Prediction of Surgical Outcome in Advanced Ovarian Cancer by Imaging and Laparoscopy: A Narrative Review

SIMPLE SUMMARY: Maximal-effort debulking surgery is the recommended approach for advanced-stage ovarian cancer. The role of imaging is to provide a preoperative systematic and structured report of tumour dissemination with special emphasis on key sites that preclude optimal resectability in ovarian cancer surgery. Imaging methods cannot reliably detect small volume carcinomatosis but yield high diagnostic performance for detecting bulky disease at critical sites for cytoreduction and can thus be reliably used to avoid unnecessary explorations. Although diagnostic laparoscopy may directly visualize intraperitoneal involvement, it has inherent limitations when investigating tumours behind the gastrosplenic ligament, in the lesser sac, mesenteric root or when exploring the retroperitoneum. The major benefit of laparoscopy appears as an ultimate triage step in situations where the imaging diagnosis is uncertain regarding resectability and the presence of diffuse small-volume carcinomatosis. ABSTRACT: Maximal-effort upfront or interval debulking surgery is the recommended approach for advanced-stage ovarian cancer. The role of diagnostic imaging is to provide a systematic and structured report on tumour dissemination with emphasis on key sites for resectability. Imaging methods, such as pelvic and abdominal ultrasound, contrast-enhanced computed tomography, whole-body diffusion-weighted magnetic resonance imaging and positron emission tomography, yield high diagnostic performance for diagnosing bulky disease, but they are less accurate for depicting small-volume carcinomatosis, which may lead to unnecessary explorative laparotomies. Diagnostic laparoscopy, on the other hand, may directly visualize intraperitoneal involvement but has limitations in detecting tumours beyond the gastrosplenic ligament, in the lesser sac, mesenteric root or in the retroperitoneum. Laparoscopy has its place in combination with imaging in cases where ima-ging results regarding resectability are unclear. Different imaging models predicting tumour resectability have been developed as an adjunctional objective tool. Incorporating results from tumour quantitative analyses (e.g., radiomics), preoperative biopsies and biomarkers into predictive models may allow for more precise selection of patients eligible for extensive surgery. This review will discuss the ability of imaging and laparoscopy to predict non-resectable disease in patients with advanced ovarian cancer.