Ovarian cancer is the second most common gynecological malignancy with approximately 230,000 women in the United States having with this disease [1]. The epithelial histology sub-type accounts for 90% of all ovarian cancers and is associated with an estimated 5-year survival of 20% when distal disease is present [2,3]. Intraperitoneal dissemination is the most common route of disease spread in ovarian cancer. Tumor cells exfoliate from the affected epithelium and are disseminated by peritoneal fluid throughout the peritoneal cavity. At the initial diagnosis, 70% of patients with ovarian cancer already have peritoneal disease [4,5].

Ovarian cancer is unique in that patients with peritoneal dissemination are considered as having resectable disease, as compared to most other cancers for which peritoneal disease is considered unresectable [6]. Patients with advanced stage ovarian cancer are managed with cytoreductive surgery and platinum-based chemotherapy. The goal of cytoreductive surgery is to remove all visible disease (i.e., complete resection). If this is not achievable, an “optimal” resection of disease (defined as 1 cm or less of residual disease) has been shown to improve disease-free and overall survival by two years [6].

In patients with ovarian cancer, the extent and distribution of tumor deposits guide clinical decisions about optimal timing of cytoreductive surgery. Since tumor burden and extent can be evaluated with imaging, the American Society of Gynecologic Oncology, the American Society of Clinical Oncology and the European Society of Gynaecological Oncology (ESGO) - European Society for Medical Oncology (ESMO) clinical practice guidelines recommend that cross-sectional imaging be obtained during initial evaluation of the women with suspected ovarian cancer [7,8]. Patients with early-stage disease, localized or regional disease, are treated with upfront surgery. Patients with more advanced disease may be managed with either primary cytoreductive surgery or neoadjuvant chemotherapy followed by interval cytoreductive surgery. Disease distribution and tumor burden influence the surgeon's assessment about the feasibility of complete (or at least optimal) resection during primary cytoreductive surgery and, hence, impact clinical decision-making [6,8]. Recently, the addition of hyperthermic intraperitoneal chemotherapy added to interval cytoreductive surgery has been showed to improve both overall and disease-free survival [8,9].

Although there are no universally accepted surgical criteria of inoperable disease and local practices depend on the center and surgeon preferences, specific anatomical tumor locations are known to be difficult to resect and are associated with suboptimal cytoreduction or require special surgical considerations [10]. This article reviews the role of imaging in the initial evaluation and management of patients with ovarian cancer, provides a practical approach to the assessment of disease extent on computed tomography (CT) and magnetic resonance imaging (MRI) and highlights advances in genomics and radiomics that can impact management of patients with ovarian cancer.