Adnexal/ Ovarian Incidentaloma Management: SRU and ACR Recommendations and O-RADS

Incidentalomas on Ultrasound: The Society of Radiologists in Ultrasound (SRU) have given guidelines for managing adnexal lesions detected on ultrasound, for simple cysts as also more complex lesions like hemorrhagic cysts and endometriosis. See the original open access article published in Radiology 2010 here, and its 2019 update here.

Simple cysts in premenopausal women on ultrasound:

Screen Shot 2019-11-05 at 12.18.54 AM

Simple cysts in postmenopausal women on ultrasound:

Screen Shot 2019-11-05 at 12.18.22 AM

Assessment of simple cysts in both pre and postmenopausal women on ultrasound follow-up studies (referred to as Fig 4 in the charts above):

Screen Shot 2019-11-05 at 12.19.14 AM

Follow-up of hemorrhagic cysts and endometriosis on ultrasound:

Screen Shot 2019-11-05 at 12.30.13 AM

O-RADS: The recently released O-RADS also provides a similar management algorithm for benign or likely benign adnexal lesions, which is mostly congruent with the SRU criteria. However, it also expands beyond the SRU criteria and incorporates management guidelines for more complex lesions like say simple-appearing cysts with a septation or echogenic contents. O-RADS 4-5 (not detailed in the image below) are highly suspicious for malignancy, and need to be evaluated immediately by a gyn-oncologist.  You can read more details on O-RADS in the 2019 Radiology article here.

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Screen Shot 2019-11-10 at 11.08.34 PM

Incidentalomas on CT/ MRI: The American College of Radiology (ACR) has also given similar criteria for simple adnexal cysts detected on CT or MRI in its 2013 article here. As I had predicted, these have just got updated recently and are now much more simplified. You can read the Feb 2020 JACR article on the update here.

Follow-up on CT/MRI:

Screen Shot 2020-02-11 at 11.43.30 PM copy


a. Exclusions: (1) normal findings, including corpus luteum, asymmetric ovary without mass, with normal shape; (2) calcifications without associated mass; (3) previous characterization with ultrasound or MRI; or (4) documented stability for 2 years.

b. Limited assessment on CT or MR: This means the cyst is consistent with a simple appearing cyst, but characterization is limited by low signal-to-noise ratio, artifact, lack of contrast assessment, or incomplete anatomic coverage.

c. US or MRI to characterize means that the study should be performed promptly for further evaluation, rather than in follow-up to assess temporal changes.

– Akshay Baheti, Tata Memorial Hospital

PS: All images are a copyright of the original published article.


2 thoughts on “Adnexal/ Ovarian Incidentaloma Management: SRU and ACR Recommendations and O-RADS

  1. Pingback: Incidental Findings Follow-up Recommendations – Cafe Roentgen

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