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Ovarian pathology: IOTA

Usmi Chauhan

Clinical Sonographer

Monash Health

Content

• Clinically useful• Benign • Malignant

• Communication between clinicians/research

DESCRIBE WHAT YOU SEE

ADNEXAL MASSES

SIMPLE COMPLEX

X

Consensus statement on how to describe adnexal masses

IOTA terms for description of an adnexal mass

Position: bilateral? Side?

Size of lesion

Type of tumour Number of locules /incomplete septum

Echogenicity

Acoustic shadows

Size of solid component

Papillary projections

Colour score

Ascites

Presence of metastases

IOTA terms for description of an adnexal mass

‘Lesion’ • Part of an ovary or adnexal mass inconsistentwith normal physiology

Struma ovarii Haemorrhagic cyst

X IOTA terms for description of an adnexal mass

‘5 types of tumour’

Solid (solid tissue comprise ≥ 80% of tumour)

Unilocular Unilocular solid Multilocular

Multilocular solid

Malignancy rate Granberg et al 1989

0.3% 2% 16%

73%40%

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IOTA terms for description of an adnexal mass

‘5 types of cyst contents’

Mixed

Anechoic Low level Ground glass

Haemorrhagic

IOTA terms for description of an adnexal mass

‘Solid component’• A structure that has echogenicity suggestive of tissue (ovarian stroma)• NOT ‘white ball’ in a dermoid cyst• NOT blood clot, or mucous

• Concave • Probe pressure• Colour Doppler

IOTA terms for description of an adnexal mass

‘Papillary projection’ • Protrusion of solid tissue into a cyst cavity ≥ 3mm (height)

• Protrusions < 3mm (height) = irregularities

• Papillary projections = solid component

Solid component but not PP IrregularityPapillary projection

IOTA terms for description of an adnexal mass

‘Septum’ • Thin strand of tissue that runs from one internal cyst surface to another

Incomplete septum • does not reach the opposite wall of the cystic structure in some scanning

planes (seen in diseased tubes)

Septum Incomplete septum

IOTA terms for description of an adnexal mass

‘Shadowing’

IOTA terms for description of an adnexal mass

‘Ascites’• Fluid outside pouch of Douglas

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IOTA terms for description of an adnexal mass

‘IOTA colour score’• Adjust settings: maximize detection of flow without artifacts (3-6cm/s; PRF 0.3-0.6 kHz)

Score 1(none)

Score 2(minimal)

Score 3 (moderate)

Score 4 (strong)

How do we use IOTA: practical applications

IOTA

Easy descriptors

Pattern recognition

Simple rules

ADNEX LR 1/LR 2

IOTA: Easy descriptorsUnilocular cyst,ground glass echogenicity, +/- wall nodularity.Premenopausal womanENDOMETRIOMA

Unilocular cyst, mixedechogenicity (white ball, dot-dash), shadowing,PremenopausalDERMOID CYST

Unilocular cyst,anechoic cyst fluid,regular walls,< 10 cmSIMPLE CYST OR CYSTADENOMA

All other unilocular cysts with regular wallsBENIGN

Mass> 50 yearsCA125 > 100 IU/mLMALIGNANT

MassAt least moderateblood flowPostmenopausalAscitesMALIGNANT

IOTA: Easy descriptors

SIMPLE CYST OR CYSTADENOMA

• Unilocular cyst• Anechoic cyst fluid• Regular walls• < 10 cm

IOTA: Pattern recognition

ENDOMETRIOMA

Wall nodularity (blood clot/fibrin)(Not papillary projection)

• Unilocular cyst• Ground glass

echogenicity• +/- wall nodularity• premenopausal woman

IOTA: Pattern recognition

DERMOID CYST

• Unilocular cyst• Mixed echogenicity

(white ball, dot-dash)• Shadowing• Premenopausal

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IOTA: Pattern recognition

HAEMORRHAGIC CYST

Reticular pattern Retracting clot

IOTA: Pattern recognition

MALIGNANT• Mass with at least moderate blood flow• Postmenopausal• Ascites

MALIGNANT• Mass• > 50 years• CA125 > 100 IU/mL

And/or

IOTA: Pattern recognition

HYDRO (PYO/HEMATO) SALPINXSerpiginous Incomplete septae

Cog wheeling Beads on a string

PERITONEAL PSEUDOCYST

IOTA: Pattern recognition

• Conforms to shape of peritoneal cavity• Prior pelvic surgery

Ovary suspended in edge of cyst

Solid Pelvic Tumours

• Myoma (uterine) • Fibroma• Thecoma • Brenner tumour • Leydig cell tumour • Malignancies

Peduculated fibroid

Fibroma

• Round, oval lobulated;

• Stripy shadows

• Min vascularity

• May mimic pedunculated fibroid

Broad ligament fibroid

Ovarian malignancyIrregular contourIrregular echogenicityIncreased vascularity

Dysgerminoma + yolk sac tumour

Solid Pelvic Tumours

Neuroendocrine tumour of ovary

Granulosa cell tumour

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IOTA: Simple Rules

Timmermen et al UOG 2008

IOTA: Simple Rules

B-rules M-rules

Unilocular cysts. Irregular solid tumour.

Presence of solid component where the largest solid component <7 mm.

Ascites.

Acoustic shadowing. At least four papillary structures.

Smooth multi-locular tumour with a largest diameter <10 cm.

Irregular multilocular solid tumour with largest diameter ≥ 10 cm.

No blood flow. Very strong blood flow.

IOTA: ADNEX modelhttps://www.iotagroup.org/sites/default/files/adnexmodel/IOTA%20-%20ADNEX%20model.html

CONCLUSION

1. Describe the mass instead of using the term ‘complex’

2. Be familiar with easy descriptors and pattern recognition

3. If uncertain, use Simple Rules +/- ADNEX

THANK YOU

THANK YOU