We have read with great interest the article by Chéreau et al regarding the comparison of peritoneal carcinomatosis scoring methods to identify patients with advanced ovarian cancer (AOC) for optimal cytoreductive surgery, and we would congratulate the authors for their effort to clarify the power of these different scores.

However, some issues need to be discussed:

The scoring methods that were considered in this study have been experienced in different clinical settings. In particular, the Aletti score follows a multicentric retrospective survey, whereas the Eisenkop and Fagotti scores arise from monocentric prospective trials. Moreover, the Fagotti score has been validated externally with the Fagotti-modified score. Finally, the peritoneal cancer index is the only prospective and multicentric scoring system, although it has been applied mainly in bowel tumors. As a matter of fact, we would encourage a comparison among scores with similar evidence based medicine levels to avoid any potential bias.

The comparison among scoring systems that were conceived for different aims appears undue. In fact, the peritoneal cancer index and Eisenkop and Fagotti scores have been processed to describe the diffusion of the disease and to correlate it with optimal cytoreduction. On the other hand, the objective of the Aletti score is to predict surgical complications in patients who actually have undergone surgery, whereas it does not take into consideration inoperable cases. As a matter of fact, the impact of these scores seems necessarily different on prognosis.

The Fagotti score has been conceived for patients with AOC (FIGO stages III/IV). The present population includes 13 patients with stage I–II (21%) and 17 patients (28%) who were submitted to neoadjuvant chemotherapy. We recently demonstrated that a different score can be applied in the subset of patients who undergo interval debulking surgery that has only 4 parameters. A cut-off of 4 is warranted to deem these patients to be inoperable. Considering a more selected and homogeneous population could modify the receiver operating characteristic curves and statistical conclusions.

It would be useful to show the overall survival and progression-free survival medians and curves in the study population.

In conclusion, the comparison of different peritoneal carcinosis scores has been an important contribution to indicate the need of a more objective ranking system than FIGO staging. However, we agree with the authors that only a multiinstitutional prospective trial and a comparison/integration with clinical/radiologic data will clarify the best scoring system definitively to predict surgical outcome in patients with AOC. With the aim to validate the Fagotti score, an Italian prospective multicentric study is now ongoing ( www.mito-group.it ).