Laparoscopic Interval Debulking Surgery for Ovarian Cancer: Fagotti versus PCI Score for Patients’ Selection

With great deal of interest, we read the article in press entitled “Complete laparoscopic interval debulking surgery for advanced ovarian cancer achieves similar survival outcomes to open approach: a propensity-matched study” [1]. This retrospective study included a rather small group of patients (37 patients) who underwent laparoscopic interval debulking surgery (IDS), comparing them with an evenly small group of patients (40 patients) who were treated by open approach. This rather small study population was shrunk more after the application of the proposed propensity score; 25 patients in each group. Although statistically significant better outcomes were found in laparoscopic group regarding early postoperative complications and hospital stay as well as overall survival (OS), the authors are correctly presenting the findings with caution despite statistical matching of the groups. The findings were similar to another propensity matched study by Jochum et al regarding both OS and progression-free survival (PFS) [2]. Regarding the selection process to assess resectability, apart from diagnostic laparoscopy we would also propose to use the Fagotti score. By using this score, it would be easier to highlight which patients are deemed fit for surgery with increased possibility for complete cytoreduction. We consider that not using Fagotti score can be a possible selection bias of the study. However, it should be mentioned that a recent nonrandomized retrospective study evaluating the role of peritoneal cancer index (PCI) versus Fagotti score showed better outcomes for PCI regarding sensitivity. More specifically, using a PCI score of 20 or more as a cutoff point of complete resectability was found to be more sensitive than using Fagotti score [3]. Our group has already shown promising results of robotic IDS in advanced ovarian cancer in a systematic review of the literature, with larger prospective studies to be necessary in order to assess more safely the possible role of robotic approach in the management of these patients [4]. We would like to question the authors whether there is a protocol in selection of patients that are fit for cytoreduction in their department based on radiological findings. For example, some research groups using either computed tomography (CT) based Fagotti score or diffusion weighted magnetic resonance imaging (MRI) or positron emission tomography CT (PET/CT) to control tumor burden and upper abdominal disease found several predictive factors for high Fagotti score in diagnostic laparoscopy [5]. That could be a part or a suggested extension of your study if the required radiological data are available. Other research groups are presenting conversion rates of laparoscopic to laparotomy approach based on diaphragmatic disease coalescing the liver to the diaphragm preventing safe mobilization [6]. Do the authors of this study having similar impression or data that can confirm this statement? Overall, LANCE trial is going to clarify the possible non-inferiority of laparoscopic compared to laparotomy approach of IDS in ovarian cancer patients. For the reason, 549 patients are going to be recruited [7]. Once again, we would like to thank the authors for sharing their retrospective study.