Laparoscopy for Diagnosing Intraperitoneal Malignancy, Application of Fagotti Score

Laparoscopy for diagnosing intraperitoneal malignancy, with application of Fagotti score for identifying patient who would have suboptimal debulking. Maciej Stukan Gynecologic Oncology Department, Gdynia Oncology Center The following video demonstrates a diagnostic laparoscopy with application of Fagotti score and biopsy for histology, in a 80-year-old patient suspected for advanced malignant disease in an abdominal cavity. The case: 80-year-old patient, with clinical signs of ascites, malnutrition and sarcopenia. She underwent treatment for breast cancer 15 years before. CT imaging suggested advanced malignant disease in all abdominal cavity. Additional laboratory tests showed: CA125: 77.5Ul/ml, CA15-3: 22.3U/ml, CEA 2.2ug/l, albumin 31.6g/l. Bioimpedance analysis: skeletal muscle mass 9.4kg (ref.values:14.1-20.2); phase angle 3.7. An abdominal and transvaginal ultrasound examination was performed – advanced malignancy, disseminated in abdominal cavity with ascites was suspected. The laparoscopy was performed with exploration of abdominal cavity and application of Fagotti score, as if we were managing an advanced ovarian cancer. Fagotti score was assessed: omental cake (2), peritoneal carcinosis (2), diaphragmatic carcinosis (2), mesenteric retraction (2), bowel infiltration (0), stomach infiltration (0), liver metastases (2) – total 10 points. Because of the patient’s clinical data (malnutrition, sarcopenia, history of breast cancer) and laparoscopic Fagotti score (in case it was an advanced ovarian cancer) we assessed there was low chance of optimal cytoreduction, and the high risk of serious adverse events if open surgery with attempt to perform debulking was considered. Biopsies for frozen section and normal histology were taken. The frozen section histology revealed undifferentiated cancer. The final histology: NST, grade 3, disseminated breast cancer. Conclusion: In the presented case, 80-year-old woman, malnourished and sarcopenic, a diagnostic laparoscopy with biopsy for histology and application of Fagotti score enabled correct diagnosis, identification of the patient who would have suboptimal debulking (if managed as advanced ovarian cancer), avoidance of possible serious adverse events of an upfront open surgery and quick rehabilitation and systemic therapy initiation. Reference: Fagotti A, Ferrandina G, Fanfani F, Ercoli A, Lorusso D, Rossi M, Scambia G. A laparoscopy-based score to predict surgical outcome in patients with advanced ovarian carcinoma: a pilot study. Ann Surg Oncol. 2006 Aug;13(8):1156-61. Epub 2006 Jun 21. PubMed PMID: 16791447.