What is the diagnosis of a complex cystic lesion with both simple and heterogeneous areas?

From the Guidelines

A complex cystic lesion with both simple and heterogeneous areas should be classified using the O-RADS US risk stratification and management system, which provides a standardized approach to evaluating adnexal lesions and guiding management decisions 1.

Key Considerations

• The O-RADS system categorizes lesions into five categories: O-RADS 0 (incomplete evaluation), O-RADS 1 (normal ovary), O-RADS 2 (almost certainly benign), O-RADS 3 (low risk), O-RADS 4 (intermediate risk), and O-RADS 5 (high risk) 1.
• The presence of both simple and heterogeneous areas within a cystic lesion suggests a non-simple unilocular cyst or a multilocular cyst, which would be classified as O-RADS 3 or higher, depending on the size, wall characteristics, and color score 1.
• Lesions with irregular inner walls, solid components, or high color scores are associated with a higher risk of malignancy and would be classified as O-RADS 4 or 5 1.

Management Approach

• For lesions classified as O-RADS 3 (low risk), management may include follow-up ultrasound in 8-12 weeks or referral to a specialist for further evaluation 1.
• For lesions classified as O-RADS 4 (intermediate risk) or O-RADS 5 (high risk), management typically involves referral to a gynecologic oncologist or a specialist for further evaluation and possible surgical intervention 1.
• The O-RADS system provides a framework for risk stratification and management, but clinical judgment and patient-specific factors should also be considered when making management decisions 1.

From the Research

Diagnosis of Complex Cystic Lesions

The diagnosis of complex cystic lesions with both simple and heterogeneous areas can be challenging.

• Complex cystic renal masses (Bosniak type III) can have benign and malignant causes, and have been traditionally considered surgical lesions 2.
• The incidence of malignancy in complex cystic renal masses can be determined through imaging-guided biopsy, which can help identify nonmalignant lesions and avoid unnecessary surgery 2.
• Complex cystic masses in the breast are defined as lesions composed of anechoic (cystic) and echogenic (solid) components, and require histological verification by percutaneous biopsy and/or surgical ablation 3.
• The etiology of complex cystic breast masses can be diverse, and can be benign or high risk, as well as malignant 3.

Diagnostic Techniques

• Fine-needle aspiration (FNA) of cystic lesions of the kidney can be used to diagnose complex cystic lesions, but interpretation of the FNA specimens remains challenging 4.
• Computed tomography (CT) remains the gold standard for diagnosing complex renal cysts, but newer diagnostic imaging modalities such as contrast-enhanced ultrasonography are demonstrating promising results 5.
• Percutaneous biopsy of complex cystic renal masses can be well tolerated and adequate for diagnosis, and can help identify malignant features 5.
• The Bosniak classification is a valuable tool for clinicians to diagnose and manage complex renal cysts, but interobserver variability can influence the diagnosis 5.

Malignant Potential

• Complex solid and cystic breast masses carry a malignant potential between 23-31% and require further evaluation with biopsy 6.
• Cystic renal cell carcinoma represents 5-7% of all renal tumors, and the ability to differentiate between benign and malignant complex cystic renal masses remains a major challenge 5.
• Regular surveillance or biopsy may be necessary to identify malignant features in complex cystic lesions, as there may be no other way to determine malignancy 5.