Benign Lesions Scored as O-RADS US v2022 4 and 5 Categories: Prevalence and Morphologic Analysis

Background Lesions scored as Ovarian-Adnexal Reporting and Data System (O-RADS) US 4 have an expected risk of malignancy of 10% to less than 50%, and those scored as O-RADS US 5 have an expected risk of malignancy of 50% or greater. However, studies of unselected populations demonstrated lower risk-of-malignancy ranges due to benign lesions being assigned these scores. Purpose To determine the frequency of benign lesions scored as O-RADS US 4 and 5 and to assess their pathologic and lexicon imaging features. Materials and Methods Consecutive patients who underwent pelvic US between January 2011 and December 2014 were included in this multicenter retrospective study (median age, 47 years [IQR, 36-56 years]). Investigators blinded to final outcome recorded O-RADS US 4 and 5 lesion lexicon features, which were analyzed and compared with the final outcome: histopathologic diagnosis, definitive characterization at CT or MRI, or complete resolution at follow-up imaging. Continuous and categorical variables were compared using the Mann-Whitney U test and Fisher exact test, respectively. Results Among 219 lesions scored as O-RADS US 4 and 5 in the study, 135 were benign and 84 were malignant at final outcome. Of the 135 benign lesions scored as O-RADS US 4 or 5, cystadenomas and cystadenofibromas (46.7%, 63 of 135) were the most common. Physiologic cysts, endometriomas, other benign nonneoplastic lesions, dermoids, fibromas, and fibrothecomas composed the remaining 53.3% (72 of 135). Per-lesion analysis demonstrated that solid component was the most common feature of benign lesions scored as O-RADS US 4 or 5 (71.1%, 96 of 135), followed by multilocularity (45.2%, 61 of 135). Analysis according to O-RADS score demonstrated that solid component was the most common feature of both O-RADS US 4 benign lesions (68.8%, 77 of 112) and O-RADS US 5 benign lesions (83%, 19 of 23) (P = .22). Conclusion Approximately half of the benign lesions scored as O-RADS US 4 or 5 were cystadenomas or cystadenofibromas, followed by nonneoplastic lesions (including physiologic cysts and endometriomas) and benign neoplasms (dermoids). A solid component was the most frequent imaging observation of benign lesions scored as O-RADS US 4 or 5. © RSNA, 2026.