A series of cases is presented to illustrate both typical and atypical imaging findings in advanced ovarian cancer. The focus is on the use of MRI, a valuable imaging modality for confirming equivocal disease sites observed on CT scans. Certain areas, such as the peritoneal reflections and porta, are better evaluated with MRI, as these can be difficult to assess with CT. This is particularly important in patients with ascites, where peritoneal disease assessment becomes more challenging to appreciate.

Additionally, uncommon metastatic sites, including lymph nodes above the diaphragm and involvement of lung parenchyma or pleura, are highlighted.

Accurately assessing the burden and distribution of disease during initial staging is crucial, as it directly influences the patient's primary treatment plan. Sites of disease that would place patients in a pathway of primary chemotherapy (i.e. before primary cytoreductive surgery) include; involved lymph nodes above the renal vessels or above the diaphragm, disease at the porta and lesser sac, hepatic parenchymal metastases and any pleural or pulmonary parenchymal disease.  In examples in this series, MRI shows these sites of disease more clearly.  CT may also underestimate disease burden, for example in hepatic parenchymal disease (Fig. 7). Furthermore, should the patient be eligible for primary reductive surgery, MRI is helpful in identifying more subtle sites guides surgical planning decisions.