Do the findings of high‑grade serous ovarian carcinoma with extensive peritoneal carcinomatosis on CT indicate terminal disease?

High-Grade Serous Ovarian Carcinoma with Extensive Peritoneal Carcinomatosis: Prognosis and Management

Extensive peritoneal carcinomatosis in high-grade serous ovarian carcinoma does NOT automatically indicate terminal disease—this represents advanced-stage (Stage III) disease that is potentially curable with aggressive cytoreductive surgery and platinum-based chemotherapy, with 5-year survival rates of approximately 27% for distant disease. 1

Understanding the Staging and Prognosis

Stage Classification:

• Extensive peritoneal carcinomatosis places this patient at FIGO Stage IIIC (macroscopic peritoneal metastasis >2 cm in greatest dimension) or potentially Stage IV if there are distant metastases to solid organs or malignant pleural effusion 1
• High-grade serous carcinoma accounts for approximately 70% of ovarian carcinomas and up to 95% of Stage III-IV disease 1
• Tumor stage is the strongest prognostic factor, with patients having regional disease showing 5-year relative survival rates of 72%, and those with distant disease at 27% 1

Critical Distinction:

• This is advanced disease, not terminal disease—the distinction is crucial for treatment planning 2
• High-grade serous carcinoma is highly chemosensitive to platinum-based therapy, making aggressive treatment worthwhile even with extensive peritoneal involvement 2

Treatment Algorithm Based on Resectability

Step 1: Evaluation by Gynecologic Oncologist

• Mandatory evaluation by a gynecologic oncologist to assess surgical candidacy, patient fitness (ECOG performance status, age, frailty, nutritional status, comorbidities), and disease resectability 2
• This evaluation is the second most important determinant for survival after tumor stage 1

Step 2: Determine Surgical Approach

For patients likely to achieve complete cytoreduction (no visible residual disease):

• Primary cytoreductive surgery is preferred over neoadjuvant chemotherapy 2
• Surgery should include total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, peritoneal biopsies, and maximal debulking of all visible disease 2
• Followed by carboplatin (AUC 5-6) plus paclitaxel (175 mg/m²) for 6 cycles 2

For patients unlikely to achieve complete cytoreduction:

• Neoadjuvant chemotherapy with carboplatin plus paclitaxel for 3-4 cycles 1, 2
• Followed by interval cytoreductive surgery after demonstrating response or stable disease 1, 2
• Then completion chemotherapy to total 6 cycles 2

Factors Suggesting Difficult or Incomplete Cytoreduction

Imaging findings that may predict suboptimal debulking include: 3

• Extensive small bowel or mesenteric root involvement
• Lymph nodes superior to the celiac axis
• Pleural infiltration
• Pelvic sidewall invasion
• Bladder trigone involvement
• Hepatic parenchymal metastases or implants near the right hepatic vein
• Implants >2 cm in the diaphragm, lesser sac, porta hepatis, intersegmental fissure, gallbladder fossa, or gastrosplenic/gastrohepatic ligament

However, imaging prediction models have not shown sufficiently high accuracy to definitively guide surgical decisions—gynecologic oncologist assessment remains paramount 1

Maintenance Therapy Considerations

BRCA Testing:

• Initiate germline and somatic BRCA1/2 testing at diagnosis to guide subsequent maintenance therapy 2
• For patients with BRCA1/2 mutations achieving complete or partial response, maintenance olaparib 300 mg orally twice daily provides approximately 70% improvement in progression-free survival 2

Common Pitfalls to Avoid

Do not:

• Confuse high-grade serous carcinoma with low-grade serous carcinoma—these are distinct tumor types with different biology and prognosis 1, 2
• Proceed with neoadjuvant chemotherapy without gynecologic oncologist evaluation 2
• Assume the disease is "terminal" based solely on extensive peritoneal involvement—this represents treatable advanced disease 1, 2
• Mistake high-grade serous carcinoma for carcinosarcoma, which requires ifosfamide-based rather than carboplatin-paclitaxel regimen 2

Alternative Management if Surgery Not Feasible

• If no radiologic response to neoadjuvant chemotherapy or patient remains medically inoperable, continuation of platinum-based chemotherapy alone (without interval surgery) is acceptable 2
• This scenario represents a palliative rather than curative approach, but still offers meaningful disease control and quality of life benefits

The presence of extensive peritoneal carcinomatosis indicates advanced disease requiring aggressive multimodal therapy, but with modern treatment approaches including optimal cytoreductive surgery and platinum-based chemotherapy, meaningful survival and potential cure remain achievable goals. 1, 2