Role of immunohistochemistry for interobserver agreement of Peritoneal Regression Grading Score in peritoneal metastasis

Pressurized intraperitoneal aerosol chemotherapy (PIPAC)–directed therapy is a new treatment option for peritoneal metastasis (PM). The 4-tiered Peritoneal Regression Grading Score (PRGS) has been proposed for assessment of histological treatment response. We aimed to evaluate the effect of immunohistochemistry (IHC) on interobserver agreement of the PRGS. Hematoxylin and eosin (H&E)–stained and IHC-stained slides (n = 662) from 331 peritoneal quadrant biopsies (QBs) taken prior to 99 PIPAC procedures performed on 33 patients were digitalized and uploaded to a web library. Eight raters (five consultants and three residents) assessed the PRGS, and Krippendorff's alpha coefficients (α) were calculated. Results (IHC-PRGS) were compared with data published in 2019, using H&E-stained slides only (H&E-PRGS). Overall, agreement for IHC-PRGS was substantial to almost perfect. Agreement (all raters) regarding single QBs after treatment was substantial for IHC-PRGS (α = 0.69, 95% confidence interval [CI] = 0.66–0.72) and moderate for H&E-PRGS (α = 0.60, 95% CI = 0.56–0.64). Agreement (all raters) regarding the mean PRGS per QB set after treatment was higher for IHC-PRGS (α = 0.78, 95% CI = 0.73–0.83) than for H&E-PRGS (α = 0.71, 95% CI = 0.64–0.78). Among residents, agreement was almost perfect for IHC-PRGS and substantial for H&E-PRGS. Agreement (all raters) regarding maximum PRGS per QB set after treatment was substantial for IHC-PRGS (α = 0.61, 95% CI = 0.54–0.68) and moderate for H&E-PRGS (α = 0.60, 95% CI = 0.53–0.66). Among residents, agreement was substantial for IHC-PRGS (α = 0.66, 95% CI = 0.57–0.75) and moderate for H&E-PRGS (α = 0.55, 95% CI = 0.45–0.64). Additional IHC seems to improve the interobserver agreement of PRGS, particularly between less experienced raters.