Fagotti Score: Impact on Surgical Approaches and Prognosis

The Fagotti score is a diagnostic tool used in the surgical evaluation of advanced ovarian cancer. It helps determine the feasibility of complete cytoreduction by assessing key intra-abdominal disease features during laparoscopic examination. This system aids surgeons in deciding whether to proceed with primary debulking surgery or consider alternative treatment strategies.

Core Components Of The Score

The Fagotti score consists of intraoperative parameters observed during laparoscopic assessment, each reflecting tumor dissemination within the abdominal cavity. These components provide a structured method for evaluating disease burden and predicting the likelihood of optimal cytoreduction.

Extent Of Peritoneal Spread

A key factor in the Fagotti score is peritoneal carcinomatosis, the spread of cancerous lesions across peritoneal surfaces. Surgeons assess implants in areas such as the diaphragmatic peritoneum and bowel serosa. A study in Gynecologic Oncology (2020) found that extensive peritoneal involvement, particularly nodules exceeding 2 cm, correlates with a lower chance of complete cytoreduction. Higher scores indicate widespread disease, reflecting the technical challenges of resection. Identifying the extent of peritoneal dissemination helps estimate the feasibility of tumor removal without excessive morbidity.

Omental Involvement

The omentum, a frequent site of metastatic spread in ovarian cancer, is evaluated for bulky nodular deposits or “cake-like” infiltration, where it is thickened and replaced by tumor tissue. A retrospective analysis in Annals of Surgical Oncology (2021) noted that patients with extensive omental disease often face more complex resections. Higher scores correspond to diffuse omental involvement, which typically indicates a higher tumor burden. Recognizing the degree of metastasis helps determine whether complete cytoreduction is possible or if neoadjuvant chemotherapy should be considered first.

Ascites Assessment

Ascites, the abnormal accumulation of peritoneal fluid, is another key parameter. Large-volume ascites—typically exceeding 500 mL—suggests a more aggressive disease phenotype and reduces the probability of optimal debulking. A International Journal of Gynecological Cancer (2019) review found that significant ascites often signals widespread peritoneal dissemination. Surgeons assess fluid volume and distribution, as excessive fluid can obscure visualization and indicate peritoneal inflammation. Higher scores reflect abundant ascitic fluid, reinforcing its prognostic significance in surgical decision-making.

Relationship To Surgical Approaches

The Fagotti score directly informs surgical decision-making by assessing the feasibility of complete cytoreduction. Surgeons use it to determine whether primary debulking surgery (PDS) is viable or if neoadjuvant chemotherapy (NACT) should be pursued first. A score of 8 or higher is associated with suboptimal debulking, often prompting a shift to NACT. A Gynecologic Oncology (2022) study found that patients with high scores had significantly lower rates of complete cytoreduction, reinforcing the score’s role in operative planning.

The laparoscopic evaluation also refines surgical strategy by offering real-time insights into tumor distribution. If extensive peritoneal involvement is found, particularly in surgically challenging areas, surgeons may opt for systemic therapy first to reduce tumor volume. Findings in The Lancet Oncology (2021) showed improved progression-free survival in patients receiving NACT before surgery when their Fagotti score indicated a low probability of complete cytoreduction. Conversely, when the score suggests a reasonable chance of no residual disease, immediate PDS is preferred due to its association with better overall survival.

The score also influences intraoperative techniques. In cases of moderate tumor burden, surgeons may adopt more aggressive debulking strategies, such as en bloc resection or multi-visceral procedures, to improve cytoreduction rates. A Annals of Surgical Oncology (2023) study found that patients with intermediate scores who underwent extensive resections had comparable survival outcomes to those with lower scores, provided complete tumor removal was achieved. This highlights the importance of tailoring surgical plans based on laparoscopic findings.

Factors That May Affect Scoring

The accuracy of the Fagotti score depends on several variables. One major factor is the surgeon’s experience with laparoscopic evaluation, as expertise in identifying and quantifying tumor spread affects scoring consistency. A European Journal of Surgical Oncology (2022) study found interobserver variability, particularly in assessing peritoneal carcinomatosis and omental involvement. Standardized training and adherence to predefined criteria help reduce inconsistencies.

Patient-specific characteristics also impact scoring. Prior abdominal surgeries may create adhesions that obscure visualization, while obesity can limit laparoscopic exploration, potentially underestimating disease extent. A Journal of Minimally Invasive Gynecology (2021) report found that patients with high BMI were more likely to have incomplete laparoscopic staging due to visualization challenges. These technical limitations must be considered when interpreting scores.

Tumor biology adds another layer of complexity. Certain ovarian cancer subtypes, such as high-grade serous carcinoma, tend to disseminate aggressively, leading to higher scores. Conversely, mucinous or endometrioid subtypes may show localized growth, resulting in lower scores despite advanced disease. Molecular profiling studies in Clinical Cancer Research (2023) found that tumors with TP53 or BRCA1/2 mutations often exhibit diffuse peritoneal spread, influencing scoring outcomes. Understanding these biological differences ensures treatment decisions align with tumor behavior.

Significance In Prognostic Evaluations

The Fagotti score predicts surgical outcomes and long-term prognosis in advanced ovarian cancer. By quantifying intra-abdominal tumor burden, it provides an early indication of whether complete cytoreduction is achievable, a factor strongly linked to overall survival. Patients with lower scores, indicating a higher likelihood of optimal tumor removal, tend to experience longer progression-free intervals and extended survival.

Longitudinal studies show that high Fagotti scores correlate with poorer survival due to the difficulty of achieving complete resection. A Journal of Clinical Oncology (2022) analysis found that patients with scores above 8 had a median overall survival of about 30 months, compared to over 60 months for those with scores below 4. These findings reinforce the prognostic value of the scoring system, guiding both surgical decisions and treatment expectations. The score also helps identify patients who may benefit more from neoadjuvant chemotherapy, improving long-term outcomes.