O-RADS US Risk Stratification and Management System:

Case-based Learning Approach

for Daily Practice
Kalesha Hack, MD • Lori Strachowski, MD • Rochelle F. Andreotti, MD • Hournaz Ghandehari, MD
Priyanka Jha, MD • Christopher Lim, MD • Chirag Patel, MD • Phyllis Glanc, MD
Author affiliations.—From the Department of Medical Imaging, University of Toronto, Sunnybrook
Health Sciences Centre, MG160, 2075 Bayview Ave, Toronto, ON, Canada M4N 3M5 (K.H., H.G., C.L.,
C.P., P.G.); Department of Radiology and Biomedical Imaging, University of California, San Francisco,
San Francisco, Calif (L.S., P.J.); and Department of Radiology, Vanderbilt University, Nashville, Tenn
(R.F.A.). Recipient of a Magna Cum Laude award for an education exhibit at the 2021 RSNA Annual
Meeting. Received April 8, 2022; revision requested May 16 and received June 3; accepted June 8.
Address correspondence to P.G. (email: phyllis.glanc@sunnybrook.ca).

Disclosures of conflicts of interest.—L.S. Royalties from Elsevier for book chapters; honoraria for
lectures from World Class CME. R.F.A. Speaker payment from Philips Healthcare. P.J. Honorarium
from World Class CME Society of Radiologists in Ultrasound UC Davis; participation on a data safety
monitoring board or advisory board for and payment for expert testimony from Donahue, Durham
and Noonan, P.C. C.L. Collaborative Research Agreement with IBM Watson Health. All other authors
have disclosed no relevant relationships.
O-RADS US Risk Assessment and Management System

The purpose of this

presentation is to
provide the user with Case-Based Learning
the necessary Approach
foundation to use
the ACR O-RADS US in
daily practice.

Note.—ACR = American College of Radiology, O-RADS = Ovarian-Adnexal Reporting and Data System.
 Objectives

WHY?
WHAT?
• O-RADS US improves care by:
HOW? • Decreasing follow-up for lesions that will
spontaneously resolve or decrease in size
WHY? • Preventing surgery and potential complications for
women with benign adnexal lesions
• Promoting rapid referral to gynecologic oncology
services for women with suspicious lesions that
improves survival
 Objectives

HOW?
WHAT?
• To achieve optimal results:
HOW?
• Use the O-RADS US lexicon accurately and apply the
risk stratification and management system to
WHY? consistently characterize, report, and assess risk of
malignancy of adnexal lesions.
• Transvaginal US (TVUS) is encouraged; transabdominal
US may be sufficient when TVUS is not feasible.
 Objectives

WHAT?
WHAT?
• This case-based presentation will demonstrate:
HOW? • How to apply O-RADS US in your daily practice by
accurately using the lexicon and highlighting key
discriminatory features
WHY?
• Guidance of what to include in the imaging report
• Technical pearls and pitfalls to avoid
 The Ground Rules

Lexicon and scoring: Management:

applies to most adnexal lesions applies to average-risk patients
(uterine origin excluded) without acute symptoms

Multiple lesions: US specialist:

score separately; management driven experience with the appearance of
by highest score adnexal lesions on US images

Individual case management: modifiable by physician

 Imaging Basics: Important Definitions
TVUS TVUS TVUS

+ + +
+ +
Fig. 1 A Fig. 1 B + = ≥ 3 mm Fig. 1 C + = < 3 mm

Simple cyst with calipers (+) measuring Unilocular cyst with a papillary projection (calipers) Unilocular cyst with focal wall
the maximum diameter (dotted arrow) with fluid on three sides (arrows) thickening (calipers)

Lesion Size Papillary Projection (PP) Wall Irregularity

 Maximum diameter of the  Solid component protruding ≥3 mm  Focal wall thickening <3 mm in
lesion in any plane into the cyst lumen (height) and height; NOT considered a solid
surrounded by fluid on three sides component
 Imaging Basics: Color Score

CS 1 CS 2 CS 3 CS 4
No Flow Minimal Flow Moderate Flow Very Strong Flow
TVUS TVUS TVUS TVUS

Fig. 2 A Fig. 2 B Fig. 2 C Fig. 2 D

Multilocular cyst with Unilocular cyst with Solid lesion Multilocular cyst with
no solid component solid component (≥80% solid) solid components

Color score (CS) = subjective assessment of internal lesion vascularity

 Technical Pearl: Color Optimization
Fig. 3 A TVUS Teaching Points: Fig. 3 B TVUS

To accurately characterize
and not miss minimal flow,
consider:

• Pulse repetition
frequency (PRF) 0.3–0.6
kHz or velocity ≤4
cm/sec

• Small size of the color

Fig. 2 A Fig. 2 B Fig. 2 D
Doppler box
Small box over papillary projection shows NOTE: Spectral Doppler US is not
• Some flow within the
CS 2, minimal flow (arrow). Some flow in box next to the region required but may be useful to
adjacent tissues (arrowheads) suggests of interest differentiate true flow from artifact,
the technique is optimized for low flow. when in doubt.
 Getting Started: A Basic Algorithm
If it is not a physiologic finding or classic benign
lesion, then the lesion should be assessed by
using one of the five subcategories below.

Physiologic Other Lesions: 5 Subcategories

(Premenopausal group)
Follicle and corpus luteum  Unilocular without solid component
 Unilocular with solid component
Classic Benign Lesions
 Multilocular without solid component
 Multilocular with solid component

 Solid or solid appearing

Intraovarian Extraovarian
 Hemorrhagic cyst  Simple paraovarian cyst
 Endometrioma  Peritoneal inclusion cyst
 Dermoid  Hydrosalpinx
Continue assessment

O-RADS Charts
 O-RADS US Key Working Charts

Use this chart when the typical features listed here

are present in these classic benign lesions to
determine management.

Convenient tool
Charts reprinted under a CC BY-NC-ND license from the American College of Radiology (https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/O-Rads).
 ACR O-RADS
Use the O-RADS US App US Smartphone
(search App
“ACR O-RADS”)
Teaching Points:

• App available for iPhone (Apple) and Android

(Google)

• In the app store, search using the following terms:

“O-RADS”, “ACR O-RADS”, “ACR guidance,” etc

• Download, then click anywhere in the purple box

to begin.

• You will only be asked relevant questions to

quickly arrive at an O-RADS score and
management recommendation.

Dermoid cyst example

 ACR O-RADS
Use the O-RADS US App US Smartphone
(search App
“ACR O-RADS”)
Teaching Point: This top bar (dotted box) records your selections for easy reference for the imaging report.
It is also an “active” field, so you can step back at any point along the way to modify if needed.

Teaching Point: Image examples are available by clicking on the picture ( )

icon within the app.
 Case 1: 24-year-old premenopausal patient with irregular bleeding
Lexicon/Descriptors Sample Report 1:
TVUS Right Sagittal
 Simple cyst ≤3 cm
 Findings: Right ovarian 2-cm follicle.
Questions  Impression: Right ovarian follicle,
 Menopausal status? normal ovary (O-RADS 1).
 Premenopausal
 Postmenopausal  Management: No follow-up
required.
 Do I need to report this?
Fig. 4
 Yes
Gray-scale TVUS image shows a right ovarian 2-  No (but you may!)
cm simple cyst (arrow) defined by its unilocular Sample Report 2:
anechoic appearance with smooth inner wall
(dotted line).  Findings: Normal right ovary.
Teaching Points:  Impression: Normal right ovary.
O-RADS 1 (physiologic) category includes the follicle and corpus luteum,
applying only to the premenopausal patient. The terms “follicle” and “corpus
luteum” may be used as stand-alone terms while avoiding the term or modifier
“cyst,” as some may interpret that description as a pathologic finding. Reporting O-RADS 1
 Case 2: 32-year-old premenopausal patient undergoing infertility evaluation
Lexicon/Descriptors
TVUS Left Sagittal TVUS Left Sagittal  Thick-walled cyst ≤3 cm
 Crenulated inner margin
 Internal echoes
 Peripheral vascularity

* Questions
 Menopausal status?
 Premenopausal
 Postmenopausal
Fig. 5 A Fig. 5 B
 Do I need to report this?
Gray-scale (A) and color Doppler (B) US images show a 2.3-cm thick-walled cyst (white dotted  Yes
line) with a crenulated inner margin (pink dotted line/fill), internal echoes (*), and peripheral  No (but you may!)
vascularity (arrows). Note that the descriptor phrase “peripheral vascularity” is preferred to the
previous commonly used descriptor phrase “ring of fire.”
Sample Report
Teaching Point: Including the term “normal” or “physiologic” is encouraged, as  Findings: Left ovarian 2.3-cm corpus
clinicians may be unfamiliar with O-RADS categories. Including “corpus luteum” luteum.
or “follicle” is optional but may be useful in scenarios such as infertility  Impression: Left ovarian corpus luteum,
normal ovary (O-RADS 1).
(indicates ovulation), pain, or high-risk screening (for reassurance).
 Management: No follow-up required.
 Case 3: 43-year-old premenopausal patient with irregular menses
Lexicon/Descriptors
TVUS Right Sagittal TVUS Right Transverse  Reticular pattern
 Retractile clot

* Questions
 Menopausal status?
 Premenopausal
 Postmenopausal
Fig. 6 A Fig. 6 B  Size?
 <5 cm
Cine loop (A) and color Doppler US image (B) show a 4.2-cm hemorrhagic cyst (arrow) with typical
 >5 but <10 cm
features: reticular pattern (*) of fine thin intersecting lines within a retractile clot demonstrated by
angular, straight, or concave margins (dotted curvilinear line) that is avascular.  >10 cm

Sample Report: Teaching Point:

A hemorrhagic cyst that is ≤5 cm requires no
 Findings: Right ovarian 4.2-cm unilocular cyst with internal reticular pattern and retractile follow-up, whereas for a >5 cm but <10 cm
clot. Avascular. cyst, short-term follow-up is recommended to
assure resolution/size decrease. A suspected
 Impression: Right ovarian 4.2-cm hemorrhagic cyst, almost certainly benign (O-RADS 2). hemorrhagic cyst in a postmenopausal patient
 Management: No follow-up required. is unusual and requires further assessment.
Case 4: 35-year-old patient with pelvic fullness and prior pelvic surgery
TVUS Left Sagittal TVUS Left Transverse TVUS Left Sagittal
Lexicon/Descriptors
 Fluid collection following
the contour of the adjacent
organs and pelvis
 Ovary at the margin
 Internal septa

Questions
 Prior surgery or
Fig. 7 A Fig. 7 B Fig. 7 C inflammatory process to
result in adhesions?
Dual-screen gray-scale (A, B) and color Doppler (C) US images show a fluid collection (white dashed line) containing
an ovary with follicles (pink dotted line/fill) at the margin and internal septa (arrows) representing adhesions.
 Yes
 No

Sample Report:  Does size matter?

 Yes
 Findings: Left adnexal fluid collection containing the ovary at the margin.
 No
 Impression: Left peritoneal inclusion cyst (PIC), almost certainly benign (O-RADS 2).
 Management: No imaging follow-up required. Clinical management directed by gynecologist. Teaching Points
 Case 4: MRI performed 3 weeks later
Coronal
A T2-weighted MRI
Teaching Points:
B

• The key discriminating feature is ovarian

* * identification within
* the cystic collection to avoid
mischaracterization as a multilocular cystic with
solid component(s).
TVS Left Sagittal TVS Left Trans
• MR images may show the extent and relationship to
the adjacent structure.

Fig. 8
• Prior surgery or inflammatory processes may result
Coronal T2-weighted MR image shows a fluid collection in adhesions and subsequent PIC formation.
(white dashed lines) containing an ovary (pink dotted
line/fill), with a cyst (increased in size since US
examination). Internal septa (arrows) represent adhesions.
 Case 5: 32-year-old patient with acute left pelvic pain
TVUS Left Transverse TVUS Left Sagittal Lexicon/Descriptors
 Hyperechoic lines and dots
 Hyperechoic component with
acoustic shadowing

Questions
 Menopausal status?
 Premenopausal
 Postmenopausal
Fig. 9 A Fig. 9 B  Size?
Color Doppler (A) and gray-scale (B) US images show a unilocular cyst containing hyperechoic  <10 cm
components with acoustic shadowing (arrows), hyperechoic lines and dots (dotted line), and no  >10 cm
internal flow. The maximum dimension was 8.3 cm.

Teaching Point:
Sample Report:
• O-RADS lexicon and scoring applies to all women, including those with
 Impression: Left 8.3-cm dermoid cyst, O-RADS 2. acute symptoms. While management may differ, accurate
characterization of a lesion is still helpful.
 Management: Urgent gynecology referral for
• Asymptomatic dermoids with typical benign features <10 cm may be
presumptive diagnosis of torsion.
followed in 1 year, if excision is not elected.
 Pearl: Available options if you are uncertain of the diagnosis of dermoid cyst

* *

Fig. 10 A Fig. 10 B Fig. 10 C

US image shows a typical dermoid cyst (*) with
the entire lesion represented as a hyperechoic
lesion with acoustic shadowing (dotted lines).
(In O-RADS 2.0, this appearance is considered
characteristic of dermoid cyst.)
US image shows a dermoid cyst with typical
hyperechoic lines and dots (dotted line) but
nonshadowing hyperechoic components
(arrows).
Options include
Hyperechoic lesion (*) without flow on the
color Doppler US image but no definite
acoustic shadowing; thus, uncertain
diagnosis.

Additional characterization by a US specialist (if Use other lesion descriptors (ie, solid, cystic ± solid, etc)
available) or refer for MRI to confirm suspected For example, Fig 10C (solid lesion, smooth, CS 1)
diagnosis of dermoid cyst. would be scored as O-RADS 3.
 Case 6: 56-year-old postmenopausal patient with BRCA mutation
TVUS Right Transverse TVUS Right Sagittal
Lexicon/Descriptors
 Hyperechoic lines and dots

Questions
 Menopausal status?
 Premenopausal
 Postmenopausal

Fig. 11 A Fig. 11 B
 Size?
Gray-scale transverse (A) and sagittal (B) US images show a 4.7-cm cystic lesion with hyperechoic
 <10 cm
lines and dots and subtle acoustic shadowing (dotted lines).  ≥10 cm
Sample Report:
 Findings: Right ovarian typical dermoid cyst with hyperechoic lines and dots
measuring 4.7 cm.
But wait!
 Impression: Right 4.7-cm dermoid cyst, O-RADS 2. Recommend annual US
Continued….
follow-up if not surgically removed.
 Case 6: 56-year-old postmenopausal patient with BRCA mutation
Fig. 12
Gray-scale TVUS cine loop captured by the sonographer
demonstrates observed peristalsis with mobile bowel contents
in this loop of bowel initially thought to be a dermoid cyst.
PITFALL!
Sample Report:
 Findings: Normal bilateral ovaries (not shown here).
 Impression: Normal bilateral ovaries, O-RADS 1.
Teaching Points:
• Bowel is a known mimic of dermoid cysts.
• Cine loops are of diagnostic value and should be obtained
when possible. If not feasible, communication between
the imager and reporting clinician is imperative.
 Case 7: 37-year-old patient with BRCA mutation presented for screening

TVUS Left Transverse Lexicon/Descriptors

 Simple cyst separate from Teaching Points:
the ovary
*  Cyst moves independent of
• O-RADS lexicon/scoring applies to all
women including those in high-risk groups;
the ovary when pressure is however, management may differ. (In this
applied with transducer case, management is the same.)

Fig. 13 Questions • The term “paraovarian cyst” includes

Gray-scale TVUS cine loop shows a  Extraovarian? paratubal cysts.
simple cyst (arrow) that moves
away from the ovary (*) with
 Yes
 No • If an extraovarian cyst is nonsimple, use
transducer pressure. ovarian descriptors and criteria to assign a
Sample Report: score and determine management.

 Findings: Simple left adnexal cyst that is separate from ovary. • Dynamic maneuvers can be very helpful to
 Impression: Left simple paraovarian cyst, almost certainly prove extraovarian cysts.
benign (O-RADS 2). No follow-up required.
“Sliding” sign
 Technical Pearl: Sliding Sign
Technical Pearl: “Sliding” Sign
Fig. 14 A Fig. 14 B
Teaching Point:

Applying gentle pressure

with the transducer where
the ovary and adjacent
lesion meet may cause
them to separate or “slide”
at the intervening plane,
permitting distinction
between exophytic ovarian
and extraovarian lesions.
Paraovarian Cyst Exophytic Follicle

US cine loop shows positive sliding Transducer pressure does not

sign with independent motion and demonstrate independent movement of
separation of the ovary and adjacent the ovary and adjacent simple cyst on this
simple cyst. cine loop.
 Technical Pearl: Jiggle Sign
Fig. 15 A Fig. 15 B
Teaching Point:

Similarly, to help distinguish an

avascular solid-appearing
component from debris or
blood clot, one may apply
gentle transducer pressure to
elicit the jiggle sign or internal
movement. A clot will jiggle
whereas a solid component will
Hemorrhagic Cyst not. Hemorrhagic Cyst
Jiggle sign helpful as this retractile
US cine loop demonstrates the jiggle
clot is small and the characteristic
sign. A diagnosis of retractile clot also
straight or concave margins are
supported by findings of internal
challenging to see, as depicted on
reticular pattern and straight margins.
this US cine loop.
 Case 8: 28-year-old patient undergoing intrauterine device (IUD) check
Fig. 16 A Fig. 16 B Lexicon/Descriptors Sample Report:

 Tubular  Findings: Right adnexal fluid-filled

 Separate from ovary tubular structure with incomplete
 Incomplete septa septa and endosalpingeal folds
 Endosalpingeal folds separate from the ovary.

Questions  Impression: Typical right

hydrosalpinx, O-RADS 2.
 Does size matter?
 Yes  Management: Management per
Gray-scale US image (A) and US cine loop (B) show a fluid-filled tubular-  No gynecologist recommendations.
shaped structure (dotted line) with incomplete septum (arrow) and tiny
endosalpingeal folds (arrowheads). Separate ovary identified (not shown).

Teaching Points:

• Management by a gynecologist is recommended for hydrosalpinges and PICs, as there may be clinical consequences (ie,
symptoms, infertility, etc).
• All three classic extraovarian lesions (paraovarian cyst, hydrosalpinx, and PIC) are always O-RADS 2, regardless of size.
 Pearl: Recognizing Endosalpingeal Folds
Case 8: 65-year-old woman, adnexal lesion on renal US
TVUS Right Transverse TVUS Right Transverse Teaching Points:

• Endosalpingeal folds:
• Short round projections along the
inner walls of hydrosalpinx
• In the axial plane, they may mimic
irregular wall thickening or PPs.
Fig. 17 A Fig. 17 B
• Tips:
Gray-scale TVUS image (A) shows a fluid-
filled lesion (white dashed line) with • “Cogwheel” appearance
regularly spaced short projections along • Contiguous on cine loops
inner wall (pink dotted line) in the axial
plane likened to a cogwheel (schematic
• Other features of hydrosalpinx
insert). Cine loop (B) demonstrates the • Tubular, incomplete septa
contiguous nature of these folds. Color • Separate ipsilateral ovary
Doppler US image (C) shows the
elongated tubular configuration (dashed
Fig. 17 C line) of this hydrosalpinx and separate
adjacent right ovary (arrow).
 Case 9: 65-year-old woman with incidental finding at bladder
Case 8: 65-year-old woman, adnexal lesion on renal US US
TVUS Midline Sagittal TVUS Midline Sagittal Teaching Points:

• Although extraovarian, the appearance

is not typical for any of the classic
extraovarian lesions (paraovarian cyst,
hydrosalpinx, or PIC).

• If a tubal pathologic entity is suspected,

Fig. 18 A Fig. 18 B one must assess by using other lesion
Gray-scale (A) and color Doppler (B) TVUS images show a cystic lesion (white dashed line)
in the pelvic cul-de-sac with possible septa (arrows) and an avascular solid-appearing
descriptors to characterize and score, as
component (pink dotted line/fill). Separate ovaries identified (not shown). was done in this case.

Lexicon Descriptors Sample Report:

 Extraovarian  Impression: Extraovarian multilocular cystic lesion with solid-
 Multilocular with solid-appearing appearing component and CS 1 (no flow); O-RADS 4, intermediate
component risk.
 CS 1 (no flow)  Management: MRI recommended (by US specialist). MRI
 Case 9: MRI performed 2 weeks later
T1-weighted FS postcontrast MRI MRI Report:
 Findings: Normal ovaries identified. Tubular structure with simple fluid,
incomplete septa, and no enhancing solid components.
*  Impression: Simple hydrosalpinx (O-RADS MRI 2).
*
Teaching Points:

• MRI has higher specificity in some scenarios owing to better tissue

Fig. 19 characterization due to the use of contrast material and the larger field of
view.
Axial T1-weighted fat-suppressed (FS) MR image
shows a tubular fluid-filled structure (dashed line)
posterior to the uterus (arrow). Separate ovaries • In this case, the MRI examination helped provide a diagnosis of simple
(*) are depicted. The presence of incomplete septa hydrosalpinx, thus avoiding surgery and additional consultations.
with resultant “waist” sign (arrowheads), simple
fluid, and no enhancing solid components are
diagnostic findings of a simple hydrosalpinx. The
internal debris seen at US has resolved.
 Cases 10 & 11: Two premenopausal patients with chronic pelvic pain
Case 10 Case 11 Lexicon/Descriptors
TVUS Left Sagittal TVUS Right Transverse  Homogeneous low-level (or ground
glass) echoes
 Bilocular (Case 10)
*
* Questions:
 Do the following matter?
*  Menopausal status
 Yes
 No
 Lesion size
Fig. 20 Fig. 21
 Yes
Color Doppler US image shows a 5.5-cm cystic Gray-scale TVUS cine loop shows a 12.5-
lesion with homogeneous low-level (ground
 No
cm unilocular cyst with homogeneous
glass) echoes (*). Some flow is seen within a low-level (ground glass) echoes (*).  Septations ± flow
single thin smooth septum (arrow).  Yes
 No
 Same score for both lesions?
(Hint: Same diagnosis; different management)  Yes
 No Continued…
 Cases 10 & 11: Two premenopausal patients with chronic pelvic pain
Case 10 Case 11
TVUS Left Sagittal TVUS Right Transverse
Teaching Points:

• Hallmark feature of typical

endometrioma is homogeneous
low-level or ground glass echoes.
Thin septa ± flow permitted.

• Size ≥10 cm for classic benign

Fig. 20 Fig. 21 ovarian lesions (hemorrhagic cyst,
Typical features of a classic Typical features of an endometrioma, endometrioma, dermoid cyst)
benign endometrioma. but the large size carries a slight upgrade from O-RADS 2 →
increased risk of malignancy (1%–<10%). O-RADS 3.

Size <10 cm = O-RADS 2 Size ≥10 cm = O-RADS 3

 Case 12: 43-year-old patient undergoing follow-up for known left endometrioma

TVS Left Transverse TVUS Left Transverse Questions

 Does this look like a typical

endometrioma?
 Yes
 No

 Solid component?
 Yes
Fig. 22
19 A Fig. 22 B  No
Gray-scale (A) and color Doppler (B) US images show a 4.8-cm thick-walled unilocular cyst (white dashed
line) with solid component (pink dotted line/fill) that is broad based and not a PP (<80% solid  Does CS matter?
at real-time imaging). Internal vascularity (arrow) confirms its solid nature.
 Yes
Sample Report:  No
 Left 4.8-cm unilocular cystic lesion with solid component.
 Impression: Unilocular cystic lesion with solid component, O-RADS 4. (An experienced sonologist
 Does size matter?
may add “In view of history, consider malignant transformation of endometrioma.”)
 Yes
Teaching Point: Regardless of history, this lesion no longer represents a typical  No
MRI performed
endometrioma; characterize by using ovarian lesion descriptors.
 Case 12: MRI performed 1 week later
T1-weighted FS MRI MRI T1 FS postcontrast MRI
Teaching Points:

• Best practice is to assess based on

present features; in this case, O-
RADS 4 for unilocular cyst with
solid component (any CS, any size)

• MRI is not necessary for all O-

Fig. 23 A Fig. 23 A RADS 3 and 4 lesions but is
Axial T1-weighted FS precontrast (A) and subtraction postcontrast (B) MR images show a cystic lesion dependent on interpreter
with crescentic high T1 signal intensity (red dotted line) indicting blood products and solid component
(white dotted line), which enhances similarly to the myometrium (arrow) at 30–40 seconds experience.
postcontrast.

MRI Report:

 Left 4.8-cm cystic lesion containing blood products and large iso- Diagnosis: Endometrioid carcinoma
enhancing solid component, O-RADS MRI 4 (῀50% risk of malignancy).
 Key Learning Points: Classic Benign Group Management

Teaching Points:

• The management for intraovarian

lesions is dependent on
3
Intraovarian menopausal status and size, unlike
Lesions that for extraovarian lesions.

• In addition to imaging
recommendations, the
management may include a
3
gynecologist to address clinical
Extraovarian issues.
Lesions

• Hemorrhagic cysts are unusual in

the postmenopausal group;
additional management indicated.

Reprinted under a CC BY-NC-ND license from the American College of Radiology (https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/O-Rads).
 Case
Case13:
13:44-year-old
44-year-oldpremenopausal woman with heavy
woman, premenopausal, heavymenses
menses
Right Transverse TVUS image Questions Teaching Points:
 Intraovarian?
 Yes • Irregular inner wall = focal thickening
 No that protrudes into the cyst lumen <3
 Locularity? mm in height; NOT considered a solid
*  Unilocular component
 Multilocular
 Solid component? • Unilocular cyst with irregular inner
Fig. 24  Yes wall upgrades the category to O-RADS
TVUS image shows an intraovarian unilocular cyst (*)  No 3, regardless of internal echoes.
with a “claw” of surrounding ovarian tissue (pink  Inner walls?
dotted line/fill). Focal wall thickening (arrow)
measures 2 mm in height (protrusion into cyst  Smooth
lumen).  Irregular
Sample Report:  Do internal echoes
 Right ovarian 3.4-cm unilocular cyst
matter? Diagnosis: Serous cystadenoma
with irregular inner wall; O-RADS 3.  Yes
Management by gynecologist.  No
 Case13:
Case 14:39-year-old
67-year-oldwoman,
woman new
withmass
unexplained weight
on outside loss
imaging
TVUS RightTransverse
TAS Right Transverse TVUS Right Transverse Lexicon/Descriptors Teaching Points:
 Unilocular cyst
with solid • PP = subset of solid
components components ≥3 mm
(height) and
surrounded by fluid
Questions: on three sides
 What matters?
 # of papillary • PPs are only relevant
Fig.
Fig. 22
25 AA Fig. 25 B projections for unilocular cysts.
Gray-scale transabdominal cine loop (A) and TVUS color Doppler image (B) show a  Yes
unilocular cyst with solid components, many of which are surrounded by fluid on three  No • Number matters
sides and therefore are considered PPs. A large representative PP (arrows) is shown <4 PPs = O-RADS 4
with associated flow.
 Lesion size
 Yes ≥4 PPs = O-RADS 5

Sample Report:  No
 CS
 Right ovarian 5.4-cm unilocular cyst with numerous PPs (≥4);
 Yes Diagnosis: Serous
O-RADS 5, high risk. Management by a gynecologic-oncologist.
 No cystadenocarcinoma
 Case
Case15:
14:56-year-old
56-year-oldpostmenopausal patient with
woman, postmenopausal, a new
new mass
mass
TVUS Left Transverse TVUS Left Sagittal Lexicon/Descriptors
 Unilocular cyst with solid
component

Questions
+ +  PP?
 Yes
 No
+ = 3.2 cm
Fig. 15 A Fig. 26 B
 Does maximum size of PP matter?
Color Doppler (A) and gray-scale (B) TVUS images show a 7.3-cm unilocular cyst with a solid
 Yes
component measuring 3.2 cm (calipers) demonstrating internal flow (arrow). Orthogonal images (But option to
show acute angles (dotted lines) at the interface of the solid component and wall where it  No include in report)
attaches, a helpful aid to characterize as a PP (fluid on three sides).

Sample Report:
 Left ovarian 7.3-cm unilocular cyst with one papillary projection, O-RADS 4. Diagnosis: Clear
 Management by gynecologist with gynecologic oncologist consultation or solely by gynecologic cell carcinoma
oncologist.
 Case 16: 47-year-old premenopausal patient with pelvic pain
TVUS Left Transverse Lexicon Descriptors
 Multilocular without Teaching Points:
solid component
• Multilocular cyst relevant features:
Questions • Smooth walls/septum or septa
 Inner walls? • CS 1–3
 Smooth • <10 cm = O-RADS 3
 Irregular • >10 cm = O-RADS 4
 Septa? • CS 4 = O-RADS 4
 Smooth
Fig. 27
 Irregular • Irregular walls/septum (septa) =
Color Doppler US image shows a large 13.1-cm multilocular
cystic lesion. The inner walls and septa are relatively
 CS? O-RADS 4
smooth with minimal flow (CS 2).  1-3
 4 • Solid component(s)
Sample Report:  Size? • CS 1–2 = O-RADS 4
 Left 13.1-cm multilocular cyst with smooth  < 10 cm • CS 3–4 = O-RADS 5
inner walls and septa, CS 2 (minimal flow), O-  ≥ 10 cm
RADS 4. Recommend US specialist
Diagnosis: Mucinous cystadenoma
(if available) or MRI.
 Case 17: 58-year-old woman with pelvic fullness
TVS Right Sagittal Lexicon Descriptors
 Multilocular without solid
component Teaching Points:

• With Doppler optimized, ends of

Questions the CS spectrum (1 and 4) are
easily recognized
 CS?
 1 (none) • If flow is clearly present but not
Fig. 28
 2 (minimal) robust = CS 3 (moderate)
Color TVUS cine loop shows a right 8.6-cm
multilocular cystic lesion with solid components.
 3 (moderate)
There is very strong flow in the solid components,  4 (very strong) • If barely present and challenging
color score 4. to see = CS 2 (minimal)

Sample Report:  Size matter?

 Right 8.6-cm multilocular cystic lesion  Yes
with solid components, CS 4, O-RADS  No (not when CS = 4) Diagnosis: High-grade serous
5. Management per gynecologic- cystadenocarcinoma
oncologist.
 CaseCase
18: 48-year-old woman
16: 58-year-old withwith
woman pelvic fullness
fullness
TVUS Right Sagittal Lexicon/Descriptors TVUS Right Sagittal
 Multilocular cystic with solid
component

Questions
 Color Score?
 None to minimal flow
(1–2)
Fig. 29 A Fig. 29 B
 Moderate to very strong
Color Doppler US image shows a multilocular With the gain corrected, the color Doppler US
cystic lesion with solid component flow (3–4)
image shows a multilocular cystic lesion with
demonstrating moderate to very strong flow (CS solid component with no internal flow (CS 1).
3–4).

Sample Report:
 Multilocular cyst with solid, moderate to
very strong flow, O-RADS 5. Gynecologic-
PITFALL! Sample Report:
 Multilocular cyst with none to
minimal flow, O-RADS 4. Gyn-
oncologist referral. Diagnosis: Borderline oncologist ± gynecologist.
serous cystadenoma
Wait! Gain too high?
 Case19:
Case 19:66-year-old
66-year-oldwoman
postmenopausal patient with bloating
with bloating
TVUS Left Transverse Questions Teaching Points:

 Lesion Category?
 Unilocular without solid
 Unilocular with solid
 Multilocular without solid
 Multilocular with solid
 Solid lesion
• A solid lesion may have cystic
areas but is not considered solid
for O-RADS until the amount of
solid tissue is ≥80%.

• Cine loops through the entire

Sample Report:
lesion help assess composition.
Fig. 30  Findings: Left 12.5-cm multilocular
Color Doppler US image shows a 12.5-cm lesion cystic lesion with solid component,
with very strong internal flow (arrow). very strong flow (CS 4).
The percentage of solid tissue on cine loops (not
shown) is approximately 60%, categorizing this
lesion as multilocular with solid components.  Impression: O-RADS 5.
Image used with permission of GE Healthcare.  Management: Refer to a Diagnosis: High-grade serous
Voluson is a trademark of GE Healthcare gynecologic-oncologist. carcinoma
 Pearl: Use Outer Contour and CS for Solid Lesions
Solid smooth Solid smooth Solid smooth Solid irregular/lobulated
CS 1 (no flow) CS 2–3 (minimal-moderate) CS 4 (very strong flow) CS any
O-RADS category 3 O-RADS category 4 O-RADS category 5 O-RADS 5 category

Fig. 31 A Fig. 31 B Fig. 31 C Fig.31 D

Ovarian fibroma Ovarian fibroma Metastasis (appendix) Granulosa cell tumor

Teaching Points:
• CS 4 (very strong flow) in a smooth solid lesion makes it high risk.
• Any irregular or lobulated outer contour is suspicious enough to place a solid lesion in O-RADS 5, regardless of flow.
 Case55-year-old
Case 20: 20: 45-year-old patient,
woman, queryquery endometriosis
endometriosis
Transabdominal US Left TVUS Left Transverse Lexicon/Descriptors: Lexicon/Descriptors: TVS
Transverse Transabdominal US  Solid lesion
 Solid lesion  CS 3 (moderate flow)
 CS 3 (moderate flow)
 Acoustic shadowing*
Question
Question  Outer contour?
 Outer contour?  Smooth
 Smooth  Irregular
Fig. 32 A Fig. 32 B
 Irregular
Transabdominal (A) and transvaginal color Doppler (B) TVUS images show a 4.2-cm solid
lesion with moderate internal flow (arrow). On the transabdominal US image, the outer *Part of the lexicon; plans are underway to include this in the risk
contour appears smooth (white dotted circle) and there is mild “venetian blind” acoustic
shadowing (between pink dotted lines). On the TVUS, the contour (white dashed line)
stratification system.
appears irregular and definite shadowing is not appreciated.

Sample Report:
 Left 4.2-cm solid mass with moderate flow (CS 3),
acoustic shadowing, and possible irregular contour. MRI
O-RADS 5. Recommend MRI as may be a fibroma.
 Case 20: MRI 4 weeks later
T2-weighted MRI without Fat
Saturation
Fig. 33
Axial T2-weighted MR image shows the lesion (arrow) is
homogeneously hypointense (as it was with diffusion-weighted
sequences [not shown]). Outer counter is smooth, not irregular.
Diagnosis: Benign ovarian fibroma
MRI Report:
 Left 4.2-cm smooth solid mass homogeneously dark at T2-weighted imaging and
diffusion-weighted imaging, O-RADS MRI 2 (<0.5 % risk of malignancy [ROM]).
Teaching Points:
• A US specialist may feel confident to designate the lesion as
a fibroma or fibrothecoma based on US findings (typically a
hypoechoic lesion with acoustic shadowing). O-RADS 2.0 has
incorporated the descriptor "acoustic shadowing" to
downgrade the risk of a solid avascular lesion with acoustic
shadowing.
• MRI is useful to confirm fibromatous nature, which leads to
downgrade in risk (as in this case).
• Occasionally, imaging features between MRI and US
may contradict each other, resulting in different O-RADS scores;
it is always prudent to use the highest score.
Important Caveat
 Case 21: 66-year-old patient with bloating and weight loss
TAS Right Transverse TAS Right Sagittal TVUS Midline Sagittal Lexicon/Descriptors
 Solid irregular lesion

Questions
*
 Ascites?
 Yes
 No
Fig. 34 A Fig. 34 B Fig. 34 C  Do echoes matter ?
Transabdominal US (TAS) images of the right adnexa (A) and right upper quadrant (B) and TVUS image of the uterus (C)  Yes
show a large 18-cm solid (>80%) lesion (*) with irregular contour and nonsimple ascites (arrow) with internal echoes  No
surrounding the liver and uterus.

Sample Report: Teaching Points:

 Right 18-cm solid irregular
lesion with ascites.
 O-RADS 5. Refer to gyn-
oncologist.
• Ascites = fluid extending above the uterine fundus when anteflexed Diagnosis: High-
or anterior/superior when retroflexed grade serous
• With unexplained ascites → attribute to lesion
• Upgrades O-RADS 3 and 4 lesion to O-RADS 5; seek other cause for cystadenocarcinoma
O-RADS 1 and 2 lesions
Conclusion: O-RADS US Risk Stratification and Management

 O-RADS US can be used by radiologists to promote the use of consistent descriptors,

help provide a risk of malignancy, and propose management strategies.

 Benefits include:

 Improved communication among imagers, health care providers, and patients

 Appropriate triage and best practice with consistent follow-up and management
based on actional information from the imaging report
Conclusion: O-RADS US Risk Stratification and Management

 With patience, practice, and online tools (webinars, reference charts, and the ACR O-
RADS app), users can easily apply the O-RADS US system in daily clinical practice.

 Helpful resources available at https://www.acr.org/Clinical-Resources/Reporting-

and-Data-Systems/O-Rads include:
 Publications
 Sample reports
 Links to webinars and training materials
 Suggested Readings
1. Andreotti RF, Timmerman D, Strachowski LM, et al. O-RADS US risk stratification and management system: a consensus guideline from the ACR Ovarian-Adnexal Reporting and Data
System Committee. Radiology 2020;294(1):168–185.
2. Andreotti RF, Timmerman D, Benacerraf BR, et al. Ovarian-Adnexal Reporting Lexicon for Ultrasound: A White Paper of the ACR Ovarian-Adnexal Reporting and Data System Committee. J
Am Coll Radiol 2018;15(10):1415–1429 [Published correction appears in J Am Coll Radiol 2019;16(3):403–406.].
3. Basha MAA, Metwally MI, Gamil SA, et al. Comparison of O-RADS, GI-RADS, and IOTA simple rules regarding malignancy rate, validity, and reliability for diagnosis of adnexal masses. Eur
Radiol 2021;31(2):674–684.
4. Cao L, Wei M, Liu Y, et al. Validation of American College of Radiology Ovarian-Adnexal Reporting and Data System Ultrasound (O-RADS US): Analysis on 1054 adnexal masses. Gynecol
Oncol 2021;162(1):107–112.
5. Glanc P, Benacerraf B, Bourne T, et al. First international consensus report on adnexal masses: management recommendations. J Ultrasound Med 2017;36(5):849–863.
6. Giede KC, Kieser K, Dodge J, Rosen B. Who should operate on patients with ovarian cancer? An evidence-based review. Gynecol Oncol 2005;99(2):447–461.
7. Hack K, Glanc P. The Abnormal Ovary: Evolving Concepts in Diagnosis and Management. Obstet Gynecol Clin North Am 2019;46(4):607–624.
8. Hack K, Gandhi N, Kahn D, Glanc P. OC03.05: External validation O‐RADS ultrasound risk stratification and management system. Ultrasound Obstet Gynecol 2021;58(S1):8–9.
9. Levine, Deborah, et al. Simple adnexal cysts: SRU consensus conference update on follow-up and reporting. Radiology 293.2 (2019): 359-371.
10. Strachowski, L, et al. O-RADS for Ultrasound: A User’s Guide, From the AJR Special Series on Radiology Reporting and Data Systems. American Journal of Roentgenology,
(2021) 216:5, 1150-1165. Strachowski LM, Jha P, Chawla TP, et al. O-RADS for Ultrasound: A User’s Guide, From the AJR Special Series on Radiology Reporting and Data
11. Sadowski, EA, et al. O-RADS MRI Risk Stratification System: Guide for Assessing Adnexal Lesions from the ACR O-RADS Committee. Radiology, (2022); 303:35–47.
12. Timmerman D. Lack of standardization in gynecological ultrasonography. Ultrasound Obstet Gynecol 2000;16(5):395–398.
13. Pi Y, Wilson MP, Katlariwala P, et al. Diagnostic accuracy and inter-observer reliability of the O-RADS scoring system among staff radiologists in a North American academic clinical setting.
Abdom Radiol (NY) 2021;46(10):4967–4973.