assessment was 0.949.
– Subjective assessment gave a positive likelihood
ratio of 11.0 and a negative likelihood ratio of 0.14.
Simple US rules to distinguish between benign
and malignant masses before surgery:
prospective validation by IOTA group
Timmerman D, et al. Ultrasound Obstet Gynecol 2010;36: 226-34
Let us take the IOTA
concept to a higher platform
Welcome to the
ADNEX Model
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Assessment of Different NEoplasias in
the adneXa (ADNEX) modelFor those who want to read
more and apply it……..
The ADNEX Model:
easy as 1, 2, 3!! Step 1: Fill in the information
ClicKKK
Step 2: Read the resulting score
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• RESULTS: Of 131 women, 63 (48.1%) had a benign ovarian tumor, 16 (12.2%) had a BOT, 17 (13.0%) had Stage I OC, 24 (18.3%) had Stage II-IV OC and 11 (8.4%) had metastasis.
• AUC was 0.92 (95% CI, 0.88-0.97) for basic discrimination between benign vs malignant tumors.
• Performance was high for the discrimination between benign vs Stage II-IV OC, BOT vs Stage II-IV OC and Stage I OC vs Stage II-IV OC, with AUCs of 0.99, 0.97 and 0.94, respectively.
• Performance was poor for the differentiation between BOT vs Stage I OC and between Stage I OC vs ovarian metastasis with AUCs of 0.64.
• CONCLUSION: The majority of adnexal masses were classified correctly
• The authors expect the model to aid in the management of women with an adnexal mass presenting to a Gyn Onc service
• RESULTS: Of 131 women, 63 (48.1%) benign; 16 BOT, 17 Stage I OC, 24 Stage II-IV OC and 11 metastatic tumor.
• The ROC curve (AUC) was 0.92 (95% CI, 0.88-0.97) for basic discrimination between benign vs malignant
• CONCLUSION: The majority of adnexal masses were classified correctly
• The authors expect the model to aid in the management of women with an adnexal mass presenting to a Gyn Onc service
• Evaluation of malignancy risks by these 2 tests highlighted a NPV of 100% (there was no case of false negative) and a PPV of 80%.
• DISCUSSION AND CONCLUSION: The IOTA classification and the ADNEX multimodal algorithm used as risks prediction models can improve the performance of pelvic US and discriminate between benign and malignant cysts in postmenopausal women, especially for undetermined lesions.
And finally the ACR listened
• They try to eliminate standard cut-and-
paste reports such as: “Complex
adnexal mass. Malignancy cannot be
ruled out. Additional imaging is
suggested (meaning MRI)”, that never
really helped patients & gynecologists
• The ACR created a task force and
published the resulting document
J Am Coll Radiol 2018;15:1415-1429. Copyright 2018 American College of Radiology
The ultimate objective will be to apply the lexicon to a risk stratification classification for consistent follow-up and management in clinical practice. This white paper describes the consensus process in the creation of a standardized lexicon for ovarian and adnexal lesions and the resultant lexicon.
• Ultrasound is the most commonly used imaging technique for the evaluation of ovarian and other adnexal lesions.
• The interpretation of sonographic findings is variable because of inconsistency in descriptor terminology used among reporting clinicians.
• The use of vague terms that are inconsistently applied can lead to significant differences in interpretation and subsequent management strategies.
• A committee was formed under the direction of the ACR initially to create a standardized lexicon for ovarian lesions.
• The ultimate objective will be to apply the lexicon to a risk stratification classification for consistent follow-up and management in clinical practice.
• This white paper describes the consensus processJ Am Coll Radiol 2018;15:1415-1429. Copyright 2018 American College of Radiology
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….and maybe the first attempt
to bring IOTA closer to the
American Ob/Gyn
readership….:
• Sensitivity of the Simple Rules and Assessment of Different NEoplasias
in the adneXa model (using a cut-off of 10% to predict malignancy) are
92% and 96.5%, respectively, and specificities are 96% and 71.3%,
respectively.
• These models are the best predictive tests for the preoperative classification
of adnexal tumors.
• Their intent is to help the specialist make management decisions when
faced with a patient with a persistent ovarian mass.
• The models are simple, are easy to use, and have been validated in
multiple reports but not in the United States.
• We suggest they should be validated and widely introduced into medical
practice in the United States.
American Journal of Obstetrics & Gynecology DECEMBER 2017
American Journal of Obstetrics & Gynecology APRIL 2016
• OBJECTIVE: The Authors sought to develop and validate a model to predict the risk of malignancy in adnexal masses using the ultrasound features in the Simple Rules.
• Quantification of the risk of malignancy based
on the Simple Rules has good diagnostic
performance both in oncology centers and other
centers.
• A simple classification based on these risk
estimates may form the basis of a clinical
management system.
• Patients with a high risk may benefit from
surgery by a gynecological oncologist, while
patients with a lower risk may be managed
locally.
Conclusion
What I do in my practice for
adnexal masses
• Perform TVS for all gynecologic patient
• Color (power) Doppler for all gyn patients
• Document masses/cysts using 3D tomographic
mode
• Describe masses in the terms of IOTA simple rules
• Add ADNEX if Ca125 available
• Call Gyn & or Gyn Onc personally explaining IOTA
• Follow the course of the workup, additional imaging,
surgery and pathology report
“Papillae” and “Nodules”
are discriminatory
sonographic markers of
ovarian masses
Let me add to the above my
experience of looking at additional
discriminative features of ovarian
masses
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What are nodules & papillae?
• The difference between them is:
– Nodules are hyperechoic, usually
shadowing, sub-centimeter,
avascular inner wall structures in
cysts & at times on septae
– Papillae are hypoechoic, usually
non-shadowing, irregularly shaped,
vascular inner wall structures in cysts (please remember→ papilla -singular, as in: “one
papilla”; papillae – plural, as in: “two, three papillae”)
Q: does the finding of
papillae in adnexal cysts
increase the risk of ovarian
cancer?
A: Depends on their
sonographic character
The questions are:
• How do we diagnose a nodule or a
papilla?
• How do we use color or power Doppler?
• Are there any other characteristic
features that help sorting them out?
• And if we sort them out, does it mean the
we will be able to say that we can predict
or rule out malignancy?
Papillary projections/nodules
within ovarian or other cysts
• Can sensitive markers of malignancy
• If found
– 1. Measure them – size matters
– 2. Their number matters
– 3. Determine surface, shape and echogenicity
– 4. Observe if they shadow or not
– 5. Look for blood vessels in it
– 6. Examine their signature tissue 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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Three kinds of nodules/papillae• Hyperechoic nodule/e
• No vessels in nodule
• Papilla does shadow
• Hypoechoic papilla/e!
• Irregular borders
• Vessels in papilla
• Does not shadow
Usually benign
(cystadeno-fibroma) 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;Goldstein & Timor-Tritsch JCU 2010
Timor-Tritsch JCU 2019 Timmerman et al, UOG 2008;
First: papillae in an
endometrioma
An example:
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?
If benign: is it a CL? or an E-oma?
If malignant: is it an epithelial Ca or clear cell Ca
Diagnosis:
decidualized E-oma
Evolution of a decidualized
endometrioma across and
after the pregnancy
9w4d 10w4d
38w5d
2 months postparum
11w5d 19w5d
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
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Nodules in a cyst
An example:
Several ovarian cysts w. nodules/papillae
What do they have in common?
They have
echogenic,
shadowing nodules
& no blood vessels
Ultrasound and histopathologic correlation of ovarian cystadenofibromas: diagnostic value of the “shadow sign”Timor-Tritsch, Yoon, Monteagudo, Ciaffarano, Brandon, Mittal, Wallach, Boyd, MD1 JUM 2019
What next?
Apply power Doppler!!
No blood vewssel in the nodule
The ultimate proof:
is comparing a series of ovarian cysts with
nodules/papillae with their histopathology
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10mm
CAF 13D renedering (teaching
value only!
a b c
Question:
Over time, do cystadenofibrmas (or,
for that matter: cystadenomas)
undergo changes in appearance and/or
size?
11.24.14 3.9.15 8.26.15 12.10.15
a
a’
c
c’
d
d’
b
b’
Answer: not really!
The answer: No, or very little
Bilateral “resilient” cystadenoma
Third: papillae in in a cyst
An example:
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Papilla with blood flow
Highly
suspicious for
malignancyHighly suspicious
for malignancy
What abaout paraovarian cysts
considered a-priori benign?
Let us analyze this case
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
©AIUM
Borderline Ovarian Tumor/
Low Malignant Potential tumor
In a significant number of
cases, mostly in reproductive
age women, cysts with
vascular papillae are
overwhelmingly consistent
with BOT of low malignant
potential
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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
We may be able to determine
the above by looking at the
sonographic characteristics of
borderline ovarian tumors
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
We looked at the detailed
morphology of the BOTs and
revealed some interesting features.
A new sonographic descriptor of Borderline
ovarian tumors of low malignant potential
• As we evaluated the sonographic appearance of the
67 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
I. Timor/L.Boyd/A. Monteagudo/R. Wallach/C. Brandon/ C.Foley: UOG 2019
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5-9 MHz transvaginal probe
One more observation
6-12 MHz transvaginal probeI. Timor/L.Boyd/A. Monteagudo/R. Wallach/C. Brandon/ C.Foley: UOG 2019
Examples of microcystic
papillary texture
I. Timor/L.Boyd/A. Monteagudo/R. Wallach/C. Brandon/ C.Foley: UOG 2019
A
5mm
B
C
10 mm
Here are the results regarding US
characteristics of BOT of LMP
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What did we learn?
• The microcystic structures seen on high
frequency transvaginal scans can be seen on
low power microscopy on the histologic slides
which confirm the observations
• This sonographic feature can be considered
as one of the US markers of BOT of LMP
• It may render increased significance to
establish the diagnosis if combined with other
common features of BOT such as vascularity
and presence of papillae
Now I will try to answer the
main question: Can IOTA be
adopted in the USA?
Does it have a future here?
The answer is Yes and No at
the same time
Yes, if our governing bodies
(ACOG, AIUM, SGO) would support:
1. Extensive education & sonographer training
the ‘front end’ of Gyn US in this country
2. Convincing “Gyn generalists”, who forever (as
a ”knee-jerk” reaction) sent and are still
sending their patients straight to MRI after a
“garden variety US” exam without even trying
to use an experienced “US site/person“
Yes, if our governing bodies
(ACOG, AIUM, SGO) would support:
3. Convincing Gyn oncologists to except and use
expert US as a 1st imaging test for their patients,
and rarely operate based upon screening US
4. Re-educating Rad’s to avoid term: “complex
mass & additional imaging suggested,” & not to
report a ”laundry list” of differential diagnoses
(a.k.a. hedging), irrelevant to Gyn’s & Onc’s alike
5. Rad’s to adopt the new “Adnexal Lexicon”
proposed by some bold ACR Rad’s leaders
Simple Rules, Not So Simple: The Use of IOTA Terminology and Simple
Rules in Inexperienced Hands in a Prospective Multicenter Cohort
StudyMeys E, et al. Ultraschall Med 2017; 38 (6): 633-641
• Results: 46 discrepancies were observed in the description of ovarian masses when non-experts utilized the IOTA terminology
– Tumor type was misclassified (n=22); poor I/O agreement between non-expert and expert % of agreement 52.0%
– Misinterpretation of simple rules by non-experts was observed (n=57), erroneous diagnosis in 15 pts (30%)
– Agreement for classifying the mass as benign or inconclusive was only moderate between non-expert and expert % of agreement 70.0%
– Level of agreement for simple rules varied greatly; % of agreement 66-94%
• Conclusion: Simple rules are a useful to distinguish between a benign and malignant ovarian masses, but not in the hands of untrained examiners. More training with both the terminology and simple rules is necessary before the simple rules can be introduced into guidelines and daily clinical practice.
No! Not in my academic and
clinical lifetime, since…….:
1. I have a bad experience with the long way clinical
advances are transformed from concepts to widely
accepted practices (it took around 20 years for “my baby”, the
transvaginal US probe, to be slowly, generally accepted and used)
2. Unlike in Europe, in the USA Gyn “generalists” & Gyn
oncologists DO NOT perform their own US scans &
surgery mostly done without lookining at US images.
3. In the USA almost all Gyn US is performed by Rad’s,
and despite my hope for a change in their practices
and their reporting…this will SURELY NOT HAPPEN
in my lifetime
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11/20/2019
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However, let us be optimistic!
There are things that can be done
• ACOG: Please re-discover Ultrasound, it is
alive and thriving. Create Gyn US courses!
• AIUM: Bring gynecologists and radiologists to sit
together developing educational CME programs,
webinars, courses talking the same (US) language
involve & teach Med students!
• Extend the teaching of Gyn US in residency
and Onc fellowship programs: THOSE ARE
THE TIMES TO LEARN THE VALUE OF US
Conclusions:
What are the chances of the Simple IOTA Rules to
take roots in the USA?
• Short term?: slim → Reasons:
– Too few Ob/Gyns & no Gyn Onc’s scan
– Almost all gynecologic scans done by Rad’s
– Neither of them are versed in the IOTA concept
– USA Oncologists favor MRI over US
• Long term 5-10 years?: not un-reasonable:
– Rad’s adopting new lexicon and O-RADS model
– Will take time to let go “complex cyst” and
“additional imaging is suggested”
– Will take years to “retool” (old customs die hard)
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
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