1. Adnexal Cyst Follow-up
When to Image Based on Choosing Wisely® and Society of Radiologists in Ultrasound (SRU) Consensus Conference Statement
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2. 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
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Intro to what the program is about and its benefits.
Website is
Time commitment: staff time dedicated to an R-SCAN project ranges from 15 to 30 hours over a three- to six-month period.
You can also gain experience using a clinical decision support (CDS) tool; gaining experience with CDS now will help referring clinicians be prepared for the implementation of federal reimbursement requirements for CDS consultation prior to ordering advanced imaging. This alternative to pre-authorization reduces time and expense for practices and patients when imaging is the next step in the diagnostic process.

3. Why Participate? R-SCAN Offers:
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
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Participants earn improvement activity credits.
More here:
Information about Protecting Access to Medicare Act here:

4. Problem: Unnecessary Imaging Follow-up for Asymptomatic Simple Adnexal Cysts
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.
The problem statement
More information on the issue here:
References:
Ekerhovd E, Wienerroith H, Staudach A, Granberg S. Preoperative assessment of unilocular adnexal cysts by transvaginal ultrasonography: a comparison between ultrasonographic morphologic imaging and histopathologic diagnosis. Am J Obstet Gynecol. 2001;184(2):48–54.
Levine D, Brown DL, Andreotti RF, et al. Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology. 2010;256(3):

5. 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 follow- up imaging is not necessary for clinically inconsequential adnexal cysts
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Choosing Wisely includes 150 patient-friendly resources and more than 500 specialty society provided recommendations.
Learn more:

6. 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:
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Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement: 6

7. 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
Complex
Note the complexity, eg, septations, wall thickening, nodules
If it is not simple, it is complex
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8. When Follow Up Imaging in Indicated in Asymptomatic Patients
Pre-menopausal
Post-menopausal
No follow up
Simple Cysts ≤ 3 cm: No need to mention in report
Simple Cysts > 3 and ≤ 5 cm: Describe in the report stating they are almost certainly benign
Cysts ≤ 1 cm: At the radiologist’s discretion to describe in the report
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
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*Some practices may opt to increase the lower size threshold for follow-up from 1 cm to as high as 3 cm. One may opt to continue follow-up annually or to decrease the frequency of follow-up once stability or decrease in size has been confirmed. Cysts in the larger end of this range should still generally be followed on a regular basis. 8

9. Indeterminate Cysts
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.
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10. 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.
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Patient handout:

11. Getting Started With R-SCAN rscan.org Standard template
To access ACR Select, visit the R-SCAN site and click on “Start your project.” 11

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Log in with an ACR username/password. If you don’t have an ACR username and password, the R-SCAN team can provide one. 12

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Click on “Practice with ACR Select.”

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Check out the instructions for how to enter data and then click on the “Enter case data” button to explore the AC guidelines and exam ratings.

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Here’s an example:
Enter a patient’s age and gender.
Select the body area of interest.
Search on a clinical indication.
Select the indication that’s the best match.
Review the appropriateness score and note the associated cost and radiation exposure.
Select the exam.

16. R-SCAN Adnexal Cyst Follow-up Educational Resources
Visit: rscan.org
Click: Resources
Click: Topic-specific Resources
Podcast
Imaging Order Simulation activity
Articles
Materials to share with patients
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A library of educational materials is available for each R-SCAN Choosing Wisely topic. 16

17. Next Steps Define the group’s goal Define participants and roles Tasks
Ensure consistency in follow up
Provide definitive follow up guidance
Promote adherence to guidelines
Define participants and roles
Tasks
Identify cases
Review cases for baseline
Plan and implement the educational intervention
Review cases for post education improvements
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18. Self-Assessment Question
Which are characteristic of a simple cyst (select more than 1)?
Solid elements
Thick septations (≥3 mm)
Thin wall (<3 mm)
Completely anechoic
Answer: C and D

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

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22. 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.
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23. Questions?