A 52-year-old postmenopausal woman presents with progressive abdominal distension, early satiety, and a 3-month history of vague abdominal pain. On examination, she has a palpable abdominal mass and ascites. Serum CA-125 is elevated at 480 U/mL. Transvaginal ultrasound shows a complex ovarian mass (8 cm) with solid and cystic components, and free fluid in the pelvis. What is the most appropriate next step in management?

Explanation

## Clinical Context This patient presents with classic features of advanced epithelial ovarian cancer: postmenopausal status, constitutional symptoms (abdominal distension, early satiety), elevated CA-125, and imaging findings of a complex ovarian mass with ascites. ## Why CT Staging is the Next Step **Key Point:** Once ovarian cancer is suspected on imaging and serology, the immediate priority is **staging** to determine disease extent and surgical feasibility, not tissue diagnosis. **High-Yield:** In suspected ovarian cancer: - **Do NOT perform diagnostic laparoscopy** — it risks rupture of the tumor capsule and upstaging the disease - **Do NOT start chemotherapy** without surgical assessment — the goal is primary debulking surgery (PDS) in fit patients with resectable disease - **CT abdomen/pelvis** is the standard staging modality to assess: - Extent of peritoneal involvement - Liver metastases - Lymph node involvement - Diaphragmatic involvement - Resectability assessment ## Management Algorithm ```mermaid flowchart TD A[Suspected ovarian cancer<br/>Imaging + elevated CA-125]:::outcome --> B[CT abdomen/pelvis<br/>for staging]:::action B --> C{Resectable disease<br/>& good performance<br/>status?}:::decision C -->|Yes| D[Primary debulking surgery<br/>+ staging]:::action C -->|No| E[Neoadjuvant chemotherapy<br/>then interval debulking]:::action D --> F[Adjuvant chemotherapy<br/>Platinum + Taxane]:::action E --> G[Interval debulking<br/>after 3-4 cycles]:::action ``` **Clinical Pearl:** The goal of primary debulking surgery is to achieve **optimal cytoreduction** (residual disease <1 cm, ideally <0.25 cm). This is one of the strongest prognostic factors in epithelial ovarian cancer. **Mnemonic: STAGE-OC** (Staging approach for Ovarian Cancer): - **S** = Serology (CA-125, HE4) - **T** = Transvaginal ultrasound - **A** = Advanced imaging (CT/MRI) - **G** = Gynecologic oncology referral - **E** = Extent assessment (resectability) - **O** = Operative planning - **C** = Chemotherapy after surgery [cite:Park 26e Ch 18]