medwireNews: Improved pre-operative risk assessment for ovarian masses could enable a substantial proportion of young women and girls to avoid having their ovaries removed unnecessarily because their tumors are benign, US researchers have found.
Among 11 children’s hospitals in the USA, 16.1% of oophorectomies performed between 2018 and 2019 were classified as being unnecessary, defined as final pathology showing benign ovarian neoplasms or mass resolution. This rate fell significantly to 8.4% (absolute reduction, 7.7%) after a newly developed, consensus-based, pre-operative risk stratification algorithm had been in use as standard care for 18 months between 2019 and 2021.
The algorithm showed good ability to discriminate benign from malignant disease with pathologic confirmation, with a reported sensitivity of 91.6%, specificity of 90.0%, a positive predictive value of 99.3%, and a negative predictive value of 41.9%.
Ovary-sparing surgery (OSS) where only tumor tissue is removed is the standard approach for managing benign lesions in adults, but its use in children ranges from 18–77%.
“This suggests that many children are undergoing unnecessary oophorectomies,” Peter Minneci (Nemours Children’s Hospital–Delaware Valley, Wilmington, USA) and co-authors from the Midwest Pediatric Society Consortium say in JAMA.
The algorithm pathway provides a standardized pathway for multidisciplinary team assessment of whether an ovarian mass is benign or malignant, based initially on whether torsion is suspected.
Patients with suspected torsion may be considered for oophorectomy or urgent detorsion, alone or alongside OSS surgery, to remove the mass, the researchers advise, with patients requiring urgent detorsion for more complex masses going on for further assessment.
By contrast, the algorithm indicates that patients without suspected torsion who have simple or hemorrhagic cysts that are asymptomatic, or are symptomatic but resolved, should undergo repeat imaging after 6–8 weeks. Patients with continuing symptoms and a 4 cm or greater mass on repeat imaging should be considered for an OSS procedure, such as cystectomy or complete mass excision, with the same recommendation for patients with symptomatic, unresolved simple or hemorrhagic masses.
Patients with complex masses should be considered for concerning features, such as a diagnosis of precocious puberty, a history of ovarian malignancy, a mass greater than 8 cm in size, tumor imaging characteristics, including papillary projections, lymphadenopathy, or ascites, and high levels of CA125, alpha-fetoprotein, and other tumor markers.
In the absence of such concerns, the algorithm indicates the mass is likely benign and may be treated with OSS and complete excision, whereas patients with concerning features are at risk for malignancy and should be forwarded to the multidisciplinary team for staging and surgery, the researchers say.
To see if using the algorithm made a difference in real-life practice, they performed a prospective study involving 519 patients scheduled to undergo surgery for an ovarian mass who were aged from 6 to 21 years, with a median age of 15 years.
Not only did the algorithm help reduce the percentage of unnecessary oophorectomies, but it also helped minimize the use of OSS for patients with malignant lesions, with just 0.7% of malignant lesions being misclassified.
“Although adherence to the algorithm was high [95%], fidelity was lower [81.8%], suggesting additional room for improvement in algorithm understanding and adoption,” the researchers observe.
Reasons for nonadherence included unfamiliarity with or misunderstanding of the algorithm and surgeon preference, while discrepancy between the initial and final interpretations of imaging scans was the main reason for deviating from correct use of the algorithm. Also, some patients had incomplete panels of tumor markers, which may have occurred because clinicians had chosen not to test for certain markers.
“The lower fidelity deserves further study to identify ways to improve algorithm implementation to benefit a greater number of patients,” says Minneci and team.
They point out that nine of the 25 unnecessary oophorectomies occurred in patients with suspected torsion, and so “better adherence to the algorithm’s guidance for detorsion and completion of preoperative risk stratification with subsequent definitive procedure may further reduce unnecessary oophorectomies.”
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