O-RADS US Assessment: Expert Guidance on Fine-tuning US Images

The American College of Radiology Ovarian and Adnexal Reporting and Data System (O-RADS) is a risk stratification system for ovarian and adnexal lesions. Its primary objective is to minimize unnecessary workup and surgery for benign and physiologic lesions while optimizing outcomes for patients with ovarian cancer. US is the primary imaging modality used in O-RADS assessment, with MRI serving a complementary role to enhance specificity of diagnosis. Given that O-RADS US serves as the gatekeeper for determining whether a lesion requires additional evaluation, requires imaging surveillance, or may be dismissed, accurate lesion characterization is paramount. However, US is a highly operator-dependent imaging modality, and image quality is directly influenced by the skill of the sonographer or sonologist performing the examination. Adherence to correct US technique is essential and is directly related to machine settings, optimization techniques, and maneuvers performed during the examination. Inadequate US technique can lead to adverse consequences, including potential of misdiagnosis, patient anxiety, and unnecessary surgery with associated morbidity. Rather than considering the operator-dependent nature of US as a limitation, we encourage users to view it as an opportunity. The authors provide a comprehensive review of gray-scale and Doppler US technique optimization, including field of view, focal zone, measurements, and gain, and outline special sonographic maneuvers to aid in identifying the location and contents of lesions. Insight into common pitfalls and troubleshooting strategies is crucial, especially in challenging cases, to improve the accuracy of adnexal lesion diagnosis by the interpreting physician. ^©RSNA, 2026 Supplemental material is available for this article.