Adnexal Lesions: O-RADS US

Adnexal Lesions: O-RADS US

US O-RADS Key Lexicon Terms

Category Term Definition Example

1. Major Categories

A. Physiologic

(consistent with normal ovarian physiology)

Follicle Simple cyst ≤ 3 cm in premenopausal women US O-RADS key lexicon terms, follicle
Corpus luteum (CL) *Thick walled cyst ≤3 cm that may have crenulated inner margins, internal echoes and intense peripheral flow *Sometimes may not have internal cystic space US O-RADS key lexicon terms, Corpus luteum  (CL)

B. Lesion

(Not consistent with normal ovarian physiology)

Unilocular, no solid component

*Single compartment

*May contain 1 incomplete septum

*Wall irregularity < 3 mm height or internal echoes
US O-RADS key lexicon terms, lesion, single compartment
US O-RADS key lexicon terms, lesion, incomplete septum
US O-RADS key lexicon terms, lesion, Wall irregularity
Unilocular cyst with solid component(s) As above, but includes solid component(s) ≥ 3 mm in height US O-RADS key lexicon terms, lesion, Unilocular cyst with solid component(s)
Multilocular cyst, no solid elements More than one compartment, but no solid component (s) US O-RADS key lexicon terms, lesion, Multilocular cyst, no solid elements
Multilocular cyst with solid component(s) As above, but includes ≥ 1 solid component(s) ≥ 3 mm US O-RADS key lexicon terms, lesion, Multilocular cyst, solid elements
Solid or solid appearing (≥80%) At least 80% solid when assessed in orthogonal 2-dimensional plane US O-RADS key lexicon terms, lesion, Solid or solid appearing
2. Size Maximum diameter Maximal diameter of the lesion in any plane US O-RADS key lexicon terms, lesion, size

3. Solid or solid-appearing lesions

A. External contour

Smooth Regular outer margin US O-RADS key lexicon terms, External contour, smooth
Irregular (Not smooth)

Non-uniform outer margin

A lobulated outer margin is considered irregular

US O-RADS key lexicon terms, External contour, Irregular

B. Internal contents

 

Acoustic shadowing 
(internal contents)

Artifact produced by attenuated echoes behind a sound absorbing structure; commonly seen with calcification or fibromatous lesion

US O-RADS key lexicon terms, Internal ontents

4. Cystic lesions:

A. Internal margin or wall including solid component

Papillary projection or nodule Solid component whose height ≥ 3mm, arise from cyst wall or septation and protrudes into the cyst cavity US O-RADS key lexicon terms, Cystic lesions, Papillary projection or nodule
Smooth

Regular, uniform inner margin that may include inner margin of a solid component that is not a papillary projection

 

Irregular (Not smooth)

*Irregular, non-uniform inner margin. May include wall irregularities due to incomplete septations, solid components < 3 mm height, papillary projections, the contour of the solid component or the margin of any internal cystic area within the solid component

US O-RADS key lexicon terms, Cystic lesions, Irregular

B. Internal content, cystic component

Anechoic fluid

No internal echoes or internal structures of any kind

US O-RADS key lexicon terms, Internal content, cystic component, Anechoic Fluid
Hyperechoic components

Area of increased echogenicity relative to ovarian parenchyma without acoustic shadowing (seen with dermoid cysts or hemorrhagic lesions)

US O-RADS key lexicon terms, Internal content, cystic component, Hyperechoic components

5. Vascularity

Color score = Overall subjective assessment of color Doppler flow within entire lesion (wall and/or internal component)

Color score = 1

No flow

US O-RADS key lexicon terms, Vascularity, no flow
Color score = 2

Minimal Flow

US O-RADS key lexicon terms, Vascularity, minimal flow

Color score = 3

Moderate Flow

US O-RADS key lexicon terms, Vascularity, moderate flow

Color score = 4

Very strong Flow

US O-RADS key lexicon terms, Vascularity, very strong flow

6. General & Extra-Ovarian findings

Fluid descriptors

Cul-de-sac fluid

US O-RADS key lexicon terms, General & Extra-Ovarian findings, Fluid descriptors
 

Ascites

US O-RADS key lexicon terms, General & Extra-Ovarian findings, Fluid descriptors, Ascites

Other

Peritoneal thickening or nodules

US O-RADS key lexicon terms, General & Extra-Ovarian findings, Fluid descriptors, Peritoneal thickening or nodules

Utilizing US O-RADS Lexicon to Determine the Category of an Ovarian or Fallopian Tubal Lesion

  1. >Major categories: A. (Physiologic) or B. (Lesion)
  2. Size: Maximal diameter
  3. Solid or solid appearing lesions:
    • A. External contour (smooth or irregular?)
    • B. Internal contents (any acoustic shadowing present?)
  4. Cystic lesions:
    • A. Inner margins or walls including solid component (any papillary projections or nodule? If so, how many? Is the inner wall smooth or irregular? Any solid components?)
    • B. Internal content, cystic component (Any internal anechoic fluid or hyperechoic components present?)
  5. Vascularity: No flow, minimal flow, moderate flow or very strong flow (make sure scale for color is as low as possible while avoiding artifact)
  6. General and extra-ovarian findings: Free fluid (cul-de-sac fluid or ascites) and other (peritoneal thickening or nodule)

US O-RADS Categories

Risk Stratification and Follow Up Recommendatins

O-RADS Score and Risk Category

Lesion Descriptors Examples

Management

Pre-menopausal

Post-menopausal

0: Incomplete N/A Repeat or alternate study
1: Normal Follicle: simple cyst ≤ 3 cm None N/A
Corpus luteum ≤3 cm None N/A

2: Almost Certainly Benign [< 1%]

Simple cyst
US-ORADS-categories, Almost Certainly Benign, Simple cyst

≤3 cm N/A None
>3 cm to 5 cm None Follow up in 1 year
>5 cm but <10 cm Follow up in 8-12 weeks
Classic Benign Lesions See Section 3

Non-simple unilocular cyst, smooth inner margin
US-ORADS-categories, Almost Certainly Benign, Non-Simple unilocular cyst

≤3 cm None

Follow up in 1 year
If concerning, US specialist or MRI

>3 cm but <10 cm

Follow up in 8-12 weeks
If concerning, US specialist

US specialist or MRI

3. Low Risk Malignancy
[1-< 10%]

Unilocular cyst ≥ 10 cm (simple or non-simple)

US specialist or MRI

Gynecologist

Unilocular cyst, any size with irregular inner wall < 3 mm height
US-ORADS-categories, Low Risk, Unilocular cyst
 

Multilocular cyst < 10 cm, smooth inner wall, color score = 1-3
US-ORADS-categories, Low Risk, Multilocular cyst

Solid smooth, any size, color score = 1
US-ORADS-categories, Low Risk, Solid smooth

Typical dermoid cysts, endometriomas, hemorrhagic cysts ≥ 10 cm (Section 3)

4: Intermediate risk [10 - <50%]

Unilocular cyst with solid component: any size, 0-3 papillary projections, color score = any
US-ORADS-categories, Intermediate Risk, Unilocular cyst, solid component

US specialist or MRI

GYN-oncologist ± gynecologist

Multilocular cyst, no solid component

  • ≥ 10cm, smooth inner wall, color score = 1-3
  • Any size, smooth inner wall, color score = 4
  • Any size, irregular inner wall and/or irregular septation, any color score

US-ORADS-categories, Intermediate Risk, Multilocular cyst, no solid component

Multilocular cyst, with solid component: Any size, color score = 1-2
US-ORADS-categories, Intermediate Risk, Multilocular cyst, solid component

Solid, smooth, any size, color score = 2-3
US-ORADS-categories, Intermediate Risk, Multilocular cyst, solid smooth component

5. High Risk [≥ 50%]

Unilocular cyst: any size, ≥ 4 papillary projections, color score = any
US-ORADS-categories, High Risk, Unilocular cyst, any size

GYN oncologist

Multilocular cyst with solid component: any size, color score = 3-4
US-ORADS-categories, High Risk, Multilocular cyst, solid component

Solid smooth, any size, color score = 4
US-ORADS-categories, High Risk, Multilocular cyst, solid smooth

Solid irregular, any size, color score = any
US-ORADS-categories, High Risk, Multilocular cyst, solid irregular

Ascites and/or peritoneal nodules
US-ORADS-categories, High Risk, Multilocular cyst, Ascites and/or peritoneal nodules

Classic Benign Ovarian and Extra-Ovarian Lesions

Classic Benign Ovarian Lesions
US O-RADS 2 if < 10 cm
US O-RADS 3 if ≥ 10 cm 

Typical hemorrhagic cyst

*Reticular pattern: Fine thin intersecting lines representing fibrin strands
*Retracting clot: An avascular echogenic component with angular, straight, or concave margins

Classic Benign Ovarian and Extra-Ovarian Lesions, Typical hemorrhagic cyst

Pre-menopausal

Post-menopausal
≤ 5 cm: none US specialist, gynecologist or MRI
5-10 cm: follow up in 8-12 weeks If persists or enlarges, referral to US specialist, gynecologist or MRI
Typical Dermoid cyst

*Hyperechoic component with acoustic shadowing
*Hyperechoic lines and dots
*Floating echogenic spherical structures

Classic Benign Ovarian and Extra-Ovarian Lesions, Typical Dermoid cyst

* Optional initial follow up in 8-12 weeks based on certainty

* If not removed, annual US follow up

*US specialist or MRI if interval change

*US specialist, gynecologist or MRI

* If not removed, annual US follow up

*MRI if interval change
Typical endometrioma

*Ground glass or homogeneous low-level echoes

Classic Benign Ovarian and Extra-Ovarian Lesions, Typical endometrioma

Classic Benign Extra-Ovarian Lesions
US O-RADS 2: Any size

Simple para-ovarian cyst

Simple cyst separated from the ovary that typically moves independent of the ovary when pressure is applied by the transducer

Classic Benign Ovarian and Extra-Ovarian Lesions, Simple para-ovarian cyst

Pre-menopausal Post-menopausal

*If simple, none

*If not simple, manage per ovarian criteria
*Optional single follow up ultrasound in 1 year
Typical Peritoneal Inclusion cyst

Follows the contour of the adjacent pelvic organs or peritoneum, does not exert mass effect and typically contains septations. The ovary is either at the margin or suspended within the lesion

Classic Benign Ovarian and Extra-Ovarian Lesions, Typical Peritoneal Inclusion cyst
Classic Benign Ovarian and Extra-Ovarian Lesions, Typical Peritoneal Inclusion cyst

   
Typical hydrosalpinx

Incomplete septation, tubular
*Endosalpingeal folds: short round projections around the inner wall of a fluid distended tubular structure

Classic Benign Ovarian and Extra-Ovarian Lesions, Typical hydrosalpinx

   

Reference

  1. Thomassin-Naggara I, Poncelet E, Jalaguier-Coudray A, et la. Ovarian-adnexal reporting data system magnetic resonance imaging (O-RADS MRI) score for risk stratification of sonographically indeterminate adnexal masses. JAMA Netw Open. 2020;3(1):e1919896.
  2. O-RADS MRI Lexicon Categories, Terms and Definitions. Release date: November 2002. https://www.acr.org/-/media/ACR/Files/RADS/O-RADS/O-RADS-MR-Lexicon-Terms-Table-November-2020.pdf
  3. O-RADS MRI Stratification System Table. Release date: September 2020. https://www.acr.org/-/media/ACR/Files/RADS/O-RADS/O-RADS-MR-Risk-Stratification-System-Table-September-2020.pdf

CME credit information

Release Date: September 7, 2022
Expiration Date: September 7, 2023
Description: Educational website with high-yield educational information and abundant imaging examples authored by Dr. Yang Guo
Faculty:

Course Directors:
Ramin Khorasani, MD, MPH
Vice Chair, Department of Radiology
Brigham and Women’s Hospital
Professor, Harvard Medical Schoo

Sanjay Saini, MD
Vice Chair, Department of Radiology, Massachusetts General Hospital
Professor of Radiology, Harvard Medical School 

Authors:
Yang Guo, MD

Department of Radiology, Brigham and Women's Hospital
Instructor in Radiology, Harvard Medical School

Jessie Chai, MD
Department of Radiology, Brigham and Women's Hospital
Instructor in Radiology, Harvard Medical School

Carol Benson, MD
Department of Radiology, Brigham and Women's Hospital
Professor of Radiology, Harvard Medical School

Atul Shinagare, MD
Department of Radiology, Brigham and Women's Hospital
Associate Professor of Radiology, Harvard Medical School
Chief, Abdominal Imaging and Intervention, Brigham Health
Interim Chief, Cancer Imaging, Dana-Farber Cancer Institute

Target Audience: This activity is intended for radiology attendings and trainees (fellows and residents) within Mass General Brigham.

Learning Objectives: Upon completion of the activity, participants will be able to identify and classify rectal cancer staging on MRI accurately and comprehensively.

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Ramin Khorasani, MD, MPH
Kathryn Nardozza
Sanjay Saini, MD

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Atul B. Shinagare, MD
Consultant: Imaging Endpoints; Virtualscopics

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Yang Guo, MD
Jessie Chai, MD
Carol Benson, MD

The following speakers have reported relevant financial relationships with an ineligible company:
Atul B. Shinagare, MD
Consultant: Imaging Endpoints; Virtualscopics

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