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Understanding the IOTA (International OvarianTumor Analysis) terminology & Classification
Using the IOTA simple rules to estimate the risk of malignancy in women with adnexal masses
Elisabeth Epstein, Associate Professor
Southern University Hospital, Karolinska Insitute
Stockholm, Sweden
Estimate the risk of malignancy in adnexal masses - Overview
• IOTA terminology & classification
• Predicting risk of malignancy using
– Pattern recognition
– Simple rules
• Case examples
Terminology
unilocular multiocular unilocularsolid multilocularsolid solid
Sonolucent hemorragic mixed ground glass Low level
Papillary projection Incomplete septa Aucoustic shadowing Assessment of vascularization
Type of lesion
Cyst contence
Defintions
Unilocular cyst
Multilocular cyst
Unilocular-solid cyst
Multilocular-solid cyst
Solid
0.3%
10%
33%
40%
62%
Classification according to Granberg -89Risk of maligancy, IOTA trial n=1066, 2005
Unilocular cyst – no septa or solid components
Incomplete septaeShould not regardedas real septae
Sludge/amorphousmaterial should not be regarded as papillary projection
”White ball”should not be classified as solid component
Irregularities < 3mm in height, should not be regarded as papillary projection
Unilocular solid – with solid component > 3mm
Pyosalpinx with cog-wheel papilations >3mm
Papillation > 3 mm in heightSolid component < 80%
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Multilocular cyst – purely cystic lesion,with at least one septae
Solid – solid component comprise>80% of the lesion
Assessment of cyst wall – if anyirregularity is seen: classify as irregular
Irregular: Sludge is alsoregarded as an irregularity
Smooth/regular Smooth/regular Irregular: papillaryprojections
Incomplete septa
•Typical finding
in hydrosalpinx
Papillary projection –solid protrusion > 3mm in height
Irregular papillary projectionsSmooth papillary projectionSeen in decidualizedendometrioma
Diffrentiate solid components from papillaryprojections
But, all solid componentsPapillary projections
Are not papillary projectionsAre solid components
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Differentiate:“amorphous” wall deposits
from solid papilary projections
Amorphous wall deposits - endometrioma
Papilary projection – suspect malignancy/ BOT
”White ball” - dermoid
BOT with papilla
Cystic Content
SonolucentAnechoic
hemorragicground glassLow levelEchogenic
mixed
Acoustic shadows
Acoustic shadow infibroma Acoustic shadow
In dermoid
Acoustic shadowing frompapillations in cystadenoma
Colour score
Colour score 1No bloodflow
Colour score 2 Minimal bloodflow
Colour score 3Moderate bloodflow
Colour score 4Marked/high bloodflow
Prediction of malignancy using the IOTA terminology
• Subjective assessment using pattern recognition
• Simple rules
• (Mathematical models)
– LR1 (12 variables)
– LR2 (6 variables)
– Adnex model® (multimodal)
– Simple Rules RM (risk predicition model9®
Subjective assessment using “Pattern recognition” in discriminating benign from malignant lesions
Absence of solid components and irregularities suggests benignity.
Solid vascularized components and irregularities suggest malignancy.
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Accuracy of ultrasound in the diagnosis of malignancy using
saubjective ”pattern recognition”
sens spec
Malignancy vs Benignity 88-96%* 90-96%*
Correct specific diagnosis over all 40%
in benign tumours 68%*
Valentin et al 1999, Timmerman et al 1999, Timmerman 2006
Expert ultrasound examiners were “uncertain” in 8% of cases Valentin L et al, 2007: (n=1066):
Serous cystadenoma Mucinous cystadenoma
Mucinous BOTSerous BOT
Struma OvariiFibroma
Intraligamental fibroid
Example of difficult tumours:
• Fibroma
• Pedunculated/intraligamental
Fibroid
• Struma ovarii
• Borderline
• Cystadeno(fibr)oma
Difficult masses 1: With papillary projections
Benign< 3 papillary projectionsPapillary max diameter < 7 mmNo papillary flowShadowing
> 4 papillary projectionsPapillary diameter > 7 mmPapillary flow
Malignant /Borderline
Difficult masses 2: Solid ovarian masses
Fibroma -benignMalignancy
CancerMalignant granulosa cell tumor Benign Brenner tumor
Regular echogenicityshadowing, and sparsevascularization supports benign diagnosis. Irregularechogenicity/outline, no shadowing suggestmalignancy
Difficult masses 2: Solid pelvic masses – can also be extraovarian pathology
Pedunculated sarcoma Intraligamental fibroids
Mescenterialfibromatosis
Neurofibromatosis
Important to lookfor the ovary!
Tubal cancer
Difficult masses 3: Multilocular cysts with
a large number of locules
Mucinous cystadenoma
Techa lutein cyst – functional; pregnancy/molar/trofoblastic disease
Mucinous intestinal borderline
Size <10 cmSuggests benign diagnosis
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Benign or malignant?
Adnexal masses: Case 1
Woman 43 years old. Benign? Malignant? Diagnosis?
Adnexal masses. Case 2
Woman 63 years old, episodes with abundant fluor.Benign? Malignant? Diagnosis?
Adnexal masses: Case 3
Incidentally detected bilateral lesion, woman 80 years old.Diagnosis? Management?
Adnexal lesions: Case 4
Woman 29 years old, incidental finding. 5cm lesion.Diagnosis? Management?
Adnexal masses: Case 5
Woman 32 years, Pregnant GW 18+ abdominal painDifferential diagnosis?
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Predicition of malignancy in adnexal masses usingIOTA models: Simple rules®
Ovarian cancer Mucinous cystadenoma Dermoid
IOTA Simple Rules - Classifies 80% of all lesions
Simple Rules• Accuracy very high in masses that apply to the rules (80%) –
sensitivity 91% specificity 96%• Simple rules works well also in the hands of less experienced
examiners (Alcazar 2013), (Sayasneh 2013)• Work better than RMI both in the hands of experienced and
less experienced examiners (Ameye 2012, Sayasneh 2013)• IOTA Simple Rules is one of the best approaches to
preoperatively classify adnexal masses as benign or malignant (Kaijser 2014)
• Correct application of the Simple Rules requires knowledge and proper use of the ultrasound features. (Timmerman 2000)
• Recomended in the national Swedish guidelines in favor of RMI especially in pre-MP women
Benign (B) - features
B1 Unilocular
B3 Acousticshadowing
B2 Solid component < 7mm
B5 No bloodflowB4 Multilocular smooth, < 10 cm
Malignant (M) - features
M1 Irregular solid lesion
M5 Strong blood flow
M2 Ascites M3 > 4 papillaryprojections
M4 Multilocular solid, > 10 cm
Simple Rules - interpretetionMalignt (M) features
• M1—Irregular solid tumour
• M2—Presence of ascites
• M3—At least four papillary structures
• M4—Irregular multilocular solid tumourwith largest diameter ≥100mm
• M5—Very strong blood flow (colourscore 4)
Benign (B) features
• B1—Unilocular
• B2—Largest solid component diameter <7 mm
• B3—Presence of acoustic shadows
• B4—Smooth multilocular tumour with largest diameter <100 mm
• B5—No blood flow
At least one B-feature, No M-features = probably benignAt least one M-feature, No B-feature= probably malignantBoth M and B features or neither B nor M features = inconclusive
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What to do with the inconclusive cases?
• Treat all inconclusive cases as malignant
• Send all inconclusive cases for expert US assessment
– (SR + SA, sens 91% spec 91%)
Simple rules:Case examples
Case example 1:
Woman, 32 years old, Largest diameter 12cm, Examined in non-oncology centre:
Case example (1) – Simple Rules tick box
Ultrasound features predictive for amalignant tumor (M-features)
Features predictive for a benign tumor (B-features)
M1 Irregular solid tumor B1 Unilocular
M2 Presence of ascites B2 Presence of solid components wherethe largest solid component has a largestdiameter < 7 mm
M3 At least four papillary structures B3 Presence of acoustic shadows
M4 Irregular multilocular solid tumor with largest diameter ≥ 100 mm
B4 Smooth multilocular tumor withlargest diameter < 100 mm
M5 Very strong blood flow (color score 4) B5 No blood flow (color score 1)
No features present
Case 1 management & findings
• Refer to oncology center? • Refer for expert US examination? • Operate in regional centre?
Histology:Mucinous Cystadenoma
Expert US assessment: Impossible to say if it is a mucinous cystadenoma or mucinos intestinal borderline,Probablility of invasive malignancy low
Case example (2)
• Patient seen in oncological center
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Case example (2) – Simple Rules tick box
Ultrasound features predictive for amalignant tumor (M-features)
Features predictive for a benign tumor (B-features)
M1 Irregular solid tumor B1 Unilocular
M2 Presence of ascites B2 Presence of solid components wherethe largest solid component has a largestdiameter < 7 mm
M3 At least four papillary structures B3 Presence of acoustic shadows
M4 Irregular multilocular solid tumor with largest diameter ≥ 100 mm
B4 Smooth multilocular tumor withlargest diameter < 100 mm
M5 Very strong blood flow (color score 4) B5 No blood flow (color score 1)
Case 2 management & findings
• Operate in regional centre?• Follow-up if no symptoms or high co-morbidity?
Histology:Benign cystadenofibroma
Expert US assessment:Papillation with shadowing and without blood flow support benign diagnosis
Case example 3
Age 74, no ascites, maximum diameter 67mm, max size of solid component 49mm, examinedin oncology centre
Case example (3) – Simple Rules tick box
Ultrasound features predictive for amalignant tumor (M-features)
Features predictive for a benign tumor (B-features)
M1 Irregular solid tumor B1 Unilocular
M2 Presence of ascites B2 Presence of solid components wherethe largest solid component has a largestdiameter < 7 mm
M3 At least four papillary structures B3 Presence of acoustic shadows
M4 Irregular multilocular solid tumor with largest diameter ≥ 100 mm
B4 Smooth multilocular tumor withlargest diameter < 100 mm
M5 Very strong blood flow (color score 4) B5 No blood flow (color score 1)
Case 3 management & findings
• High risk of ovarian cancer • Should undergo surgery in oncology centre• Preoerative assessment of tumor extension indicated (CT, PET-CT; Ultrasound) – to assess if optimal debulkingcan be done. If not* – consider tru-cut biopsy – to establish diagnosis and to select Chemo.
Histology:Stage III ovarian cancer
*•Pulmonary metastasis, deep liver metastasis, •carcinosis on small intestine/•LN metastasis above renal arteries•Bulky tumor in lever hilum
Case example 4 Woman 32 years old. Unilateral lesion max diameter 97mm, seen in oncolony unit
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Case example (4) – Simple Rules tick box
Ultrasound features predictive for amalignant tumor (M-features)
Features predictive for a benign tumor (B-features)
M1 Irregular solid tumor B1 Unilocular
M2 Presence of ascites B2 Presence of solid components wherethe largest solid component has a largestdiameter < 7 mm
M3 At least four papillary structures B3 Presence of acoustic shadows
M4 Irregular multilocular solid tumor with largest diameter ≥ 100 mm
B4 Smooth multilocular tumor withlargest diameter < 100 mm
M5 Very strong blood flow (color score 4) B5 No blood flow (color score 1)
Case 4 managment and findings
• Expert US assessment: Features resembelling teratoma. Struma Ovarii? Malignancy can not be ruled out.
• Advisable to perform ooforectomy
• Pre surgical tumor markers & CT
Case example (5)
• Patient seen in oncological center, age 65• Smooth solid mass right ovary, measuring 68x68x65 mm• Free fluid in the pouch of Douglas, but no ascites present
Case example (2) – Simple Rules tick box
Ultrasound features predictive for amalignant tumor (M-features)
Features predictive for a benign tumor (B-features)
M1 Irregular solid tumor B1 Unilocular
M2 Presence of ascites B2 Presence of solid components wherethe largest solid component has a largestdiameter < 7 mm
M3 At least four papillary structures B3 Presence of acoustic shadows
M4 Irregular multilocular solid tumor with largest diameter ≥ 100 mm
B4 Smooth multilocular tumor withlargest diameter < 100 mm
M5 Very strong blood flow (color score 4) B5 No blood flow (color score 1)
Case example (5)
• Expert US assessment: fibroid?
• CT, tumor markers prior to surgery
Advice
• Experienced examiners: pattern recogntion doesthe job.
• Moderate experienced examiners: Simple rulesand Simple Rules RM help you in a largeproportion of cases. Consider referinginconclusive cases for expert US assessment
• It is crucial to understand the terms and defintions to be able to use the models!
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IOTA collaboration website
• http://www.iotagroup.org
• Educational material– IOTA Terminology
– ”Easy descriptors”
– Simple rules
• IOTA models software– LR2, simple rules
– ADNEX® model
• IOTA online lectures
How to make a report on an adnexal mass?
• Describe lesion(s) according to IOTA classification
– Unilocular, multilocular, etc…..
– Colourscore (1-4)
– Mobility?
• Assess probability of malignancy
– Certainly bening, probably benign, inconclusive, probablymalignant, certainly malignant
• Try to give a specific diagnosis
– Fibroma, endometrioma, borderline tumor, hydrosalpinx, peritonela cyst, etc….
• Give advise on managment
Thank you for your attention!
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