What determines resectability according to Fagotti PIV (Peritoneal Cancer Index) for ovarian cancer?

Fagotti Peritoneal Cancer Index (PIV) for Determining Resectability in Ovarian Cancer

The Fagotti score is a laparoscopic-based scoring system that evaluates seven key anatomical sites to determine resectability in advanced ovarian cancer, with a score ≥8 indicating likely unresectable disease that should be treated with neoadjuvant chemotherapy rather than primary debulking surgery.

Components of the Fagotti Score

The Fagotti Peritoneal Index Value (PIV) evaluates seven anatomical parameters during diagnostic laparoscopy, with each parameter scored as either 0 (absent) or 2 (present):

1. Peritoneal carcinomatosis: Extensive peritoneal involvement with tumor nodules
2. Diaphragmatic disease: Widespread infiltrating carcinomatosis or large nodules infiltrating most of the diaphragm
3. Mesenteric disease: Large infiltrating nodules or involvement requiring bowel resection
4. Omental disease: Tumor diffusion to the gastric greater curvature
5. Bowel infiltration: Infiltration of the intestinal serosa that would require resection
6. Stomach infiltration: Infiltration that would require resection
7. Liver metastases: Surface liver nodules

Interpretation and Clinical Application

• Total score range: 0-14 points
• Threshold for unresectability: ≥8 points 1
• Clinical significance:
  • Score <8: Patient is suitable for primary debulking surgery (PDS)
  • Score ≥8: Patient should receive neoadjuvant chemotherapy (NACT) followed by interval debulking surgery

Validation and Performance

The Fagotti score has demonstrated strong external validity with excellent inter-observer concordance (ICC of 0.83 [95% CI 0.71; 0.93]), confirming its reproducibility in assessing resectability 1. When used in clinical trials like SCORPION, the score has been effective in identifying patients with high tumor load who would benefit from NACT rather than PDS 2.

Practical Implementation

1. Diagnostic laparoscopy: Performed prior to deciding between PDS and NACT
2. Systematic evaluation: All seven anatomical sites must be assessed
3. Documentation: Each parameter scored as 0 or 2
4. Decision-making:
   • If score <8: Proceed with PDS
   • If score ≥8: Recommend NACT followed by interval debulking surgery

Limitations and Considerations

• Some parameters may be difficult to evaluate laparoscopically, particularly mesenteric involvement, stomach infiltration, and liver damage 1
• An "explorable Fagotti score" (excluding frequently unexplorable parameters) has been proposed with even better inter-observer concordance (ICC 0.86 [0.75-0.94]) 1
• Laparoscopy has high specificity (1.00) but moderate sensitivity (0.70-0.71) in predicting resectability 3, 4

Comparison with Other Scoring Systems

When compared with other peritoneal carcinomatosis scoring methods (FIGO, Eisenkop, Aletti, and Peritoneal Cancer Index), the Fagotti score (particularly the modified version) has demonstrated superior performance in predicting resectability 5.

Integration into Clinical Pathway

The Fagotti score should be incorporated into a comprehensive evaluation approach that includes:

1. Initial assessment by a gynecologic oncologist 2
2. CT of abdomen/pelvis with contrast and chest imaging 2
3. Diagnostic laparoscopy with Fagotti scoring
4. Multidisciplinary discussion of findings
5. Treatment decision: PDS vs. NACT based on score threshold

The Fagotti score represents a valuable tool in the personalized management of advanced ovarian cancer, helping to avoid futile primary surgeries in patients unlikely to achieve optimal cytoreduction.