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BENIGN vs MALIGNANT

Ovarian masses can be classified as either benign or malignant using simple ultrasound features.

Several scoring systems have been developed in classifying these masses.

In the latest International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), they
have recommended the use of IOTA Scoring system, which makes use of a set of 10 ultrasound
rules that classify ovarian masses into benign, or malignant masses, otherwise known as B-rules
or M-rules. [1]

B-RULES M-RULES
B1 Unilocular M1 Irregular solid tumor
B2 Presence of solid component, M2 Presence of ascites
Largest diameter <7mm
B3 Presence of acoustic shadows M3 At least 4 papillary structures
B4 Smooth multilocular tumor with M4 Irregular multilocular solid tumor with
largest diameter <100mm largest diameter >= 100mm
B5 No blood flow M5 Very strong blood flow

The IOTA SS has a sensitivity of 95% and a specificity of 91%.


The presence of M1, M2, M3, and M4? yields a score of 4M features and no B features; which
denotes that the patient has a VERY HIGH RISK OF MALIGNANCY, giving her a 47- 99%?
estimated individual risk of malignancy. [2]

However, in the latest Philippine Society of Ultrasound in Obstetrics and Gynecology (PSUOG)
guideline, in the absence of color flow, which is true for this case, the Sassone scoring instead
of the IOTA SS will be utilized. With a specificity of 83% and sensitivity of 100%, this scoring
involves evaluation of the inner wall structures, wall thickness, septa and echogenicity. A score
greater than or equal to 9 is considered malignant. That of the patients Sassone score is 10,
which strongly suggests that the ovarian tumor is malignant. [1]

VARIABLE VALUES

1 2 3 4 5

Inner wall Smooth Irregularities Papillarities (>3 mm) N/A Mostly solid
structures (<3 mm)
Wall Thin (<3 Thick (>3 Mostly solid
thickness mm) mm)
(mm)
Septa (mm) No Thin (<3 mm) Thick (>3 mm )
septa
Echogenicity Sonoluc Low Low echogenicity Mixed High
ent echogenicity with echogenic core echogenicit echogenicit
y y
Aside from ascites, it is also cited in Comprehensive Gynecology that the presence of pleural effusion,
can be associated with malignancy owing it to the inability of the parietal pleura to reabsorb pleural
fluid because of the involvement of mediastinal lymph nodes by the tumor.

Another theory of having higher risk of malignancies is associated with frequent ovulation, in which
women who ovulate regularly appear to be at higher risk. This puts the patient at a higher risk as she is
nulligravid. [3]

Another is the personal history of breast cancer which results from mutation in BRCA1 and BRCA2
genes, the same genes that are also involved in hereditary ovarian cancers. Familial Ovarian Ca could
occur in women approximately 10 years younger than those with nonhereditary tumors. The patient, a
38y/o has an underlying history of breast cancer, which again, further supports a higher likelihood of
malignancy. [4]

REFERENCES:
[1] A retrospective study on the accuracy of sassone, lerner and IOTA simple rules in determining
malignancy of
ovarian masses in a tertiary hospital ob-gyn ultrasound diagnostics unit*
[2] IOTA Simple Rules
[3] Comprehensive Gynecology p 765
[4] Novaks Gynecology p 2338?

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