# Assessment of ultrasound ovarian-adnexal reporting & data system (O-RADS) for pediatric patients

## TL;DR

This study evaluates how well the O-RADS ultrasound system works for assessing ovarian lesions in children, finding it has high sensitivity but low specificity.

## Contribution

The study assesses the diagnostic performance and inter-radiologist agreement of O-RADS US in pediatric patients, a population with rare malignancies.

## Key findings

- Most pediatric ovarian lesions were classified as O-RADS 2 (benign), with high sensitivity and NPV but low PPV.
- Inter-radiologist agreement was moderate (κ=0.42) when applying O-RADS US in pediatric cases.
- The low malignancy rate in children makes O-RADS US application challenging, suggesting potential need for pediatric-specific modifications.

## Abstract

Ovarian-Adnexal Reporting & Data System Ultrasound (O-RADS US) is a validated scoring system in adult women with adnexal lesions to help assess the risk of potential malignancy. Limited data exists for children in whom malignancy is rare.

To evaluate inter-radiologist agreement and diagnostic performance when using the O-RADS US in pediatric patients with ovarian lesions.

Retrospective IRB-approved study included pelvic ultrasounds (US) from 2015 to 2020 in pediatric patients (<18 years). Pelvic US with ovarian lesions measuring >3 cm in premenarchal patients and >5 cm in menarchal patients were included. Three pediatric radiologists reviewed each US and recorded imaging characteristics and O-RADS classification. Diagnostic performance was assessed, and agreement among radiologists was calculated.

In total, 160 pelvic US exams were included in 160 patients, with a mean patient age of 12.1 years (SD=4.9). Most lesions were classified as O-RADS 2 (almost certainly benign), and fewer cases as O-RADS 4 (intermediate risk) or O-RADS 5 (high risk). Inter-radiologist agreement for O-RADS category was moderate (κ=0.42). Diagnostic performance of US O-RADS demonstrated high sensitivity and NPV (100% for all three reviewers). Specificities were 74-82%, and PPV was low at 5-7% for distinguishing malignant/borderline lesions from benign lesions.

Application of the O-RADS US system in pediatric patients may be challenging due to the low overall malignancy rate. Nevertheless, an O-RADS 2 classification provides meaningful reassurance, reflecting minimal malignancy risk in children. Larger studies are needed to determine the clinical utility of O-RADS US and whether pediatric-specific modifications are required.

The online version contains supplementary material available at 10.1007/s00247-026-06546-w.