Simple Adnexal Cysts: SRU Consensus Conference Update on Follow-up and Reporting

Abstract

T he Society of Radiologists in Ultrasound (SRU) convened a multidisciplinary consensus conference in 2009 to make recommendations for adnexal cyst follow-up. Our goal was to define characteristics of benign adnexal cysts to reduce surgical evaluation and imaging follow-up (1). Commensurate with the overall goal of the Choosing Wisely campaign to reduce unnecessary imaging (2), the consensus recommendations published in 2010 established size thresholds for benign-appearing cysts not requiring follow-up (Table E1 [online]). This effort was successful. One study (3) found that the guidelines reduced overall US utilization because of decreased radiologists' recommendations for follow-up of benign-appearing cysts, while another study (4) validated the guideline in mostly symptomatic women and suggested that the utility of the SRU framework was not limited to asymptomatic cysts. Recent large studies (5-7) showing no increased risk of malignancy in women with simple adnexal cysts irrespective of cyst size justify reevaluation of the 2010 SRU guidelines, specifically to address the follow-up and reporting of simple cysts. The consensus group met by teleconference from February through June 2019 under the auspices of the SRU, and consisted of 20 experts in US, gynecologic imaging, gynecologic pathology, gynecologic oncology, epidemiology, radiology, and minimally invasive surgery (Table E2 [online]). Before starting the phone discussions, three of the author group (D.L., M.D.P., D.L.B.) reviewed the literature in Tables E3 and E4 (online) (with each article having at least two reviewers) and made the summary information from the literature, along with reasons for exclusions of studies, available to the larger group. The pathology expert (J.H.) did not participate in votes regarding clinical recommendations. We used a modified Delphi model for discussion and voting cycles among experts. In this article, we use the term strong consensus when there was greater than or equal to 90% agreement among the 19 voting panelists (18 individuals), moderate consensus for recommendations based on greater than or equal to

Surveillance in Older Women With Incidental Ovarian Cysts: Maximal Projected Benefits by Age and Comorbidity Level

“…For many such patients, follow-up may be considered overly burdensome or unnecessary. For women who are not surgical candidates, or whose cyst meets SRU criteria for deferring follow-up, our findings underscore the importance of avoiding unwarranted surveillance imaging [9]. To provide context for estimates presented in the present analysis, in the setting of colorectal cancer screening programs (with colonoscopy) beginning at age 50, researchers have projected LE gains ranging from 90 to 100 days per person screened, using mathematical models [22].…”

“…1). This length of follow-up was elicited from SRU recommendations for simple ovarian cysts >3 to 5 cm detected in postmenopausal women; the higher end of this size threshold is noted to be for "exceptionally wellvisualized simple cysts" [9].…”

“…In the follow-up strategy, women underwent annual imaging surveillance for 2 years [9]. In the base-case analysis, if a suspicious cyst was detected during follow-up, we assumed that patients were treated and underwent laparoscopic salpingo-oophorectomy before the cancer spread.…”

“…Regardless, many women with simple adnexal cysts undergo ultrasound surveillance. Current Society of Radiologists in Ultrasound (SRU) recommendations suggest follow-up for adnexal cysts >3 to 5 cm detected on ultrasound [9]. Current ACR Incidental Findings Committee recommendations suggest follow-up for simple adnexal cysts >3 cm that are detected on CT [10].…”

“…In reality, most radiology practices experience wide variability in referral patterns for ovarian cysts [11]. It is not uncommon for postmenopausal patients to undergo serial ovarian imaging over several years for ovarian cysts-for smaller cysts and longer time periods than would be supported by existing recommendations [9,10]-without a clear end point. The drivers of such variability are likely multifactorial.…”