Okay, so my name is Leo. I'm a radiologist and what I'm going to try and run through is these sort of topics. And I've just spent the last 40 minutes, I think a few more slides because I understand there's a bit more time to fill. So I'm going to go through this. I personally don't mind being interrupted at any stage. Being interrupted is a sign of strength. It means I haven't explained it very well. So it's not your fault. It's my fault. Or we can do them at the end, whichever suits you. Okay. So let's just start to go through these. So the first way that we analyse the indeterminate annexum mass was also this was the risk and malignancy index. And what they did was it's a very simple scoring system. They said if there was just a simple cyst, you score 0. For each abnormality, you gave a score of 1 or more. And for reasons which were never quite clear, they dropped out 2. So you gave a score on ultrasound of 0, 1 or 3. And their experience was that Doppler wasn't useful. So if you had a single septation, you scored 1. If you had multiple septations, you'd score 3. If you saw solid nodules in the site, you got 3. This is what they did. So what they did is you give the, as a proxy for age, if you're pre-menopausal, you get a score of 1. If the patient is post-menopausal, they get a score of 3. So you multiply the menopausal status, the ultrasound appearance, and the CA125 into a combined score. And in their original article, if the score was over 200, the risk and malignancy was about 60%. If it was less than 50, it was a risk and malignancy of 4%. So this was quite a powerful tool. So just to practice that, if you're not immediately familiar with it, here's a transvaginal scan. And they didn't distinguish between transvaginal and abdominal scanning. But I think most people would accept now that transvaginal scanning is preferred. This is a simple ovarian cyst. So what's the risk and malignancy here? Well, it's going to get a score of 0. And 0 times anything is 0. So the risk of malignancy with a simple cyst is very low. So here's a single septum. And in terms of what we'll talk about in a minute, it's a thin septum. So that would give a score of 1. Now, if you look closely here, so I've got the laser pointer, there is actually a small module here. So strictly, if you saw that module, you would give it a score of 3 because you're not allowed to give 2, OK? And equally, if you get multiple abnormalities like this, then you give them a score of 3. So 0, 1, and 3 were the possible scores. And one of the disadvantages to the risk and malignancy you do need to know what the CA125 is. And we find that not everybody does that in advance. Just briefly about CA125, I hope I'm not patronising you. But remember that it's found in the majority of ovarian epithelial tumours. So the germ cell tumours wouldn't express it. The upper limit of normal for us is around 35 international units. And it's only raised in about 50% of stage 1 disease, which explains why you get a lot of false negatives. And it's also raised in endometriosis and fibrosis and many other things. Mr Das, who's sitting behind me, sometimes asks in the NDT, what are the top 25 causes of a raised CA125? And so that's why you get false positives. So it is a flaw, but it was a big improvement on the initial staging. So just for you to practice, and again, I hope I don't patronise you. So what score would you give here? This is a large cyst, it's about six centimetres, but it's no internal echoes. So that's going to give us a score of 0. Here's an abnormality with a thin septation. Oops. So what score are you going to give that? So that's a score of 1. And just to practice the next bit, OK, what's the score here? So the CA125 is 10. She's postmenopausal, we're told. So what you're going to do is say, well, how many abnormalities here? There's only really one. These are low internal amplitude echoes. And if you've got experience of ultrasound, you may recognise that this could be an endometrioma. She's postmenopausal, so we're going to give her a score of 1 for the ultrasound, 3 for the postmenopausal status, and 10. So what's the score here? Going to give her a score of 30. So the risk of malignancy here is quite low. Now, how you use this information is up to you, but there are two possible ways you could use it. You could use it to determine who does the surgery. If you're in a hospital like ours, when there's a large number of general gynaecologists, and quite a small number of gynaecologists, you could say, well, this probably could go to one of the general gynaecologists. And the other way you could look at it is to say, well, this lady's not that urgent, so we could either follow it up if that's what she wants to do, or we can take it out, but we don't need to do it quite so quickly. So here's another patient. So again, she's postmenopausal. Her CA1250 is much higher, and if you look here, this solid area is about 6 centimetres, so this is quite a sizable lump. Well, she will still get a score of 1 for a single abnormality. She's postmenopausal, so she gets a score of 3. Her CA125 is 100, so what score are we going to give her? 300. So this is now a much higher risk, so this patient should probably be prioritised, and you may wish to, if this is how your practice works, you may need to send this lady to an experienced gynaecologist rather than perhaps a general gynaecologist who is less skilled. So, as I say, there are clearly flaws with CA125 because of false positives, false negatives. So the next thing that came along were these so-called simple rules. Now, the IOTA simple rules I personally find reasonably straightforward, but I'd have to say a significant number of my radiological colleagues aren't terribly keen on them, because they're a little bit more complicated, not much. So the advantage of IOTA is it only uses ozone. It also ignores age, because there isn't really much difference in risk between a 49-year-old and a 52-year-old, and so that was also a slightly false issue. It ignores the CA125, and I'll go through this now in a minute, but you'll describe some benign features or malignant features, and unfortunately some people have both. It's quite reproducible, lots of people have found that it's consistent, so if you do it one day and you do it the next day, you'll be consistent, but one of the big changes in it was that Doppler is useful. So originally, when the original RMI came out, and we're talking about a paper from over 30 years ago, Doppler wasn't useful there, but they certainly found it useful, and I'll go through that. So they describe five benign features, and we'll just run through those, and they're reasonably straightforward, aren't they? So what they mean by unilocular, that's a posh word for meaning it's a simple cyst, so if it's a simple cyst, it's benign, much like RMI. If you've got thin septations, and they define thin which is helpful at seven millimetres, and then that's benign. Then that's benign. They talk about acoustic shadows, what they really mean is, is there calcification, because calcification in the very masses is nearly always benign. It usually means you've got something like a dermoid with fat in it. If it was smooth and not too big, it's benign. This is the Doppler bit, if there was no blood flow at all, it was benign, and they calculate sensitivity for these, and if you've got no flow, about 99% of these were benign. So if you've got a B feature in your indeterminate mass, it is benign, unless you've also got an M feature, and we'll go through the M feature. The M features are linked, and they're obviously the opposite. So if you've got an irregular solid tumour, much more likely to be malignant. If you've got ascites, and they define ascites as quite a lot of ascites, so arising out of the pelvis. At least four papillary structures, and they did quite a lot of analysis that showed two would be okay, six was always bad, and they decided to use four as a cut off. If it's irregular, multilocular, mainly solid, but also cystic and more than 10 centimetres, it's likely to be malignant, and if there was very strong blood flow. The problem I have with the Doppler is it's very off. I don't think I've ever really seen very strong blood flow, but that will depend, I think, on your experience. My experience is quite difficult. So if you have an M feature, then it's malignant, unless there's a B feature, okay. So we'll just run through a few of these. So does this have a B or an M feature? So here's a little nodule in the wall. If I tell you it's, say, four millimetres, I've zoomed this in and cut the size off. So is that B or M? Well, it's less than seven millimetres, so that's going to be a B feature. It's the second one, so B2. So when we score these patients in the MDT, we generally now record these prospectively. Is this M or B? Well, here's a little mass. It's got some populations with it, but it hasn't got four. I think there were three. There's no flow, so is that a M or a B feature? Well, it's less than four, so it's not got an M feature. There's no flow, so that's B5, so that's highly likely to be benign. But what about this? This is an abdominal sound. You can see a little sad ovaries floating in all this water. So this is clearly quite marked ascites. So is that benign or malignant? So that's malignant. So you can see, with a little bit of practice, this isn't really terribly difficult to work out in the majority. Now, in the original paper, what they said was, if you found it difficult, find somebody more expert, which isn't always as easy as it sounds. However, something I'd like to point out, what both of these things omit, is what I find the single most useful finding, and that's a mental case. Now, just to emphasize, I work in the UK, where abdominal TB is not a big problem, and we don't have a very big HIV problem. But if you look at studies for a mental biopsy, which I'll talk about in a minute, worldwide, there's a lot of worldwide, then up to 50% of these mental cases turn out to be TB. So if you look at series from India, and you look at series from China, and I couldn't find anything on the mental cake in Nigeria, but I did look. But clearly, many of your population will be at high risk of tuberculosis. And so, for you, it may be less useful, but I still find it very, very helpful. If you see thickamentum like this, and ascites, in our experience, these are always malignant. It may not be an ovarian primary, but you need to consider biopsying this to try and find out what it is. And it looks like this, it's often echogenic, it's blind ending, it moves about a little bit, but you don't get peristalsis like you do in Bell. So what about this? So this is got some low internal echos, it's got another little nodule in the wall. So in Iota, what score would you give it? Well, it isn't unilocular, it hasn't got a thin septation, it hasn't got more than four papillary structures, so it hasn't really got a B-rule or an M-rule, unless it had strong or absent Doppler. So the problem with these is that they're indeterminate, okay, and I'll come back to how you might approach those in a minute. So here's the case I showed you a little earlier, here's the populations, these are more than seven millimetres, so it hasn't really got a benign rule, but could this be malignant, because it's more than 10 centimetres. It's got no flow, so that's a benign rule. And so how do you score this case? Well, it's got no flow, so that's a B-rule, it's got more than four populations, so that's M3, so overall it's in the lower sub-frames. Okay, so here... Can you mute your mic, please? Okay, so what we'd have to do, I think, is check the CA125 here to help you try and sort out the risk. You'd look at age, clearly cancer is much more common in somebody who's 60 than if they're 16, and to look for these secondary signs of malignancy, which I've said are really quite helpful. There are a couple of other situations in which both of these techniques are not terribly helpful. So this is another well-known one, this is an abdominal obstetric, we've got a full bladder here, there's a small ovarian mass, but you can see it's quite bright and echogenic, and nearly all of these will be dermoids. So fat is echogenic, but unless there's also calcification, which is present in the minority of dermoids, it can be difficult to sort that out. So we need to work out a way of sorting that out, and the easiest way, if you have ready access to it, is MR. So I'll use this case a bit later, but just to briefly explain MR. So fat here, this is a fat suppressed sequence, so it's turned all the subcutaneous fat black, the hemorrhage generally is white, so is fat on a normal sequence, but if you suppress the fat suppressed, you get signal drop out here. So this is very useful to use MR to distinguish between a dermoid, which contains fat, and an endometrioma, which only contains hemorrhage. On the fat sequence, remember the patient is lying down, so that this is their head, this is their feet, so they're lying on their bottom here, and that's why the fluid level goes this way rather than that way, and so fat floats on water. So that's how you can use MR to look for fat. The other thing that's very useful for is endometriosis. Now again, MR is very useful because MR really, sorry, ultrasound isn't very good, and we'll try and avoid CT where we can in younger patients. So this is a T1 weighted, now if you're not, this is why I asked if there were many radiologists there, if you find it difficult to remember, most people do, what T1 and T2 is. If you remember, for those of you who ever pour tea, if you pour tea out of a teapot, when it first comes out, it's black, so T1 water is black, whereas if you add milk, it goes white, so T2, which is after you've added the milk, that goes white. So this is a T1, so we would expect fluid like the bladder, like an ovarian cyst, to be black, okay. This is high signal, it's white, and the things that are present with high signal on T1 are blood and fat, also melanin, so things like melanomas, protonaceous fluid. So if you look at the subcutaneous fat that we all have, that's high signal. These two things do have high signals, so are they blood or are they fat? Whereas on T2, this is called T2 shading, they go darker, fat here is still high signal, and so you can just use T1 and T2. Here's some fluid, which is a little bit of ascites, not very much, so I wouldn't get too worried about that, but T2 shading is a classic feature of endometriosis, it's not always found, and if you go on to do T1 fat suppressed, then if it was an endometrioma, it would be high signal, if it's got fat in it, it would be low signal. So have a look here, so here's a lump in a 31-year-old, okay, now this is big, it's 19 centimetres, it's multilocular, so that's a malignant feature. There's multiple abnormalities, some of these septations are thick, some are thin, there's solid areas, so we're going to give an ultrasound score of three. There's no flow in here, so that's benign, so now we've got a classic conundrum, because we've got a mixture, we've not got M details at all, so we've got an M and a B. So what you can do is use MR, so here's a T2 MR, so the bladder here is white, this is a sagittal study, so if you're not familiar with them, here's the spine, here's the bladder, and some of this fluid is dark, so that would be water, some is higher signal and some is quite high signal, so you're not quite sure this is protonated fluid, whether it's fat or whether it's hemorrhage. So fat is high signal, and this is high signal, okay, so it's that fluid and that's fat. Now if we then suppress the fat, and this looks a bit strange and I apologise for that, because I've just magnified it a bit, but all this fat here has gone black, here's the white from the CSF, so this is fluid, this is suppressed, okay, so this is now high signal intensity, so it's more likely to be hemorrhage. The fat is black, this is high signal, so this is unlikely to be fat. So let's just talk about the secondary signs of malignancy, okay, now these are quite frequent, but they don't appear with the exception of ascites in the other scoring mechanisms, and that's why I think no single scoring mechanism is satisfactory, which is why we end up combining them and look for the other details which we'll talk about in a moment. So certainly ascites for us, certainly a mental cake for us, peritoneal deposits are almost invariably going to be malignant, and if we talk about MR that's true too, if you see MR peritoneal deposits it's always malignant, and obstructive kidney, unless it's from another cause like a stone, liver deposits, I'll talk about splenic deposits in a moment, and something like bowel obstruction usually means that the bowel's been invaded, so all of those are strong signs of malignancy, irrespective of ACA125, and irrespective of the age, and irrespective of the other scoring mechanisms. So just briefly, and I apologise again for that expression, teaching grandma to suck eggs, it's important to recognise that CT is the mainstay, we still find some of our local radiologists do MR routinely, and not CT, and it's not very helpful and we have to ask them to go back. If you want to stage an ovarian tumour, you need to look at the lungs, the medestinum, the upper abdomen, and CT is overwhelmingly the best tool, but the main role here is in deciding if the disease is resectable. I'll talk about a few easy errors which are easily avoided once you know what they are, but like all things that are pointed out, everything is obvious once it's been pointed out to you, but you may not be aware of it. I'm going to talk a bit about a mental kit that can be missed. When I was training in radiology, we talked about wet and dry tuberculosis. You may see the same in Nigeria, so that you'll see some with thick mental kit and ascites and some without it. In ovarian malignancy, ascites is overwhelmingly common, but not inevitable, so it can be easy to miss it and I'll explain how you can look for it. We don't know what is the best lymph node size. It's generally a proxy for involvement, but we recognise that lymph nodes can be involved with infection and they can be involved but not in large, but at the moment, until we get better functional imaging, lymph node size is a proxy for involvement. I'll talk in a little bit more detail about cardophrenic nodes, because we've found certainly we've missed quite a few of these recently and we'll talk about what is the normal size. And finally, just to point out that the POV is quite a common site for metastatic disease, so I imagine it's the same for many of you. People who've had a particular previous history of breast cancer, that's melanoma, that's rectal cancer, you're not quite sure if this is a primary or secondary tumour, and so what we would advise is biopsy if in doubt. Now, I'm not going to patronise you with too many easy things, but a mental kit like this is very obvious on CT. So, this is the right side, this is the left side, here's the back, here's the front, this is the kidneys. So, these are retroperitoneal. So, this is the duodenum, the third part. So, lymph nodes here would be para-aortic, but below the renal vessels. But this mental kit actually is surprisingly difficult to see in ultrasound, and this is another advantage of CT, it's much easier. But with a bit of practice, you can see this with ultrasound, but it does take some practice and some feedback. Compare it with this, which was a thin lady, who was initially reported as having no evidence of metastatic disease, but you can see she really is quite thin, unusually slim, and there's no fat between the bowel, but there was some soft tissue here, which did turn out to be missed a mental kit. So, what clues are there? One of the clues you can use is this. If you look at the CA125, our pathology system helpfully graphs this quite easily for you. So, CA125, and this is a separate tool in the issue of response to chemotherapy, but in those patients who do express it, who then have surgery, and it drops down to normal, if it shoots back up again, you can be almost certain that they've got metastatic disease. So, if you have this information, and you may not, okay, the commonest cause of radiological error in the UK now is inadequate or erroneous information. If you just said post-op CT, you might get that missed, but if you said post-op CT with rising CA125, hopefully, you would see this cake here. And then again, with practice, you can balance this. If your RIDL2 colleagues are not keen on doing this under ultrasound, then you can do it under CT. And you will, and Dr. Toffazell occasionally rings me up and says, you do realise you hit some bowel here. And there is a certain inevitability about that, that occasionally you will hit some bowel, but provided the patient isn't, you know, compromised, provided the patient doesn't have very bad bleeding disorder, or is anticoagulated with warfarin, then it's usually an eventful. So, beware of nodes in unusual places. And what we found in our audits, that this is one of the sites that we look for. If you just look at this, this is a CT of the upper abdomen. So, in case you don't see T too often, this is the liver, here's the aorta, this is the spleen. If you look below the diaphragm here, there's a lot of dirty fat, there's a lot of peritoneal nodules here. This is likely to be ovarian cancer, and you would stage it probably as 3C. But the important thing is this little lymph node here, which is one of the cardiophrenic nodes, which is above the diaphragm. So, this is in the thorax. So, now you need to decide whether it's abnormal or not. Now, most people in general radiology will use 10 millimetres for nodes. Increasingly, we've moved to 8 millimetres for the short axis. But there's a recent European publication which suggested that 3 millimetres was normal, and over 5 was pathological, but we don't know that. And so, one of the issues, if you're looking at your evaluation, is are you understaging tumours? And you will be if you miss big nodes here. I'm not saying this is a big node, but just be careful. Now, peritoneal deposits for the less experienced radiologists can be easy to miss. So, in here, we've given some positive oral contrast. So, the bowel has some in the small bowel. This is faeces in air, but then stuck on the outside. This is ascites, which is fairly dark grey, not as dark as the fat. But in here, these are little peritoneal deposits or cirrhosal deposits, and there may be little ones here. And at the beginning, these can be easy to miss. Have a little look here. Now, if you've looked, we call this learning. We've done, the medical school uses this technique called spiral learning. So, we check and recheck, have you learned it? So, you've looked at your cardiophrenic node. So, hopefully, you've seen that there's something here, but that's not very big. If you look over here, there's a cluster of little nodes. So, is this stage four? And I have to say, at this stage, we don't know. For those centres that can access PET, it may well be that PET is useful, but we have to remember that all PET is looking at is molecular turnover using glucose. So, for example, in the groin, we know that it doesn't readily distinguish between infected nodes and pathologically tumour-involved nodes. But these nodes here are very rarely enlarged in infection. So, is this stage four disease? I'm not sure. But what I think you and perhaps we as well need to do is sit down and agree a way forward because the old joke is if you ask four radiologists for their opinion, you'll often get five opinions. So, we don't know what to do about these yet, and I'm still not sure. One of the things that we see increasingly common, and again, some of the general radiologists may not recognise it, is if you have neoadjuvant chemotherapy, so some cycles, usually four, sometimes six, you may see calcification within the peritoneal deposits, and you may see calcification on the surface here. And that's something to be aware of, that calcification generally is a good thing. But it's less for common ovarian cancer, but it's a big problem in breast cancer, that what you have to avoid in chemotherapy responses is what's called pseudo-progression. We like to think that CT is very good at staging cancer, increasingly we recognise it does miss some things. So, in some patients, particularly with breast cancer, often with melanoma, some other cancers, you do a pre-chemotherapy and you show normal liver. Six cycles, four cycles later, you do some CT, you show liver masses, and you think this is evidence of progression. It's not. It can be evidence of chemotherapy effect, and that's then called pseudo-progression, so it's something to be aware of. So, if you see liver masses which are appearing during the chemotherapy, you need to be careful you don't stop the chemotherapy, have a look at CA125, if the CA125 is dropping, it may be a response. And from time to time, it's well recognised now in some patients, and it will only get more, we hope, this calcification, when you resect it, there's no visible tumour in it. So, it can be a very good sign. Surface deposits from the ovary can be difficult in big lesions to decide if this is on the diaphragm, on the surface of the liver, or in the liver, and it does make a difference. So, this clearly is on the surface here, but this I'm not quite sure whether it's visceral or not. And then, depending on the skill of the gynaecology surgeon, and whether either you do this, or you get a liver surgeon in with you, do you try and resect these? So, I apologise for the next slide, but for those of you who've once worked in the northern hemisphere, and we're talking about far north, and not in the southern hemisphere, where Christmas occurs at a very different time of year, these were traditional toys that were given out. And here's Father Christmas, and here's the little snowflakes, and you shake these things, and the snowflakes come all around the bowl, and if you wait, they gradually settle. So, why is this useful? Well, that's how ovarian cancer spreads, if you remember. So, this is why I wonder if any radiologists, because they sometimes forget this, that the pattern of spread is very different. So, whereas surface deposits will occur in cancer of the ovary, this situation, a visceral intrapartic deposit, is very rare in primary ovarian tumours. And if you see that, it's much, much more likely to be either a metastatic disease, or the primary isn't in the ovary, it's actually, for example, in the uterus, it could be a sarcomere, or something else. So, that's why I show my little snowflakes, I'm afraid. So, if you see this sort of thing, just think this is unlikely. If it's clearly intrapartic, with a bit of liver over it, it's most unlikely to be an ovarian primary tumour, unless it's very, very advanced. This, again, when you see perineal nodules studded around here, this is quite common, and I quite often have to remind my general radiological colleagues that primary perineal carcinoma, and you can debate with things like stick lesions, whether this is truly a fallopian tube tumour, or does it arise in the primary, these are quite common. And if you see this, essentially, it's a primary perineal carcinoma scarletological needs the same treatment. So, what are the criteria for acceptability? I think we'll have a little time at the end to discuss this, and I have to stick my hands up and say, I don't know. We, at the moment, don't have a reporting template, I think we need one. What are we going to put in it? Well, there are a number of things you can put in it, but obviously the more things you put in it, the longer it takes, and therefore the less proper it will be. But I still think we're going to have to adopt it. For most of my gynaeonic colleagues, multiple mesenteric nodes that are clearly pathological are unlikely to be resectable. Paraortic nodes can be resected, particularly if they're below the renal vessels, but are they above the renal vessels? If they are, it's quite likely to be unresectable. So, if you're trying to decide who gets neoadjuvant treatment, then this might be a good marker. Depending on your surgical competency, and I don't mean that derogatively, I'm not competent to reduce a spinal MR, I don't have a problem admitting that, is the diaphragm involved? If it is, then is the surgery the right answer? What size are these cardiophrenic nodes, and do you use 3, 5, 8 or 10? But just to emphasise, we should always use the short axis. So, those are some thoughts. So, here, this is an 84-year-old patient, so not young, okay, but fit and, say, performance status 0 or 1. Are these resectable? So, here's the diaphragm, nice and thin here. These are multiple thick nodules, maybe a centimetre or more. This streaky fat is usually a sign of widespread metastatic disease, but that may be resectable. Is this in your unit, and would you go for neoadjuvant treatment and try and take that out? Another thing is what you do about these, if you have, this is a pleural effusion, so here's the heart, so the lady, these are both breasts, these are the lungs, there's the aorta, this is a pleural effusion. If you look closely, there may be a little enhancement of the pleura here, more than there is on this side, which is a bit alarming. So, is this malignant, and who decides whether this needs training? And I think probably the honest answer is all of these should be aspirated for two reasons, to try and improve the general fitness of the patient, and also to see if they're malignant. You do end up with cytology, not histology. My pathological colleagues here are excellent, but they don't like us doing smears, they much prefer we send a 20, 30, 40 mils of fluid, spinning it down, doing a cell block, and they find it much easier then to do all the stains that they need. So, I don't do this very often, but I think probably we should do it more often. What we often do is ask the physicians or somebody to aspirate this, but that's quite helpful in deciding. If you see a CT like this, so this is a side teeth, this is bowel, here's thick mental cake, then these frequently now will biopsy. This may be resectable, and if it's clearly resectable, you don't need to do anything, but if you see thick cake like this, and perhaps the patient's performance status is poor, if they've got a positive cytology in their lung, then how do you get a firm histology, and we would normally biopsy them. If your riddle of two colleagues are a bit cautious, it's easy to see with CT, you stick a needle in here, take your biopsy and take it out. With a bit of practice, particularly when there's a side teeth, you can see the momentum here. It's easier to do it when there's a side teeth, not like the CT I showed you with cake with no fluid, and then you stick a needle in here, you biopsy it, and here's a 16-gauge needle. Generally, I use a bigger needle. There's a thing called a coaxial technique, you put a guiding needle in and biopsy through that, advantage of that, the patient only gets one needle in their abdomen, and you can get excellent histology. As far as I can work out, I haven't got 100% for it, but we have had no false positives and no false negatives from histology with a 16-gauge needle and multiple biopsies. Clearly, one of these may miss occasionally too, you may just get fat, but the third one will be positive. So just, we were going to discuss a case, I just found this case at short notice, just to show how you might approach this. Here's a patient now, she's 21 years old, but we have had patients with malignant disease at that age. She's had two weeks of pain, so what would you do next? And multiple people will do multiple things here, but you need to qualify how much pain, if she's in severe pain, does she need immediate surgery, could this be torsion, could it be an ectopic, hopefully you've excluded pregnancy, what would you do next? Well, whilst you're there, I would suggest what you would do is do colour Doppler, and there is no flow here, so this is a little bit of flow in the myometrium, but there's no flow, so that's helpful now, because that's a benign rule. When we did MR, and this was the MR I showed you earlier, she's 21, so this is T2, her fluid in the bladder is white, so this is white here, so is this fat or is it hemorrhage? So what we're going to do, she's got a little bit of ascites, but she's got an ovarian cyst, so there's our fluid level, there's the ascites, so here we've done a fat suppress sequence, and this now suppresses, so we can be confident that's fat. In an older patient, or if you don't have ready access to MR, you could do CT, because again, CT is quite specific, so now we're dealing with a 21-year-old patient with pain, who has what looks like a dermoid, and so the problem is that if you only scan patients with pain, and in general we do, you can't assume that the pain is due to the mass, because the vast majority of patients do have a dermoid, so hopefully this lady will settle, and then you can decide whether or not you need to do anything sometime later. Okay, and then just finally, just because I thought I should briefly talk about this, probably the MR adnex score, if you have ready access to MR, we don't have that easy access to MR, it's probably the most reliable, but essentially, with one or two exceptions, with one or two exceptions, it works off the same principle. So it looks at the septum, is it single or multiple, okay, so we've already said that if it's single, that will give you a score of one, if it's multiple, it will give you a score of three. If they're thin, okay, then we've talked about that with the IF2 symbol rules, thicker septations are much more likely to be malignant. T2 is the one in which it's high or low signal, that makes a difference. One exception is diffusion-weighted imaging, I don't have time to talk very much about that, but diffusion-weighted imaging is a bit like vaping, if you see people vaping, if there's smoke in the car, then the car window is closed, if the window's open, the smoke dissipates, so there's restriction if the window's closed, if the windows are open, there's no restriction. Diffusion weighting is the same, it looks at the movement of the protons in the cells, so if there's high signal, it's high restriction, that's a sign of malignancy, and if there's no restriction, then they're nearly always benign. You can look for wall enhancement, this can be used in CT and MR, strong enhancement is usually a sign of malignancy, and like the other things, if you see growth societies, or if you see peritoneal deposits or metastases, these are likely to be malignant. So that, I think, will feature more commonly, particularly in older patients, and particularly in those patients who want to conserve their ovarian status, for example, then I think MR, if you google MR adnex, there are multiple papers, I just checked this morning there, which are readily available on the internet, and they're not password protected. So that's just a quick run through essentially how I do it, I apologise if I bored you, and some of it is fairly simple, and I just want to emphasise that, if you stick to some simple rules, not necessarily these simple rules, you can triage these quite effectively, and so I frequently get asked, what do you think this is? And then if Dr Toffizal or Dr Roberts or Professor Finnell with me, I say, the gynaecological pathology textbook has got over a thousand pages in it, how do you expect me to know what this is? There are hundreds of different types of tumours, but what I can tell you is what to do next, and that'll be based on whether it's high, medium or low risk, and then working out in your own hospital pathways to try and sort that out. Thank you Liam.

Leo

indeterminate adnexal masses

IOTA

ultrasound findings

malignancy

biopsy

resectability

evaluation