Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemoperfusion in Adolescent and Young Adults with Peritoneal Metastases

Our plain-English summary of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemoperfusion in Adolescent and Young Adults with Peritoneal Metastases, by M. Dhir, L. Ramalingam, Y. Shuai, et al (Annals of Surgical Oncology, 2017).

The study

• Authors: M. Dhir, L. Ramalingam, Y. Shuai, S. Pakrafter, H.L. Jones, M.E. Hogg, A.H. Zureikat, M.P. Holtzman, S.A. Ahrendt, N. Bahary, J.F. Pingpank, H.J. Zeh, D.L. Bartlett, H.A. Choudry
• Journal: Annals of Surgical Oncology
• Published: 2017;24(4):875-883
• Cited by: 6 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Several studies suggest that young patients may derive less oncologic benefit from surgical resection of cancers compared with older patients. We hypothesized that young patients may have worse outcomes following cytoreductive surgery with hyperthermic intraperitoneal chemoperfusion (CRS/HIPEC) for peritoneal metastases.

Methods: Perioperative and oncologic outcomes in adolescent and young adults (AYA), defined as younger than age 40 years (n = 135), undergoing CRS/HIPEC between 2001 and 2015 were reviewed and compared with middle-aged adults, defined as aged 40-65 years (n = 684).

Results: The two groups were similar with regards to perioperative characteristics except that AYA were more likely to be symptomatic at presentation (65.2 vs. 50.9%, p = 0.003), had lower Charleson comorbidity index (median 6 vs. 8, p < 0.001), were less likely to receive neoadjuvant chemotherapy (32.8 vs. 42.5%, p = 0.042), and had longer operative times (median 543 vs. 493 min, p = 0.010). Postoperative Clavien-Dindo grade 3-4 morbidity was lower in AYA (17 vs. 26%, p = 0.029), and they required fewer reoperations for complications (3.7 vs. 10.4%, p = 0.014). AYA had longer median overall survival (103.6 vs. 73.2 months, p = 0.053). In a multivariate Cox regression analysis, age was an independent predictor of improved overall survival [hazard ratio 0.705; 0.516-0.963, p = 0.028].

Conclusions: Young patients with peritoneal metastases derive similar benefits from CRS/HIPEC as middle-aged patients. Young age should not be a deterrent to consideration of CRS/HIPEC for peritoneal metastases.

In plain English

This was a retrospective review of a University of Pittsburgh database of 1400 patients who had cytoreductive surgery with heated chemotherapy circulated through the abdomen (CRS/HIPEC) between 2001 and 2015. The authors compared 135 patients aged 17 to 39 with 684 patients aged 40 to 65. All were treated for cancer that had spread in the abdomen from malignant peritoneal mesothelioma, appendix cancer or colorectal cancer. The study did not examine asbestos exposure. Serious in-hospital complications occurred in 17% of younger and 26% of older patients. Reoperations for complications occurred in 3.7% and 10.4%. Median overall survival was 103.6 months for younger and 73.2 months for older patients (p = 0.053, not below the study's 0.05 significance level). Among the 100 mesothelioma patients it was 260.1 versus 54.9 months (p = 0.016). In an adjusted analysis of all patients, younger age was linked to better survival (hazard ratio 0.705, 95% confidence interval 0.516 to 0.963). In adjusted analyses within each diagnosis, age was no longer an independent predictor. The authors concluded that age by itself does not mean a poor outlook. They noted the retrospective design and selection bias.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective analysis of a prospectively maintained database (single-center surgical series comparing two age groups)
• Who was studied: From a database of 1400 CRS/HIPEC patients treated 2001 to 2015 at the authors' center (University of Pittsburgh Medical Center): 135 patients aged 17 to 39 years (adolescents and young adults, AYA) and 684 patients aged 40 to 65 years (middle-aged adults, MAA). All were treated for peritoneal metastases from malignant peritoneal mesothelioma, appendix cancer or colorectal cancer. Patients older than 65 were excluded.
• Exposure: Not an asbestos exposure study. The factor compared was age group (under 40 vs 40 to 65) among patients receiving cytoreductive surgery with hyperthermic intraperitoneal chemoperfusion (CRS/HIPEC) for peritoneal metastases from malignant peritoneal mesothelioma, appendix cancer or colorectal cancer. Asbestos is not mentioned.
• Main results:
  • AYA patients were more often symptomatic at presentation than MAA patients (65.2% vs 50.9%, p = 0.003).
  • AYA patients had a lower Charlson comorbidity index than MAA patients (median 6 vs 8, p less than 0.001).
  • Clavien-Dindo grade 3 to 4 in-hospital complications occurred in 17% of AYA vs 26% of MAA patients (p = 0.029).
  • Reoperations for complications occurred in 3.7% of AYA vs 10.4% of MAA patients (p = 0.014).
  • In all patients, median overall survival was 103.6 months for AYA vs 73.2 months for MAA (p = 0.053).
  • The mesothelioma subgroup comprised 100 patients (25 AYA, 75 MAA).
  • When stratified by diagnosis, the survival difference was significant only for malignant peritoneal mesothelioma: median 260.1 months for AYA vs 54.9 months for MAA (p = 0.016).
  • In the multivariable Cox analysis of all 819 patients, young age (under 40 vs 40 to 65) was associated with improved overall survival (hazard ratio 0.705, 95% CI 0.516 to 0.963, p = 0.028).
  • When analyzed separately by diagnosis and adjusted for other factors, young age was no longer an independent predictor of survival.
  • Among mesothelioma patients, AYA had a lower rate of CDKN2A deletion than MAA (15% vs 33%), but this difference was not statistically significant (p = 0.307).
• The authors' conclusion: The authors concluded that perioperative and oncologic outcomes of AYA with peritoneal metastases are comparable to those of middle-aged patients, and that age by itself does not mean a poor prognosis. In the abstract they state that young age should not be a deterrent to considering CRS/HIPEC.
• Limitations the authors state:
  • The study was retrospective and subject to selection bias.
  • Only patients selected for CRS/HIPEC were included, so the results may not apply to all young adults with peritoneal metastases.
  • Socioeconomic and psychosocial factors could not be studied because the data were not available.
  • Pathologic variables other than grade were not available for all patients. For example, microsatellite instability data existed for only 133 patients.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Colon cancer, Mesothelioma, Peritoneal mesothelioma.

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, Surgical Resection, HIPEC, Neoadjuvant Chemotherapy, Median Overall Survival, Overall Survival, Hazard Ratio.

Related studies

• The results of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in 1200 patients with peritoneal malignancy — B. Moran, T. Cecil, et al. (2015)
• Repeat Cytoreductive Surgery and HIPEC for Peritoneal Surface Malignancy and Peritoneal Carcinomatosis — J.F. Wong, G.H. Tan, et al. (2015)
• Institutional learning curve of cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion for peritoneal malignancies — P.M. Polanco, Y. Ding, et al. (2015)
• Cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for children, adolescents, and young adults: the first 50 cases — A. Hayes-Jordan, H. Green, et al. (2015)
• Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in Asian patients: 100 consecutive patients in a single institution — M.C. Teo, G.H. Tan, et al. (2013)
• Early recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) — G.H.C. Tan, C.S. Chia, et al. (2018)

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