IOTA simple rules presentation

IOTATerminology,SimpleDescriptorsandSimpleRules

SusanneJohnson

PrincessAnneHospital

Southampton

UKsusanne.johnson@uhs.nhs.uk

Ovarianpathology

•  ClassificaGonsystemforovarianpathology

•  StandardisaGonofterminology–IOTA

•  IOTASimpleDescriptors(paKernrecogniGon)

•  PredicGonofmalignancy–IOTASimpleRules

•  Workedexamples

•  Quiz

Ovariancystsandtumours

IOTA

Premenopausalvspostmenopausal women

Normalovaries

BenignovariantumorsBorderlineovariantumors

Invasiveovariancancer

Invasive ovarian cancer IOTA

ThereportreallymaKers

•  Isitbenignormalignant?

•  Simplecyst

•  Complexcyst

•  CanwedobeKer?

Howtoreportthisabnormality?

By the end of this presentation you will be able to report this!

Ovarianpathology

•  ClassificaGonsystemforovarianpathology•  StandardisaGonofterminology-IOTA

•  PredicGonofmalignancy–IOTASimpleRules

•  Workedexamples

•  PaKernrecogniGon•  Quiz

ClassificaGonsystemforadnexalmasses

•  Benignovarian

•  Benignnon-ovarian

•  Primarymalignantovarian

•  Secondarymalignantovarian

ClassificaGonsystemforadnexalmasses

BENIGNOVARIAN:•  PolycysGcovaries•  FuncGonalcysts•  Endometriomas•  Serouscystadenoma

•  Mucinouscystadenoma•  Matureteratoma

•  Fibroma(rare,cancauseMeig’ssyndrome:ascitesandpleuraleffusion)

•  Thecoma(veryrare,cansecreteoestrogenandprogesterone)

ClassificaGonsystemforadnexalmasses

BENIGNNON-OVARIAN:•  Paratubalcyst•  Hydrosalpinges•  Tubo-ovarianabscess•  Peritonealpseudocysts•  Appendicealabscess•  DiverGcularabscess•  Pelvickidney

ClassificaGonsystemforadnexalmasses

PRIMARYMALIGNANTOVARIAN•  Epithelialcarcinoma

–  Borderline–  Serouscystadenocarcinoma(commonestovariancancer,50%malignancies)–  Mucinouscystadenocarcinoma(10%ovarianmalignancies)

•  Borderlinevariantispseudomyxomaperitonei–excludeappxprimary–  Endometrioidcarcinoma(25%ovarianmalignancies)(associatedwithendometrialcain20%)–  Clearcellcarcinoma(<10%ovarianmalignancies)

•  Germcelltumour–  Malignantteratoma–  Dysgerminoma

•  Sex-cordtumour–  Granulosacelltumour(secretesoestrogen)

ClassificaGonsystemforadnexalmasses

SECONDARYMALIGNANTOVARIAN

•  10%ofovarianmalignancy

Predominantly:

•  breast•  gastrointesGnalcarcinoma(Krukenbergtumour)

Ovarianpathology

•  ClassificaGonsystemforovarianpathology

•  StandardisaGonofterminology–IOTA

•  IOTASimpleDescriptors(paKernrecogniGon)

•  PredicGonofmalignancy–IOTASimpleRules

•  Workedexamples

•  Quiz

StandardisaGonofterminology

•  IOTAgroup

•  TermsanddefiniGonsofadnexalpathology

•  TRANSVAGINALULTRASOUND

IOTAdefiniGons–  Unilocular,unilocular-solid,mulGlocular,mulGlocular-solidorsolid

–  Cystcontents–anechoic,lowlevel,groundglass,haemorrhagicormixed

–  Solidmaterialorpapillarystructuresorwallirregularity(presenceandsize)

–  Vascularity

–  Shadows

–  Ascites

Unilocular

IOTA

Unilocular-solid

IOTA

MulGlocular

IOTA

MulGlocular-solid

IOTA

Solid

IOTA

CysGccontents

IOTA

MixedcysGccontents

IOTA

Internalwallofthecyst

IOTA

PapillaryprojecGon>3mm

IOTA

IOTAdefiniGons

•  Solidcomponent–structurethathasechogenicitysuggesGveofGssueBUTthewhiteballofadermoidisnotsolidGssueandbloodclotormucinisnotsolidGssue

•  Ifprotrusion>3mm=papillaryprojecGon(countassolidcomponent)

If<3mm=irregularity

•  Irregular–meansanirregularinternalwallORirregularoutercontourofasolidlesion

•  Ascites–fluidoutsidePOD

Vascularityscore•  ColourDopplerorPowerDoppler(moresensiGve)

•  PRF0.3•  Velocityscale3-6cm/sec•  Balance220•  AdjustDopplergaintojustbelowartefactlevel

•  Noflow=1•  Minimalflow=2•  Moderateflow=3•  Strongflowthroughout=4

Ovarianpathology

•  ClassificaGonsystemforovarianpathology

•  StandardisaGonofterminology–IOTA

•  IOTASimpleDescriptors(paKernrecogniGon)

•  PredicGonofmalignancy–IOTASimpleRules

•  Workedexamples

•  Quiz

SimpleDescriptors

•  CertainabnormaliGesarereallyobvious:–  PATTERNRECOGNITION

•  Endometrioma

•  BenigncysGcteratoma-dermoid

•  Simplecystorcystadenoma

•  FuncGonalcysteghaemorrhagiccyst

•  Malignanttumourwithascites

Simple Descriptors of an ovarian mass used to make a diagnosis

BD, benign descriptor; MD, malignant descriptor.

WhenSimpleDescriptorsdonotapply:

•  Ifthemassisnotinstantlyrecognisable

•  andSimpleDescriptorsdonotapply:

– ThenapplySimpleRules

Ovarianpathology

•  ClassificaGonsystemforovarianpathology

•  StandardisaGonofterminology–IOTA

•  IOTASimpleDescriptors(paKernrecogniGon)

•  PredicGonofmalignancy–IOTASimpleRules

•  Workedexamples

•  Quiz

Benignormalignant?PotenGaltests

•  ClinicalexaminaGon•  ColourDopplerImaging:PIorRI?•  Morphologicscoringsystems(80+)•  SerumCA125,othermarkers(HE4…)•  Riskofmalignancyindex(RMI)

•  Computermodels(logisGcregression+other)

•  SubjecGveassessment(paKernrecogniGon)

•  Simpleultrasound-basedrules

Morphologic Classification (n=1066)

Type of tumor N Malign. %

1.Unilocular cyst

313 2 0.6

2.Unilocular solid

132 44 33

3.Multilocular cyst

196 20 10

4.Multilocular solid

284 116 41

5.Solid tumo ur 136 84 62

IOTA

BMJ2010

Simple Rules FEATURES of a benign mass (B-features)

AmassisclassifiedasbenignifatleastoneB-featureispresentandnoM-featuresare

present

Simple Rules FEATURES of a malignant mass (M-

features) Amassisclassifiedas

malignantifatleastoneM-featureispresentand

noB-featuresarepresent

SimpleRules

•  Rule1:IfoneormoreMfeaturesarepresentinabsenceofBfeature(s),themassisclassifiedasmalignant.

•  Rule2:IfoneormoreBfeaturesarepresentinabsenceofMfeature(s),themassisclassifiedasbenign.

•  Rule3:IfbothMfeaturesandBfeaturesarepresent,orifnoBorMfeaturesarepresent,theresultisinconclusiveandasecondstagetestisrecommended.

Ovarianpathology

•  ClassificaGonsystemforovarianpathology

•  StandardisaGonofterminology–IOTA

•  IOTASimpleDescriptors(paKernrecogniGon)

•  PredicGonofmalignancy–IOTASimpleRules

•  Workedexamples

•  Quiz

Workedexamples–asagroupUsethesheetwiththeSimpleRules

•  LookatthemassanddescribeitusingIOTAcriteria

•  SimpleDescriptors/paKernrecogniGon–isitobvious?

•  Ifnot-applySimpleRules

•  Decidewhetherbenign,uncertainormalignant

•  Suggesthistologicaldiagnosis

Simpledescriptors/PaKernrecogniGon

premenopausal

Endometriomaunilocular,groundglassechogenicity,premenopausal

Simpledescriptors/PaKernrecogniGon

premenopausal

Dermoidunilocular,mixedechoes,shadows,premenopausal

Simpledescriptors/PaKernrecogniGon

<10cm

Serouscystadenomaunilocular,regularwalls,<10cm

Simpledescriptors/PaKernrecogniGon

postmenopausal

Stage4ovariancarcinomawithascites

tumourwithatleastmoderatebloodflow,ascites,postmenopausal

ExampleswhereSimpleDescriptors/easypaKern

recogniGondonotapply….

•  ApplySimpleRules

–  threeworkedexamples:

Example 1 <10cm

DiagnosGcsieve•  IOTAdescripGon

–  Unilocular,unilocular-solid,mulGlocular,mulGlocular-solidorsolid–  Cystcontents–anechoic,lowlevel,groundglass,haemorrhagicormixed–  Solidmaterialorpapillarystructuresorwallirregularity(presenceandsize) NO–  Vascularity1-4 2

–  Shadows NO–  Ascites NO

•  SimpleDescriptors–donotapply–  endometrioma/dermoid/simplecyst/haemorrhagiccyst/malignancy

•  Simplerules–  Benign-unilocular,smoothmulGloculartumor<100mm,largestsolidcomponentdiameter<7mm,

acousGcshadows,nobloodflow(colorscore1)

–  Malignant-Irregularsolidtumor,IrregularmulGlocular-solidtumor≥100mm,≥4papillarystructures,ascites,verystrongbloodflow(colorscore4)

–  Uncertain

Example 1

Simplerules:BENIGNMucinouscystadenoma

Example 1

Example 2

DiagnosGcsieve•  IOTAdescripGon

–  Unilocular,unilocular-solid,mulGlocular,mulGlocular-solidorsolid–  Cystcontents–anechoic,lowlevel,groundglass,haemorrhagicormixed–  Solidmaterialorpapillarystructuresorwallirregularity(presenceandsize)–  Vascularity1-4 4

–  Shadows NO–  Ascites NO

•  SimpleDescriptors–donotapply–  endometrioma/dermoid/simplecyst/haemorrhagiccyst/malignancy

•  Simplerules–  Benign-unilocular,smoothmulGloculartumor<100mm,largestsolidcomponentdiameter<7mm,

acousGcshadows,nobloodflow(colorscore1)

–  Malignant-Irregularsolidtumor,IrregularmulGlocular-solidtumor≥100mm,≥4papillarystructures,ascites,verystrongbloodflow(colorscore4)

–  Uncertain

Example 2

Simplerules:MALIGNANTMetastasisfrombowelprimary

Example 2

Example 3

DiagnosGcsieve•  IOTAdescripGon

–  Unilocular,unilocular-solid,mulGlocular,mulGlocular-solidorsolid–  Cystcontents–anechoic,lowlevel,groundglass,haemorrhagicormixed–  Solidmaterialorpapillarystructuresorwallirregularity(presenceandsize)–  Vascularity1-4 1-2

–  Shadows NO–  Ascites NO

•  SimpleDescriptors–donotapply–  endometrioma/dermoid/simplecyst/haemorrhagiccyst/malignancy

•  Simplerules–  Benign-unilocular,smoothmulGloculartumor<100mm,largestsolidcomponentdiameter<7mm,

acousGcshadows,nobloodflow(colorscore1)

–  Malignant-Irregularsolidtumor,IrregularmulGlocular-solidtumor≥100mm,≥4papillarystructures,ascites,verystrongbloodflow(colorscore4)

–  Uncertain (NOBENIGNRULESANDNOMALIGNANTRULES=UNCERTAIN)

Example 3

Simplerules:UNCERTAINBorderlineovariantumour

Example 3

Ovarianpathology

•  ClassificaGonsystemforovarianpathology

•  StandardisaGonofterminology–IOTA

•  IOTASimpleDescriptors(paKernrecogniGon)

•  PredicGonofmalignancy–IOTASimpleRules

•  Workedexamples

•  Quiz

QUIZUsethesheetwiththeSimpleRules

•  LookatthemassanddescribeitusingIOTAdefiniGons

•  ApplySimpleDescriptors(paKernrecogniGon)

•  ApplySimpleRules

•  Decidewhetherbenign,uncertainormalignant

•  Suggesthistologicaldiagnosis

SheetwithSimpleRules

•  Therewillbe10imagesforthequizwithworkedanswers

Conclusion

•  ApplyIOTAterminologyandSimpleRulestoalladnexalmasses,keeparecordandchasethehistology– wereyouright?

•  SimpleorcomplexVERSUS

•  IOTAcriteria,SimpleDescriptorsandSimpleRules–acomprehensiveandinformaGvereport

Tosumup

•  Carefulhistory•  SystemaGcscan–don’tpanicwhentherearemanyseparate

abnormaliGes

•  UsetheIOTAclassificaGontodescribethelesion•  ApplySimpleDescriptors(paKernrecogniGon)•  ApplySimpleRules

•  (applyothermodelsegLR2,ADNEX)•  Clearreport

–  Benign/uncertain/malignant

–  Suggestedhistology

•  Chasethehistology–wereyouright?

Resources

•  IOTA–papers,courses,apps(riskcalculators),conferences

hKp://www.iotagroup.org

•  ISUOG–papers,journalclubslides

•  GEposter

IOTAwebsite

IOTAapps

IOTAapps

IOTAwebsitehKp://www.iotagroup.org

GEPoster

THANKYOU