Using quality improvement methodology to improve ovarian salvage for benign ovarian masses

Reducing Unnecessary Oophorectomies for Benign Ovarian Neoplasms in Pediatric Patients

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.

Use and Accuracy of Intraoperative Frozen Section Analysis for Ovarian Masses in Children and Adolescents

STUDY OBJECTIVE

Describe the current practice patterns and diagnostic accuracy of frozen section (FS) pathology for children and adolescents with ovarian masses DESIGN: Prospective cohort study from 2018 to 2021 SETTING: Eleven children's hospitals PARTICIPANTS: Females age 6-21 years undergoing surgical management of an ovarian mass INTERVENTIONS: Obtaining intraoperative FS pathology MAIN OUTCOME MEASURE: Diagnostic accuracy of FS pathology RESULTS: Of 691 patients who underwent surgical management of an ovarian mass, FS was performed in 27 (3.9%), of which 9 (33.3%) had a final malignant pathology. Among FS patients, 12 of 27 (44.4%) underwent ovary-sparing surgery, and 15 of 27 (55.5%) underwent oophorectomy with or without other procedures. FS results were disparate from final pathology in 7 of 27 (25.9%) cases. FS had a sensitivity of 44.4% and specificity of 94.4% for identifying malignancy, with a c-statistic of 0.69. Malignant diagnoses missed on FS included serous borderline tumor (n = 1), mucinous borderline tumor (n = 2), mucinous carcinoma (n = 1), and immature teratoma (n = 1). FS did not guide intervention in 10 of 27 (37.0%) patients: 9 with benign FS underwent oophorectomy, and 1 with malignant FS did not undergo oophorectomy. Of the 9 patients who underwent oophorectomy with benign FS, 5 (55.6%) had benign and 4 (44.4%) had malignant final pathology.

CONCLUSIONS

FSs are infrequently utilized for pediatric and adolescent ovarian masses and could be inaccurate for predicting malignancy and guiding operative decision-making. We recommend continued assessment and refinement of guidance before any standardization of use of FS to assist with intraoperative decision-making for surgical resection and staging in children and adolescents with ovarian masses.

American college of radiology ovarian-adnexal reporting and data system ultrasound (O-RADS): Diagnostic performance and inter-reviewer agreement for ovarian masses in children

Objective

To evaluate the diagnostic performance and inter-observer agreement of the American College of Radiology Ovarian-Adnexal Reporting and Data System Ultrasound (O-RADS) in the diagnosis of ovarian masses in children.

Methods

From June 2012 to December 2021, 163 ovarian masses in 159 patients with pathologic results were retrospectively analyzed. Each mass was classified into an O-RADS category according to the criteria. The diagnostic performance of O-RADS for detecting malignant ovarian masses was assessed using histopathology as the reference standard. Kappa (k) statistic was used to assess inter-observer agreement between a less-experienced and a well-experienced radiologist.

Results

Out of 163 ovarian masses, 18 (11.0%) were malignant and 145 (89.0%) were benign. The malignancy rates of O-RADS 5, O-RADS 4, and O-RADS 3 masses were 72.7%, 34.6%, and 4.8%, respectively. The area under the receiver operating characteristic curve was 0.944 (95% CI, 0.908-0.981). The optimal cutoff value for predicting malignant ovarian masses was  > O-RADS 3 with a sensitivity, specificity, and accuracy of 94.4%, 86.2% and 86.2% respectively. The inter-observer agreement of the O-RADS category was good (k = 0.777).

Conclusions

O-RADS has a high diagnostic performance for children with ovarian masses. It provides an effective malignant risk classification for ovarian masses in children, which shows high consistency between radiologists with different levels of experience.

Obstetrician-Gynecologists' Experience and Comfort in Treating Children and Adolescents with Gynecologic Needs

STUDY OBJECTIVE

To determine which obstetrician-gynecologists care for pediatric and adolescent patients, their practice and referral patterns for common gynecologic symptoms, and desired training opportunities in pediatric and adolescent health care DESIGN: An Internet-based questionnaire designed to elicit information regarding the practice patterns of obstetrician-gynecologists SETTING: United States PARTICIPANTS: Obstetrician-gynecologists practicing clinical medicine and participating in the Pregnancy-Related Research Network (PRCRN) INTERVENTIONS: None MAIN OUTCOME MEASURES: Practice patterns of obstetrician-gynecologists in treating gynecologic issues in pediatric and adolescent patients RESULTS: Of the 103 participants that met the inclusion criteria, most see pediatric patients rarely, if ever. Most participants treat adolescent patients at least monthly in their clinical practice. Just over half (n = 60, 58.3%) have a pediatric-adolescent gynecologist within 50 miles of their practice location, which is associated with referring pediatric patients with vulvar itching but not in the treatment of other gynecologic conditions. The areas in which participants feel they had the least adequate training and had interest in receiving more training were vulvar conditions in pediatric patients and abnormal pubertal development.

CONCLUSION

Obstetrician-gynecologists feel comfortable managing most adolescent gynecologic conditions themselves and less comfortable managing pediatric gynecologic conditions. Referral patterns vary by distance to pediatric-adolescent gynecologists only in the scenario of pediatric vulvar itching. Participants expressed interest in future training in pediatric gynecologic conditions, especially vulvar conditions and pubertal development. Understanding the patterns and gaps in provision of care for these patients is key to enacting effective interventions to improve the quality of care for young women and children with gynecologic needs.

What Should Be the Topics of a Prospective Study on Ovarian Masses in Children?—Results of a Multicenter Retrospective Study and a Scoping Literature Review

Purpose: to determine management problems of ovarian masses in girls in order to form a baseline for prospective randomized studies of the established topics and quality improvement of our management. Materials and Methods: We performed a national analysis of clinical aspects of ovarian masses in girls operated on in Poland, analyzed retrospectively medical files of all consecutive patients aged 0–18 who underwent surgeries for ovarian lesions between 2012 and 2017 at 17 pediatric surgical departments and complemented the analysis with a scoping review of a recent primary research related to ovarian masses in children. Results: The study group comprised 595 patients. Forty-four (7.39%) girls were diagnosed with malignant tumors. The overall preservation rate was 64.54%. The analysis revealed that positive tumor markers (OR = 10.3), lesions larger than 6 cm (OR = 4.17) and solid mass on ultrasound examination (OR = 5.34) are interdependent variables differentiating malignant tumors from non-malignant lesions (X42 = 79.1; p = 0.00000). Our scoping review revealed 10 major branches of research within the topic of ovarian masses in pediatric population. Conclusions: We have developed an overview of the field with the emphasis on the local environment. Our next step is a multi-institutional prospective study of a quality improvement project implementation based on the obtained knowledge.

Recommendations for Postoperative Surveillance of Pediatric Benign Ovarian Neoplasms

STUDY OBJECTIVE

To assess postoperative management of pediatric patients with benign ovarian neoplasms, to develop recommendations for postoperative care.

DESIGN

A retrospective cohort study.

SETTING

Eight pediatric hospitals in the midwestern United States.

PARTICIPANTS

Patients up to 21 years of age who underwent surgery for a benign ovarian neoplasm between January 2010 and December 2016 were included.

INTERVENTIONS

No prospective interventions were evaluated.

MAIN OUTCOME MEASURES

Main outcome measures included postoperative imaging findings, recurrence rates, reoperation rates, and the timing of the aforementioned results.

RESULTS

A total of 427 patients met inclusion criteria. After the index surgery, 155 patients (36%) underwent a routine imaging study. Among those with routine imaging, abnormalities were noted in 48 patients (31%); 7 went on to have reoperation (5%), and no malignant pathologies or torsion were identified. Excluding the 7 patients who went on to have a reoperation as a result of routine imaging, 113 patients developed symptoms postoperatively and underwent imaging as a result (27%, 113/420). Abnormalities were noted in 44 (10%); 15 of these patients underwent reoperation (4%), among them 2 with malignancies and 3 with torsion. Of these 44 patients, 23 had initially undergone routine imaging and subsequently went on to have symptomatic imaging, with 17% (4/23) undergoing reoperation.

CONCLUSIONS

Routine imaging did not identify malignancy; most lesions identified on routine imaging were incidental findings. Although the study was not powered to appreciate a statistically significant difference, patients with malignancy or torsion were identified in the symptomatic group. This suggests no benefit from routine imaging, and supports symptomatic imaging postoperatively to minimize costs and patient/family burden.

Factors Associated with Torsion in Pediatric Patients with Ovarian Masses

BACKGROUND

Management of ovarian torsion has evolved toward ovarian preservation regardless of ovarian appearance during surgery. However, patients with torsion and an ovarian neoplasm undergo a disproportionately high rate of oophorectomy. Our objectives were to identify factors associated with ovarian torsion among females with an ovarian mass and to determine if torsion is associated with malignancy.

METHODS

A retrospective review of females aged 2-21 y who underwent an operation for an ovarian cyst or neoplasm between 2010 and 2016 at 10 children's hospitals was performed. Multivariate logistic regression was used to assess factors associated with torsion. Imaging data were assessed for sensitivity, specificity, and predictive value in identifying ovarian torsion.

RESULTS

Of 814 girls with an ovarian neoplasm, 180 (22%) had torsion. In risk-adjusted analyses, patients with a younger age, mass size >5 cm, abdominal pain, and vomiting had an increased likelihood of torsion (P < 0.01 for all). Patients with a mass >5 cm had two times the odds of torsion (odds ratio: 2.1; confidence interval: 1.2, 3.6). Imaging was not reliable at identifying torsion (sensitivity 34%, positive predictive value 49%) or excluding torsion (specificity 72%, negative predictive value 87%). The rates of malignancy were lower in those with an ovarian mass and torsion than those without torsion (10% versus 17%, P = 0.01). Among the 180 girls with torsion and a mass, 48% underwent oophorectomy of which 14% (n = 12) had a malignancy.

CONCLUSIONS

In females with an ovarian neoplasm, torsion is not associated with an increased risk of malignancy and ovarian preservation should be considered.

Application of Implementation Science to OB/GYN Quality Improvement Efforts

Although there is no shortage of guidelines and toolkits outlining clinical practices that are evidence-based and have been shown to improve outcomes, many hospitals, and L&D units struggle to figure out exactly how to implement strategies that have been shown to work. This paper will describe suggestions to help obstetrics and gynecology units successfully implement evidence-based strategies to improve quality and safety based on the theoretical framing structures of implementation science, including theories such as the Health Beliefs Model, the Theory of Planned Behavior, Ecological Perspectives, COM-B, CFIR, and tools such as Driver Diagrams.

Understanding the Value of Tumor Markers in Pediatric Ovarian Neoplasms

PURPOSE

The purpose of this study was to determine the diagnostic accuracy of tumor markers for malignancy in girls with ovarian neoplasms.

METHODS

A retrospective review of girls 2-21 years who presented for surgical management of an ovarian neoplasm across 10 children's hospitals between 2010 and 2016 was performed. Patients who had at least one concerning feature on imaging and had tumor marker testing were included in the study. Sensitivity, specificity, and negative and positive predictive values (PPV) of tumor markers were calculated.

RESULTS

Our cohort included 401 patients; 22.4% had a malignancy. Testing for tumor markers was inconsistent. AFP had high specificity (98%) and low sensitivity (42%) with a PPV of 86%. The sensitivity, specificity, and PPV of beta-hCG was 44%, 76%, and 32%, respectively. LDH had high sensitivity (95%) and Inhibin A and Inhibin B had high specificity (97% and 92%, respectively).

CONCLUSIONS

Tumor marker testing is helpful in preoperative risk stratification of ovarian neoplasms for malignancy. Given the variety of potential tumor types, no single marker provides enough reliability, and therefore a panel of tumor marker testing is recommended if there is concern for malignancy. Prospective studies may help further elucidate the predictive value of tumor markers in a pediatric ovarian neoplasm population.

TYPE OF STUDY

Retrospective Cohort Review.

LEVEL OF EVIDENCE

Level III.

Ovary-sparing surgery for benign pediatric ovarian masses

PURPOSE OF REVIEW

This review highlights progress in the management of pediatric ovarian neoplasms. Recent research has identified disparities in the management of patients with benign ovarian neoplasms based on a variety of factors. However, the long-term effects of unilateral oophorectomy have prompted an emphasis on ovary-sparing surgery (OSS) for benign masses. One of the challenges still facing providers is the preoperative differentiation between benign and malignant masses.

RECENT FINDINGS

Recent studies highlight the variability in practice patterns surrounding the management of benign ovarian neoplasms. Progress continues to be made in identifying reliable factors that can be used to inform preoperative risk stratification of patients who present with ovarian neoplasms. These factors include imaging characteristics, symptoms and tumor markers. In addition, the safety of OSS with regard to recurrence and upstaging in appropriate settings continues to be demonstrated.

SUMMARY

This review highlights the importance of multidisciplinary collaboration in the treatment of ovarian neoplasms given the varied surgical approach by specialty. Multiple retrospective studies have identified factors that can be used for preoperative risk stratification and selection of patients for OSS. Prospective studies evaluating the accuracy of these factors for preoperative risk stratification are needed.

Adnexal Torsion

Adnexal torsion is an uncommon gynecologic disorder caused by the partial or complete rotation of the ovary and/or the fallopian tube on its vascular support. Delay in treatment can impact fertility adversely. The objective of this report is to provide clinical recommendations based on the latest evidence. Specifically we discuss epidemiology, clinical presentation, diagnostic approach and management of adnexal torsion in adolescents.