A 58-year-old postmenopausal woman from Mumbai presents with progressive abdominal distension and mild abdominal pain for 3 months. She denies vaginal bleeding or weight loss. On examination, she has a firm, fixed, irregular mass palpable in the lower abdomen. Serum CA-125 is 280 U/mL (normal <35). Transvaginal ultrasound shows a complex adnexal mass with ascites. CT abdomen reveals omental caking and peritoneal nodules. What is the most appropriate next step in management?

Explanation

## Clinical Diagnosis & Staging **Key Point:** This patient has advanced ovarian cancer (FIGO Stage IIIC/IV) with omental caking, peritoneal nodules, and ascites—hallmarks of metastatic disease. ## Rationale for Neoadjuvant Chemotherapy **High-Yield:** In advanced ovarian cancer with extensive peritoneal involvement (omental caking, peritoneal nodules), **neoadjuvant chemotherapy (NACT) followed by interval cytoreductive surgery (ICS)** is preferred over primary cytoreductive surgery when: - Extensive upper abdominal disease (omental caking) - Multiple peritoneal implants - Likelihood of suboptimal primary debulking is high - Patient performance status is borderline **Clinical Pearl:** The CHORUS and EORTC trials demonstrated that NACT → ICS achieves similar overall survival to primary debulking while reducing perioperative morbidity and allowing better patient selection for surgery. ## Treatment Algorithm ```mermaid flowchart TD A[Advanced Ovarian Cancer]:::outcome --> B{Extent of disease & feasibility of optimal debulking?}:::decision B -->|Likely optimal debulking| C[Primary Cytoreductive Surgery]:::action B -->|Extensive peritoneal/omental disease| D[Neoadjuvant Chemotherapy]:::action C --> E[Platinum-based adjuvant chemotherapy]:::action D --> F[Interval Cytoreductive Surgery]:::action F --> G[Platinum-based chemotherapy completion]:::action E --> H[Response assessment & maintenance therapy]:::outcome G --> H ``` **Key Point:** Standard chemotherapy regimen is **carboplatin + paclitaxel** (TC) or **carboplatin + paclitaxel + bevacizumab** (BEV-TC) for platinum-sensitive disease. ## Why This Patient Needs NACT | Feature | Finding | Implication | |---------|---------|-------------| | Omental caking | Present on CT | Extensive upper abdominal disease | | Peritoneal nodules | Multiple | High tumor burden | | Ascites | Present | Advanced stage | | Optimal debulking likelihood | Low (<50%) | NACT preferred | [cite:FIGO Guidelines 2023, NCCN Ovarian Cancer v3.2023]