Reducing Unnecessary Oophorectomies for Benign Ovarian Neoplasms in Pediatric Patients
Authors: Minneci Peter C. , Bergus Katherine C. , Lutz Carley , Aldrink Jennifer , Bence Christina , Breech Lesley , Dillon Patrick A. , Downard Cynthia , Ehrlich Peter F. , Fallat Mary , Fraser Jason D. , Grabowski Julia , Helmrath Michael , Hertweck Paige , Hewitt Geri , Hirschl Ronald B. , Kabre Rashmi , Lal Dave R. , Landman Matthew , Leys Charles , Mak Grace , Markel Troy , Pressey Joseph , Raiji Manish , Rymeski Beth , Saito Jacqueline , Sato Thomas T. , St Peter Shawn D. , Cooper Jennifer , Deans Katherine ,   Midwest Pediatric Surgery Consortium, Besner Gail , Kandel Jessica , Rescorla Frederick , von Allmen Daniel , Warner Brad , Inge Thomas , Kasten Steven , Holcomb George , Gourlay David , Anagnostopoulos Petros , Fox Sarah , Criss Cory , Speck Elizabeth , Gadepalli Samir , Van Arendonk Kyle , Flynn-O'Brien Katherine , Ladd Alan , Goldstein Seth , Raval Mehul , Wright Tiffany , Carter Stewart 
Published: October 2023

Importance

Although most ovarian masses in children and adolescents are benign, many are managed with oophorectomy, which may be unnecessary and can have lifelong negative effects on health.

Objective

To evaluate the ability of a consensus-based preoperative risk stratification algorithm to discriminate between benign and malignant ovarian pathology and decrease unnecessary oophorectomies.

Design, Setting, and Participants

Pre/post interventional study of a risk stratification algorithm in patients aged 6 to 21 years undergoing surgery for an ovarian mass in an inpatient setting in 11 children’s hospitals in the United States between August 2018 and January 2021, with 1-year follow-up.

Intervention

Implementation of a consensus-based, preoperative risk stratification algorithm with 6 months of preintervention assessment, 6 months of intervention adoption, and 18 months of intervention. The intervention adoption cohort was excluded from statistical comparisons.

Main Outcomes and Measures

Unnecessary oophorectomies, defined as oophorectomy for a benign ovarian neoplasm based on final pathology or mass resolution.

Results

A total of 519 patients with a median age of 15.1 (IQR, 13.0-16.8) years were included in 3 phases: 96 in the preintervention phase (median age, 15.4 [IQR, 13.4-17.2] years; 11.5% non-Hispanic Black; 68.8% non-Hispanic White); 105 in the adoption phase; and 318 in the intervention phase (median age, 15.0 [IQR, 12.9-16.6)] years; 13.8% non-Hispanic Black; 53.5% non-Hispanic White). Benign disease was present in 93 (96.9%) in the preintervention cohort and 298 (93.7%) in the intervention cohort. The percentage of unnecessary oophorectomies decreased from 16.1% (15/93) preintervention to 8.4% (25/298) during the intervention (absolute reduction, 7.7% [95% CI, 0.4%-15.9%]; P = .03). Algorithm test performance for identifying benign lesions in the intervention cohort resulted in a sensitivity of 91.6% (95% CI, 88.5%-94.8%), a specificity of 90.0% (95% CI, 76.9%-100%), a positive predictive value of 99.3% (95% CI, 98.3%-100%), and a negative predictive value of 41.9% (95% CI, 27.1%-56.6%). The proportion of misclassification in the intervention phase (malignant disease treated with ovary-sparing surgery) was 0.7%. Algorithm adherence during the intervention phase was 95.0%, with fidelity of 81.8%.

Conclusions and Relevance

Unnecessary oophorectomies decreased with use of a preoperative risk stratification algorithm to identify lesions with a high likelihood of benign pathology that are appropriate for ovary-sparing surgery. Adoption of this algorithm might prevent unnecessary oophorectomy during adolescence and its lifelong consequences. Further studies are needed to determine barriers to algorithm adherence.