American College of Radiology

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Released April 4, 2012; updated June 29, 2017

Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts.

Simple cysts and hemorrhagic cysts in women of reproductive age are almost always physiologic. Small simple cysts in postmenopausal women are common, and clinically inconsequential. Ovarian cancer, while typically cystic, does not arise from these benign-appearing cysts. After a good quality ultrasound in women of reproductive age, don’t recommend follow-up for a classic corpus luteum or simple cyst <5 cm in greatest diameter. Use 1 cm as a threshold for simple cysts in postmenopausal women.


These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

(1-5) The American College of Radiology (ACR) initially solicited expert opinion from physician leaders with its Board of Chancellors. A working group was then formed to further identify common clinical scenarios in which imaging may be misused and should be reconsidered. Members of the group included the physician chairs or vice chairs of seven ACR commissions such as Quality and Safety, Appropriateness Criteria and Metrics. An initial list of topics was narrowed down based on the highest potential for improvement, representing a broad range of tests and the availability of strong guidelines. Members then researched specific recommendations and evidentiary statements based on their expertise. Recommendations that were too general or were well covered by other existing measures and initiatives were eliminated to identify the final five things list.

(6-10) The Choosing Wisely initiative was presented to the organization’s physician leaders at a Board of Chancellors meeting and a working group selected five initial low-value imaging targets for reduced utilization. The second set of targets was created by the following working group, with the goals of minimizing unnecessary imaging and biopsy generated by discovery of incidental findings, improving patient safety through reduced radiation exposure, and reducing unnecessary consultations based on imaging findings.

  • Pamela T. Johnson, MD, Chair, Choosing Wisely Recommendations
  • Jacqueline A. Bello, MD, FACR, Chair of Commission on Quality and Safety
  • Mythreyi B. Chatfield, PhD, Executive Vice President for Quality and Safety
  • Jonathan Flug, MD, MBA, Quality Management Committee
  • Jenny K. Hoang, MBBS, lead author on ACR White Paper for Managing Incidental Thyroid Nodules
  • Alec J. Megibow, MD, MPH, FACR, Committee on Economics – Body Imaging Commission
  • Pari V. Pandharipande, MD, MPH, Chair of Committee on Incidental Findings
  • Saurabh Rohatgi, MD, Committee on Quality Experience – Commission on Patient and Family Centered Care

Research: For the topics related to incidental findings on imaging exams, the American College of Radiology has created evidence-based white papers to provide guidance to practicing radiologists on making management recommendations. The white paper publications and additional relevant literature serve as the evidence supporting those recommendations. For the remaining recommendations pertaining to body CT protocol design, published literature was reviewed to define acceptable indications for multiphase protocols.

ACR’s disclosure and conflict of interest policy can be found at www.acr.org.

Sources

Levine D, Brown DL, Andreotti RF, Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology 2010 256:943-54.

Harris RD, Javitt MC, Glanc P, Brown DL, Dubinsky T, Harisinghani MG, Khati NJ, Kim YB, Mitchell DG, Pandharipande PV, Pannu HK, Podrasky AE, Royal HD, Shipp TD, Siegel CL, Simpson L, Wall DJ, Wong-You-Cheong JJ, Zelop CM; Expert Panel on Women’s Imaging.  ACR Appropriateness Criteria® clinically suspected adnexal mass. [Online Publication]. Reston (VA) American College of Radiology (ACR); 2012. Available at: https://acsearch.acr.org/docs/69466/Narrative/.

American College of Obstetricians and Gynecologists. ACOG Committee Opinion: number 280, December 2002. The role of the generalist obstetrician-gynecologist in the early detection of ovarian cancer. Obstet Gynecol 2002;100(6):1413–1416.

American College of Obstetricians and Gynecologists. ACOG Practice Bulletin. Management of adnexal masses. Obstet Gynecol 2007;110(1):201–214.

Patel, MD, Ascher, SM, Paspulati, RM, Shanbhogue, AK, Siegelman, ES, Stein, MW, Berland, LL. Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 1: White Paper of the ACR Incidental Findings Committee II on Adnexal Findings. Journal of the American College of Radiology, 2013; 10(9): p675-681

Timmerman D, Valentin L, Bourne TH, et al. Terms, definitions and measurements to describe the sonographic features of adnexal tumors: a consensus opinion from the International Ovarian Tumor Analysis (IOTA) Group. Ultrasound Obstet Gynecol 2000;16(5):500–505.