Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement

The clinical ultrasound report: Guideline for sonographers

The reporting roles of sonographers in Australasia vary considerably. A large number of sonographers already routinely produce formal reports, while others are moving into clinical ultrasound roles where reporting is expected. This article summarises the best practice in reporting of ultrasound examinations based on international literature and addresses key topics including report structure, clinical content, style and language. Numerous examples and sample phrases are provided and common pitfalls are discussed.

Selecting treatment method for ovarian masses in children - 24 years of experience

BACKGROUND

Epidemiology and pathology of ovarian tumors in the pediatric population are very different of these encountered in women. Few attempts have been made to analyze the whole spectrum of ovarian pathology in children, and only some of them included series of more than 200 cases. We performed a retrospective analysis of clinical and diagnostic aspects of ovarian tumors and tumor-like lesions in girls in order to identify the characteristics associated with malignancy with an attempt to elaborate a clinical management algorithm.

RESULTS

The study group comprised 214 patients operated on for ovarian tumor in years 1991-2014 at the pediatric surgical center. Non-neoplastic ovarian lesion was diagnosed in 127 females. Sixty-five patients had a benign tumor and 22 had a malignant lesion. Abdominal pain was the most common symptom in the non-malignant lesion group. Patients with ovarian malignancy presented predominantly with abdominal distension and palpable mass. In the non-malignant group imaging studies revealed cystic lesion in 124 patients (68.89%) and solid mass in 10 (5.55%). Malignant lesion showed a solid or mixed structure in all cases. Positive tumor markers were noted in 14 (13.7%) patients with a benign lesion and in 14 (70%) with ovarian malignancy. Large lesions were found in 77.3% of girls with a malignant mass, while only in 32.8% of patients with a benign lesion (p < 0.001). In the group of solid tumors positive tumor marker results occurred more frequently in patients with diagnosed malignant tumors (p < 0.05). Positive tumor markers, large size of the lesion and age below 14 years were independent variables differentiating malignant tumors from non-malignant lesions (p = 0.00000).

CONCLUSIONS

Predominantly solid structures noted on imaging studies, large dimension and positive tumor markers are clinical predictors of malignancy. A diagnosis of purely cystic lesions with negative markers or of a small size should be an indication for a gonad-sparing procedure. Treatment guidelines for ovarian lesions in children should be established on the basis of multicenter prospective studies and introduced as soon as possible in order to improve and unify the ovarian preservation rates across the pediatric surgical centers.

Imaging of Female Pelvic Emergencies

Pelvic pain is a common complaint in female patients who present to the emergency department. Although encountered frequently, the path to a definitive diagnosis is not always a straightforward one, and imaging offers a valuable tool to aid in this diagnostic challenge. Radiologists must be familiar with the most common etiologies of female pelvic pain in the emergency setting, their imaging characteristics, and the best way to further evaluate challenging clinical presentations. This allows the radiologist to serve as a valuable asset to the treating physician, aiding in accurate diagnosis, and in guiding the course of treatment, all while ensuring the "Image Wisely" principle. A sonographic approach to female patients presenting to the emergency setting with pelvic pain has been presented in this article and some example entities along with their imaging findings have also been reviewed.

First International Consensus Report on Adnexal Masses: Management Recommendations

The First International Consensus Conference on Adnexal Masses was convened to thoroughly examine the state of the science and to formulate recommendations for clinical assessment and management. The panel included representatives of societies in the fields of gynecology, gynecologic oncology, radiology, and pathology and clinicians from Europe, Canada, and the United States. In the United States, there are approximately 9.1 surgeries per malignancy compared to the European International Ovarian Tumor Analysis center trials, with only 2.3 (oncology centers) and 5.9 (other centers) reported surgeries per malignancy, suggesting that there is room to improve our preoperative assessments. The American College of Obstetricians and Gynecologists Practice Bulletin on "Management of Adnexal Masses," reaffirmed in 2015 (Obstet Gynecol 2007; 110:201-214), still states, "With the exception of simple cysts on a transvaginal ultrasound finding, most pelvic masses in postmenopausal women will require surgical intervention." The panel concluded that patients would benefit not only from a more conservative approach to many benign adnexal masses but also from optimization of physician referral patterns to a gynecologic oncologist in cases of suspected ovarian malignancies. A number of next-step options were offered to aid in management of cases with sonographically indeterminate adnexal masses. This process would provide an opportunity to improve risk stratification for indeterminate masses via the provision of alternatives, including but not limited to evidence-based risk-assessment algorithms and referral to an "expert sonologist" or to a gynecologic oncologist. The panel believed that these efforts to improve clinical management and preoperative triage patterns would ultimately improve patient care.

Diagnostic performance of the Gynecology Imaging Reporting and Data System for malignant adnexal masses

OBJECTIVE

To evaluate the Gynecology Imaging Reporting and Data System (GI-RADS) for diagnosis of malignant adnexal masses in a Chinese population.

METHODS

A retrospective study was conducted of patients who underwent evaluation of suspected adnexal masses at a hospital in Tianjin, China, between January 1, 2015, and January 31, 2016. Ultrasonographic diagnosis was based on the GI-RADS classification-a standardized summary of imaging data that estimates the risk of malignancy-and compared with the final pathological diagnosis.

RESULTS

Among 242 patients, thick wall, solid papillary projection, solid area, central blood flow, ascites, and GI-RADS classification were associated with malignancy (P<0.05 for all variables). The 263 masses evaluated were classified as GI-RADS 2 (functional cyst; n=65), GI-RADS 3 (benign neoplasm; n=68), GI-RADS 4 (one or two morphological findings suggestive of malignancy; n=101), and GI-RADS 5 (≥3 morphological findings suggestive of malignancy; n=28). Four malignant cases with false-negative findings were misclassified as GI-RADS 3, whereas 24 benign cases with false-positive findings were misclassified as GI-RADS 4. The sensitivity, specificity, false-positive rate, false-negative rate, accuracy, and Youden index of the GI-RADS classification were 96.4%, 84.3%, 18.5%, 3.0%, 89.3%, and 80.7%, respectively.

CONCLUSION

The GI-RADS classification performed well in the diagnosis of malignant adnexal masses.

Multiparametric MRI for differentiation of borderline ovarian tumors from stage I malignant epithelial ovarian tumors using multivariate logistic regression analysis

OBJECTIVE

To assess the value of contrast-enhanced MRI, apparent diffusion coefficient (ADC) measurement, and CA-125 measurement for differentiating borderline ovarian tumors (BOTs) from stage I malignant epithelial ovarian tumors (MEOTs).

MATERIAL AND METHODS

This retrospective study included 43 patients with BOTs and 43 patients with stage I MEOTs who underwent contrast-enhanced MRI with DWI and CA-125 analysis. Two radiologists evaluated the MRI findings in consensus. Univariate and multivariate analyses were performed to detect the best predictor variables for MEOTs.

RESULTS

Mixed cystic/solid and predominantly solid appearances, as well as thickened irregular septa, were more frequent in MEOTs. A papillary architecture and internal branching (PA&IB) pattern was more frequent in BOTs. MEOTs had thicker walls and septa, larger solid components, and higher CA-125 values. The mean ADC value of solid components (ADC_mean) and minimum ADC value of whole lesions (ADC_min) were lower in MEOTs. Multivariate analysis revealed that ADC_min and maximum diameter of the solid components were independent indicators of MEOTs with an AUC, sensitivity, and specificity of 0.86, 81%, and 84%, respectively.

CONCLUSION

ADC_min and maximum diameter of solid components were useful for differentiating BOTs from MEOTs.

"Incidentalomas" on abdominal and pelvic CT in emergency radiology: literature review and current management recommendations

The purpose of this article is to familiarize radiologists and clinicians with a subset of common and uncommon incidental findings on abdominal and pelvic computed tomography examinations, including hepatic, splenic, renal, adrenal, pancreatic, aortic/iliac arterial, gynecological, and a few other miscellaneous findings, with an emphasis on "incidentalomas" discovered in the emergency setting. In addition, we will review the complex problem of diagnosing such entities, and provide current management recommendations. Representative case examples, which we have encountered in our clinical practices, will be demonstrated.

Imaging of Extranodal Genitourinary Lymphoma

The genitourinary (GU) system is commonly affected by disseminated lymphoma. Rarely, lymphoma can originate from and remain localized to one of the GU organs and thus presents as primary extranodal disease. Up to 40% of lymphomas present as extranodal disease, with only 3% having the GU system as the primary site of involvement. This article describes and correlates the radiologic and pathologic features of extranodal lymphomatous disease affecting the GU system with specific focus on the kidneys, adrenal glands, testicles, and ovaries. Lymphoma of the uterine body and cervix, external female genitalia, urinary bladder, and prostate gland is briefly discussed.

Evidence-Based Cancer Imaging

With the advances in the field of oncology, imaging is increasingly used in the follow-up of cancer patients, leading to concerns about over-utilization. Therefore, it has become imperative to make imaging more evidence-based, efficient, cost-effective and equitable. This review explores the strategies and tools to make diagnostic imaging more evidence-based, mainly in the context of follow-up of cancer patients.

Gynecological pelvic pain as emergency pathology

Acute pelvic pain is a common condition in emergency. The sources of acute pelvic pain are multifactorial, so it is important to be familiar with this type of pathologies. The purpose of this article is review the main causes of gynecological acute pelvic pain and their radiologic appearances to be able to make an accurate diagnosis and provide objective criteria for patient management.

Magnetic Resonance Imaging of Gynecological Malignancies: Role in Personalized Management

Gynecological malignancies are a leading cause of mortality and morbidity in women and pose a significant health problem around the world. Currently used staging systems for management of gynecological malignancies have unresolved issues, the most important being recommendations on the use of imaging. Although not mandatory as per the International Federation of Gynecology and Obstetrics recommendations, preoperative cross-sectional imaging is strongly recommended for adequate and optimal management of patients with gynecological malignancies. Standardized disease-specific magnetic resonance imaging protocols help assess disease spread accurately and avoid pitfalls. Multiparametric imaging holds promise as a roadmap to personalized management in gynecological malignancies. In this review, we will highlight the role of magnetic resonance imaging in cervical, endometrial, and ovarian carcinomas.

[Gynecological tumors of the true pelvis: Radiological diagnosis for pelvic tumors made simple]

Tumors of the reproductive organs are among the most common female tumors. Computed tomography (CT) and magnetic resonance imaging (MRI) are used for establishing the differential diagnosis, for staging and increasingly for treatment stratification. Sonography is the first line imaging modality for assessing benign and malignant tumors of the uterus as well as ovarian and adnexal lesions. In sonographically indeterminate masses MRI is used for clarification as it allows not only a prediction of the dignity but also in most cases a specific diagnosis. The MRI examination is also superior to CT in the assessment of tumors resembling benign pelvic lesions. Whereas MRI has become established as the modality of choice for local staging and treatment planning in cancers of the uterine cervix and endometrial cancer, CT is used for staging of ovarian cancer due to the propensity for peritoneal spread outside the pelvis at the time of initial diagnosis.

Clinical, radiological, and histopathological analysis of paraovarian cysts

Introduction:

Paraovarian cyst arise from either mesothelium or from paramesonephric remnant. These present as either adneal mass or as an incidental finding. Diagnosis is usually established on ultrasound and it is important to differentiate these from ovarian cyst.

Material and Methods:

The present study is a retrospective analysis of 32 women with a confirmed diagnosis of paraovarian cyst after surgery. The clinical profile, symptoms and radiological findings of these patients were noted from the hospital records. A correlation was made with the surgical findings and the final histopathological diagnosis.

Results:

Only 2 patients were postmenopausal and one case was diagnosed during pregnancy. Ultrasound accurately diagnosed paraovarian cyst in 87.5% patients. 78% paraovarian cysts were found to be simple and none had any malignant change. We reported a higher incidence of cystic adenomatoid tumor in these paraovarian cysts.

Conclusion:

In our study, most paraovarian cysts occur in reproductive age group and present as an adnexal mass. Ultrasound is the diagnostic modality and a paraovarian cyst needs to be differentiated from ovarian cyst. Most of them were simple cysts on histopathology.

Diagnostic potential of tumor DNA from ovarian cyst fluid

We determined whether the mutations found in ovarian cancers could be identified in the patients' ovarian cyst fluids. Tumor-specific mutations were detectable in the cyst fluids of 19 of 23 (83%) borderline tumors, 10 of 13 (77%) type I cancers, and 18 of 18 (100%) type II cancers. In contrast, no mutations were found in the cyst fluids of 18 patients with benign tumors or non-neoplastic cysts. Though large, prospective studies are needed to demonstrate the safety and clinical utility of this approach, our results suggest that the genetic evaluation of cyst fluids might be able to inform the management of the large number of women with these lesions.

DOI:http://dx.doi.org/10.7554/eLife.15175.001

More than a third of women develop ovarian cysts during their lifetimes. The vast majority of these cysts are harmless, but a small number are caused by ovarian cancers. These cancers often produce no symptoms until the disease has spread throughout the abdomen or to other organs, so many women go undiagnosed until their chances of being successfully treated are low. Currently, there is no reliable way to determine whether an ovarian cyst is cancerous without performing surgery. As a result, many women undergo unnecessary, invasive surgeries for harmless ovarian cysts.

Tumors shed cells and cell fragments into any fluid that surrounds them. Fluids from cysts in the pancreas, kidney, and thyroid are routinely examined to identify whether they contain cancerous cells. Now, Wang, Sundfeldt et al. show that ovarian cancers also shed DNA into the surrounding cyst fluid. Furthermore, mutations found in this DNA can provide valuable information about whether the cysts are cancerous.

The study was performed by extracting DNA from the fluid in ovarian cysts that had been surgically removed from 77 women. Of these cysts, 10 were harmless cysts, 12 were benign tumors, 31 were invasive cancers, and 24 were so-called borderline tumors, which fall somewhere between the benign tumors and invasive cancers. Only cysts associated with the borderline tumors and invasive cancers need to be surgically removed. Here, Wang, Sundfeldt et al. report that DNA mutations that are characteristic of ovarian cancers were found in 87% of the cysts associated with borderline tumors and invasive cancers. In contrast, these mutations were not found in any of the cysts that do not require surgery.

Fluid can be extracted from an ovarian cyst with a needle during an outpatient visit. Therefore, the results presented by Wang, Sundfeldt et al. suggest a relatively straightforward way of testing the DNA from ovarian cysts before deciding whether surgery is really necessary. First, however, larger studies that follow women with cysts over time will be necessary to confirm that this type of testing is effective and safe.

DOI:http://dx.doi.org/10.7554/eLife.15175.002

"Chasing a Ghost": Factors that Influence Primary Care Physicians to Follow Up on Incidental Imaging Findings

Purpose To explore provider and patient characteristics that influence how primary care providers (PCPs) communicate and manage incidental imaging findings. Materials and Methods This HIPAA-compliant study was approved by the institutional review board. Through semistructured interviews, researchers explored concerns and perspectives of 30 PCPs on receiving and acting on incidental imaging findings. Open-ended questions were designed to elicit a range of responses rather than quantifiable data. Thematic codes were developed and explicitly defined. Three research assistants independently coded all 30 deidentified transcripts and resolved discrepancies (κ = 0.85). Codes pertaining to PCP and patient characteristics were organized into an explanatory model. Results Some PCPs felt compelled but frustrated to pursue costly follow-up for incidental imaging findings of limited clinical importance. Other PCPs did not act on findings that were unfamiliar or occurred in an unusual clinical context when follow-up recommendations were not given; the challenges of researching the clinical importance of these findings or seeking specialist consultation led to inaction. Some PCPs reported using a uniform approach to communicate and manage incidental findings, while others adapted their approach to the patient and the finding. Sometimes PCP characteristics such as follow-up style superseded patient characteristics. At other times patient characteristics such as health literacy superseded PCP characteristics. Conclusion PCPs cited a variety of objective and subjective factors that influence how they communicate and manage incidental imaging findings. These results suggest that some patients may receive inappropriate follow-up of incidental imaging findings and present an opportunity for radiologists to help PCPs and patients to best use the information conveyed in imaging reports. ^© RSNA, 2016 Online supplemental material is available for this article.

Perineural (Tarlov) Cyst Imitating Complex Adnexal Cyst

Patients are frequently referred for pelvic sonograms to evaluate for adnexal masses. Determining the etiology of the adnexal mass can be challenging, but is necessary to establish a follow-up strategy and correct diagnosis. It is particularly important in those cases when adnexal lesions appear to be complex and the ovaries are not visualized sonographically. Perineural cysts were found incidentally by Tarlov in 1938 during autopsy. This report documents a lesion now bearing his name, Tarlov cysts (TCs). They are defined as cerebrospinal fluid–filled saccular lesions located in the extradural space of the sacral spinal canal and are formed within the nerve root sheath at the dorsal root ganglion. The perineurium and neural tissue make up the cysts’ walls. Usually asymptomatic, a TC is mostly found on magnetic resonance imaging (MRI) of the lumbar spine and sacrum. Occasionally, a TC mimics an adnexal cyst.

The Value of Ultrasound Monitoring of Adnexal Masses for Early Detection of Ovarian Cancer

Although ultrasound has so far been found to be ineffective as a screening tool for ovarian cancer, it is commonly used as a means of evaluating or following ovarian or adnexal masses once they are detected. We review the use of serial ultrasound for the management of adnexal masses and propose an approach to monitoring based on an understanding of the overall risk of cancer among the population in question and an assessment of how the potential benefit of monitoring compares with potential risk. In our approach, masses that are symptomatic, large (>10 cm), associated with an elevated CA 125 level or overt signs of malignancy, or that are determined to have a worrisome appearance by stringent ultrasound criteria should be evaluated surgically. Women with masses that have none of these characteristics should be offered monitoring. Short-term initial ultrasound monitoring carries significant potential benefit in terms of aiding detection of early malignancy and avoidance of unnecessary surgery. However, if a mass remains stable but persistent, the potential benefit of ongoing monitoring wanes with time, whereas the potential harms, in terms of patient anxiety, cost, and the risk of incidental findings and unnecessary surgery increase. Therefore, monitoring of stable lesions should be limited in duration in order to limit potential harms from overtreatment and overdiagnosis.

Big Data and the Future of Radiology Informatics

Rapid growth in the amount of data that is electronically recorded as part of routine clinical operations has generated great interest in the use of Big Data methodologies to address clinical and research questions. These methods can efficiently analyze and deliver insights from high-volume, high-variety, and high-growth rate datasets generated across the continuum of care, thereby forgoing the time, cost, and effort of more focused and controlled hypothesis-driven research. By virtue of an existing robust information technology infrastructure and years of archived digital data, radiology departments are particularly well positioned to take advantage of emerging Big Data techniques. In this review, we describe four areas in which Big Data is poised to have an immediate impact on radiology practice, research, and operations. In addition, we provide an overview of the Big Data adoption cycle and describe how academic radiology departments can promote Big Data development.

Potential harms outweigh benefits of indefinite monitoring of stable adnexal masses

The management of women with asymptomatic adnexal masses should aim to balance potential benefit with potential harm. While masses with highly worrisome features or other signs of malignancy should be referred for surgery, the vast majority of masses have an indeterminate or benign appearance and are candidates for observation. Evidence supports the use of initial short-term serial ultrasound in distinguishing between benign and malignant masses. However, benefit from prolonged, potentially life-long monitoring of stable masses has not been demonstrated. Since the goal of monitoring an adnexal mass is to observe for worrisome growth or increasing complexity as an indicator of malignancy, if the mass remains stable, the likelihood of malignancy and therefore, the potential benefit of observation wanes with time. The recognition that Type 2 high grade serous cancers, which are responsible for the majority of deaths from ovarian cancer, arise from fallopian tube rather than ovarian precursors, further diminishes the likelihood that monitoring a stable ovarian mass will lead to early diagnosis of high grade disease. While some Type 1 cancers may develop from ovarian precursors, the available data suggest that any measurable benefit of monitoring known lesions for detection of these cancers is realized within the first year of observation. The argument in favor of indefinite, potentially life-long monitoring of stable masses also fails to adequately account for the risks of perpetual imaging, which include the risk of incidental findings, an increased likelihood of unnecessary surgery, patient anxiety and cost. It is not always better to order a test than not order a test. Given the absence of evidence of benefit, observation of stable small adnexal masses should be limited in duration in order to minimize potential harms.

Acute Gynecologic Disorders

Premenopausal women with acute pelvic pain comprise a significant percentage of patients who present to the emergency room. Etiologies can be gynecologic, urologic, gastrointestinal, or vascular. Signs and symptoms are often nonspecific and overlapping. The choice of imaging modality is determined by the clinically suspected differential diagnosis. Ultrasound (US) is the preferred imaging modality for suspected obstetric or gynecologic disorders. CT is more useful when gastrointestinal or urinary tract pathology is likely. MR imaging is rarely used in the emergent setting, except to exclude appendicitis in pregnant women. This article presents a comprehensive review of imaging of acute gynecologic disorders.

Ultrasound follow up of an adnexal mass has the potential to save lives

Ovarian cancer is among the most dreaded cancers since it is often found at a late stage where the opportunity for extended survival is poor. Ultrasound has been utilized in several ovarian cancer screening trials in asymptomatic women in order to detect ovarian cancer at early stages where survival rates are high. Efforts to improve screening for ovarian cancer are ongoing. While ovarian cancer screening in asymptomatic women is not recommended for clinical application currently, the care of women with adnexal masses found by ultrasound in clinical practice can benefit from close evaluation of the evidence obtained from large prospective ovarian cancer screening trials and by relating this evidence to recent advances in the understanding of different types of ovarian cancer. Post-menopausal women who have an adnexal mass discovered by ultrasound have a much higher risk of developing ovarian cancer than women with normal ultrasound. The preponderance of reported evidence indicates that ultrasound monitoring of an adnexal mass is safe, cost effective and can achieve an improved positive predictive value in detecting ovarian cancer when ovarian abnormalities resolve during surveillance. Proposals to arbitrarily discontinue ultrasound monitoring can negatively impact patient care and generate medical-legal actions, especially because there is no evidence to support safe discontinuation. In this review, we outline a rationale for continuing ultrasound surveillance of ovarian abnormalities.

The accuracy of pre-operative imaging in the management of hepatic cysts

BACKGROUND

Biliary cystic tumours (BCT) [biliary cystadenoma (BCA) and cystadenocarcinoma (BCAC)] warrant complete resection. Simple liver cysts (SLC) require fenestration when symptomatic. Distinguishing between BCT and atypical SLC with pre-operative imaging is not well studied.

METHODS

All patients undergoing surgery for a pre-operative suspected SLC or BCT between 1992 and 2014 were included. Peri-operative data were retrospectively reviewed. A blind radiological review of pre-operative imaging was performed.

RESULTS

Ninety-four patients underwent fenestration (n = 54) or complete excision (n = 40). Final pathology was SLC (n = 74), BCA (n = 15), BCAC (n = 2) and other primary malignancies (n = 3). A frozen section (FS) was performed in 36 patients, impacting management in 10 (27.8%) by avoiding (n = 1) or mandating a liver resection (n = 9). Frozen section results were always concordant with final pathology. Upon blind review, a solitary lesion, suspicious intracystic component, septation and biliary dilatation were associated with BCT (P < 0.05). Diagnostic sensitivity was high (87.5-100%) but specificity was poor (43.1-53.4%). The diagnostic value of imaging was most accurate when negative for BCT (negative predictive value: 92.5-100%).

CONCLUSION

Radiological assessment of hepatic cysts is relatively inaccurate as SLC frequently present with concerning features. In the absence of a strong suspicion of malignancy, fenestration and FS should be considered prior to a complete resection.

Focused Decision Support: a Data Mining Tool to Query the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial Dataset and Guide Screening Management for the Individual Patient

The Prostate, Lung, Colorectal, and Ovarian Cancer (PLCO) Screening Trial enrolled ~155,000 participants to determine whether certain screening exams reduced mortality from prostate, lung, colorectal, and ovarian cancer. Repurposing the data provides an unparalleled resource for matching patients with the outcomes of demographically or diagnostically comparable patients. A web-based application was developed to query this subset of patient information against a given patient's demographics and risk factors. Analysis of the matched data yields outcome information which can then be used to guide management decisions and imaging software. Prognostic information is also estimated via the proportion of matched patients that progress to cancer. The US Preventative Services Task Force provides screening recommendations for cancers of the breast, colorectal tract, and lungs. There is wide variability in adherence of clinicians to these guidelines and others published by the Fleischner Society and various cancer organizations. Data mining the PLCO dataset for clinical decision support can optimize the use of limited healthcare resources, focusing screening on patients for whom the benefit to risk ratio is the greatest and most efficacious. A data driven, personalized approach to cancer screening maximizes the economic and clinical efficacy and enables early identification of patients in which the course of disease can be improved. Our dynamic decision support system utilizes a subset of the PLCO dataset as a reference model to determine imaging and testing appropriateness while offering prognostic information for various cancers.

Added Value of Assessing Adnexal Masses with Advanced MRI Techniques

This review will present the added value of perfusion and diffusion MR sequences to characterize adnexal masses. These two functional MR techniques are readily available in routine clinical practice. We will describe the acquisition parameters and a method of analysis to optimize their added value compared with conventional images. We will then propose a model of interpretation that combines the anatomical and morphological information from conventional MRI sequences with the functional information provided by perfusion and diffusion weighted sequences.

[Incidental radiological findings]

All findings which arise in the context of radiological diagnostics, potentially affect the health of a subject but with no intention to detect the corresponding finding are considered to be incidental radiological findings (IF). The prevalence of IFs is increasing due to the wider use of modern imaging techniques, such as magnetic resonance imaging (MRI) and computed tomography (CT) in routine clinical practice and the inclusion of imaging, such as whole body MRI in large population-based cohorts. The reporting of radiological IFs can lead to further diagnostics and treatment. The management of IFs in the clinical routine is regulated by the guidelines of the various academic societies. The management of IFs in the setting of research studies differs depending on various factors, such as study design and health status of enrolled subjects. In general, IFs must be disclosed to the subject if the radiological IFs are potentially clinically relevant; however, subjects must also be protected from the consequences of false positive findings. This review article discusses radiological IFs in the setting of the clinical routine and research studies and provides a basic summary of the management recommendations for commonly occurring IFs.

Outcomes from ultrasound follow-up of small complex adnexal masses in women over 50

OBJECTIVE

The discovery of a complex adnexal mass in an older woman often raises concern for cancer. We evaluate outcomes for a large population-based cohort of women older than age 50 years with a small complex adnexal mass reported on ultrasound, without elevated CA125 or other evidence of malignancy, including time to detection of malignancy and stage at diagnosis for those initially observed.

STUDY DESIGN

Women older than age 50 years who had an ultrasound during 2007-2011 reporting a complex adnexal mass 1-6 cm in size were identified. Previous or subsequent pelvic ultrasounds were reviewed to determine when the mass was first identified and whether there was change over time. Women with concurrent elevated CA125, evidence of metastatic disease, or less than 24 months of clinical follow-up were excluded. Surgical pathology from removal and diagnoses of ovarian cancer within 24 months of follow-up were identified.

RESULTS

Among 1363 complex masses identified, 18 cancers or borderline tumors (1.3%; 95% confidence interval, 0.8-2.1%) were found. Six cases were diagnosed among 204 women who had immediate surgery after initial ultrasound (15%), and 12 additional cases were found among 994 women with at least 1 repeat ultrasound (73%). Growth was apparent on ultrasound by 7 months for all borderline and epithelial ovarian cancers. Of the 12 cases diagnosed during follow-up, 10 were found to be stage 1 at surgery.

CONCLUSION

Among isolated adnexal masses reported as complex and 1-6 cm on pelvic ultrasound in women older than 50 years, the overall risk of malignancy is low. All cases of epithelial cancer and borderline tumor demonstrated growth by 7 months of observation.

Consensus conference on core radiological parameters to describe lumbar stenosis - an initiative for structured reporting

PURPOSE

To define radiological criteria and parameters as a minimum standard in a structured radiological report for patients with lumbar spinal stenosis (LSS) and to identify criteria and parameters for research purposes.

MATERIAL AND METHODS

All available radiological criteria and parameters for LSS were identified using systematic literature reviews and a Delphi survey. We invited to the consensus meeting, and provided data, to 15 internationally renowned experts from different countries. During the meeting, these experts reached consensus in a structured and systematic discussion about a core list of radiological criteria and parameters for standard reporting.

RESULTS

We identified a total of 27 radiological criteria and parameters for LSS. During the meeting, the experts identified five of these as core items for a structured report. For central stenosis, these were "compromise of the central zone" and "relation between fluid and cauda equina". For lateral stenosis, the group agreed that "nerve root compression in the lateral recess" was a core item. For foraminal stenosis, we included "nerve root impingement" and "compromise of the foraminal zone".

CONCLUSION

As a minimum standard, five radiological criteria should be used in a structured radiological report in LSS. Other parameters are well suited for research.

KEY POINTS

The five most important radiological criteria for standard clinical reporting were selected. The five most important quantitative radiological parameters for research purposes were selected. These core criteria could help standardize the communication between health care providers.