0:02

Hello, and welcome to Noon Conference, hosted by modality

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Noon Conference connects the global radiology community

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to learn alongside top radiologists from around the world.

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Today we are honored to welcome Dr.

0:24

Christopher Fung for a lecture entitled A CRO Rads.

0:28

What, why, and when Dr.

0:31

Fung completed his radiology residency at the University

0:34

of Alberta in Edmonton, a Canada,

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he then completed a fellowship in cross-sectional imaging at

0:40

Johns Hopkins in Baltimore, Maryland.

0:42

He has practiced as a clinical

0:44

and academic radiologist at the University

0:47

of Alberta Hospital since 2016,

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where he specializes in abdominal and pelvic imaging

0:52

and guideline development.

0:54

At the end of the lecture, please join Dr.

0:56

Fung in a q and a session

0:57

where he will address questions you

0:59

may have on today's topic.

1:01

Please remember to use the q

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and a feature to submit your questions so we can get to

1:05

as many as we can before our time is up.

1:07

With that, we are ready to begin today's lecture. Dr.

1:10

Fung, please take it from here.

1:13

Okay, thank you. Yeah, I'll stop talking on mute.

1:15

Um, great. Well, thanks everyone for coming.

1:18

And, uh, thanks to modality for inviting me.

1:20

Uh, very excited to give this talk on A CRO rads.

1:24

Uh, so, uh, as my bio bio said, uh,

1:28

I'm a Canadian radiologist

1:29

and, um, I'm interested in guideline development in addition

1:32

to, uh, a lot of ultrasound.

1:33

And so A CRO RADS really blends right into that.

1:37

So let's get started here.

1:39

Uh, so just for my disclosures, um,

1:41

I do have a research grant with executive imaging,

1:43

which was in regards to prostate cancer.

1:46

Um, I'm also a partner radiologist, uh,

1:48

with MIC medical imaging here in Edmonton, Alberta.

1:52

Uh, so today what are we gonna talk about?

1:54

We're gonna talk a little bit about where RADS comes from,

1:57

uh, what it is, uh,

1:58

and then run through RADS ultrasound, run through ed's MRI,

2:03

and then do some case review.

2:05

Um, so this is where we're going.

2:06

Um, all these pictures on our, on these, uh,

2:09

slides are actually from the University of Alberta.

2:11

So those of you who think the Canada's full of snow and,

2:15

and winter, well, it is, uh, a bunch of the time

2:17

as you can see here, but we still get

2:19

where we're going just like you will too.

2:21

Um, for this talk and,

2:23

and specifically for the cases, actually,

2:25

I do encourage people to download, uh,

2:27

the a CR guidance app on their phones.

2:30

Um, I've included the QR codes here

2:33

for both Android and Apple devices.

2:35

Um, I use this every day, uh, anytime I see a lesion.

2:40

Um, and I do encourage everyone to use it, number one,

2:42

because, um, it's easy and two,

2:44

because, uh, it is continually updated.

2:47

So if there's a new update that comes out with respect

2:49

to rads, you don't worry.

2:50

You have to worry about reading about it in radiology

2:53

or finding it in the table of contents.

2:55

It actually is updated as part of the A CR.

2:57

Uh, so when RADS 2022 came out for ultrasound, the,

3:01

the update, uh,

3:02

it was immediately uploaded into the app as well.

3:05

Uh, so it makes it so it's a seamless process

3:08

and, um, keeps everyone on the same page.

3:11

Uh, so I'll be, when we go through the cases, walking

3:13

through what you should be seeing, uh, on the phone, uh,

3:17

when you're using this, uh, app,

3:20

and hopefully, uh, you'll get used

3:22

to it, uh, fairly quickly.

3:24

Uh, I'll bet that slide up again right

3:26

before we get the cases, in case you missed that.

3:28

Uh, so ACR r rads, where does this come from?

3:30

Um, what's the history behind it?

3:32

Well, so RADS itself stands

3:34

for the ovarian AD NL reporting and data system.

3:38

And this was a consensus guideline created

3:39

by the American College of Radiology in 2018 initially, uh,

3:44

which was then updated in 20 20, 20 22,

3:47

and released an MRI, uh, also in 2022.

3:49

Initially, it was designed

3:51

for the average risk asymptomatic patients.

3:53

So this isn't for patients that have, uh, known malignancy

3:57

or or known lesions.

3:58

Uh, this is for the patients who are just walking, talking,

4:00

breathing, walk into your office,

4:03

and, oh my gosh, they've got something in their ovarian, uh,

4:07

stroma or in the adnexa.

4:09

And one of the biggest things that we need to learn, uh,

4:11

when we start using RADS is the actual descriptors

4:15

or lexicon, uh, within the system.

4:18

And it is critical, uh, that you know what those are

4:21

and, uh, and how to use them appropriately.

4:23

Uh, otherwise you won't be talking the same language

4:25

as everybody else, and you'll end up with the wrong result.

4:28

And so, um, where did it originally came from?

4:32

It came from, uh, a pathologic review of over 5,900 patients

4:37

who had, had, uh, who had path proven disease.

4:41

And, and they stratified all

4:42

of those patients into various categories based on the risk

4:45

of malignancy and the appearance on imaging.

4:48

Uh, and one of the most important things are,

4:51

I guess, why do we use this?

4:53

Well, one of the biggest reasons is

4:55

because you actually can decrease surgical referral

4:57

for benign lesions.

4:58

And any operation that doesn't need

5:01

to be done probably shouldn't be done.

5:02

There are risks and benefits, and they're lesions

5:06

unless they're having symptoms from them,

5:08

which case they're not asymptomatic.

5:10

Um, I, I don't know how it works

5:13

where anyone who's listening is, is working, obviously.

5:15

But, um, if you work here in, uh, Edmonton, Alberta, um,

5:19

our local GY oncologists actually request O rats, uh,

5:23

for every case that, that, uh, they get sent.

5:25

Uh, it really does help guide them in terms

5:27

of their discussion about management.

5:29

And I think that is gonna increase as, uh,

5:32

as people become aware of it, people become using it, um,

5:35

or people get used to using it.

5:37

And, uh, and the evidence, uh, continues

5:39

to back, uh, using it.

5:41

And there are a number of studies looking at various scoring

5:43

systems, rads among them, showing that, uh, OA ds,

5:48

uh, is on par with any other scoring system

5:50

that is widely used, uh, internationally.

5:53

And so I think that, uh, it's really great, uh,

5:56

to get everyone on board

5:57

and, uh, get everyone on the same page when, uh,

6:00

discussing these lesions.

6:01

'cause it just decreases ambiguity and,

6:03

and helps sort of figure out what to do with, uh,

6:07

with patients with these lesions so

6:08

that they get the best care possible.

6:11

Uh, so I'm gonna put, I'm gonna put this up.

6:14

You're gonna see this, um,

6:16

because this is the, the typical tables

6:18

that they use in rads, uh, in the actual papers a few times.

6:21

Um, but I'm not gonna talk too much about this individual,

6:25

um, table, uh, for rads, MRI or, or Rads ultrasound.

6:29

I'm just gonna put it up there to show this is

6:30

the table that you should look at.

6:32

If you don't have that app

6:35

or whatever, uh, it'll, it'll walk you through, uh,

6:37

what you need to do and, and what you need to suggest.

6:41

Uh, it's a little bit challenging to read.

6:43

It's lots of colors. It's really small text.

6:45

Um, but you can see in the, uh, uh,

6:48

table the over rise category on the left.

6:50

The risk category, which is the IOTA model, is,

6:53

uh, just to the right of that.

6:54

And that some people will include the risk of malignancy,

6:57

others will choose not to.

6:59

It depends on your local practice.

7:01

Uh, here we don't usually include the risk of malignancy

7:04

because it freaks patients out.

7:05

Um, but every place is gonna be different.

7:08

But you can see here the lexicon that I was talking about,

7:10

it's all in here.

7:12

And so it is really important to use these terms

7:16

and not use alternative terms that, uh, may not be as clear.

7:20

Uh, so these terms were vetted, uh, by the Society

7:23

of Radiologists and ultrasound, uh,

7:25

before the O Rats, uh, lexicon, or sorry,

7:27

before the O Rats, uh, uh, documents were even published.

7:30

Uh, two years prior to that,

7:32

they had published the lexicon trying

7:33

to get everyone on the same page for,

7:35

for reporting the same.

7:36

And so we're gonna go through these, uh,

7:38

categories one by one.

7:40

Uh, first off though, as I said,

7:43

ultrasound was released in 2020.

7:44

There were key changes released in 2022.

7:47

Um, first off, they looked at the governing principles, uh,

7:51

and they changed, uh, some

7:52

of the governing principles from the original update.

7:54

So if you were going by the 2020 paper, um,

7:57

you should probably take a look at what happened in 2022.

8:00

'cause there are a few changes here.

8:01

Uh, number one,

8:03

and the, one of the biggest things they did is they changed

8:05

it so that you can use this on normal ovaries.

8:09

There was a bit of confusion about what do you do with,

8:12

with a normal ovary, what's the RAD score of that?

8:15

'cause it wasn't really listed in there.

8:16

Well, now it's RADS one.

8:18

And so that, that really changed it.

8:20

There, there's also some clarification about, uh, what

8:22

to do when you don't know if they're in menopause, what

8:25

to do, um, uh, with hemorrhagic follicles

8:29

or hemorrhagic cysts, uh, in early

8:31

and late, uh, menopause, that wasn't very clear.

8:33

And then what does it mean to be an ultrasound specialist?

8:36

So they really defined that.

8:38

Uh, and then interval change,

8:39

they talked about initial change, and that is a big one,

8:41

and we're gonna talk about that, uh, a little bit here.

8:43

So, RAD zero, uh, was also, uh, included.

8:47

And so OAD zero, uh, is where you don't have enough, uh,

8:51

or the, the pictures are inadequate technically

8:54

to actually make a diagnosis.

8:55

Uh, just like BIRADS zero. So you need other testing.

8:58

It might be a repeat, it might be a DMR.

9:01

Previously it was just M mri,

9:02

so they added a repeat ultrasound as an option.

9:04

Um, RADS one, as I said, can mean normal ovaries assessment

9:08

of growth, uh, was a big, uh, change here.

9:10

So the average linear dimension change of 10

9:13

to 15% is the number you have to remember.

9:15

And that average linear dimension is just the three

9:18

measurements, length, widths,

9:19

and height, uh, divided by three.

9:20

Uh, there's nothing fancy about it.

9:22

Uh, now if it decreases, uh,

9:25

at first followup, then it's benign.

9:26

And if it increases at

9:27

first followup, then you keep on moving.

9:28

And so this is really stretched out, uh, the, uh,

9:31

follow-up recommendations

9:33

and decrease the overall follow-up recommendations from

9:36

what the original paper said in 2020.

9:39

Uh, and, and in keeping with that theme,

9:41

they actually ended surveillance

9:42

for these lesions at two years and not at five years.

9:45

And we're gonna go through that a little bit.

9:46

They also added the term bi ular.

9:48

And this was a bit of a confusing one to me.

9:50

Um, but when you actually look at these lesions,

9:52

it makes sense because when you see these, uh, lesions

9:55

of practice, everyone who's done this enough has seen these,

9:58

these simple lesions with just a single septation within it.

10:02

Um, and you look at it

10:03

and you say, wow, is that really gonna be a mucin?

10:05

Cystadenoma? Probably not.

10:07

So they added bilock to recognize that a lot

10:10

of those things actually, all of those things were nothing.

10:13

And so, and they expanded the lexicon in that way.

10:15

And we're gonna, again, go through that a little bit.

10:18

So here's the summary of the update

10:20

to management recommendations.

10:21

Uh, I'm not gonna go into it.

10:23

You can look up the paper yourself.

10:24

It's on the bottom right there.

10:25

Um, but, uh, there's the categories there,

10:28

and they have recommended, uh, wording

10:30

that you use in your reports.

10:32

Um, you certainly don't have to, but it's nice to have it.

10:34

'cause then it again, keeps everyone on the same page.

10:37

So, um, when we talk about RADS ultrasound,

10:41

I'm gonna talk about the 2022 update.

10:43

Uh, and that's what we're gonna go through.

10:45

So, um, these are the actual images that are table sort

10:50

of figures from, uh, from the 2022 update

10:52

and assessment category.

11:00

Chance of malignancy here.

11:02

This is exactly what anyone sees when out there,

11:04

the vast majority of them.

11:06

Uh, and so my connection's unstable. That's a good sign.

11:10

Um, so if there's no lesion on it whatsoever,

11:14

this is clearly a benign ovary, uh,

11:16

they can be a little bit challenging

11:18

because you might think, oh my goodness, maybe it's a, uh,

11:20

maybe there's a solid lesion there.

11:22

But, uh, once you get used to looking at these,

11:24

it's just a straight ovary.

11:27

There's nothing to it. Simple follicles.

11:28

I don't need to go into. Everyone kind

11:29

of shouldn't hopefully know what they look like,

11:31

but they're simple cysts, less than three centimeters.

11:33

I personally don't like the term cyst.

11:35

I prefer the term follicle.

11:36

But the term follicle is obviously only in patients

11:38

who are premenopausal,

11:39

postmenopausal patients do not have follicles.

11:42

And then finally, the Corpus lu tm,

11:44

the Corpus L TM takes 'em getting used to.

11:46

Um, I know our residents struggle with it,

11:48

but the granulated margins here really tell you

11:50

that this is a corpus lutetium.

11:52

And then the ring of fire, quote unquote, on the,

11:55

on the color Doppler, uh, really sends that diagnosis home.

11:59

Sometimes it can be solid appearing, uh,

12:01

but again, you get that nice ring around them, uh,

12:04

in the patient of the correct age.

12:06

Um, this is a corpus lutetium.

12:08

Um, yeah, we're gonna move on to category two.

12:13

Uh, and you we're gonna move all the way through, uh,

12:15

all the different categories here.

12:16

So category two is almost certainly benign,

12:18

less than 1% chance of malignancy.

12:19

These are the large simple follicles.

12:21

So when we talk about,

12:22

or simple cysts, the large ones over three centimeters, uh,

12:25

but less than 10, uh,

12:27

or less than 10 centimeters of the post-menopausal.

12:30

Um, so, uh, they're just

12:34

anti coic fluid, um, and, uh, on a single ovary

12:38

and it's size that matters in this one.

12:41

Now, I, as I said, it was ncoic for that first category,

12:44

ocular cyst with smooth inner walls that are not simple.

12:47

Um, so these have internal homogenous echoes,

12:51

or heterogeneous echoes, I should say,

12:52

sorry, internal echoes.

12:54

And they often are speckled like this.

12:55

They might have a single internal septation

12:57

or incomplete septations.

12:59

That's not really a wall irregularity,

13:01

as long as it's nice and smooth.

13:02

And so that incomplete septation

13:04

or the presence of heterogeneous internal echoes, uh, again,

13:08

uh, almost certainly benign.

13:10

Um, and, uh, yeah, there's not much else to say about that.

13:15

We see these all the time. Uh, a bilock of assistance,

13:17

as I said, was added in 2022.

13:19

It's a single, uh, septation that is complete.

13:22

It is thin that there might be some internal echoes.

13:26

Uh, so don't let the complexity

13:28

of fluid fool you, uh, on these.

13:30

Uh, it's enough to push it out of rads one,

13:33

but that's about all that we will say.

13:35

Uh, and finally, they, they have these, uh, benign ovarian

13:38

and benign extra ovarian lesions.

13:39

And so we're gonna go through those quite quickly here.

13:42

Um, so these are, uh, the benign, uh, extra variant

13:46

and ovarian lesions.

13:47

Um, if you're a resident, uh,

13:50

or if you're staff, this would've been drilled into you,

13:52

presumably what these look like.

13:53

But hemorrhagic follicles

13:55

or hemorrhagic cysts, uh, they're avascular.

13:57

They've got a reticular pattern,

13:58

or sometimes they have retractile clot.

14:00

Um, both of those are totally normal.

14:04

I've seen these called, uh, all sorts of crazy actually

14:06

by people who don't do, uh, a lot of ultrasound.

14:09

But they, they always look very much like this,

14:12

this particular sort of, uh, net like pattern.

14:15

Um, and as you sweep through,

14:16

they become even easier to see.

14:18

This tractile clot can confuse a lot of people.

14:20

People think that sometimes it's a solid mass.

14:23

The key there is doppler,

14:24

and we're gonna go into that in some of the cases.

14:26

Uh, your typical dermoid, uh, or mature teratoma.

14:29

They can have a number of different appearances.

14:31

The classic one is this tip of the iceberg sign,

14:33

where they have this very bright echogenic focus.

14:35

And then, uh, shadowing deep.

14:38

Uh, sometimes you can get this dot dash

14:39

or reticular pattern from hair in there.

14:42

And then floating echogenic, spherical structures,

14:44

little globules of fat that sit in there.

14:46

That's possible. I've personally actually never seen it.

14:49

Um, but, uh, it's in the papers a lot.

14:51

So keep an eye for it.

14:52

And it, I'm sure it's striking if you do see this,

14:55

your typical endometrioma.

14:57

Um, these have homogenous internal echos, uh, avascular,

15:02

uh, they can be bilateral.

15:04

Uh, you can get peripheral pump tape prophy

15:07

as they can calcify.

15:09

Uh, big things to look out

15:10

for here is any internal solid component,

15:12

because they do have a risk

15:13

of malignant transformation into Endo Detroit, uh,

15:16

or clear cell carcinomas.

15:19

Uh, but if they don't have any, uh, solid component,

15:21

these are just typical benign.

15:23

Uh, and that's, that's what they are.

15:25

Uh, your pair of variance cyst.

15:27

The big thing here is that they're off of the ovaries

15:29

or separate from the ovaries, but they're the same

15:31

as an ovarian cyst or follicle, uh, anti coic.

15:34

Um, and, uh, uh, very benign looking.

15:38

Uh, peroneal inclusion cysts, they tend to involve, uh,

15:41

the bowel and surround the ovaries.

15:43

So you'll see them, uh, draped over the bowel.

15:45

And they're very irregular in their margin

15:48

because they follow the actual bowel itself.

15:49

So I always have my texts sweep right

15:51

across the edges of these.

15:52

And if you see that typical log,

15:54

they ly can tend to be a bit bigger.

15:56

They can have internal septations.

15:57

They always have an ovary somewhere in or beside them.

16:01

Uh, they have to be touching

16:02

the ovary 'cause that's how they start.

16:03

Um, and in your hydros, um, again,

16:06

it's separate from the ovary tubular structure.

16:08

In this case, they can be very confusing, um,

16:10

because of these, uh, endo cell chi, uh,

16:13

endo cell peo folds, uh, they can look like septations.

16:16

They can look like all sorts of things.

16:17

They can have complex fluid in them.

16:19

Uh, but your typical hydro ins is simple, uh, fluid, just,

16:24

um, a tubular structure with these thin lines.

16:27

And again, sins are everything for these.

16:29

They make it so much easier to tell.

16:31

Um, category three, now we're starting

16:33

to get into actual chances of malignancy here.

16:36

Previously, there's less than 1% now into one to 10% here.

16:38

Um, so if you've got that cyst that's over 10 centimeters.

16:42

Uh, same thing, koic. This gets category three.

16:46

Uh, if you have irregular internal walls

16:48

where you have focal thickening,

16:49

but it's less than three millimeters,

16:51

and that three millimeters is actually from the wall out

16:54

to the top, just like you're measuring the top

16:56

of a mountain, it's not the base of a mountain.

16:57

It's how high it is. Um, less than three millimeters.

17:01

This is a category three. You have multiple molecules.

17:04

So it's not just bi ular, you have at least three.

17:07

Um, or you have a color score of four.

17:10

Uh, and we're gonna get into the color score a little bit.

17:12

But basically it's a, uh, a score where you judge

17:15

how fast you think the blood is flowing through that, uh,

17:17

lesion, uh, if it's a solid lesion with

17:21

or without shadowing, but has a smooth contour, uh,

17:24

and a low color score.

17:26

Uh, this is a category three, and if it's a solid lesion

17:29

but has shadowing and a smooth contour, but,

17:31

and a higher color score, um,

17:33

then it's still category three.

17:36

So as you can tell, the color score

17:38

actually does matter a lot.

17:39

Uh, the code score four, as we're gonna see right away,

17:42

is gonna push into more, uh, exciting things here.

17:45

So, um, multilocular systems on these solid components, uh,

17:49

is gonna be a four.

17:51

Uh, but, and the key here is

17:53

that the actual walls are irregular.

17:55

So it combines the papillary thickness,

17:57

or sorry, the, uh, thickening that we saw

18:00

before, uh, with multiple septations.

18:03

So if you have them without, it's a three

18:05

and you have 'em with, it's a four, um,

18:08

the multilocular assist without,

18:10

but a color score of four, um, or less than four, sorry,

18:13

but is greater than 10 centimeters, uh,

18:16

pushes you into this category.

18:17

Or if you have a color score of four, uh,

18:19

but don't have any solid

18:20

components that sit in this category.

18:22

Papillary projections, in other words,

18:24

over three millimeters pushes you into a four immediately.

18:27

Same with any solid components.

18:29

Same, uh, with, uh, those same solid components and,

18:32

and septations, uh, but a code score of one to two.

18:35

Uh, and same here with a code score

18:37

of two to three, and it's solid.

18:39

So then what makes up five?

18:41

Uh, well, category five we a real bad thing.

18:49

The

18:54

High flow is color score four gain, uh, in a solid lesion,

18:58

irregular margins in a solid lesion,

19:00

any ascites or peritoneal nodules.

19:03

Um, this is pretty clearly bad.

19:05

And, um, I don't think anyone is gonna miss category fives.

19:09

Most people get really freaked out about category fives.

19:13

I just wanted to come back to

19:15

that original publication in 2019 on

19:17

what are we talking about for typical benign lesions.

19:19

Uh, and I'd said earlier that, you know, uh, moid, cys

19:23

and hemorrhagic follicles can have a varied appearance.

19:25

And so this, I thought was a really nice example, uh,

19:28

of a number of different appearance of typical dermoids.

19:31

And, um, I just put it out there just so

19:33

that everyone has seen this at least once.

19:35

And again, I expect, uh,

19:36

most residency programs will teach it fairly, uh, in depth.

19:40

But there's that tip of the iceberg sign here.

19:41

Here's that reticular, um, pattern of, uh, hair.

19:46

Uh, here's the dot dash pattern, uh, here in d uh,

19:50

and, uh, here's a, a nodule with, uh,

19:53

fairly marked posterior shadowing, similar to, uh,

19:57

a actually in that one.

19:58

Uh, and here you can see another, uh, fatty nodule here,

20:02

kuski nodule here, and then a number of those fatty spheres,

20:06

uh, in this, uh, dermoid on the bottom right in.

20:10

Contrast that to endometriomas.

20:12

And I, and I do that because, uh, there's a bit of confusion

20:14

as you can imagine, uh, just even look at this.

20:16

But homo typical endometriosis have a very homogenous,

20:20

uh, appearance.

20:21

So very homogeneous internal echoes.

20:23

They don't have those speckles that you saw in the,

20:25

uh, RADS two lesion.

20:27

Sometimes they can have these septations, um,

20:30

sometimes they can have these calcifications,

20:32

but it's always these nice,

20:34

or typically these nice, uh,

20:36

homogenous internal echos are very classic

20:38

for typical endometriomas.

20:39

So, and hemorrhagic cysts, again, uh, that, uh,

20:43

reticular pattern, you can see it here

20:45

and you can see how it's different than the reticular

20:47

pattern, uh, that

20:48

or the mesh, like mesh like pattern

20:50

that you see in, uh, dermoids.

20:53

So, um, and you can imagine what's happening here.

20:55

You get this, you can have these almost homogenous looking

20:57

echoes, but they're bone complex.

20:59

There's these lines that start forming, and it's

21:00

because you're forming these webs of fibrin in them.

21:03

Uh, and that progresses into this reticular pattern

21:07

and this reticular pattern, and

21:08

then they start retracting down.

21:09

And so you can get, you know, any lesion along the spectrum,

21:13

uh, and that produces all of these different appearances

21:15

and it really can be quite confusing.

21:17

So use your Doppler, uh,

21:19

to help you figure out if this is really a solid mass

21:21

or, uh, uh, a papillary projection

21:24

or if it's just retract on.

21:27

Okay. Uh, let's do MRI quickly and then get to the cases.

21:31

'cause um, uh, that was a lot. So, oh my goodness, sorry.

21:36

This chat stuff. Um, oh, okay. That's the, thanks.

21:42

Hello. Sorry. Okay, I'm gonna keep going.

21:46

We do questions at the end, just so everyone knows.

21:48

So this is, uh, from the river valley, uh,

21:53

o's MRI is, they don't have a nice app for Rads, MRI,

21:56

but what they do have is this rads MRI calc.com.

22:00

And when I first saw this website, I thought,

22:01

oh my gosh, what is this madness?

22:03

Like, somebody's just put up this website,

22:04

but it was actually from the ACR r.

22:06

And so it's a calculator.

22:07

And you can see the OS MRI, I'm gonna go

22:09

through all the categories again,

22:11

but in the same way that you're gonna see

22:12

with the cases the os MRI is very simple.

22:15

Go to the calculator and it has four questions.

22:18

Do they have peritoneal nodules or ascites?

22:20

Well, that's bad. It's immediately gonna be like a five.

22:23

Is there a finding of a corpus lutetium

22:25

or hemorrhagic follicle,

22:26

less than three centimeters in a

22:28

premenopausal woman, yes or no?

22:29

If it's yes, then it's gonna be benign.

22:33

Is there fat, yes or no?

22:35

And that's really gonna push it to benign.

22:36

If there's fat in there and MRIs, wonderful for fat,

22:39

we're gonna go into it.

22:40

Is there an enhancing solid tissue component

22:42

associated with the index lesion?

22:44

Yes or no? And you can imagine, yes, pushes you to RADS four

22:46

or five, no pushes you away.

22:49

It is literally that straightforward,

22:51

which is why we're not gonna spend a huge amount of time.

22:53

I said I was gonna put up this, this table from the thing.

22:56

All the rads have this table, an MRI, it looks like this.

22:59

You can see it's a little bit more simple, um,

23:01

because they don't have management

23:03

recommendations associated with this.

23:04

They just give the score, uh, in large part

23:06

because by the time they're getting MRIs,

23:08

usually you're gonna see gynecology.

23:10

Um, this was a really nice review, uh, by new red et all,

23:14

uh, back in 20, just in 2024.

23:16

And they were looking at, um, problem solving and tips

23:20

and tricks for rads, MRI.

23:21

And I really liked it. I

23:22

encourage everyone to take a look at this paper.

23:24

But they had this beautiful table

23:26

of the different signal characteristics of non simple fluid.

23:30

And so you can see it on all the different phases,

23:32

or, sorry, all different sequences there.

23:34

Um, I'm not gonna go through what each of these look like,

23:37

but um, I thought this was a really nice one.

23:40

I share this with my residents.

23:41

Um, it's a beautiful example

23:43

or a beautiful summary of, of how

23:45

to tell the different fluids.

23:46

And so if you get stuck and you're like, I can't remember if

23:48

that's hemorrhagic or not, um, that's fine.

23:51

Just pull up this table or pull up a similar table.

23:53

And this is nice 'cause I,

23:55

I like pictures as opposed to words.

23:56

It's not just like two too dark T one bright.

23:58

Um, this actually has what they look like.

24:00

And so bottom line is fat.

24:02

Um, middle line is protein, so that's c,

24:05

b is endometrial endometrioid fluids.

24:08

So blood products and a is hemorrhagic fluids.

24:10

So you can see the difference between, uh,

24:12

continual oozing from endometrial products

24:14

versus a previous bleed.

24:16

And then, uh, changes there in

24:17

with respect to the hemoglobin.

24:18

So really nice slide there. Uh, so rads, MR one.

24:23

Uh, so Rads MRI one is normal or physiologic.

24:26

And so normal ovaries in premenopausal,

24:29

they should have follicles in post.

24:30

They may have one, maybe usually none. They're very small.

24:34

Um, postmenopausal ovaries.

24:36

The key to look out there is, uh, you can mistake them

24:39

for lymph nodes.

24:42

So I always follow out from the, uh, edge

24:45

of the uterus along the broad ligament to

24:46

where I can imagine the broad ligament would be

24:49

towards any structure.

24:50

And they should be separate, ideally from the vasculature.

24:54

They might be around there, but they shouldn't be like

24:55

pasted on there the way that lymph nodes are.

24:58

Um, so, and then physiologic observations and,

25:02

and you'll find that they, they call them observations

25:04

and not necessarily lesions in this case.

25:06

Um, follicles, again,

25:08

less than three centimeters hemorrhagic cysts, um,

25:11

we can refer back to that table,

25:12

but they should have very typical, um, enha

25:15

or, sorry, not not enhancement

25:17

and uh, uh, signal characteristics on T one and T two.

25:21

Uh, and then a Corpus LI team.

25:22

And again, look for that ated margin.

25:24

Uh, that really, really helps you on the ated margin.

25:26

I find really sh shines on the, uh,

25:29

post gadolinium sequences.

25:31

Um, you can see that margin really well.

25:33

And so I rely on the post gadolinium.

25:34

'cause before then, um, the, uh, the purpose

25:38

of the TM can look like all sorts of crazy

25:40

and can really, really potentially fool you.

25:44

So RADS two, almost certainly benign.

25:46

Um, this follows the ultrasound.

25:48

Uh, so if they have fat in them

25:50

with no enhancing solid component, um,

25:53

that is very reassuring.

25:54

So you can see the top example there with dermoid, the dark,

25:57

dark lesion everyone talks about.

25:59

Um, that's a, um, fibrous tumor.

26:02

So T two dark t uh, DWI dark.

26:05

Uh, you can see the example here.

26:07

Um, and it should be, uh, I mean dark

26:12

and then the, uh, the T one signal.

26:14

You know, sometimes my residents will say, well, uh,

26:17

but this one's not, uh, this one's not as dark as,

26:20

as on T two isn't.

26:21

It's supposed to be really, really dark on T one

26:23

two, T one as well.

26:25

Um, and it actually may not be,

26:27

it may be iso intense on T one.

26:28

So it's the DWI

26:29

and it's the T two, uh, that really tell you.

26:32

That's the, that's the dark, dark, uh, thing

26:34

that you're looking for for an RADS two Ls, MI two lesion,

26:38

dilated fallopian tube, simple hydros.

26:40

Uh, similar to the, uh, ultrasound category in MRI,

26:44

you can really see the internal fluid component.

26:46

And a, again, you're looking for T two bright, T one dark,

26:49

typical fluid and non enhancing.

26:51

Um, you see enhancing soft tissue,

26:53

it obviously is gonna push you higher ovarian cyst

26:57

with any type of fluid, anything ovarian.

27:00

Um, they don't get too fussed about as long as it's cystic.

27:03

So, uh, no one has been as key there, uh,

27:05

to make sure that it's cystic.

27:06

But if it's perva, uh, this is an RADS MRI too,

27:11

uh, so that this continues.

27:14

Sorry, it was a very long table. So I, I split into two.

27:17

Um, any sort of hemorrhagic follicle.

27:20

And so they can have fluid, fluid levels.

27:22

Um, the, again, the key here is that they don't have, uh,

27:26

any, uh, wall enhancement or soft tissue.

27:28

What RADS is PCOS, uh, PCOS would be considered RADS one,

27:32

uh, 'cause they're just follicles.

27:34

Uh, so, uh, cyst with simple fluid

27:38

or endometrial, uh, fluid.

27:40

So an endometrioma is considered RADS two.

27:42

Again, no solid enhancing tissue. I can't say that enough.

27:46

No solid enhancing tissue.

27:48

Anytime you have that, it's gonna push you higher.

27:50

And we're gonna see that right away.

27:52

Well, we see that right away. We'll see. So rads MR three.

27:55

So if there is fluid, but it is not simple.

27:58

This is the proteinaceous hemorrhagic or muus fluid,

28:00

but it's not an endometrioma either.

28:03

Um, again, no enhancing tissue.

28:06

Uh, this pushes you into RADS three, uh,

28:09

if it's multilocular, but no lipid, no lipid content.

28:12

Again, fat pushes you down. Uh, no fat pushes you up.

28:16

Uh, and no enhancing solid tissue.

28:18

Uh, this is an RADS three, uh, Brenner tumors, uh, here

28:23

with the low signal, uh, on T two and DWI.

28:26

But they have, and they have a,

28:28

a low risk intensity curve here.

28:31

And the intensity curve time intensity

28:32

curve is from the enhancement.

28:33

So I don't know, you don't have to do time intensity curves.

28:37

Our institution actually doesn't do these.

28:39

You can eyeball them, uh,

28:40

and that's an acceptable way to do them.

28:42

Uh, but if you do have the ability

28:44

to do time intensity curve,

28:45

it does make these things a lot easier.

28:46

And you'll see in RADS three, four,

28:49

and five, the time intensity curves start mattering a lot.

28:52

Um, so in this case, it's a low risk time intensity curve.

28:56

Here you can see it's less than myometrium.

28:57

It's nice and flat. Um, that's an RADS three lesion

29:01

and then a dilated fallopian tube

29:03

with non, uh, simple fluid.

29:05

Uh, or if there's thick walls

29:08

and there's simple fluid, those two things will push you in.

29:10

And again, they're looking for, is there something funny

29:12

about this fallopian tube?

29:14

Is it infected? Is there, uh, something, uh,

29:16

growing there potentially?

29:18

And we'll talk about that in a second. I suspect.

29:20

So over reds four, um, we start getting into,

29:24

in intermediate risk, time intensity curve.

29:26

So it's not that flat one, you can see it comes

29:27

up and then plateaus here.

29:29

Um, so intermediate risk,

29:31

time intensity curve for a solid lesion.

29:42

Um, and, uh,

29:44

and an intermediate risk, uh, time intensity curve.

29:47

So in this case, this was a pappa projection

29:49

and a low grade serous tumor, uh, with

29:51

that intensity curve here, if you have a solid lesion, uh,

29:55

with enhancement of the, uh, uh, sorry,

30:00

if you have a solid lesion here, uh, that's, uh, got,

30:05

that does not have T two dark, dark, uh,

30:07

T two dark and dwi I dark.

30:08

Sorry about that. I'm having

30:10

problems getting my words out right now.

30:12

Um, then, uh, then if it's in a four

30:15

and then if you've got a fatty lesion, uh,

30:17

but it's got a solid component.

30:20

And so if you remember before, if it had fat

30:22

and no solid component, it was a two.

30:24

If it has fat, but has a solid component,

30:26

it immediately pushes it up into a four.

30:28

Um, and, uh, and the reason is

30:30

because toomas can have malignant transformation

30:33

as can be seen in this case

30:34

that they included in the table a dermoid

30:36

with squamous cell carcinoma within.

30:38

And you can see this big enhancing ugly mass

30:40

arising from this fatty dermoid.

30:43

And you can see the fat there on the fat saturated

30:45

sequence right there with the star.

30:47

Okay, RADS five, I mean, again,

30:50

no one's missing these things.

30:51

They're solid lesions. They are avidly enhancing.

30:54

And you can see that on either eyeballing them

30:57

or with a time intensity curve where it's above

30:59

or equal to myometrium.

31:00

Um, and, uh, and they give two examples here.

31:04

Uh, and again, this excludes the dark, dark, uh, T two,

31:07

dark TWI dark lesions.

31:10

Um, so if it enhances greater than myometrium, uh,

31:12

or has a bad time intensity curve, uh, these are bad.

31:17

Okay? So we're gonna go onto to cases.

31:20

Um, we have a lot of squirrels here.

31:22

And so when they were taking pictures of the university,

31:24

they took pictures of squirrels.

31:25

Uh, so this guy got a peanut. Um, so don't run away.

31:29

That's why I put the squirrel there.

31:30

Do download this app, this is your chance.

31:33

And, um, I'll give people like 10 seconds whilst I drink a

31:37

sip of coffee to download this.

31:39

And then we're gonna go through some cases,

31:46

10 seconds.

31:46

Takes a long, long time when you're just standing here.

31:50

So sorry about that, but hopefully everyone's ready.

31:52

Here we go. Okay, so this is case one.

31:55

So, um, you can see here, uh, this is, so, uh, if,

32:00

if you're using the, um, the app, I'm telling you right now,

32:03

these are all gonna be ultrasound reds.

32:04

Um, and it's just because the app I thought would be a lot

32:07

more fun than everyone trying

32:08

to type things on a computer with Zoom.

32:09

So these are all gonna be ultrasound reds cases.

32:10

So, um, we're gonna walk through them,

32:13

but I'm gonna let you try and walk

32:14

through it yourself, uh, just quickly.

32:17

And then we're gonna go through the answers.

32:18

So, um, you can see this is a left ovary,

32:22

9.2 centimeters in length.

32:24

Um, there's something going on

32:26

with respect to these septations.

32:27

And so let's move forward.

32:31

So if you've got your app in front of you

32:33

and you haven't sort of done this

32:34

or haven't figured out where you're at and,

32:36

and got the answer, then we'll walk through it step by step.

32:39

So if you're on your app,

32:40

you can see this is an ovarian lesion.

32:42

You can assume that 'cause I, um,

32:45

but this is an ovarian lesion

32:47

and if you follow the app, it asks, uh, about

32:50

what step of the lesion this is.

32:51

Uh, this is an other lesion, oh, oh, sorry, okay, sorry,

32:55

I'm getting distracted by the chats.

32:56

Okay. Um, it's an other lesion.

32:59

And so if we continue on here, uh, it's cystic

33:01

with no solid component.

33:03

Uh, it has smooth septations, it is multilocular.

33:07

So you can see that there are at least,

33:09

uh, three components here.

33:11

There's actually four. Um, the color score is one to three.

33:14

It's not screamingly vascular,

33:15

but it certainly isn't, you know, uh, too low,

33:18

but it's also less than 10 centimeters.

33:20

There is no ascites

33:21

or peritoneal nodules that have shown you if there were.

33:24

And so this is an RADS three lesion.

33:27

So there's a one to 10% chance of ri

33:29

of malignancy on this lesion here.

33:31

So we call it an RADS three.

33:33

They ultimately did this MRI

33:35

and on the MRI here, uh, same case, you can see, oh,

33:38

here, I'll run through it this way.

33:40

You can see those septations there.

33:42

Uh, you can see it's fairly big, um, nine centimeters.

33:46

And uh, you don't see that color score, uh, there,

33:49

the little vascularity that we saw on, uh, on r

33:52

uh, ultrasound.

33:54

But, uh, they took this out.

33:55

This turned out to be a benign mucin cystadenoma, uh,

33:58

on path, which I mean is in keeping with that OAD score.

34:02

So, um, there's the case one.

34:05

So that case did have some doppler.

34:08

And so one of the things you have to be really careful about

34:09

with respect to doppler is

34:11

that you're doing your doppler correctly.

34:13

'cause day in and day out,

34:15

and I'm really harp, I really harp on my text about this.

34:17

I literally did this to the poor tech student yesterday, um,

34:20

where they showed me a case like this and uh,

34:23

and they put this huge box around it

34:25

and said, look, there's no, there's no color here.

34:27

Uh, I'm really happy with this

34:29

and you should not be really happy with this.

34:31

Uh, so this is the same patient.

34:34

Uh, and you can see

34:35

what they have done here is they have confined the box down

34:38

to where they really wanna see if there's color.

34:40

It's not the whole thing, it's

34:42

where they really wanna see it.

34:43

So decrease the box size to, to what it is

34:45

that you wanna look at in ultrasound.

34:47

Make sure your scale is appropriate.

34:49

The number of times that I have had technologists tell me

34:52

that, you know, there's no color here

34:53

and their scale is at 24 or 22 or 21 or whatever,

34:58

and you're looking at one of these things, they should be

35:00

around four centimeters a second.

35:02

Um, the default for a lot of machines is somewheres

35:05

around 20 centimeters a second,

35:06

especially if you're doing intraabdominal organs, um,

35:09

and falls quite correctly.

35:11

Um, make sure they crank that scale down.

35:14

'cause these, the flow in these are not

35:16

that fast for the most part.

35:17

Color score four excluded.

35:19

Uh, if you want to see if there's a color score, two

35:21

or three, you're gonna miss 'em every time.

35:23

Uh, you PRF most people don't mess with,

35:25

but if you take a look, it should be

35:28

between three and six megahertz.

35:29

If you are unsure if there is vascularity, that's true.

35:32

And we've all seen flashes before where a tech has shown you

35:35

and you're like, oh, there's a lot of color there.

35:37

I don't know what's real. Have them put spectral

35:39

on it, takes 'em no time.

35:40

Uh, and it'll solve all your problems.

35:43

So if there's two things I want you

35:45

to remember outta doppler, it's decrease the box size

35:47

and make sure the scale is right.

35:49

Um, if you want, if you have space in your head

35:51

for one more thing, spectral, spectral everything

35:53

that you're not sure about, uh,

35:55

because if they can't spectral it, in my mind it's not real.

35:58

Okay? Uh, so this is the next case. So here we go.

36:03

We've got a right ovarian lesion.

36:05

You can see it's 6.5 centimeters there, uh,

36:09

in maximal diameter,

36:10

although you can do your average diameter

36:11

of 6.5 plus 5.1 plus 5.4 ti over three.

36:15

Um, which will give you somewhere around, you know,

36:18

5.5 or so.

36:21

But you can see here there's a little nodule.

36:23

And again, uh, I tried to fool you

36:25

because our tech measured every bit of this

36:27

'cause they couldn't remember which bit of it to measure.

36:29

So I would suggest that you don't go by measurement three.

36:32

You don't go by measurement one, you go by measurement Two.

36:35

It's like a mountain measured,

36:36

like a mountain from bottom to top.

36:37

It's not about how wide the mountain is all.

36:40

So measurement two here, four millimeters. Okay?

36:43

So we got a four millimeter projection sitting off of there.

36:46

They've even put color on

36:47

what could they do better While they could have

36:49

turned the scale down a little bit.

36:50

But in this case, when they did that, they got a lot

36:52

of flash and they could have made this a bit smaller

36:54

that, uh, sufficed it.

36:56

At least they made the box a little bit smaller.

36:57

So I'll take that. So I'll give you three seconds

37:02

to take my coffee and then we're gonna walk through.

37:06

Here we go. So again, this is an ovarian lesion.

37:09

Um, it is an other lesion.

37:11

This isn't one of your benign physiologic ones,

37:13

but in this case, it actually

37:14

does have some solid components.

37:16

It's cystic with some solid components. It is ocular.

37:18

You don't see any septations in this thing.

37:20

And again, coming back to

37:21

what I had said earlier when we were going through the, uh,

37:24

RADS two, three categories, the complexity

37:26

of the fluid doesn't actually matter.

37:28

You can see there's internal echoes in this one.

37:30

Makes no difference. Uh, it's a unilocular thing.

37:33

There are less than four papillary projections.

37:35

You can see there's just the one there, uh, with no ascites

37:39

and no peritoneal nodules.

37:40

So what have we got here? Well, we've got an

37:42

OAS four lesion.

37:43

And so this is 10 to less than 50% risk of malignancy.

37:47

Um, they took this out, uh, without doing an MRI.

37:50

Uh, and this was a, a borderline s cystadenoma on pathology.

37:54

Uh, so, um, again, it doesn't, it is in keeping

37:58

with the pathologic proven data.

38:00

Um, and you know, even just doing quality assurance on,

38:03

on some of these in own, uh, site, uh,

38:05

that is, uh, what we see.

38:07

So, uh, I'm a big fan of rads. It's working. So here we go.

38:12

Uh, so one of the pitfalls with respect to cystic lesions

38:15

that I wanted to talk about is the idea of a daughter cyst.

38:18

Um, I could ask this from the residents, not infrequently.

38:21

Well, I see this one septation

38:23

and then there's this other one and I'm really working

38:25

'cause it's a multilocular cys.

38:26

This is an RADS four or five.

38:28

And I look at it and I'm like, well

38:30

this is actually a ocular cyst.

38:32

A daughter cyst is another follicle

38:34

that is sitting in the ovary

38:35

and volume averages into the cystic lesion.

38:38

Uh, it's not a multilocular cyst. The way you can tell.

38:41

They have these, um, acute margins here with the,

38:45

uh, ovarian wall.

38:47

They sort of sweep in and out.

38:48

They usually see it on the edges and they're nice and round.

38:51

They are, they look like follicles.

38:54

And so if you see this, uh, don't count it as part

38:57

of the original lesion, just say it's

38:59

another follicle and leave it alone.

39:00

I just consider them follicles and I ignore them.

39:03

Um, if you wanna say that there's a daughter cyst

39:05

that's totally, or daughter follicle is totally fine.

39:07

Uh, but in OAD scoring, you would count this

39:09

as a bi oulu cyst.

39:10

You would ignore the daughter follicle.

39:12

Um, and so I encourage you to do so. Don't get confused.

39:15

Tell all your residents, it's okay.

39:17

People can, uh, foll before they ovulate. Okay?

39:22

Uh, next case. Uh, okay, I'll give you a bit.

39:27

You can see there's a left and next lesion here.

39:30

Um, it's six and a half centimeters in, in one diameter.

39:34

So you can take that as you will.

39:35

Um, there's a doppler score here so you can determine

39:39

what you think about that Doppler score.

39:41

Is it really, really, uh, high flow? Is it kind of middle?

39:44

Is it no flow or low?

39:47

We'll give you time for me to sip my coffee.

39:52

Okay? I'll give you a clip here.

39:54

And I find the clips are fantastic. I love clips.

39:59

So this is that lesion. You can see it there

40:02

and you can see the uterus here.

40:04

So just ignore the uterus, focus on this

40:07

and I'll draw your attention to the margins.

40:10

If you can look that

40:13

Okay, It's probably enough time looking at that.

40:16

Gonna make people sick. Okay? So this is an ovarian lesion.

40:19

Uh, it is an other lesion.

40:22

Uh, again, it's not physiologic, it's fully solid

40:24

or at least 80% solid.

40:26

Uh, now the reason I drew your attention to

40:29

that clip is it really brings out that irregular contour.

40:31

You can see it behind here. It's not a nice round smoothing.

40:34

There's some contour irregularity.

40:35

The second you say that there's cont irregularity, boom,

40:38

it spits out OS five.

40:40

And that is absolutely correct in this case, uh,

40:43

of endometrial carcinoma.

40:44

Uh, so irregular margins shove you right into the five

40:49

category right away if it's a solid lesion.

40:52

Now I bring forward this case

40:53

because it's a bit subtle to see that honestly.

40:56

Um, it wouldn't surprise me to have, you know,

40:57

a staffer resident, uh, potentially miss that,

40:59

especially if they don't do a lot of rads.

41:02

So let's say just hypothetically that you decided

41:05

that this is an ovarian lesion, it's another lesion.

41:08

It's solid, but it's a smooth cont.

41:10

Let's say you forgot all about what lobulated looks like.

41:12

The the old red calculator actually has a little, uh,

41:14

picture thing beside each, uh, category.

41:17

And you can click on it, it'll

41:18

show you what it's talking about.

41:19

I really like it for that. But let's say you get this one

41:22

wrong and it's smooth.

41:24

Well, let's non shadowing.

41:25

So if you follow down the smooth pathway,

41:26

it actually spits out these, these questions.

41:28

Is it shadowing an on?

41:29

This is non shadowing,

41:30

it's a color score four, it's really vascular.

41:32

Look at those arterial wave forms.

41:34

This is still an RADS five.

41:36

So even if you mess this up, um, you still come

41:39

to the right answer because there's

41:40

so many ancillary features in this case

41:41

that say it's an RADS five.

41:43

And so I kind of joked earlier that, you know, anyone

41:46

who looked was it's an RADS five

41:48

'cause they're really bad and most people don't miss it.

41:49

It's, it's true. Uh, even if you, if you muck up the,

41:52

the scoring system because you miss one of the things,

41:54

you're still probably gonna end up in the right place.

41:56

And again, this was endometrial carcinoma,

41:59

but I would suggest to you

42:00

that that was an irregular margin.

42:01

So another pitfall here is, is what if you see a lesion

42:05

that's solid or not solid and, and it's para ovarian.

42:08

Well, we kind of talked about

42:09

and in the uh, MRI rads MRI category that uh, if it's perva,

42:14

it doesn't matter as long as it is cystic.

42:17

It doesn't matter what the internal thing is

42:18

that it's an rads, uh, two, uh, and ORs MRI two.

42:22

And uh, and that is true, uh,

42:25

but in ultrasound, uh,

42:26

it actually does matter if it's solid or not.

42:28

And so, um, here's a case of, uh, perva.

42:33

How do you tell if it's perva?

42:34

Well, I always tell our techs

42:36

and our residents take the probe, put it on the ovary

42:39

and in between the lesion and the ovary and push.

42:42

And if they slide together, then their ovarian,

42:44

if they slide apart their perva,

42:46

you can see here this lesion here is sliding.

42:49

Apart from there, this was actually a neurofibroma, uh,

42:52

adjacent to the ovary, but not on the ovary

42:54

completely separate from it.

42:55

Um, so this is not ovarian.

42:57

And so I just wanted to, uh, show that push sign

43:00

'cause it is so important for figure

43:01

something as ovarian a pair of variant.

43:03

Um, you can't do it in MRI obviously you rely on anatomy,

43:06

but in ultrasound it can be more dynamic than you think.

43:08

So I strongly encourage everyone to, to give this a whirl.

43:11

If you see something that you think is

43:12

maybe ovarian, maybe not.

43:13

We do it all the time in a topic. It is like game changing.

43:16

So, okay, that's enough of that, uh, final case here.

43:21

Uh, so this one, this is off of an ovary.

43:24

I know it says midline, but this is actually the left ovary.

43:27

Um, you can see that it's gigantic.

43:28

It's at least 10, 10 and a half centimeters.

43:31

Um, so I'll let you take a look at that.

43:34

Everyone knows what they're gonna call it anyway, regardless

43:36

of the, uh, regardless of the score.

43:38

But we're gonna do it anyway. Uh, this is ovarian.

43:41

Uh, it is another lesion. It is solid.

43:45

It has an irregular contour. You can see these loation here.

43:48

It doesn't have to be fully irregular.

43:49

You can see this margin here is smooth.

43:51

Any irregularity counts as irregularity.

43:53

So this was immediately over. That's five. What a surprise.

43:56

Uh, I don't actually have path on this yet.

43:58

Um, this was a case from, uh, a little bit ago.

44:02

Uh, and so we haven't taken it out yet,

44:04

but this person has peritoneal metastases.

44:05

On, on, on ct. Uh, you can see the actual ascites here.

44:09

This doesn't even get into the ascites score.

44:11

You can see in the calculator. It doesn't even hit it.

44:13

'cause as soon as they hit irregular contour

44:15

it, it negates everything else.

44:16

You don't need to know if there's ascites.

44:18

Uh, but you can see

44:19

that there is complex fluid on this, uh, case here.

44:22

So, so one last, uh, pitfall for you.

44:27

Uh, this is a case of mine. When I was making this talk.

44:29

Uh, I looked it up thinking, oh man,

44:31

this is a great case of disc gerin.

44:33

Uh, and so you can see this o over here.

44:36

It's huge 6.6 centimeters, very complex looking

44:38

with this weird sort of mass like appearance.

44:41

The follicles are all displaced.

44:42

Uh, here on this clip you can see there's a big cystic

44:45

component as well associated with this.

44:47

You couldn't separate them off. Um, it looked really bad.

44:51

Uh, and here we go. Okay.

44:54

And on MRI, um, here you can see that same thing.

44:58

Big cystic component, big cell component.

45:00

The cell component looks really funny on M mri.

45:02

Here's a T one just to, to show you

45:04

that there's no fat in it or no microscopic fat in it.

45:07

But the T two here, very strange appearance.

45:11

Uh, they took this out.

45:13

It was actually actin mycosis, um,

45:17

infection can fool you.

45:18

Uh, the OAD score on this would've been five.

45:21

Um, but you can get fooled with infection, uh, for sure.

45:25

So keep it to the back of your mind.

45:27

People that are at high risk, uh, tb, uh,

45:30

if they've had previous surgery, uh,

45:31

this person had actually had a ruptured appendicitis, um,

45:35

and had had grumbling pain for a while.

45:37

And so, um, uh, you can get fooled.

45:41

I was totally fooled by this case.

45:42

So meia culpa, uh, let's keep going here. So that's the end.

45:46

I'm sure everyone feels like all these people on the field

45:49

here at the university, uh, wiped out.

45:51

I know I do. Uh, 'cause that's a lot of talking for me,

45:54

but, uh, I hope you enjoyed that.

45:56

I'm happy to take any questions.

45:58

Thank you so much Dr. Fung. Yes.

46:00

And at this time we will open the floor

46:02

for any questions from our audience.

46:03

You may submit your questions through the q and a feature.

46:08

And Dr. Fung, it looks like we've got three questions

46:10

already in there, if you're able to pull that box up.

46:15

Oh, sure. Got it. Here. There we go. Okay.

46:17

Do we know what the punctate,

46:18

echogenic foci in the periphery

46:20

of endometrial represents histologic

46:22

micro calx question mark?

46:24

Uh, yeah. Um, usually they're calcifications

46:26

or microcalcifications that, that's what I've seen.

46:29

Um, the concern is if they, they turn into masses.

46:33

Um, oh, I'd like to answer this question live.

46:36

I hope everyone can see, hear that. Okay, there we go.

46:38

Usually the concern is if they turn into masses

46:40

or not, um, septal thickening

46:42

or sorry, uh, peripheral thickening.

46:44

Uh, again, the concern is can they turn into

46:46

endometrial carcinoma?

46:47

Those little echogenic foci do not.

46:50

Um, we, we see them, uh, from time

46:52

to time using more chronic endometriomas.

46:55

Um, but if they do become focal, uh, vascular masses, then

46:59

or not become, that's a bad term.

47:02

If there are vascular masses,

47:04

they're not usually associated.

47:05

But that is what we're looking for is vascular masses.

47:06

Not those little echogenic foci.

47:08

Those I don't get worried about at all.

47:10

Stroma ov, oh, sorry,

47:11

we gonna talk, start from the top here.

47:13

Okay. Uh, what should we do if the lesion is classic corpus

47:15

le t morphologically bmo,

47:17

but no ring of fire include color

47:19

range till we get ring of fresh.

47:20

We call it benign mass.

47:21

So in those cases where I can't get a good doppler,

47:24

and that happens, um, especially in some of the ovaries

47:27

that are way out to the side,

47:28

you can't really get on them very well.

47:30

Um, we call them classic corpus lutetia here.

47:33

Um, they're so common.

47:35

Uh, so the morphology is so typical that if,

47:37

even if you can't get the ring of fire,

47:39

we call them corpus lutetium.

47:40

So that's, that's what we do.

47:43

Uh, what if I'm assuming,

47:45

what if the lesion is T one hyperintense,

47:48

but T 2D WI dark, uh, I just had a case like this recently.

47:52

So in those cases, I personally consider them, uh,

47:56

still T 2D WI dark.

47:58

Um, I would go back to that table on pitfalls

48:00

and just make sure it doesn't match up with any

48:01

of those other features and ensure that it is not enhancing,

48:05

although I suspect it will be not enhancing, uh, assuming

48:07

that it is not enhancing, uh, I would go

48:10

by the T 2D WI dark.

48:11

The dark, dark feature is just so benign that, uh, that it,

48:15

it pushes me that way.

48:16

Could it have internal hemorrhage? It is possible.

48:19

Um, it could be, you know, an,

48:21

an endometrioma that does that.

48:23

Um, but again, these are benign lesions

48:25

and so I don't get fussed, uh, about that.

48:27

The dark, dark really strongly pushes to, uh, to,

48:31

uh, benignity.

48:33

Uh, so the question is what is what category str vera,

48:37

tumor vera, is it teratoma that is actually functional?

48:41

And so the, the teratoma itself is, uh,

48:45

is not necessarily causing, you know,

48:48

it is not a malignant thing.

48:49

So this is trying to get into malignant potential.

48:51

The functionality of the teratoma

48:53

is actually separate from rad.

48:54

So you would still call this, I would call this an RADS two

48:57

because it's a classic benign lesion, but

48:59

because they're having symptoms clinically,

49:01

they're probably gonna take it out.

49:02

Uh, so category two,

49:04

because it's not as long as CMA

49:05

doesn't have like big solid components.

49:06

If it has big solid components,

49:07

then it's gonna be a category four.

49:11

Um, do you inject a dynamic series contrast

49:15

or only if you're gonna do a curve?

49:16

Um, so that is up to use.

49:20

So every single site is gonna be different about that.

49:23

Uh, so we currently actually do a, uh, a single phase,

49:28

uh, to assess for enhancement.

49:30

And that is the recommendation.

49:31

If you're not gonna do dynamic curves.

49:33

Um, but I like dynamic curves.

49:36

I think there are a lot easier

49:37

to see personally even eyeballing them.

49:39

And it allows you the option

49:41

of doing a time intensity curve if you

49:43

have the software available.

49:45

Uh, so at our institution, we do only do a single phase,

49:48

uh, for most of these.

49:50

Um, but if I'm worried, I actually protocol them

49:53

as we would a prostate where we inject, uh, contrast

49:56

and then run every 13 seconds.

49:58

Uh, or, uh, sometimes I'll protocol them as,

50:01

as a quasi liver where we do like an arterial late arterial,

50:05

uh, portal venous phase and delay.

50:06

Uh, it depends on the lesion itself for those.

50:09

Um, but uh, it is institution dependent.

50:13

Uh, what, how they protocol

50:14

or how you protocol your contrast injection.

50:17

There isn't really a wrong answer.

50:18

If you read the reds MI, uh,

50:22

endometriosis endometrioma may show peripheral vascularity.

50:26

Uh, yes they can. Yeah, they can.

50:28

And you'll see that in a lot of lesions

50:30

that they can show peripheral vascularity.

50:31

Now some of that might be reactive from the ovary itself.

50:34

Um, but the key is do they have any internal vascularity?

50:37

I don't get fussed about, uh,

50:38

peripheral vascularity for the most part.

50:41

Um, endometriomas as, as we saw in one

50:43

of those slides there, uh, they have

50:45

that classic homogenous echogenic appearance.

50:47

And to push me, uh, as long all the components

50:53

will, using contrast enhanced ultrasound help narrow down

50:55

the differential and ovarian lesions.

50:57

Oh, I love this question.

50:59

I love contrast enhanced ultrasound.

51:01

The research is, is coming on contrast enhanced ultrasound,

51:05

but I can't say that there's sufficient evidence

51:08

to support it, um, uh, in the way that, you know,

51:11

we use Color Score and MRI,

51:13

but I, I personally believe that yes, it's going

51:16

to help narrow down the differential.

51:17

We just don't have the research yet to,

51:19

to really come down hard on things.

51:21

Uh, but I would encourage anyone, uh, who is capable

51:25

of doing it and see what that shows.

51:27

Because like Contrast n its ultrasound is, is, uh,

51:30

is an amazing tool

51:31

and I think it's really gonna help, uh, figure out and,

51:34

and we use it for problem solving right now.

51:36

Uh, if there's a lesion that is,

51:39

uh, actually enhancing or not.

51:40

Those, those lesions that I showed with Retractile clot

51:43

or papular projections, they're not always clear.

51:45

And so they really, it really helps to have the resolution

51:48

of ultrasound and the, uh,

51:50

and information from the contrast.

51:51

So I love that question. Thank you.

51:54

Do we need to put RADS

51:55

and Aorta category side

51:56

by side the impression, or we choose one?

51:58

Uh, again, institution dependent.

52:00

If you look at the, uh, a CR uh, website, uh,

52:04

they have report templates where they include

52:06

or do not include the IOTA category.

52:09

Um, it is up to your referring providers

52:12

and your groups, uh, for what they would like to do.

52:14

Um, the ODS category should be there,

52:17

but the IOTA category, as I said, uh, during the lecture,

52:20

can really, if you have patients, uh,

52:22

that get their reports, they can really get scared

52:24

by the risk of malignancy.

52:25

And so a lot of places choose not to have

52:28

that IOTA category in there.

52:30

Um, but conversely, uh, many places do

52:32

because their reports go to their referring

52:33

docs, they're referring docs, find it helpful.

52:35

So, uh, if you're gonna choose one, choose the RADS one.

52:39

Um, we only use rads.

52:41

I don't usually put the risk of malignancy

52:42

'cause our patients can see their reports.

52:44

Um, but, uh, it's a group decision. There's no wrong answer.

52:48

There is a lack of do flow on ultrasound Reassuring.

52:52

Uh, great question, aji. Thank you.

52:54

Um, as i, I highlight in the pitfall, it is reassuring if,

52:58

uh, you've done the Doppler correctly.

53:00

Um, I get very skeptical about a lack of doppler flow,

53:04

Doppler flow on solid lesions.

53:06

I personally believe that usually, usually, uh,

53:09

if there is a lack of doppler flow on a solid lesion is

53:12

because my tech has done something, uh,

53:14

where they haven't optimized the

53:15

lesion as well as they could.

53:17

Uh, but in general, if it's done well,

53:19

yes, it is reassuring.

53:20

Um, I didn't talk about this in the talk,

53:22

but, uh, one of the things I always have them do if they

53:24

don't see flow, and I think they've optimized it really

53:26

well, is, is make sure they put a power, uh, clip on.

53:29

Uh, or if you have micro flow, try that.

53:32

Um, both of those are really good, uh, uh,

53:35

to, to assist up the flow.

53:36

But in general, yes it is

53:37

because as you saw,

53:38

the color score four really pushes you high

53:41

and you don't tend to miss color score four.

53:42

They're really, really obvious no matter

53:44

how bad your technique is.

53:46

So, um, long, long answer for a short question.

53:50

Uh, yes, it is generally reassuring.

53:55

Awesome. I think you got 'em all. Dr. Fung.

53:58

Yeah, I guess so.

54:00

Well, thanks everyone for coming and,

54:01

and thanks for modality for, for having me.

54:03

There's a references that I used, uh,

54:05

today if anyone would like them. But

54:07

Yes, thank you so much for, uh, sharing your expertise

54:10

with us today and taking the time

54:12

to answer all the questions.

54:14

And thanks to all for participating in our noon conference

54:17

and asking great questions.

54:19

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54:21

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54:23

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54:24

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54:29

Be sure to join us on Wednesday,

54:30

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54:33

Mahan Mather will deliver a lecture entitled review

54:36

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54:40

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54:43

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54:47

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