 Hello everyone. We welcome you to today's session. We have named it as Radiology Updates in Body Imaging with Dr. Amaya Kulkarni. Amaya is a dear friend and deeply inclined towards academics as well as research and a very key radiologist as well with key interest in body imaging. He agreed to take a few topics for our residency wanted to, but we thought that why only for few people and why not to keep for everyone for everyone's benefit. So thank you Amaya for taking out time for taking these updates for all the Indian radiologist subscribers and members. So as you know, our dear friends Indian radiologists have been working hard towards these updates and bringing in education right up to your doorsteps on your mobile phones, on your laptops, with all these online events ongoing since last few years. We have been doing journal clubs. We have been doing master classes as well as dedicated three to five days learning programs on ultrasound CT based studies as well as on MR. So we have our breast imaging masterclass which was a great success last year and even this year we are receiving registrations in good numbers. Registrations are still on and next Sunday we are going to have this masterclass. So please do register. It's going to cover basics and advances in breast imaging including all the modalities which are currently in use as well as upcoming modalities by experts on national as well as international platforms. We do have papers and posters submission as well and MMC credit points for the same. The registration links will be shared soon on the chat box. Kindly register and hope we meet next Sunday with breast imaging masterclass. We are coming up with the 21st MRI teaching course which is something which is already famous and much awaited even amongst all the budding radiologists. It's going to be an extensive five day course which will be hybrid that is we're going to have sessions online as well as two days on site. So please be a part of it. It's in August this year and registration links will be shared soon. It will be covering basics like anatomy and physics of MRI as well as advances into neuroimaging, musculoskeletal imaging as well as body imaging. We have kept a very attractive offer for registration as you can see on your screen and please do take benefit of it. We have MMC credit points applied for and papers and poster submissions with last date on 31st of July. We have more of these upcoming events like Sonobus, CTBus, an MRI teaching course which I already mentioned about. Thankful to the organizing team, the core members Dr Deepak Patkar, Dr Sanjeev Mani, Dr Jignesh Thakur and Dr Shailen Desingh who have been taking efforts and time out of their busy schedule to bring up all these programs. I'm also thankful to my colleague Dr Gauria Hocha as well as Mamta Patkar ma'am for all their efforts. With this we come to the today's session by Dr Amaya Kulkarni. He has also been kind and was associated with us for the journal club as well and he took a wonderful journal club session on body imaging where he spoke about the Bosnik classification of cystic renal masses. So he's going to take over a few weekends, important six to seven body imaging topics. So stay tuned friends and Amaya is staff radiologist at Zuravinsky Hospital of Hamilton Health Sciences and assistant professor at McMaster University. His key specialty areas are breast and body imaging. His research interests are radiomics, body and breast imaging and he's also a presently fellowship contender in breast and cross-sectional imaging at McMaster University, Hamilton, Canada. We welcome you Amaya and just landed yesterday night and you're still with us so thank you for that over to you. Thank you so much for the kind introduction because I welcome everyone for this teaching session by Indian radiologist. So it's going to be an interactive session today so we will have lots of questions. There will be some quiz based questions. Much of this talk is based on lots of lots of images so please make sure that I pay attention to all of those. At any time if you have any question for any sections of this presentation you can probably just ask about an individual case as we go through them and just type that question in the chat feature. If you have any specific question about any specific slide which talks about certain points of this iota classification system then just type them down. At the end of session we'll go back to those slides or we'll try to discuss them so that we clear most of them today. So without any further without waiting any further let me share my screen and start the presentation. So I hope everybody is able to see the screen. All right so essentially what we're going to talk today is what led to development of the much discussed and much talked orads these days. So it all started with these iota philosophy which was built in much of the studies in Europe and we'll basically build on those things so that eventually as Mityush had discussed about we will head to the core orads concepts sometime in the future. So the goals I will discuss in the next slide. So basically disclosures I don't have any financial relevant disclosures these are the acknowledgments of my amazing colleagues who helped me put together this presentation. This was presented at 2020 RSNA annual meeting and it is recently published in radiographics as a radiographics essential publication. Okay so we're going to start with the first question here. So some pre-session or pre-seminar test. So the question is which of these is a benign lesion? Do you think it is A, it is B, it is C or it is D? So if you want you can just type your answers in the in the Q&A or chat session here or you can if you're using YouTube you can just type it there as well. So you can basically just type your answers and I'll be able to I'll be able to go to them. So what do you think is it lesion A, lesion B or C or E which of these you feel is benign? So maybe I'll give a few seconds and remember they like I'm not like I'm not disclosing any of the descriptors of this lesion. I'm just showing you some pictures lesion A as you can see there's a there's a transpisional ultrasound in with a 2D color Doppler and lesion B is just a grayscale transpisional ultrasound with the lesion in the long axis. Lesion C shows you that there is a lesion again on transpisional grayscale ultrasound and lesion D is a pretty large appearing lesion again on transpisional ultrasound only in grayscale. So I'm starting to see some odd answers here so the first answer is all and many of you are answering all so this is a very good assessment from all of you excellent. So we can start with the next question now. So the next question is question number two how do you define this abnormality? So I know it's it's difficult to type this out but for those of you who have been assessing lots of adnexal masses and do lots of ultrasound scans they can just type it may be pretty easy for you just to type. I mean what do you think you describe as a just complex lesion complicated lesion or do you want to use any other descriptors? How do you want to talk about this abnormality? So let's just give a couple of seconds here just to wait and see if anybody wants to answer. So this this example is just to it's just to reiterate the concept of iota and how we want to discuss about that in the next few slides. So for those who have been using or trying to assess adnexal lesion with ultrasound just type a quick response to this question if you feel that it's just complex complicated or is there any other descriptor that you want to use here? So I'm trying to see if you answer is here complex okay that's really fair and maybe let me just quickly check if there's anything coming up on the on the YouTube session here as well. So there are a few options for the previous answer but anyways we'll wait so complicated okay all right so maybe we'll go okay so there's there's one answer on YouTube it says multi separated and that's actually a very good descriptor here well defined complex lesion with thick septa okay so thanks for answering those questions so it's really important to understand these concepts and how these descriptors can change your assessment so I'm going to come back to this questions again at the end of the session two okay the next question here is which of these is a definite malignant neoplasm do you think it is A, B, C or D? So if you feel any if you feel strong about any of these you can just type it here and in the meantime there is one answer in the session here called as multi locular multi separatist with low level echoes and that's a really good job machine thanks for answering that so we're getting all of all sorts of answers here option number B which is this lesion option number C also option number D and option number A so we're getting lots of options here as which of these lesions is definitely cancers or malignant and we're also getting some options on the on the YouTube talking about lesion A okay so remember these images well and then we will head to our presentation now so the introduction of the session is basically just to understand the key lexicon terms because that is really really important when you're assigning any lesion categories to any of the any of the types here I'm just going to quickly turn off my video here just to make sure it isn't super imposed on what I'm trying to list this okay yeah the next is to become familiar with iota international or variant tumor analysis groups 10 simple rules that's the basis of this talk today then number three is to apply these rules and assess how we can classify lesions so remember this session is going to be a pretty imaging based session so once we go through the basics we'll we are going to discuss some cases and where you will be able to apply the B and M rules so in terms of assessment of adenix and lesions I would have as you would have seen in some of the question answers now it is essentially a management dilemma so lesions both benign and malignant lesions they just get described as complicated or complex lesions that ultrasound well that does not help anyone that does not have the sonographer and that does not also help the surgeon what to do with them are they cancerous or not should we do surgery or should we just follow up should we refer to an MRI get further assessment should we do any blood work all of those questions are unanswered if the lesions are just explained as complicated or complex on ultrasound so what happened because of these dilemmas is it can cause it can basically cause sub-optimal classification which essentially puts a patient into increased follow-up imaging when it is not needed it can delay oncologic referral because things are just being worked up and essentially for malignant lesions that is a very very important concept to remember that we should not do any kind of delay in oncologic referral by just adding more steps when it is not needed or even for it coming for even benign lesions and this is something we should definitely don't want to do why would somebody want a surgery and put through the risk of anesthesia and getting uterus and adenix out when the lesion is just going to be benign um so international ovarian tumor analysis hence what we're going to just refer to as iota so they came up with 10 simple rules to classify a series of benign malignant lesions just by using ultrasound features because remember ultrasound is going to be the first imaging modality which most of these women are going to undergo that's going to be the baseline and that is going to decide the future steps to understand this we are going to go to terms and definitions as described by emerman at allen 2000 but before that let's hit a few other core concepts here so in terms of simple rules there are five b or benign rules and there are five m or malignant so so remember so five b for benign and m for malignant so just add them become 10 rules so they are derived from a multi-center analysis of almost over 1200 surgically excised adenixal masses and these were around 1076 patients and they found that the sensory specificity of these rules was almost 93 and 90 percent respectively so what did they talk about in terms of our personal assessment so they talked about ecogenicity they talked about cystic fluid contents they talked about wallet regularities they talked about lock use and solid components as well as a cytos and essentially what happens now is that we are trying to or they were trying to develop a lexicon so lexicon is just in-depth knowledge of terminology and language to describe certain branch of science like here which just talks about adenixal lesions so for example when we talk complex it can include whole sorts of things including a multi-locular solid ovarian neoplasm it may have thick irregular septations it could just mean a pure solid irregular mass as well as some cysts with multi-locular cystic appearance and low level echo so it's just so variable as you think in your head if you talk about just complex or complicated lesions but if I tell you that this is a unilocular simple cyst you exactly know what I'm talking about if I tell you if I'm talking about a multi-locular cyst with solid components or papillary projections then you exactly know what I'm talking about but I could just say complex lesion and just run away with it but nobody would know what I'm talking about so that's the whole concept of lexicon which was developed in 2000 and published in 2000 by Tim Elman et al so to understand that I just kept it just like a small graphic representation and let's just talk about that so I'm going to do a few drawings here just to give you an idea of what we're talking about so just imagine that these black oval structures here are just the cystic masses so the key concepts hover around unilocular and multi-locular cysts here so remember both of these can be with or without solid components whenever you see solid components you can just call it as unilocular solid cyst and whenever you see just a fluid component you just call it unilocular cyst and do the same for multi-locular cysts so in case of unilocular cysts remember it can have a single incomplete separation so you know something like this it can still be called unilocular cyst a normal ovary surrounding the unilocular cyst remember don't measure normal ovarian tissue as a solid component so for example you may have seen this appearance quite a few times so remember that everything outside of the straight line is the ovarian parankama so we'll have your normal ovarian polycos which are lying there so don't include this as solid lesion this is just the normal ovarian parankama so the problem starts when you start to see wall irregularities or a papillary projection or solid papillary projection so what is the solid papillary projection you start to see this hump of soft tissue which is present along the walls of this lesion and that is when you start to get concerned about it's going to be suspicious from that point onwards whenever you see solid tissue or septicians you have to turn on your color Doppler and we'll talk about that in the next slide then the next component here is multilocular cyst so again multilocular cyst by definition is any ovarian cystic neoplasm which has at least one complete septation but obviously it can have multiple other variations such as this even this appearance you have to call it as a multilocular cyst now even these lesions can have solid papillary projections or solid components so you can have the component along the septicians you can have these solid papillary projections along the walls the wall may be irregular as well so again when you're evaluating these try to exclude the normal ovarian parankama which can be present at the periphery as that is not a true solid component it just benign or normal appearing ovarian issues then some important things to exclude don't include don't include mucine balls or rucitans cannot use when you're measuring solid components those lesions are essentially benign so don't include them in your measurement or descriptors okay so let me uh let me get to the next slide here all right so so now with adding all of these permutations and definitions we are left with six options number one is unilocular cyst number two is unilocular cyst with solid unilocular solid cyst three is multilocular cyst four will be your multilocular solid cyst so we're discussed about these the next will be a purely solid lesion which is more than 80 percent of a cystic mass we will have a very small cystic component in these ones and the last one is not classifiable so not classifiable by ultrasound can mean a whole lot of different things essentially it can be that the lesion is too large to capture an ultrasound maybe it's a big mass with lots of echoes which prevent you from assessing all the wall characteristics and all the lesions present along the wall and it can also be from patient factors when the ultrasound is just not optimal those are the situations when you have to definitely resort to additional imaging modalities now when we discuss about ORADS basically this section gives you a better management guidelines so this iota terms and definitions served as a baseline or the basis for development of lexicon and ORADS so this it is very important to understand this concept how to measure the papillary projections at the wall thickness so imagine if you have an ovarian lesion like this so i borrowed this graphics from this paper where it talks about terms and definitions so you basically have to draw tangential line and major the height of the papillary projections from this tangential line and in this case if the lesion was a papillary projections were along this wall you just have to measure the the maximum height of it so if it is more than three millimeters as shown in this graphic that is when you call it a solid papillary projections for anything which is less than three millimeters it's going to turn out to be just wall irregularities remember it is important to understand lexicon and the recommended measurement guidelines because if you don't measure them correctly say you just have like this oblique diagonal measurement and say okay now it's more than three millimeters it won't classify to be a solid papillary projection because you're not measuring it in the right way it has to be a perpendicular line to the wall of the ovary or it has to be a perpendicular line to a tangential line drawn where the convex protrusion is present within a hump of normal appearing liver normal appearing ovary or normal apparent tissue so it's very important to understand these concepts now they also talk about a very significant finding which we always look for whether the lesion is vascular or not because again that is a subjective assessment but even in that subjective assessment you can still classify into four categories as colors for one two three and four so one and four are pretty easy one is when you don't have any vascularity in the lesion and four is when the vascularity is so significant that the entire thing just lights up it becomes difficult to classify three and four three is essentially when there is minimal or mild vascularity and four is going to be a three is going to be your moderate so two and three are going to be difficult but one and four are pretty straightforward so as we all know ultrasound is a very opera dependent tool so how to ensure that the color doctor settings on my device are same as yours because I may just I may have a totally different prf and a totally different velocity and I'll say that okay this lesion is one where it is actually a vascular lesion and vice versa you may have turned on power doctor and say that oh this lesion is highly vascular so to minimize that to minimize those errors they also recommend what should be the color doctor settings to have a consistent color score across the board so the prf has to be at least around 0.3 and the velocity has to be between three to six centimeter per second that is when you are going to standardize your color doctor measurement so remember the key concept here is to standardize to make sure that the lesions are assessed consistently and that is when you would be able to recommend that is when you're going to be recommending appropriate category with this lesion so what are these rules so this is just a table which I did that basically from the paper which was published by the iota group so you have as we discussed you have five m rules and five v rules so remember m is going to be for malignant and v is going to be for benign so you have rules such as in the malignant class you have going to have rules such as irregular solid tumor presence of acitis at least four papillary projections irregular multi-locular solid tumor of more than or equal to 10 centimeters and very strong blood flow so color score of four these are your five m rules so now after we discussed the lexicon now you must be understanding most of these terminologies if not you can always refer back to that paper it's very very useful to understand that what are the v rules number one you know locker assist number two presence of any solid components largest solid component is going to be less than seven millimeter and then presence of acoustic shadows so all the posterior shadowing that you can see in lesions with uh dermoids then smooth multi-locular tumor but it is less than 10 centimeters and there is no blood flow which means that a color score of one so remember they are not talking about color score of two and three because even they know that it is hard to differentiate between two and whenever you have two variables which are very closely spaced to one another it increases the subjective feeling and that just complicates the classification algorithm so that's why they have improved color score and color score of one here okay so now you understand this how do we apply them so say you're doing ultrasound and you see one or more m rules but no b rules then the lesion can safely be classified as malignant if you see one or more b rules but no m rules then it can be classified as benign if both of these are rules apply then it cannot be classified according to the algorithm you need to address this in some way maybe do an mr mail to repeat the ultrasound at an expert experts opinion and again the same thing if none of these apply again it cannot be classified according to iota classification and you may have to think about are you really looking at an alexa lesion or if there's something else going on here okay so it's just a small pictorial representation of what what each of these categories means so again on the top you can see five b rules and on the bottom you can see five m rules so let's start with the m ones because they are the most concerning ones so number one is irregular solid tumors as you can see that there's this large solid irregular lesion which is projecting along the wall of this ovarian mass remember popular projections if they go grow too big essentially they're going to turn out to be a regular solid tumor right and then presence of ascites so if you have a large ovarian mass but presence of ascites as you can see here in the asterisks that is one of the factors which point towards m2 because remember ovarian euclasms can cause ascites peritoneal lesions and peritoneal carcinomatosis m3 is at least four papillary projections as you can see in this lesion i'm pretty sure it's really small so it's hard to figure that out but you can see these septiations which are making it a multi-locular cystic mass with solid components so all these echogenic areas that you see here not echogenic per se but like solid appearing lesions these are nothing but papillary projections which are along the septiations so remember the papillary projections can be along the wall as well as along these septiations so here you are seeing them along the septiations to them at least four of them are present you give it as an embryo then irregular multi-locular solid tumor with largest diameter of more than 10 centimeters so this is a very large so as you can see this picture is transvaginal but this is just a convex probe put in the lower pelvis of the patient's abdomen and you see this large tumor in the pelvis more than 10 centimeters and it's a multi-locular solid tumor with a regular solid component there m5 is very strong color so you can see this solid ovarian neoplasm and you see this very high vascularity within this lesion the b-rules again unilocular cystic lesion or unilocal cyst very simple to assess presence of solid components with largest dimension diameter of less than seven millimeters so as you can see that there's a small papillary projections here so less than three millimeters so remember it has to be more than three to call it as a papillary projection right then presence of acoustic shadowing so you can see that there is this this these echogenic lesions but you see this poster shadowing so you see most of these with dermoid but there is a mimicar great mimicar and we're going to talk about that in one of the cases here then smooth multi-locular tumor with largest diameter of less than 10 centimeters so you can see that these are smooth walls just multi-locular cysts but there are no papillary projections and no blood flow at all within the septiations for the or the papillary projections it gives a color score of one so these are just the lexicon which define the 10 simple rules okay so where does iota fit with orads because all of us have been started to use orads and have been like somebody will ask you that okay what is the orads category of this lesion you gave me a report that is the 10 or 15 centimeter mass but what is the orads category so before we discuss about orads it is important to understand the concepts of iota because that is where the lexicon of orads is taken from so the the original the the original descriptors here essentially led to orads and there is another iota adnex model which basically predicts the mathematic risk of malignancy so if you don't know about that you can just google it out if you're doing an ultrasound of the adnex elation if you see the mass you can go to that calculator and predict the risk of malignancy if you know certain clinical and biochemical features of that patient as well so orads are present uh so what does it do in addition to iota it not only specify it only specifies characteristics of common benign or malignate over lesions but it also provides management recommendations so remember just like by rats the same thing is in orads it provides you some management recommendation what should you do next should we follow up do an MRI or just exercise and recommend to surgery so those are essentially what you get more in orads in addition to iota then both the models as we discussed here the iota adnex as well as orads they are complementary and can be used as a part of decision-making process in the evaluation management of adnex lesions so for example in iota adnex you can add a certain biochemical markers c125 you can ask you can ask the patient certain risk factors and put all of that information to create the additional findings so what are the standard pathologies that you come across when you're doing ultrasound so you see normal ovaries benign findings like follicle hemorrhagic cysts or acompostidium cyst including functional cysts you can see benign tumors as the statenomas you will see borderline tumors and you will see invasive tumors so the these lexicon terminology which we discussed right now they will help you assess multiple features of all of these pathologies and the ten simple rules will assess to see if it falls under this category or anything else the lesions which cannot be classified they may fall under a various mixture of other types of lesions the most important part of this presentation we have this case library here where we are going to discuss about eight different cases and try to see if we can apply these simple rules so for the sake of having a better visibility of these images I have turned off my video I've done it on at the end of the session so let's start with case number one so I have given you three ultrasound static ultrasound images image number one as you see on the left side is a transabdominal grayscale ultrasound you see a lesion and definitely looks like a cystic lesion and I have turned on colored ocular to show that there is no vascularity along these separations as well as the wall in some other part of this lesion you see these you definitely see these low-level echoes but there's a suspicion that the patient might have this irregular solid component and then you see this asterisk model it is nothing but the benign ovarian stroma which is pushed to the periphery but much of the portion of the solid component that we are suspecting here it does not show any colored ocular so in your head now you start to assess okay what M and V rule I can apply to this lesion so in terms of the descriptor you see here like it's a 21-centimeter lesion it's a multi-locular cystic mass there is no blood flow in any of the any of the separations here and the patient is pre-monoposal with CA 125 or 63 kU per liter she presented to ED with pelvic pain and that is why the patient had this ultrasound so obviously we see that it doesn't it doesn't have certain or it does have certain features for example here it does not have blood flow so you can safely assign a color score of 1 it is definitely not a unidoc cyst definitely has something which looks more than 7 millimeters so none of these other B rules are going to apply here so you have at least one B rule which you can straight away apply to this lesion now what M rules you can apply or whether you can apply any one of them so you see this irregular solid component here right so it's going to have at least this M rule so which means that it's a irregular multi-locular solid tumor and the lesion is more than 20 it's a 21 centimeter lesion so it's more than 10 centimeters so you can safely apply this M rule we did not see any ascites and we did not see a typical solid irregular tumor and there were at least there were no other criteria which you could mean definitely not the color score so you have at least one M rule and at least one B rule so which puts under a class of lesions which cannot be classified using these terminology so essentially the patient since the patient was also in pain they also did a CD of dominant pelvis and all that you see here on CT is that there's a large abdominal pelvic cystic neoplasma as you can see here it's pretty large going all the way to the epigastrium and you were seeing this portion on the ultrasound in terms of those multi-locular or septicians in the lesion. The patient underwent a oophorectomy because of the increase of 135 levels just above the baseline and they did perform iodide next model or assessment of the patient other risk factors and they excised it out so rightly this lesion turned out to be serious borderline ovarian tumor so it was not just plain simple benign cystidinoma it was a borderline tumor so what what is the key point here so quick classification two using this 10 simple rules can help you assess make a decision whether the lesion is deline mariguin or inclusive if it is inclusive you definitely assess it further to see a 125-repertory gynecology services and assess if they want to take it out look at other risk factor of the patient whether the patient has any BRC mutations because remember those patients are going to have higher risk of ovarian malignancies so all of those factors are going to play a key role in making a decision at the end of the day but ultrasound will at least help you assess whether this is straight away a malignant lesion or not or straight away a benign lesion which does not need further follow up so the next case here so case number two is going to be I have this sine loop here I'm not sure how it's going to play on your screen but let me just play it anyways in the meantime you can see one of the static images of this lesion here so let's just play the sine loop so it's just a transabdominal ultrasound you see as the sine loop sweeps through this lesion you see this large irregular solid component which is present at one of the walls of this lesion and it also shows some amount of vascularity and proper assessment so visibly again it is fairly easy to say here it's not definitely one and it is not going to be definitely a color score of four so it's neither of those so that helps you close the loop here with the 10 rules but whether it is two or three that is the harder thing to discuss about and that's the reason why I was telling you that those two and three are not included in this because with the goal to make the goal is to make them the rules should be simple so now we looked at the sine loop and now what we can think here is that this lesion definitely is pretty large it was a 12 centimeter mass so again in terms of size it is not going to be less than two here so you're going to hear going to be more than 10 centimeter see if it has a regular multilocular solid element so the answer is yes it is a regular multilocular solid element and this lesion does not have any of the b rules so we have one at least one m rule that applies in this case right and once that happens you can just classify this lesion as a malignant lesion so let's see what it turned out to be so in final histopathology it was a stage 4 mucinocidinococinoma as you can see this patient underwent a CT which was performed as a part of staging protocols so remember in this case once you are fairly confident on ultrasound in suggesting that it's going to be malignant MR may or may not help you to have any further additional information if you're not sure about what to do next then definitely yes MR will help you but in this case the imaging features were pretty concerning for a lesion with malignant feature so this turned out to be stage 4 mucinocidinococinoma and you can see that this solid component was the one which you saw here on the ultrasound and there was no peritoneal disease or no abdominal pelvic acytus so increase these rules will increase your confidence of staging of stating the light level of a lesion being malignant and just expedite referral to gynecologic oncology services for further management on histopathology it looks something like this that i'm not i'm not a pathologist but just to give you an idea of what these mucinous neoplasms with higher grade are going to look like so you definitely see that these are this is disorderly arrangement of glands there are lots of papillary projections that are looking here inside it and you can obviously see new sometimes you can see peripheral form appearance of this structure so something similar to vcs that you can get like if you see these lots of whole like areas which are nothing but new duct or gland formation which is forming in the lesion let's go to the next one so case number three i have given you a sagittal graysky ultrasound in this patient with very menopausal and so look at this like this is transabdominal assessment right so it's a pretty large region so you can see here it's an 18 centimeter left adnexal cyst or left adnexal lesion and this was one of the questions that i asked you so the correct way of describing will be a multi-locular cyst with low level echoes as one of you had rightly pointed out now the problem here is that the patient had c 125 or 458 which was obviously done after the fact but i'm going to offer assessment you can see along the separations that there is very strong vascularity again it can be subjective in this case it was classified as category three but that's just something which can cause a little bit of objective variation there are some papers which describe about inter-observer agreement about color score and between one category to the adjacent one it's a little bit difficult to do that so anyways so you see this vascularity and further inferiorly when we did the transvaginal ultrasound you can see that the patient had these papillary projections which were kind of some of them measured up to seven millimeters so this is something which is really important to understand like the reason why i'm reading these facts is like there are certain numbers which help you assign the b and m rules so these projections were kind of around that seven millimeter mark so now what you see here that the patient has solid components but they were all less than seven millimeters the papillary version was less than seven millimeters and this patient had this large multi-locular cyst but there were at least four papillary projections so now we have a mixture of two findings here right so you have these things where there are at least four papillary projections but each projection or the solid component is less than seven millimeters so that kind of creates a little bit of a challenge here so we have one v rule and one m rule so essentially the lesion will not be classified according to these simple rules in this case you obviously have to resort to additional tests and that is why the ca125 was done it showed a very very elevated ca125 uh the patient had an outside mr which i did not have access to so i'm just showing you this kernel c image here so you can obviously see that the urinary barrier is kind of displaced inferiorly and there is a large uh large pelvic mass and it shows these enhancing septations or septa and one of the papillary projections that you can see here is pretty large and probably this was not a contact for on the ultrasound so remember ultrasound is going to have a little bit of limitation for assessing large ovarian lesions and patients who are also of large body habitus just because of poor penetration so in this case the final pathology turned out to be a polar differential in mucinus adenocarcinoma so it is important to understand the significance of lesions that cannot be classified as in this tool because again remember lesions that cannot be classified they can end up being just totally benign lesions or they can also be uh completely malignant so unless proven otherwise you cannot just simply consider them as banana they have to be further worked out let's go to the next one so fourth case here again you have uh two ultrasound images so one on the left side of the screen is just an actual grayscale uh ultrasound uh using convex probe here you can see that the patient has these septations and the septations here appear that they are irregular so now uh you see this um this is just an actual grayscale ultrasound which shows a woman who is in her 30s is a large 11 centimeter left-hand excel multi-locular cystic lesion it is filled with low-level echoes and it definitely had these irregular septations or wall irregularity and septal irregularity but it also had some of those areas which appeared as solid components so this lesion looked pretty suspicious on ultrasound at the time of performing the ultrasound and plus we did not have any price to compare we turned on the color Doppler and uh there was no vascularity within the solid components as well as the septations so now what we are left with we have a lesion which is more than 10 centimeter looks like an irregular uh solid tumor and the lesion also appears to have no blood flow so there are two different sets of rules happening here number one is one M rule and the other is one B rule so again the lesion cannot be classified using this tool now so uh final histopathology on this patient was endometriotic cyst so let's see what we learned from this lesion so we did the MR for this patient so this is actual post-contrast well vik MR even facts of estimate you definitely see these septations plus you also see these arrows pointing towards some of the enhancing um enhancing papillary projections or solid components so remember the endometrial mass can appear quite complex apologies if I'm using complex term here but this this complex has nothing to do with the lexicon it is just to show you the nature of this region they can be fairly challenging to assess and it may show suspicious features on for example the enhancement whenever you see the enhancement remember if any one of you who started using MRI or ads you have to grade the assessment based on comparison with the myometrium and see if it is more or less enhancing we are going to talk about that sometime in the future but just some food for thought endometriot and clear cell tumors they remain as a differential diagnosis in these patients especially who have had a history of endometrioma and usually MRI is the next step and even that may remain equivocal and the patients usually may end up getting a surgical excision in this patient is here by 25 or 53 kilo k u per liter so remember these values are going to help you assess adnex model as well okay so let's look at the next case here so the next case is again we have two ultrasound images here of one patient with an adnexal mass so you can see this actual grayscale ultrasound and a color Doppler which shows you that there is a lesion which shows these echogenic components right so right of the Vatican oh yeah the patient has echogenic components with some maybe some of them show posterior shadow let's search for those so you search and rightly you can find some of those which are posterior shadow so you right away apply this b3 category here but now what is happening in addition to this is that on starting color Doppler again periphery can be challenging process because compressed over and gamma will be present there but in this patient there was some thick irregular or irregular thickness along the step patients as well as some of these echogenic areas they showed vascularity so that is something which is not expected from endometriomas for the most part they will be essentially the Rokotanskin audience for most of the part they are not going to show this much of vascularity of the Doppler so now you can see that there are echogenic components so b3 rule and there is vascularity which is fairly significantly high like I apologize for using the power Doppler here but trust me it was very high so we applied it as 1m rule and 1b rule so again remember that you are not going to be able to classify this correctly so unfortunately for this patient there were multiple serial follow-up ultrasound because of the fact that it was recommended as just an echogenic component it's going to be benign so let's just do a follow-up but on one of the last ultrasound one of the radiologists picked this up and they recommended know this patient needs further assessment with MRI and probably a gynecology consultation the CA-125 in this case was 1073 k per liter so remember it was very very high dermoids won't have that right so that was assessed and it was excised so it turned out to be a low grade seelus over in carcinoma of the right ovary but unfortunately the patient also had peritoneal metastasis I'm going to show that to you in the next slide so the key point to understand and remember in this case is color flow in the echogenic shadowing solid component is distorted with the diagnosis of a dermoid cyst right typical benign dermoids won't have that it is important to review all iota simple rules to avoid premature conclusions and labeling certain lesions as benign when they're technically not so systematic evaluation is the key so let's look at the histopathology of this patient so as I told you the patient had peritoneal disease I guess you can see in this actual P2 image there is peritoneal disease along the liver capsule and then on high power histopathology image here this is just an H and E stem the reason why I'm showing you this slide is not to discuss about pathology per se but see all of these all of these violet purple or blue appearing areas so dystopic calcifications are going to stand like that so these are nothing but samoma bodies which can be seen with some of the papillary neoplasms so remember this one of the pitfalls that it can easily land into so apply the systematic apply the 10 simple rules systematically in these cases case number six so we have this actual transabdominal grayscale ultrasound which shows that there's a large solid appearing lesion there so it was a six centimeter ovarian irregular solid mass and it was actually picked up on a staging CT perform which was for gastric carcinoma so anyway they saw the adenisal mass but did the ultrasound and ultrasound you see very high vascularity we blame it as a color score of four so now you have one M rule and another M rule here right so two M rules so one is irregular solid tumor and one it is very strong blood flow so based on these two rules we can safely classify this lesion as malignant so remember one or more M rules it is going to be malignant so one key factor to remember here is that patient had a gastric carcinoma and this was a staging CT so final histopathology was a critical tumor from gastric carcinoma in this case the reason why I included this case is that even for these these metastatic lesions in the ovary you can technically have the same outcomes as the primary adenisal neoplasma I mean they recommend that we should not be using them when we're suspecting a metastatic pathology but this case is just to show that how well the simple rules that perform even in case of metastasis because the grayscale uncolored upper features are going to be severely abnormal even in these cases so the key point here is that whenever you see a solid mass with highly concerned and very high vascular flow it is highly concerning for malignancy so you can see there in this axial portal venous phase CT image that this is the gastric wall thickening and keeping with the carcinoma and on this coronal portal venous phase you see that there's lots of acytus peritoneal carcinomatosis and can work tumor involving the ovaries there so again remember cancer of GI primaries can present with curcumber metastasis like we see so often that usually women of childbearing age they will present it present with curcumber metastasis more often and they would have really large very very solid appearing ovarian masses and so it should be made to exclude a primary neoplasm in the form of a colonic carcinoma or gastric carcinoma. Case number seven so you see that there is one grayscale image here on the left side and one on the sorry on the right side and one on the left side the one on the left shows you a large ovarian mass and you also see large lots of acytus there and uncolored upper you definitely see some vascularity so the way it should be described is that I'll give you that I mentioned this is 12 centimeter so this is a multi-locular solid lesion with more than four irregular solid components as you can see one of the components is here on one of the walls but there are multiple other areas in the lesion as well and these show increased vascularity we get it as color scroll three and then in this patient as we'll see 125 was elevated as we were doing this ultrasound for this patient we also saw that patient had a site is and in one of the actual ultrasound image through the right flank it shows that the patient has peritoneal disease right so when you see this what is the likelihood of a benign neoplasm presenting with a peritoneal carcinomatosis zero none so when you see this you have to start thinking about malignancy so now what you can do here is definitely the patient has a site which is a malignant feature in this case and patient also has an irregular solid tumor which is more than 10 centimeters so you can apply two of these M rules but none of the B rules so this is essentially in keeping with a malignant process so patient underwent a staging examination and the staging essentially showed you remember we saw one of these peritoneal kind of deposits here we see that on this coronal CT scan as well and in the pelvis you see this large irregular multi-locular solid lesion with enhancing solid components so when adnexal lesions appear clearly malignant ultrasound a targeted assessment can be made for additional sonographic findings such as a cytos if you see any peritoneal disease elsewhere because that can just expedite staging process for this patient case number eight which is the last case of these this multi-modality assessment or multi-imaging library this is again very interesting so you see this transvaginal ultrasound image which shows you that there is a large mass as I have labeled here and this is the ovarian pattern chioma which is just adjacent to this mass whenever you see this kind of appearance on transvaginal transvaginal assessment you have to make sure whether this is arising from the ovary or not and to do that you can just plain and simple you just apply a little bit of pressure at the point where these structures are close to one other and try to see if the ovary separates from the mass so this is at rest or normal and when you put pressure if it was not arising from ovary the ovary will be pushed on one side and the mass will be on the other in this case it did not so it appeared as if it was arising from the ovary or within the ovary so the patient had a history of left hand uh multiple cell tumor just to add it in one of the different like one of the clinical aspects to remember what you're dealing with and the patient had a metastatic left axon in pornography which was three years later at the same time when we were doing staging CT we discovered the patient had this adnexal mass on CT right so that's why the ultrasound was left for so we see that the patient has a left adnexal irregular solid mass measuring five centimeters and the mass is inseparable from the ovary and it shows moderate vascularity so it does not light up like some of the other ones which we saw earlier so now what M rules and B rules you can apply so definitely it is an irregular solid tumor but none of the other B or M rules can be applied so you can safely say that it's probably going to be a malignant process just based on having at least one M rule so the patient underwent a uh an oophorectomy and final histopathology in this patient turned out to be a murky carcinoma metastasis in the ovary so murky cell uh cancers or murky cell carcinomas they are very aggressive and they can basically metastasize anywhere and then uh dynamic assessment is very important without the sound because you want to you want to basically you want to exclude the possibility that maybe you're just dealing with a broad ligament fibride or maybe it's just a perinculative fibride which sits close to the ovary because in those cases if you exert pressure the ovary will separate from this lesion but if it does not then you can be pretty certain that it is arising from this lesion so that is a very important point to remember when you're doing dynamic assessment so just for the sake of for the assessment the patient also underwent a pelvic MR examination so this is a dynamic assessment as you can see uh in the earlier arterial phase uh the solid component of this lesion does not enhance and it just shows this gradual filling in as we go to uh some of the delayed phases of acquisition and this is still below the level of enhancement of the myometrium right so the curve or dynamic enhancement curve that is what you are uh you have to discuss in MRI organs so what does it look like a histopathology so just for the sake of discussion here remember like these multiple cell tumors are very very aggressive lesions they have a very high nuclear to cytoplasmic ratio as you can see these like darts in nuclei and there's hardly any cytoplasm and uh you can see these multiple apoptotic bodies just to show you high turnover of cells and you also see if if you uh if you're dependent on what kind of screen you're seeing but some of these nuclei you can see that they are kind of like small stippled areas within them this appearance is called a salt and pepper you can also see this with biorondocrat tumors so just to show you that it is such a high aggressive or high uh great appearing neoplasm and remember this patient presented with an axillary met three years down the line from the the first excision of skin lesion and now the patient also has admixtal and ovarian metastasis so uh in conclusion so just by discussing about these eight cases we basically talk about uh how simple rules can be applied in clinical practice uh this tool can just increase your confidence and accuracy in categorization and characterization of admixtal lesion is a benign malignant or inconclusive when it turns out to be inconclusive you have to be more vigilant and really decide whether you want to recommend further management you want to do any blood blood workup you want to do any MRI examination or want to see a guinea or guinea oncology person assess them first uh systematic application of iota rules can avoid potential pitfalls and we saw in one of the case when it was labeled as ecogenic uh material and caused as benign but when it turned on the colored upper the vascularity was really high so systematic application helped to further assess that lesion which turned out to be a low grade neoplasm uh another thing which you can do to improve your adiarest to lexicon and systematic application is use of templates uh it is fairly easy to find some of these templates online if you're not able to find you can easily create one if you don't use voice recognition software as you can just create your own templates on microsoft word it is fairly easy to create pick list options that if you go to developer tools on microsoft word uh in terms of limitations many lesions may still remain as not classified right because we saw that there were multiple red one rule and one m rule or none of the bm rule applied those can be not classifiable uh and then uh these basically these can be include sometimes large dermoid cysts maybe an endometrioma because they are not typical in some of the instances and in those cases you have to follow them up with either mr and do further diligence risk stratification and recommendations for further imaging evaluation is not clearly defined as for iota but as we move down the iota ad next model and the orads talk about those things in much detail so for further readings i have just put down some articles here some of the ones you can just clearly go to iota website and just access some of the published literature there it is fairly easy to access that information and it is very easy to digest it's a very nice pictorial article that they have published online so make sure that you go and check them out uh these are my references and uh thank you so i'm going to uh just quickly go to q and a station see if there are any questions there so if you have any questions um we will be able to go over them so let me go back to question i think there is one question here why are we studying iota rules when we have better classification system as orads so that's a very relevant question so the reason why we started as we discussed mitusha was talking about a series of some of the body imaging session that we want to do some of the centers where over in neoplasms and cancer surgeries are not easily available i even now i still do see a lot of ultrasound reports which are just complex and complicated so step one is starting with lexicon the lexicon for orads is based on iota and it's a it's basically amalgamation of two different uh not two different but like just build on the basic lexicon which was described by the iota and that's the reason why we describe starting with the iota terminologies here and we will build on this in the future so it is very very important to understand that it may be very easy to write a report saying that it's a complexist and just recommend the patient to see a surgeon but not all complexes are going to be cancers and not all complexes will need surgery and that's the whole idea behind these lexicon terminologies and risk assessment so remember iota classification with 10 rules will be just a very quick and easy assessment when you're at the console scanning the patient which will help you decide in your head what you want to do next so for example if you're doing the ultrasound as we saw in one of the cases today that the patient had a lesion which looks suspicious like this and then you sort of hope the patient has a cytos so when you thought that okay this lesion is definitely going to be malignant so now you make a more thorough search with ultrasound to find this peritoneal deposit so it's very easy to use these simple rules and that's why they're called as simple rules and they just help you arrive at a conclusion faster than ORADS or faster than you have to go back search literature more and then come back so when you're at the console maybe you want to give a quick quick thought into your head what you want to do next it really really helps you so there is one question here how to differentiate between compressed normal ovaric tissue from solid lesion and normal ovarian vascularity from increased vascularity so that's a very good question and the reason why it is really important to understand that is that physiological processes in ovaries are fairly common one of those is our question here so let me go to that question first i think i started this session here okay there so now if you look at these four images option number c or the case number c as you can see here is a small benign appearing lesion here right so the way we will describe it if it was to be described is a unilocular cyst and there are no septations or papillary projections or solid components in this case it's for just a normal follicle but you can see that at the periphery of the follicle the slide the thank you slide is projecting oh okay sorry i think it has got stuck there now i think now yeah okay so this was one of the questions that we discussed earlier today so we see that there's this um anicoic cyst and if we were to describe this you could have just called it as a unilocular cyst no septations no solid components or no papillary projections uh but nonetheless this was nothing of that sorry but just a benign follicle but in case of benign follicles you can definitely see that the ovarian pattern come out ovarians from it just gets compressed to the periphery uh one of the simple uh tasks or one of the simple tests that you can do when you're at the console look at the patients other ovary that just gives you a very good comparator or an internal comparator of how the ovarian tissue is going to look like for that patient in terms of vascularity assessment for the ovarian vascularity and how to differentiate that from increased vascularity so remember that the ovarian tissue may or may not show you a lot of vascularity as you may remember like you may be seeing a lot of patients who come through ed for rule of torsion if you scan 10 different patients each one of them is going to show you variable vascularity in the ovaries you're just trying to rule out whether there's arterial or venous insufficiency when you're putting your pulse Doppler or pulse spectral assessment so the ovarian vascularity is going to be quite quite variable the goal of iota terminology by assessing color score is number one to arrive at a simple conclusion whether it is color score one or whether it is color score four one is very easy no vascularity it is going to be color score one four is also going to be very challenging sometimes but you definitely see that the papillary projections or solid components those are the areas where you want to assess the vascularity it may or may not be different from the adjacent ovarian parankama sometimes it could be maybe slightly confounding when the adjacent ovarian tissue is highly vascular but the likelihood of the solid component being higher in vascularity from the ovarian parankama is what we are dealing with for the most part when we say that it is color score four because that is the area of neo angiogenesis there is carcinogenesis happening there so that is going to attract more vascularity which is definitely going to be more than the adjacent vascular adjacent ovarian parankama so i hope that answers that question and just to quickly go over one of the quiz questions that we had how to describe so we already looked at this lesion and as it was described correctly in the session today in all the options it is basically a multi-locular cystic adnexal lesion with multiple global level echoes and this lesion at this at least in this image there are no papillary projections or solid components let me just check yeah there are no questions on the youtube chat feature as well there is just one question definition of complex and complicated cystic what exactly is the difference yeah so that's a very good question so basically iota or oratz they don't want us to use these terms anymore we just have to define them as unilocular cyst unilocular cyst with low level echoes unilocular cyst with solid component irregular solid area in the cyst unilocular or multi-locular cyst with papillary projections so basically we are just trying to use so an analogy to this will be say in in byrads when we are assessing breast lesions with ultrasound or even with with with MRI or maybe even with mammogram what we have to use is the lexicon terminologies described there so you can just say that okay there is a complex breast mass but no it is a speculated breast mass and it contains suspicious micro calcifications which could equals to complex breast mass or suspicious breast mass right so it's basically a similar analogy they don't they they're not encouraging us to use the complex and complicated terminologies they want us to use more standardized terms such as you have your uh yeah such as these so we are using either unilocular cyst unilocular cyst unilocular solid cyst multi-locular solid cyst it has low level echoes it is anechoic it has papillary projections it has irregular solid component the lesion is totally solid and that is the way we should be describing them because that helps us apply these rules as well as apply the ORRATS classification system any other questions i think there is something no there is nothing on the on the youtube as well so i think you have made things pretty clear for them and your approach was quite systematic so i think the doubts have got cleared right now there are no questions yeah so basically what what we did here today is that we discussed about iota terms and definitions and how we can apply simple rules so remember these lexicon terminologies essentially created the further advances into creating iota-atnix model as well as the ORRATS risk stratification system so we will be discussing about ORRATS sometime in the future and at that time you will be referring to these similar lexicon terminologies they may be adopted completely or maybe tweaked a little bit but the philosophy kind of remains the same we have to use systematic approach and we have to use lexicon terminologies so that we can apply these rules and we can apply the risk stratification system so i think with this we can conclude today's session and thank you Amir for this wonderful session and taking out time for all of us and we'll be meeting you online again next week with the best amazing masterclass and also we're looking forward to more of such sessions so we'll be putting on various groups and social media platforms above the upcoming sessions and updates by Dr. Amir Kulkarni. Thank you Indi and Radheva just for this amazing opportunity and have a have a good day everyone if you have any questions you can always reach out to me i have given my email address on one of the thank you slides there so feel free to reach out to me. So thank you everyone on a Sunday morning being with all of us and discussing this important topic i have again pasted the links to registration for various masterclasses and MRI teaching course on the chat box and we keep the session live for next few minutes so that you can take those links if you want. All these sessions are also there live as well as recorded on youtube channel of Indian ideologies do subscribe to the channel to see more of such educational videos and the links are also shared for the upcoming masterclasses. Dr. Amir has shared his email as well on the chat box so if somebody wants to connect you're most welcome thank you once again.