Outcomes of Cytoreductive Surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in patients older than 70 years; survival benefit at considerable morbidity and mortality

Our plain-English summary of Outcomes of Cytoreductive Surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in patients older than 70 years; survival benefit at considerable morbidity and mortality, by K.I. Votanopoulos, N.A. Newman, G. Russell, et al (Annals of Surgical Oncology, 2013).

The study

• Authors: K.I. Votanopoulos, N.A. Newman, G. Russell, C. Ihemelandu, P. Shen, J.H. Stewart, E.A. Levine
• Journal: Annals of Surgical Oncology
• Published: 2013;20(11):3497-503
• Cited by: 70 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Cytoreductive surgery (CRS)/Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is associated with prolonged survival in selected patients with peritoneal surface disease. Yet, for elderly patients (older than 70 years of age) CRS/HIPEC is controversial, due to associated morbidity.

Methods: A retrospective analysis of a prospective database of 950 procedures was performed. Type of malignancy, demographics, performance and resection status, hospitalization, morbidity, mortality, and survival were reviewed.

Results: A total of 81 patients (median age 73, range 70-87) underwent CRS/HIPEC between 1991 and 2011. Median follow-up was 48.1 months. Complete cytoreduction was achieved in 44 %. Median survival was 31.8 months for appendiceal cancer, 41.5 for mesothelioma, 54.0 for ovarian cancer, 13.2 for colon cancer, and 7.6 for gastric cancer. The 30-day mortality was 13.6 %. The combined grade III and IV morbidity was 38 %. Median ICU and hospital stay for uncomplicated patients was 1 and 8 days, respectively. The 3-month mortality was 27.4 %. There were no deaths in the octogenarian group. In stepwise multivariate analysis, type of primary (p = 0.03), albumin (p = 0.02), and R status (p = 0.007) were predictive of survival only in the absence of complications. Splitting the data at the midpoint of surgical experience, there was a drop in 1- and 3-month mortality over time to 9.5 and 19.3 %, respectively, while the median survival increased from 11.2 (N = 39) to 46.9 months (N = 42).

Conclusions: HIPEC in the elderly is associated with a steep learning curve and considerable morbidity and mortality. However, age alone is not a contraindication for the procedure. Institutional experience and stringent patient selection are key factors for prolonged survival.

In plain English

This was a retrospective review of a database of 950 cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) procedures at one institution, Wake Forest University. It covered 81 patients who had the operation after their 70th birthday, between 1991 and 2011 (median age 73, range 70 to 87). Ten had mesothelioma. Most of the rest had appendiceal, colon, ovarian or gastric cancers. The article did not discuss asbestos. All visible tumor was removed in 36 patients (44 %). Serious (grade III and IV) complications occurred in 38 % of these older patients, compared with 23 % of younger patients. Mortality was 13.6 % at 30 days and 27.4 % at 3 months. There were no deaths among the 7 patients aged 80 and over. Median survival was 41.5 months for the mesothelioma patients. Between the earlier and later periods, 3-month mortality fell from 35.9 % to 19.3 %, and median survival rose from 11.2 to 46.9 months. Age was not a significant predictor of survival. The authors concluded that age alone is not a contraindication but that the procedure carries considerable morbidity and mortality. They noted the study was retrospective and from a single institution.

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 single-institution surgical database
• Who was studied: 81 patients aged 70 or older (median age 73, range 70 to 87) who underwent CRS/HIPEC for peritoneal surface disease at Wake Forest University, North Carolina, between 1991 and 2011. Primaries were 32 appendiceal, 20 colon, 10 mesotheliomas, 8 ovarian, 6 gastric and 5 other. 7 patients were aged 80 to 87.
• Exposure: The exposure studied was the treatment itself, cytoreductive surgery with hyperthermic intraperitoneal chemotherapy performed after age 70. Asbestos exposure was not studied.
• Main results:
  • Of the 81 patients, 10 had mesothelioma. The others had appendiceal (32), colon (20), ovarian (8), gastric (6) and other (5) cancers.
  • Complete cytoreduction (R0 or R1) was achieved in 36 of 81 patients (44 %).
  • Major morbidity (grade III and IV) occurred in 38 % (31 patients) of the elderly cohort.
  • Major morbidity (Clavien III/IV) was 23 % in younger patients (under 70) versus 38 % in the elderly (p = 0.002).
  • 30-day mortality for the entire elderly cohort was 13.6 %, and 3-month mortality was 27.4 %.
  • There were no deaths in the octogenarian group, which comprised 7 patients aged 80 to 87.
  • Median survival by primary was 31.8 months for appendiceal cancer, 41.5 months for mesothelioma, 54 months for ovarian cancer, 13.2 months for colon cancer and 7.6 months for gastric cancer.
  • Comparing the earlier period (1991 to 2003) with the later period (after 2004), 1- and 3-month mortality fell from 17.9 and 35.9 % to 9.5 and 19.3 %. Median survival rose from 11.2 months (n = 39) to 46.9 months (n = 42).
  • Median survival was 13 months for patients with postoperative complications (n = 54) and 39 months for those without (n = 27).
  • Age and ECOG performance status were not significant predictors of survival.
  • In the multivariate model without complications, type of primary (p = 0.03), albumin (p = 0.02) and completeness of cytoreduction (p = 0.007) were associated with survival.
  • When complications were included in the model, only institutional experience and absence of complications remained significantly associated with survival.
• The authors' conclusion: The authors concluded that CRS/HIPEC in the elderly carries a steep learning curve and considerable morbidity and mortality, but that age alone is not a contraindication. They named institutional experience and stringent patient selection as key factors for prolonged survival.
• Limitations the authors state:
  • The study was a retrospective review from a single institution.
  • The authors said the 3-month mortality should be regarded as a historic value, because the cohort includes patients who would not be considered candidates today.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Median Survival, Mesothelioma, Ovarian Cancer, Colorectal Cancer, Stomach Cancer, Multivariate Analysis.

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• Morbidity of the abdominal wall resection and reconstruction after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) — M.F. Nunez, A. Sardi, 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)
• A Novel Tool for Predicting Major Complications After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy — J.M. Baumgartner, T.G. Kwong, et al. (2016)
• Efficacy of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy in the management of malignant ascites — R.W. Randle, K.R. Swett, et al. (2014)
• The Role of Ki-67 and Pre-cytoreduction Parameters in Selecting Diffuse Malignant Peritoneal Mesothelioma (DMPM) Patients for Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) — S. Kusamura, P.A. Torres Mesa, et al. (2016)

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