Advanced adnexal mass in a frail postmenopausal woman: primary debulking or neoadjuvant chemotherapy?
A 67-year-old para 2 with a BMI of 31 presents with 3 months of bloating and early satiety. Examination reveals ascites and a fixed pelvic mass. Transvaginal ultrasound shows a 9 cm multilocular cystic-solid right adnexal mass with papillary projections and marked vascularity. CT shows omental nodules but no liver parenchymal disease. CA125 is 640 U/mL and HE4 is 410 pmol/L. ECOG performance status is 1. She has COPD with FEV1 58% predicted, an eGFR of 52 mL/min/1.73 m², and a history of unprovoked pulmonary embolism 4 years ago; she is not currently anticoagulated. The multidisciplinary team must choose between primary debulking surgery and neoadjuvant chemotherapy.
1. What is the most likely diagnosis, what do the ROMA and imaging findings add, and what must be done before committing to neoadjuvant treatment?
Read the worked answer
The most likely diagnosis is advanced epithelial ovarian cancer, probably high-grade serous carcinoma with omental metastases (stage IIIC). The ultrasound features-a multilocular cystic-solid mass with papillary projections, marked vascularity, and ascites-are high-risk on IOTA-type assessment. The ROMA combines CA125 and HE4 with menopausal status; in a postmenopausal woman, a very high ROMA score substantially raises the probability of malignancy, but it does not replace histology. Imaging also helps assess resectability: omental nodules suggest peritoneal spread, while the absence of liver parenchymal disease and the absence of bulky upper abdominal disease may still permit complete cytoreduction. Before neoadjuvant chemotherapy, obtain a tissue diagnosis, usually by image-guided core biopsy of an omental or adnexal lesion, or by diagnostic laparoscopy with biopsy and cytology. A multidisciplinary review should assess surgical fitness, expected residual disease, and the patient's goals. If primary surgery is chosen, proceeding without preoperative biopsy is acceptable after informed consent, because the diagnosis will be confirmed at frozen section or definitive histology. Exclude a gastrointestinal primary if symptoms suggest it, but the adnexal mass and omental pattern make ovarian cancer most likely.
2. Compare primary debulking surgery with neoadjuvant chemotherapy and interval debulking for this patient, and justify your recommendation.
Read the worked answer
Primary debulking surgery aims to remove all macroscopic disease before chemotherapy and may improve survival when complete resection is achievable with acceptable morbidity. However, it requires a long operation, bowel surgery, ICU support, and recovery that can delay chemotherapy. Randomised trials such as EORTC 55971 and CHORUS showed that neoadjuvant chemotherapy followed by interval debulking is not inferior in overall survival and reduces perioperative morbidity, although complete resection remains the strongest prognostic factor. This patient is relatively high risk for primary surgery: COPD with reduced FEV1, eGFR 52 mL/min/1.73 m², ascites, omental disease, and a prior pulmonary embolism. Her ECOG status is 1, so she is not bedbound, but the combination of respiratory and renal compromise makes a prolonged debulking procedure hazardous. If imaging and laparoscopy suggest that complete resection would require extensive bowel surgery or leave residual disease greater than 1 cm, neoadjuvant carboplatin and paclitaxel for three to four cycles followed by interval debulking is the better option. If the MDT judges complete resection feasible with limited morbidity, primary surgery is reasonable. The decision should be shared with the patient, documenting the trade-off between upfront tumour removal and perioperative risk.
3. Outline thromboprophylaxis and perioperative optimisation for this patient, including the implications of her previous unprovoked pulmonary embolism.
Read the worked answer
Active cancer, major pelvic surgery, immobility, obesity, and a previous unprovoked pulmonary embolism place her at high venous thromboembolism risk. For major abdominal cancer surgery, use mechanical prophylaxis plus prophylactic low-molecular-weight heparin, starting preoperatively or according to anaesthetic guidance, and continue for 28 days after surgery. Because she has a history of unprovoked PE, clarify whether she has a thrombophilia or residual thrombus; if she has a history of cancer-associated thrombosis or recurrent events, therapeutic anticoagulation may be needed rather than prophylaxis. Her eGFR of 52 mL/min/1.73 m² allows standard or slightly adjusted low-molecular-weight heparin dosing, but avoid fondaparinux if renal function is unstable. For chemotherapy, carboplatin dosing requires accurate renal function; consider measured GFR if there is doubt. Optimise COPD with smoking cessation, bronchodilators, physiotherapy, and pulmonary review before surgery. Correct anaemia, assess nutrition, and involve critical care for postoperative planning. If neoadjuvant chemotherapy is chosen, arrange imaging after three cycles and plan interval debulking before chemotherapy resistance develops. Discuss the risks of surgery and chemotherapy, including infection, renal injury, and VTE, during shared decision-making.