A 58-year-old postmenopausal woman from Delhi presents with a 3-month history of progressive abdominal distension, early satiety, and mild abdominal pain. She denies vaginal bleeding or weight loss. On examination, she has a firm, fixed pelvic mass and ascites. Serum CA-125 is 680 U/mL (normal <35). Transvaginal ultrasound shows a 6 cm complex ovarian mass with septations and solid components. What is the most appropriate next step in management?

Explanation

## Clinical Assessment This patient presents with a classic presentation of advanced ovarian cancer: postmenopausal status, abdominal distension, ascites, elevated CA-125, and imaging findings consistent with malignancy. ### Key Diagnostic Features **High-Yield:** The combination of a complex ovarian mass >5 cm, ascites, elevated tumor marker (CA-125 >600), and clinical symptoms in a postmenopausal woman is diagnostic of epithelial ovarian cancer until proven otherwise. The firm, fixed pelvic mass suggests advanced disease (likely Stage III or IV). ### Staging Workup Before Surgery **Key Point:** Before any surgical intervention in suspected advanced ovarian cancer, comprehensive staging imaging is mandatory to: - Assess extent of peritoneal involvement - Evaluate for distant metastases (liver, lungs, diaphragm) - Determine resectability and surgical candidacy - Guide the decision between primary cytoreduction vs. neoadjuvant chemotherapy **Clinical Pearl:** CT abdomen and pelvis with IV contrast is the standard staging modality for ovarian cancer. It helps identify: - Peritoneal deposits and omental involvement - Lymph node enlargement (>1 cm short axis) - Liver parenchymal metastases - Pleural effusion or lung base involvement ### Why This Sequence? ```mermaid flowchart TD A[Suspected advanced ovarian cancer]:::outcome --> B[Complete staging imaging: CT A/P + CXR]:::action B --> C{Resectable disease?}:::decision C -->|Yes, good performance status| D[Primary cytoreductive surgery]:::action C -->|No, extensive disease| E[Neoadjuvant chemotherapy first]:::action D --> F[Platinum-taxane chemotherapy]:::action E --> G[Interval debulking surgery]:::action G --> F F --> H[Maintenance therapy consideration]:::outcome ``` **High-Yield:** The NCCN and FIGO guidelines recommend: 1. **Staging imaging first** (CT abdomen/pelvis, CXR, consider CA-125 trend) 2. **Then decide:** Primary cytoreduction (if resectable) vs. neoadjuvant chemotherapy (if extensive disease, poor performance status, or unresectable) 3. **Avoid diagnostic laparoscopy** in suspected advanced ovarian cancer—it does not change management and delays definitive treatment ### Why Not the Other Options? - **Diagnostic laparoscopy:** Inappropriate in advanced ovarian cancer; does not provide staging information that CT cannot give, and delays definitive treatment - **Immediate surgery without staging:** Risks inadequate cytoreduction if disease is extensive; staging imaging guides surgical planning - **Neoadjuvant chemotherapy without staging:** While neoadjuvant is sometimes appropriate, the decision requires prior imaging to confirm unresectability or poor surgical candidacy **Mnemonic: STAGE-THEN-OPERATE** — Always complete staging imaging before committing to primary cytoreductive surgery in ovarian cancer. [cite:FIGO Ovarian Cancer Guidelines 2021, NCCN Ovarian Cancer v3.2023]