O-RADS MRI scoring is an effective way to assess malignancy risk in adnexal masses referred after inconclusive ultrasound results, but improvements are needed for the metric, according to a commentary published on 13 May in European Radiology.
Prof. Isabelle Thomassin-Nagara. Courtesy of Sorbonne Université.A group led by Prof. Isabelle Thomassin-Naggara, PhD, of the Hôpital Tenon in Paris wrote that additional MR criteria may be added to the scoring metric to better find borderline cystadenomas among malignant tumors, and that current trials may validate the method to inform clinical management of patients with potential ovarian cancer.
"O-RADS MRI score is a robust, reproducible, and simple way to assess the risk of malignancy of an adnexal mass referred after ultrasonography," Thomassin-Naggara and co-authors noted.
O-RADS MRI is a scoring system that characterizes adnexal masses found on imaging and assessing risk. A 2022 study by researchers in France and the U.K., led by Thomassin-Naggara and colleagues, found that their five-point scoring system with MRI could distinguish between malignant and benign ovarian cysts with an accuracy of 90%.
The authors wrote that the scoring system's better specificity can reclassify masses as benign, indeterminate, or malignant on ultrasonography.
Thomassin-Naggara's team wrote that there are two next steps to improve the use of this scoring method.
The first is to include O-RADS MRI scoring into clinical management guidelines, which would have a significant impact during multidisciplinary tumor board sessions. In fact, two ongoing studies are focusing on this: One is the Ascordia study in France, which is exploring the impact of an MR scoring system of therapeutic strategy of pelvic adnexal masses, and the other is the MR in ovarian cancer (MROC) study in the U.K., which is evaluating the ability of O-RADS MRI scoring to identify the impact of the score on treatment planning.
The second is having clinicians better define the type of malignant tumors found, the authors wrote.
"This is particularly relevant in premenopausal women in whom the surgeon may opt for a conservative surgery if the tumor is only a serous borderline cystadenoma," they noted. "Hence, some researchers evaluated additional MR criteria to improve O-RADS MRI score and particularly O-RADS MRI 4 category, which is the less informative category due to its large positive predictive value range."
![Examples of ultrasound findings and techniques. (A) Images in a 39-year-old male patient with a mass in the left thigh. The mass is heterogeneous on the B-mode US image (compared with the patient in D) and showed increased microvascularity (superb microvascular imaging [SMI]) and shear-wave elastography (SWE) values. Undifferentiated pleomorphic sarcoma was diagnosed at biopsy (with pleomorphic rhabdomyosarcoma in surgical specimen). (B) Images in an 18-year-old male patient with a mass in the left leg. The mass is hypoechoic on the B-mode image, with no other findings suggestive of malignancy. The lesion is in contact with the cortex of the tibia, which is slightly irregular. CT revealed a doubtful anteromedial tibial erosion. The microvascular study demonstrated high vascularization, suggestive of malignancy. Periosteal Ewing sarcoma was diagnosed with both histologic and immunohistochemical confirmation. (C) Images in a 69-year-old female patient with a lump growing on the outside of the left leg. Multiple SWE examinations were performed (please note the high values obtained in the measurements, whereas the color map highlights the stiffness relative to adjacent tissues). SMI showed areas of increased vascularization to target for sampling. Undifferentiated spindle cell sarcoma was diagnosed at biopsy, with residual leiomyosarcoma in the surgical specimen after neoadjuvant therapy. (D) Images in a 56-year-old female patient with a mass in the right thigh. The mass is heterogeneous at both B-mode ultrasound (similar to patient A) and MRI (coronal T2-weighted spectral attenuated inversion recovery [SPAIR]; T1-weighted pre-contrast and postcontrast imaging), which even shows uptake after the administration of paramagnetic contrast material, which is traditionally suggestive of malignancy. Low values at SMI and elastography are suggestive of benignity. Spindle cell lipoma was diagnosed at biopsy, with atypical spindle cell lipomatous tumor in the surgical specimen.](https://img.auntminnieeurope.com/mindful/smg/workspaces/default/uploads/2026/08/images-radiol250278fig2.APCFLSvX6p.jpg?auto=format%2Ccompress&fit=crop&h=100&q=70&w=100)
![Examples of ultrasound findings and techniques. (A) Images in a 39-year-old male patient with a mass in the left thigh. The mass is heterogeneous on the B-mode US image (compared with the patient in D) and showed increased microvascularity (superb microvascular imaging [SMI]) and shear-wave elastography (SWE) values. Undifferentiated pleomorphic sarcoma was diagnosed at biopsy (with pleomorphic rhabdomyosarcoma in surgical specimen). (B) Images in an 18-year-old male patient with a mass in the left leg. The mass is hypoechoic on the B-mode image, with no other findings suggestive of malignancy. The lesion is in contact with the cortex of the tibia, which is slightly irregular. CT revealed a doubtful anteromedial tibial erosion. The microvascular study demonstrated high vascularization, suggestive of malignancy. Periosteal Ewing sarcoma was diagnosed with both histologic and immunohistochemical confirmation. (C) Images in a 69-year-old female patient with a lump growing on the outside of the left leg. Multiple SWE examinations were performed (please note the high values obtained in the measurements, whereas the color map highlights the stiffness relative to adjacent tissues). SMI showed areas of increased vascularization to target for sampling. Undifferentiated spindle cell sarcoma was diagnosed at biopsy, with residual leiomyosarcoma in the surgical specimen after neoadjuvant therapy. (D) Images in a 56-year-old female patient with a mass in the right thigh. The mass is heterogeneous at both B-mode ultrasound (similar to patient A) and MRI (coronal T2-weighted spectral attenuated inversion recovery [SPAIR]; T1-weighted pre-contrast and postcontrast imaging), which even shows uptake after the administration of paramagnetic contrast material, which is traditionally suggestive of malignancy. Low values at SMI and elastography are suggestive of benignity. Spindle cell lipoma was diagnosed at biopsy, with atypical spindle cell lipomatous tumor in the surgical specimen.](https://img.auntminnieeurope.com/mindful/smg/workspaces/default/uploads/2026/08/images-radiol250278fig2.APCFLSvX6p.jpg?auto=format%2Ccompress&dpr=2&fit=crop&h=167&q=70&w=250)
