Preoperative Algorithm Might Halve Unnecessary Oophorectomies in Children

Derick Alison
Derick Alison
7 Min Read

A new algorithm appeared promising to help reduce the number of unnecessary oophorectomies in young patients, researchers found.

At 11 children’s hospitals implementing the algorithm, the percentage of oophorectomies for benign disease decreased from 16.1% before adopting the risk predictive tool to 8.4% afterward (absolute risk reduction 7.7%, P=0.03), Peter Minneci, MD, MHSc, of Nemours Children’s Health in Delaware Valley, Delaware, and colleagues reported in JAMA.

Algorithm sensitivity for identifying benign lesions in the intervention cohort was 91.6% (95% CI 88.5-94.8), with specificity of 90.0% (95% CI 76.9-100), positive predictive value of 99.3% (95% CI 98.3-100), and negative predictive value of 41.9% (95% CI 27.1-56.6).

“Nationally, there was variability in the surgical procedures being performed in young girls who presented with ovarian masses across children’s hospitals,” Minneci told MedPage Today. “This study developed and implemented a consensus-based, preoperative risk stratification algorithm across pediatric surgical specialists who treat these patients, including pediatric surgeons and pediatric and adolescent gynecologists.”

“Algorithm use decreased variability in care and safely minimized the number of unnecessary oophorectomies for benign ovarian lesions,” Minneci added.

As evidence that many children are getting unnecessary oophorectomy, Minneci’s group pointed to the wide range in ovary-sparing surgery (OSS) rates, accounting for anywhere from 18% to 77% of procedures for benign ovarian neoplasms in kids.

“Oophorectomy can lead to premature ovarian failure, early menopause, and associated increased risks of cognitive impairment, osteopenia, impaired sexual health, and cardiovascular disease,” they added.

“Furthermore, patients with benign ovarian neoplasms are at increased risk of developing a contralateral second neoplasm. This may result in unintentional castration due to potential contralateral torsion or surgical castration if oophorectomy is ultimately required for malignant disease,” Minneci and coauthors continued. “Preoperative risk stratification through a comprehensive evaluation including history and physical examination, imaging studies, and serum tumor markers is critical to help identify lesions that are likely to be benign and appropriate for OSS.”

Their study comprised 519 kids and adolescents ages 6 to 21 years (median around 15) who were undergoing surgery for an ovarian mass in an inpatient setting at 11 children’s hospitals in the U.S. between August 2018 and January 2021.

The first 6 months of that period entailed preintervention assessment, followed by 6 months of intervention adoption and 18 months of intervention use. There were 96 patients in the preintervention phase, 105 in the adoption phase, and 318 in the intervention phase.

The algorithm directed patients to OSS if they had no suspected torsion and a symptomatic simple or hemorrhagic cyst that was unresolved or a complex mass with negative tumor markers and no concerning features.

All patients underwent an operation: 273 OSS, 43 oophorectomy, and two detorsions without additional intervention.

Benign disease was confirmed in 96.9% in the preintervention cohort and 93.7% in the intervention group.

Misclassification of patients with malignant disease as eligible for OSS occurred in a “low” 0.7% of patients after adoption of the algorithm (two of 275), “both of whom had immature teratomas that were completely excised without oophorectomy and without subsequent symptoms, ipsilateral or contralateral recurrence, or need for additional operations,” the researchers noted.

Among 318 patients in the intervention group, 174 presented with suspected torsion, one of whom was pregnant and underwent urgent detorsion with OSS, and two of whom underwent detorsion alone, the researchers reported.

Among the 165 cases presenting with suspected torsion with benign masses confirmed on pathology, unnecessary oophorectomies were performed in nine cases, with pathology revealing mature teratoma in five, mucinous tumor in two, and cyst in two.

Of 144 patients without suspected torsion, 54 had radiographically simple or hemorrhagic cysts and 90 had complex masses (85 with concerning features).

Algorithm adherence during the intervention phase was 95.0%, and fidelity was 81.8%. The most common reason for deviation was failing to evaluate tumor markers or evaluating an incomplete panel.

“One very encouraging finding was the high adherence with the algorithm, which suggests that the providers readily adopted and were able to use the algorithm,” Minneci said. “This algorithm can be readily adopted into practice and provides a simple way to decrease variability in care and safely promote ovary-sparing surgery for young females who present with ovarian masses.”

At the same time, there were several limitations of the study.

First, clinical practice at participating sites started to change during the planning of the study such that the percentage of unnecessary oophorectomies decreased from an expected 27% to 16% in the preintervention cohort, Minneci and colleagues wrote.

Additionally, results of the study may not be broadly generalizable, they noted, since it was performed at tertiary children’s hospitals with pediatric surgical subspecialists.

“Future studies are needed to determine barrier to algorithm adherence and adoption,” Minneci and colleagues concluded.

  • author['full_name']

    Jennifer Henderson joined MedPage Today as an enterprise and investigative writer in Jan. 2021. She has covered the healthcare industry in NYC, life sciences and the business of law, among other areas.

Disclosures

The study was supported by a grant through the Thrasher Research Fund.

Minneci had no disclosures. Co-authors reported receiving honoraria from the American College of Obstetricians and Gynecologists; receiving grants from AbbVie, the Patient-Centered Outcomes Research Institute, the Agency for Healthcare Research and Quality, and the National Institute on Minority Health and Health Disparities; and owning stock in FlexDex.

Primary Source

JAMA

Source Reference: Minneci PC, et al “Reducing unnecessary oophorectomies for benign ovarian neoplasms in pediatric patients” JAMA 2023; DOI: 10.1001/jama.2023.17183.

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