Imaging as a Surgical Decision System in Modern Gynecologic Oncology

Imaging traditionally supports gynecologic oncology through diagnosis, staging, and estimation of resectability. Contemporary treatment, however, requires longitudinal decisions about which lesion matters, when local intervention is justified, and which modality is proportionate. This critical narrative review proposes imaging as a longitudinal surgical decision system integrating disease trajectory, treatment response, target selection, operative planning, and post-intervention assessment. We define imaging-target mismatch as discordance between the radiologically dominant lesion and the lesion with greatest clinical actionability, and operationalize the disease-modifying surgical window as open, uncertain, or closed across six decision domains. Serial imaging may reveal response-created opportunities, oligopersistence, oligoprogression, competing dissemination, or the need for tissue confirmation, while CT, MRI, ultrasound, and FDG PET/CT provide complementary decision-specific information. Three-dimensional reconstruction, intraoperative imaging, radiomics, and artificial intelligence may enhance planning, but require prospective external validation and should support rather than replace multidisciplinary judgment. Decision-oriented reporting should communicate the target, lesion-level trajectory, competing disease, anatomical feasibility, residual uncertainty, and the relevance of findings to the proposed intervention. Imaging should therefore guide not only what can be treated, but what should be treated, when, and for what therapeutic purpose.