A 52-year-old postmenopausal woman presents with a 3-month history of progressive abdominal distension, early satiety, and a palpable abdominal mass. Transvaginal ultrasound shows a complex ovarian mass (8 cm) with ascites. CA-125 is 850 U/mL. She is otherwise fit for surgery. What is the most appropriate next step in management?

Explanation

## Clinical Context This patient presents with clinical and biochemical evidence of advanced ovarian cancer (elevated CA-125, ascites, large complex mass). The key decision is whether to proceed directly to surgery or obtain staging imaging first. ## Rationale for Correct Answer **Key Point:** Before primary cytoreductive surgery (PCS) in ovarian cancer, comprehensive staging imaging (CT chest, abdomen, pelvis ± MRI) is mandatory to assess: - Extent of peritoneal disease - Liver metastases - Diaphragmatic involvement - Resectability of upper abdominal disease - Presence of distant metastases This imaging guides the surgical team on feasibility of optimal debulking and identifies patients who may benefit from neoadjuvant chemotherapy (NACT) instead. ## Decision Algorithm ```mermaid flowchart TD A[Suspected advanced ovarian cancer]:::outcome --> B[Obtain staging CT chest/abdomen/pelvis]:::action B --> C{Resectable disease?}:::decision C -->|Yes, optimal debulking likely| D[Primary cytoreductive surgery]:::action C -->|No, upper abdominal involvement| E[Neoadjuvant chemotherapy]:::action D --> F[Platinum-based adjuvant chemotherapy]:::action E --> G[Interval debulking after 3-4 cycles]:::action F --> H[Complete response/remission]:::outcome G --> H ``` **High-Yield:** The goal of cytoreductive surgery is **optimal debulking** (residual disease <1 cm, ideally R0). Staging imaging predicts this likelihood and prevents futile surgery in patients with unresectable disease. **Clinical Pearl:** In this case, the patient is fit for surgery AND has no contraindications to imaging. Staging CT is the standard of care before any surgical decision in ovarian cancer. ## Why Not Neoadjuvant Chemotherapy First? NACT is reserved for: - Patients deemed unfit for surgery - Extensive upper abdominal/diaphragmatic disease - Unresectable metastatic disease This patient has not yet been staged; imaging may show she is a candidate for PCS. ## Why Not Staging Laparoscopy? Laparoscopy has a limited role in modern ovarian cancer management. CT imaging is now the standard for preoperative assessment and is less invasive than diagnostic laparoscopy. [cite:Berek & Hacker's Gynecologic Oncology 6e Ch 10]