A 58-year-old postmenopausal woman from Delhi presents with progressive abdominal distension, early satiety, and vague lower abdominal pain for 3 months. On examination, she has ascites and a fixed left adnexal mass. CA-125 is 850 U/mL (normal <35). Transvaginal ultrasound shows a complex left ovarian mass with internal septations and free fluid in the pelvis. CT abdomen reveals omental caking and peritoneal nodules. What is the most likely stage of her ovarian cancer?

## Clinical Presentation & Staging This patient presents with **advanced-stage epithelial ovarian cancer** with multiple indicators of peritoneal spread: ### Key Findings - **Ascites** — suggests peritoneal involvement - **Omental caking** — pathognomonic for Stage III disease - **Peritoneal nodules** — metastatic disease beyond the ovary - **Elevated CA-125** — correlates with disease burden - **Complex ovarian mass** — malignant morphology ### FIGO 2014 Staging (Ovarian Cancer) | Stage | Definition | |-------|------------| | **IA** | Tumor limited to one ovary; capsule intact; no surface involvement; negative peritoneal washings | | **IB** | Tumor limited to both ovaries; capsule intact; no surface involvement; negative washings | | **IC** | Stage IA or IB with capsule rupture, surface involvement, or positive peritoneal washings | | **IIA** | Extension to uterus and/or fallopian tubes | | **IIB** | Extension to other pelvic tissues | | **IIC** | Stage IIA or IIB with capsule rupture, surface involvement, or positive washings | | **IIIA** | Microscopic peritoneal metastases beyond pelvis | | **IIIB** | Macroscopic peritoneal metastases ≤2 cm | | **IIIC** | Macroscopic peritoneal metastases >2 cm **OR** positive retroperitoneal lymph nodes | | **IV** | Distant metastases (pleural effusion, liver parenchyma, brain) | **Key Point:** Omental caking and peritoneal nodules >2 cm constitute **Stage IIIC disease** — this is the most common presentation of epithelial ovarian cancer at diagnosis. ### Why This Patient is Stage IIIC 1. **Omental involvement** — omental caking is macroscopic peritoneal metastasis >2 cm 2. **Ascites with peritoneal nodules** — evidence of peritoneal seeding beyond the pelvis 3. **No mention of distant metastases** — rules out Stage IV (no pleural/liver parenchymal involvement) **Clinical Pearl:** ~70% of epithelial ovarian cancers present at Stage III or IV because early-stage disease is asymptomatic and ovarian cancer lacks a screening test. **High-Yield:** The presence of **omental caking alone** automatically assigns Stage IIIC, regardless of tumor size or grade. This is a critical exam point.