Preoperative risk stratification of adnexal masses: can we predict the optimal surgical management?

Study Objective: To characterize preoperative risk stratification with aim of identifying the accurate surgical approach of benign and malignant adnexal masses in pediatric patients.

Design: A retrospective chart review of all cases of adnexal masses surgically managed between January 2001 and December 2006.

Setting: The Hospital for Sick Children, Toronto, Canada.

Participants: 129 cases of 126 pediatric and adolescent patients who underwent operative management of their adnexal masses.

Main Outcome Measures: Ultrasonographic characteristics (cyst size and character), surgical approach (laparoscopy vs laparotomy) and method of cyst removal (cystectomy vs oophorectomy). Data was assessed with a Fisher Exact test where appropriate (P < .05).

Results: Malignancies were more frequently treated by laparotomy (n = 14, 98.6%, P < .001), and benign cases by laparoscopy (n = 78, 97%, P < .001). On ultrasonography, malignant masses were more often complex (n = 16, 100%, P = .006) and ≥8 cm (n = 16, 100%, P < .001) than benign masses (≥8 cm n = 60, 53%, complex n = 76, 67%). Combining ultrasonographic measurements of ≥8 cm and complexity identified 100% of malignant masses (n = 16) and 36% of benign masses (n = 41, P < .001, PPV = 37.1, NPV = 100%). Additional imaging including CT/MRI was ordered by pediatric surgeons (n = 17, 77%) more often than pediatric gynecologists (n = 44, 41%, P = .002). Furthermore, pediatric surgeons managed adnexal masses by oophorectomy (n = 12, 55%) more often as compared to pediatric gynecologists (n = 19, 18%, P < .001).

Conclusion: Using preoperative characteristics of complexity and ≥8 cm reduces the number of benign masses treated with laparotomy while ensuring malignant masses are managed with an open approach.