O-RADS
O-RADS™ US v2022 — Assessment Categories
Release Date: November 2022
| O-RADS Score | Risk Category [IOTA Model] | Lexicon Descriptors | Management | ||
|---|---|---|---|---|---|
| Pre-menopausal | Post-menopausal | ||||
| 0 | Incomplete Evaluation [N/A] | Lesion features relevant for risk stratification cannot be accurately characterized due to technical factors | Repeat US study or MRI | ||
| 1 | Normal Ovary [N/A] | No ovarian lesion | None | ||
| Physiologic cyst: follicle (≤3 cm) or corpus luteum (typically ≤3 cm) | |||||
| 2 | Almost Certainly Benign [<1%] | Simple cyst | ≤3 cm | N/A (see follicle) | None |
| >3 cm to 5 cm | None | Follow-up US in 12 months* | |||
| >5 cm but <10 cm | Follow-up US in 12 months* | ||||
| Unilocular, smooth, non–simple cyst (internal echoes and/or incomplete septations) | ≤3 cm | None | Follow-up US in 12 months* | ||
| Bilocular, smooth cyst | >3 cm but <10 cm | Follow-up US in 6 months* | |||
| Typical benign ovarian lesion (see “Classic Benign Lesions” table) | <10 cm | See “Classic Benign Lesions” table for descriptors and management | |||
| Typical benign extraovarian lesion (see “Classic Benign Lesions” table) | Any size | ||||
| 3 | Low Risk [1 – <10%] | Typical benign ovarian lesion (see “Classic Benign Lesions” table), ≥10 cm | Imaging:
Clinical: Gynecologist |
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| Uni- or bilocular cyst, smooth, ≥10 cm | |||||
| Unilocular cyst, irregular, any size | |||||
| Multilocular cyst, smooth, <10 cm, CS <4 | |||||
| Solid lesion, ± shadowing, smooth, any size, CS = 1 | |||||
| Solid lesion, shadowing, smooth, any size, CS 2–3 | |||||
| 4 | Intermediate Risk [10 –<50%] | Bilocular cyst without solid component(s) | Irregular, any size, any CS | Imaging: Options include:
Clinical: Gynecologist with gyn–oncologist consultation or solely by gyn–oncologist |
|
| Multilocular cyst without solid component(s) | Smooth, ≥10 cm, CS <4 | ||||
| Smooth, any size, CS 4 | |||||
| Irregular, any size, any CS | |||||
| Unilocular cyst with solid component(s) | <4 pps or solid component(s) not considered a pp; any size |
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| Bi- or multilocular cyst with solid component(s) | Any size, CS 1–2 | ||||
| Solid lesion, non-shadowing | Smooth, any size, CS 2–3 | ||||
| 5 | High Risk [≥50%] | Unilocular cyst, ≥4 pps, any size, any CS | Imaging: Per gyn-oncologist protocol Clinical: Gyn-oncologist |
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| Bi- or multilocular cyst with solid component(s), any size, CS 3–4 |
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| Solid lesion, ± shadowing, smooth, any size, CS 4 |
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| Solid lesion, irregular, any size, any CS |
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| Ascites and/or peritoneal nodules†† | |||||
GLOSSARY
| Smooth and irregular: refer to inner walls/septation(s) for cystic lesions, and outer contour for solid lesions; irregular inner wall for cysts = <3 mm in height | Solid: excludes blood products and dermoid contents; solid lesion = ≥80% solid; solid component = protrudes ≥3 mm (height) into cyst lumen off wall or septation |
| Shadowing: must be diffuse or broad to qualify; excludes refractive artifact | pp = papillary projection; subtype of solid component surrounded by fluid on 3 sides |
| CS = color score; degree of intralesional vascularity; 1 = none, 2 = minimal flow, 3 = moderate flow, 4 = very strong flow | Bilocular = 2 locules; multilocular = ≥3 locules; bilocular smooth cysts have a lower risk of malignancy, regardless of size or CS |
| Postmenopausal = ≥1 year amenorrhea (early: <5 yrs; late: ≥5 yrs); if uncertain or uterus surgically absent, use age >50 years (early = >50 yrs but <55 yrs, late = ≥55yrs) | |
|---|---|
*Shorter imaging follow-up may be considered in some scenarios (eg, clinical factors). If smaller (≥10–15% decrease in average linear dimension), no further surveillance. If stable, follow-up US at 24 months from initial exam. If enlarging (≥10–15% increase in average linear dimension), consider follow-up US at 12 and 24 months from initial exam, then management per gynecology. For changing morphology, reassess using lexicon descriptors. Clinical management with gynecology as needed.
**There is a paucity of evidence for defining the optimal duration or interval for imaging surveillance. Shorter follow-up may be considered in some scenarios (eg, clinical factors). If stable, follow-up at 12 and 24 months from initial exam, then as clinically indicated. For changing morphology, reassess using lexicon descriptors.
† MRI with contrast has higher specificity for solid lesions, and cystic lesions with solid component(s).
†† Not due to other malignant or non-malignant etiologies; specifically, must consider other etiologies of ascites in categories 1–2.
O-RADS™ US v2022 — Classic Benign Lesions
Release Date: November 2022
| Lesion | Descriptors and Definitions For any atypical features on initial or follow-up exam, use other lexicon descriptors (eg, unilocular, multilocular, solid, etc.) | Management If sonographic features are only suggestive, and overall assessment is uncertain, consider follow-up US within 3 months |
|---|---|---|
| Typical Hemorrhagic Cyst | Unilocular cyst, no internal vascularity*, and at least one of the following: .Reticular pattern (fine, thin intersecting lines representing fibrin strands) .Retractile clot (intracystic component with straight, concave, or angular margins) | Imaging: Premenopausal: ≤5 cm: None >5 cm but <10 cm: Follow-up US in 2–3 months Early postmenopausal (<5 years): <10 cm, options to confirm include: Follow-up US in 2–3 months or US specialist (if available) or MRI (with O–RADS MRI score) Late postmenopausal (≥5 years): Should not occur; recategorize using other lexicon descriptors. Clinical: Gynecologist** |
| Typical Dermoid Cyst | Cystic lesion with ≤3 locules, no internal vascularity*, and at least one of the following: .Hyperechoic component(s) (diffuse or regional) with shadowing .Hyperechoic lines and dots .Floating echogenic spherical structures | Imaging: ≤3 cm: May consider follow-up US in 12 months† >3 cm but <10 cm: If not surgically excised, follow-up US in 12 months† Clinical: Gynecologist** |
| Typical Endometrioma | Cystic lesion with ≤3 locules, no internal vascularity*, homogeneous low–level/ground glass echoes, and smooth inner walls/septation(s) ± Peripheral punctate echogenic foci in wall | Imaging: Premenopausal: <10 cm: If not surgically excised, follow-up US in 12 months† Postmenopausal: <10 cmand initial exam, options to confirm include Follow–up US in 2–3 months or US specialist (if available) or MRI (with O-RADS MRI score) Then, if not surgically excised, recommend follow-up US in 12 months† Clinical: Gynecologist** |
| Typical Paraovarian Cyst | Simple cyst separate from the ovary | Imaging: None Clinical: Gynecologist** |
| Typical Peritoneal Inclusion Cyst | Fluid collection with ovary at margin or suspended within that conforms to adjacent pelvic organs ± Septations (representing adhesions) | Imaging: None Clinical: Gynecologist** |
| Typical Hydrosalpinx | Anechoic, fluid–filled tubular structure ± Incomplete septation(s) (representing folds) ± Endosalpingeal folds (short, round projections around inner walls) |
*Excludes vascularity in walls or intervening septation(s)
**As needed for management of clinical issues
† There is a paucity of evidence for defining the need, optimal duration or interval of timing for surveillance. If stable, consider US follow-up at 24 months from initial exam, then as clinically indicated. Specifically, evidence does support an increased risk of malignancy in endometriomas following menopause and those present greater than 10 years.