Elsevier

Gynecologic Oncology

Volume 110, Issue 3, September 2008, Pages 354-359
Gynecologic Oncology

External validation of a laparoscopic-based score to evaluate resectability of advanced ovarian cancers: Clues for a simplified score

https://doi.org/10.1016/j.ygyno.2008.04.042Get rights and content

Abstract

Background

The relevance of laparoscopy-based score in identifying patients with advanced ovarian cancer for optimal cytoreductive surgery has been evaluated.

Methods

55 patients with stage III–IV ovarian cancer, having undergone both laparoscopy and laparotomy for cytoreductive surgery, were retrospectively analyzed. Seven parameters were assessed: omental cake, peritoneal carcinosis, diaphragmatic carcinosis, mesenteric retraction, bowel infiltration, stomach infiltration, liver metastases. Each parameter was assigned 2 points if present and 0 if not (Fagotti score). Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values, and accuracy were calculated for each parameter. Receiver Operating Characteristic (ROC) curve analysis was used to predict the surgical outcome.

Results

A laparoscopy-based score of ≥ 8 was associated with suboptimal cytoreduction with sensitivity, specificity, PPV, NPV, and accuracy of 46%, 89%, 89%, 44%, and 60% respectively. ROC curve analysis gave an Area Under the Curve (AUC) of 0.74. A modified score was set up by selecting 4 of the 7 parameters which satisfied the inclusion criteria in our population: diaphragmatic carcinosis, mesenteric retraction, stomach infiltration, liver metastases. Thirteen patients (12%) had a modified score of ≥ 4 and 42 patients (88%) had a score of < 4 with an optimal cytoreduction rate of 0% and 43% respectively (P = 0.002). A modified score of ≥ 4 was associated with suboptimal cytoreduction with sensitivity, specificity, PPV, NPV, and accuracy of 35%, 100%, 100%, 43%, and 56% respectively. ROC curve analysis gave an AUC of 0.68.

Conclusion

This simplified laparoscopy-based score was at least as accurate as the Fagotti score to predict resectability.

Introduction

The main issue in patients with ovarian cancer is to identify candidates for complete primary cytoreductive surgery. Indeed, the amount of postoperative residual tumour remains the most important survival determinant in patients with advanced stages [1], [2]. Given the risk of re-growth of tumour cells between chemotherapy cycles and to avoid laparotomy with suboptimal cytoreduction, there is a need for tools to evaluate the resectability of advanced ovarian cancer.

Several pre-operative scoring systems have been advocated to predict the optimal resectability of ovarian cancers. The presence of voluminous ascites has been found to be associated with suboptimal cytoreductive surgery [3], [4]. Models based on clinical and CT findings as well as serum tumour markers have also been developed, but their false-negative rates range from 5% to 37% [5], [6], [7]. Bristow et al. proposed a score based on radiological findings taking into account peritoneal thickening, peritoneal implant size, bowel mesentery and suprarenal lymph node tumours, as well as spleen and pelvic sidewall involvement to identify unresectable disease [6]. However, external or cross-validation of these predictive algorithms failed to recognise good candidates for cytoreductive surgery or neoadjuvant chemotherapy [7].

Recently, Fagotti et al developed a laparoscopy-based score for predicting surgical resectability taking into account omental involvement, peritoneal and diaphragmatic carcinosis, mesenteric retraction, bowel and stomach infiltration, and liver metastases [8]. In this model, a predictive index score of ≥ 8 had an accuracy of 74% for identifying patients with residual tumours after debulking surgery. However, as no external validation of the Fagotti score has been published to date, we were prompted to evaluate the usefulness and the limits of this laparoscopy-based score and to suggest a simplified score to identify good candidates with advanced ovarian cancer for complete cytoreductive surgery.

Section snippets

Patients

Between January 2004 and December 2006, 55 patients referred to the Department of Obstetrics and Gynecology at Tenon Hospital with strong evidence of FIGO stage III/IV ovarian cancer underwent a diagnostic laparoscopy to assess the possibility of optimal debulking surgery. All data were analyzed retrospectively. The inclusion criteria were no contraindication to surgery, and signed informed consent. Patients had primary cytoreductive surgery only when optimal macroscopic cytoreduction (residual

External validation of the laparoscopy-based score to predict resectability of ovarian cancer

The clinicopathological characteristics of the 55 patients are given in Table 1. Diaphragm carcinosis was observed in 18 cases by CT scan and 23 cases by laparoscopy; mesenteric retraction was observed in 11 cases by CT scan and 16 cases by laparoscopy. In our model, 29 patients out of 55, treated by neoadjuvant chemotherapy, were considered as suboptimally debulked. In the remaining 26 patients treated by primary surgery, diaphragm carcinosis was observed in 8 cases by CT scan and 10 cases by

Discussion

The present study confirms the relevance of Fagotti's laparoscopy-based score to predict the resectability of ovarian tumours. Our simplified laparoscopy-based score was at least as accurate as the Fagotti score in predicting resectability in women with advanced ovarian cancer.

The main issue in patients with ovarian cancer is to identify women with a high likelihood of having a first optimal or complete cytoreduction. Several models based on clinical and/or imaging techniques have failed to do

Conflict of interest statement

No conflict of interest.

Cited by (117)

  • The BUMPy road of peritoneal metastases in ovarian cancer

    2022, Diagnostic and Interventional Imaging
    Citation Excerpt :

    Several numerical surgical scoring systems have been proposed to quantify the intra-abdominal disease extent. These systems include the peritoneal carcinomatosis index (PCI) [85–87], Eisenkop score [88], Fagotti score [89], Fagotti-modified score [90], and Aletti score [91] (Table 3). Each scoring system assesses different aspects of the peritoneal disease and provides a different numeric score.

  • A prospective study on the diagnostic pathway of patients with stage IIIC-IV ovarian cancer: Exploratory laparoscopy (EXL) + CT scan VS. CT scan

    2021, Gynecologic Oncology
    Citation Excerpt :

    This study did not directly investigate the ability of CT or EXL to predict the surgical outcome of debulking. Such attempt was already endeavoured by CT scan [2–4] and by EXL [8–12] in retro- and prospective studies. Our aim was not to propose a new algorithm or validate the laparoscopic score.

View all citing articles on Scopus
View full text