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Transcript of How to assess an ovarian cyst for malignancy? objectives •The normal ovary •Types of adnexal...
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Chairman, Division of Clinical Support ServicesSenior consultant radiologist Department of Diagnostic and Interventional ImagingKK Women’s and Children’s Hospital
1
How to assess an ovarian cyst for malignancy?<Insert cover image here>
Adj A/Prof Ong Chiou Li
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Learning objectives
• The normal ovary
• Types of adnexal masses
• Ultrasound evaluation of adnexal masses
• Features of physiological ovarian structures
and pathology
• Differentiating benign from malignant
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Cyclical change in ovaries
• Follicular development
– Follicular phase• Antral follicles 2-4mm
• Dominant follicle 10mm (9-6 days prior to luteal surge)
– Ovulation• 20 – 24mm ( max diameter 15-30mm)
– Luteal phase
• Variation in ovarian volume
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6 weeks
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Corpus luteum
• Luteal phase
• Wall is slightly thicker and slightly
echogenic
• Hypervascular wall
• May haemorrhage and present with
complex appearances
• May simulate ectopic pregnancy
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“Lace-like, fishnet appearance”
-Fibrin strands
Septa
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Follow-up
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“Solid-looking haemorrhagic cyst”
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Functional ovarian “cysts”
• Women of child bearing age
• Usually unilocular and anechoic
• Thin-walled
• Less than 3cm, but can be larger
• Stimulated ovaries
• Resolves with ovulation
• May persist
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Left ovary
Ovarian hyperstimulation syndrome
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Adnexal masses
• Ovarian
– physiological/pathological
• Non-ovarian
– Uterus
– Bowel
– Lymph nodes
– Tubal
– Urinary tract
– Others – e.g. peritoneal inclusion “cyst”
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Ovarian cysts
• Functional “cysts” – cyclical change
• Drugs
• Benign cysts
– Non-neoplastic cysts
– Neoplastic
• Malignant cysts
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Seen on Day 2
Ultrasound follow-up
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C - Fimbrial cyst
C
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Simple cysts
• Up to 10 cm, any age ( risk of malignancy less
than 1%)
• Premenopausal, cysts up to 3cm considered
physiological, no follow-up required
• >3cm up to 5cm, likely benign, no follow-up
• Greater than 5cm, up to 7cm, annual follow-up
• More than 7cm, usually require further imaging
(MRI or surgery)
17
Levine et al. Society of Radiologists consensus statement of Radiology 2010
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Ultrasound evaluation of adnexal masses
• Location (ovarian / extraovarian)• Size• Morphological assessment
– Wall thickness, septation, internal echoes, solid areas, papillary structures, echogenicity, shadowing
• Colour / spectral Doppler– Colour morphology– Vessel location– Diastolic notch– Analysis of waveforms : RI / PI
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Endometrioma
• Predorminantly cystic
• Single or multiloculated
• Diffuse low level echoes or anechoic
• May be associated with hydrosalpinx
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Endometriotic cysts
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Small dermoid cyst
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Mature cystic teratoma
• Benign germ cell tumour
• Usually asymptomatic
• Echogenic contents +/- shadowing
• Echogenic strands and dots
• Fat-fluid level
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Ovarian neoplasms
• Epithelial
• Germ cell
• Sex cord-stromal tumours
• Metastases
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Epithelial neoplasms
• 60% of all ovarian neoplasms
• 85% of malignant neoplasms are epithelial
• Types of tumours– Serous (50%)
– Mucinous, endometrioid (20% each)
– Clear cell (10%)
– Undifferentiated (<5%)
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Mucinous tumour of the ovary
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20-year-old with LIF pain Borderline mucinous tumour
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35-year-old
Clear cell ca in endometrioticcyst
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Non-epithelial tumours
• Germ cell tumours
– Teratomas, dysgerminoma, endodermal sinus
tumours
• Sex cord tumours (1-2% of ovarian
malignancies)
• Metastatic (bowel, breast, melanoma, etc)
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Ovarian fibroma
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Thickened endometrium in post-
menopausal woman
Hyperplasia, polyps or
neoplasia?
Granulosa cell
tumour
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Benign features
• Unilocularity
• Thin wall
• Few septa
• Absence of papillary projections
• Crescent sign1,2
1. Kushtaqi P, Kulkarni KK. SMJ 2008
2. Hillaby K, et al. UOG 2004
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Morphological assessment
• 1:178 unilocular cysts ( >40 years) is
malignant.
Malignant cyst contained papillary
excresence.
Granberg et al ’89 (1017 adnexal specimens)
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Morphological assessment
• 1.1% incidence of malignancy in simple cysts in
women > 40 years (Osmers et al ’96)
• Unilocular and bilocular cysts – identical risk
• 36% malignancy in multiloculated cysts and those
with complex solid masses (Andolf ’89)
• Risk of malignancy very low for isolated unilocular
simple cysts (Modesitt, 2003, n=2763)
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Differentiating benign from malignant
• Solid component
• Central blood flow on colour Doppler
• Abnormal free fluid
• Septation
Hyperechoic structures, no solid component
Brown DL, 1998 (n= 211)
Ultrasound scoring
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Malignant ovarian tumours
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Degenerated pedunculated fibroid
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Usefulness and limitations of Doppler
waveform analysis
• Improves confidence in diagnosis1
• Overlap with inflammatory masses and corpus luteal cysts
• Overlap of indices between benign and malignant masses
• Intraobserver and interobserver variation
1. Valentin, 1999
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Risk of malignancy
• Risk of malignancy index1-2
• Scoring systems3-5
• Logistic regression models6
1. Jacobs I 1990, 2. Tingulstad 1996
3. Brown DL 1998, 4. Lerner JP, 1994 5. Sassone AM 1991
6. Holsbeke CV 2007 (IOTA, External validation of mathematical models)
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Ten simple rules (International Ovarian tumour analysis, IOTA)
"M" rules "B" rules
M1 Irregular solid tumour B1 Unilocular
M2 Presence of ascites B2 presence of solid components <7mm
M3 At least 4 papillary structures B3Presence of acoustic shadows
M4Irregular multilocular solid tumour, diameter >/= 100mm B4
Smooth multiloculartumour, <100 mm
M5 Very strong blood flow (score 4) B5 No blood flow (score 1)
1. Timmerman et al, UOG 2008 (n=1233 adnexal tumours), IOTA study2. Nunes N, et al, UOG 2014 (validation & meta-analysis), rules applied to 78% of tumours)
Applicable to 76% of tumours (sensitivity =93%, specificity = 90%, LR+: 9.45, LR-:0.08)
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Limitations of 10 simple rules
• Rare benign tumours
• Stromal tumours
• Peritoneal inclusion cysts
• Tuboovarian complex (ovarian
abscesses)
• Hydrosalpinx
42
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CONCLUSION
• Benign ovarian masses outnumber malignant
• Overlap of sonographic appearances
• Efficacy and limitations of colour Doppler
• Use of MRI for problem-solving, workup of masses of uncertain origin, or possibly benign ovarian lesions
• CT for pre-operative staging