Adnexal Cyst Followup When to Image Based on

Adnexal Cyst Follow-up When to Image Based on Choosing Wisely® and Society of Radiologists in Ultrasound (SRU) Consensus Conference Statement

What Is R-SCAN? § Collaborative activity for referring clinicians and radiologists to improve patient care through clinical improvement § R-SCAN Collaboration Goals: § Ensure patients receive the most appropriate imaging exam at the most appropriate time based on evidence § ACR Appropriateness Criteria, other appropriate use criteria, and consensus statements § Reduce unnecessary imaging tests focused on imaging Choosing Wisely® topics § Lower the cost of care 2

Why Participate? § R-SCAN Offers: 3 § Data-driven system for moving toward value-based imaging and patient care § Opportunity to focus on highly relevant imaging exams to improve utilization § Collaborators can fulfill their Improvement Activity requirements under the MIPS § Easy way to practice with clinical decision support (CDS) technology § In preparation for PAMA § Free and immediate access to Web-based tools and CME activities

Problem: Unnecessary Imaging Follow-up for Asymptomatic Simple Adnexal Cysts 4 § High utilization of pelvic ultrasound results in the incidental detection of a large number of ovarian cysts. Among simple cysts in premenopausal women, fewer than 1% of simple cysts represent malignancy [1]. In postmenopausal women, the risk for ovarian malignancy is extremely low, with most demonstrating stability or resolution on follow-up. These findings are almost always of no clinical importance in asymptomatic women and can be safely ignored [2]. § Despite the low risk for malignancy in some cysts, however, it is common practice for radiologists to recommend surveillance and follow-up imaging. This can sometimes lead to unnecessary surgeries to remove a cyst that is unlikely to become cancerous or may have healed on its own.

Using Evidence to Guide Imaging Ordering § Choosing Wisely campaign § Collaborative effort between ABIM Foundation and over 70 medical specialty societies § Helps patients and medical professionals avoid wasteful or unnecessary medical tests, treatments, and procedures § The American College of Radiology recommends through the Choose Wisely campaign that followup imaging is not necessary for clinically inconsequential adnexal cysts 5

SRU Consensus Conference Statement § The Society of Radiologists in Ultrasound (SRU) convened a panel of specialists to arrive at a consensus regarding the management of ovarian and other adnexal cysts imaged at ultrasonography (US) in asymptomatic women. The conference made recommendations on: § § Which masses require no follow-up Which masses need imaging follow-up When this evaluation should occur Which masses warrant surgical evaluation § Full text is located here: https: //pubs. rsna. org/doi/full/10. 1148/radiol. 10100213 6

Categorizing Adnexal Cysts § Simple § Thin wall (<3 mm) § No calcification or septate § Completely anechoic (may not be when there is internal hemorrhage) § Through transmission § No solid components 7 § Complex § Note the complexity, eg, septations, wall thickening, nodules § If it is not simple, it is complex

When Follow Up Imaging in Indicated in Asymptomatic Patients No follow up Pre-menopausal Post-menopausal Simple Cysts ≤ 3 cm: No need to mention in report Cysts ≤ 1 cm: At the radiologist’s discretion to describe in the report Simple Cysts > 3 and ≤ 5 cm: Describe in the report stating they are almost certainly benign 8 US follow-up in 12 months Cysts >5 and ≤ 7 cm: Describe in the report stating they are almost certainly benign Cysts >1 and ≤ 7 cm: Describe in the report stating they are almost certainly benign* MRI or Surgical Evaluation should be considered Cysts >7 cm

Indeterminate Cysts 9 § A cyst that is otherwise simple but has a single thin septation (<3 mm) or a small calcification in the wall is almost always benign. Such cysts should be followed in a similar fashion as a simple cyst, as indicated by patient age and cyst size. § Other indeterminate features are multiple thin septations or a solid nodule without detectable flow at Doppler US. These findings are suggestive of neoplasms, most often benign. Irregularity or tiny areas of focal thickening of the cyst wall may be difficult to distinguish from a small solid component and thus are indeterminate for malignancy. § Cysts with either of these indeterminate features merit more attention. In a woman of reproductive age, this entails a short-interval follow-up (6– 12 weeks) with US or occasionally MRI.

Key Points: Talking With Patients Here are talking points to explain to patients why imaging follow-up is not necessary for benign, simple cysts: § Most ovarian cysts are low-risk for cancer, do not cause symptoms, and can be ignored. Simple ovarian cysts often appear during the menstrual cycle and heal on their own. § Research has shown that if the cyst does not show signs of cancer, cancer is not likely to grow later. § For cysts already classified as benign, repeated ultrasounds are highly unlikely to identify anything of value. 10

Getting Started With R-SCAN rscan. org 11

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R-SCAN Adnexal Cyst Follow-up Educational Resources 1. 2. 3. 16 Visit: rscan. org Click: Resources Click: Topicspecific Resources § Podcast § Imaging Order Simulation activity § Articles § Materials to share with patients

Next Steps 1. Define the group’s goal a. Ensure consistency in follow up i. Provide definitive follow up guidance ii. Promote adherence to guidelines 2. Define participants and roles 3. Tasks a. b. c. d. 17 Identify cases Review cases for baseline Plan and implement the educational intervention Review cases for post education improvements

Self-Assessment Question Which are characteristic of a simple cyst (select more than 1)? A. Solid elements B. Thick septations (≥ 3 mm) C. Thin wall (<3 mm) D. Completely anechoic 18

Self-Assessment Question At what size should a simple cyst be considered for immediate further imaging or surgical evaluation? A. <10 cm B. >3 cm C. >7 cm D. ≥ 5 cm 19

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Summary § Adnexal cysts are a common clinical finding on US. Most simple cysts under 10 cm are benign, with a risk of malignancy under 1%, and a majority of them resolve on their own. § Clinically inconsequential cysts, as outlined in this presentation, should not be recommended for follow-up imaging. Additional imaging is unlikely to uncover any useful, actionable information, and is more likely to identify conflicting, misleading information that may result in unnecessary surgical intervention. § Explain to patients concerned about ovarian cancer why their risk is negligible, and for those being seen for pelvic pain what their next options are. 22

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