Outcomes of Cytoreductive Surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in Patients Older Than 70 Years; Survival Benefit at Considerable Morbidity and Mortality

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 step-wise 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.

Current perspectives on hyperthermic intraperitoneal chemotherapy in gastric cancer

“…Votanopoulos et al support stringent patient selection (including some of the above metrics) and noted that using these metrics for patient selection was key for prolonged survival. 48 Similar conclusions were reached in a study by Macrì et al 46 Although some studies have shown patient age to be negligible in CRS-HIPEC patient selection, patients >60 years of age with tumor stage T3 or T4 have been associated with a higher risk of gastric cancer PC. 47 In other words, in the absence of other known factors that affect response to CRS-HIPEC, patient age should not be a contraindication to receiving CRS-HIPEC.…”

“…These include in vitro chemotherapy sensitivity 45 and patient age. 20,46,47 For example, a study by Votanopoulos et al, 48 examined CRS-HIPEC in the elderly (mean age was 73 years old) and concluded that age alone was not a contraindication for the procedure. Votanopoulos et al support stringent patient selection (including some of the above metrics) and noted that using these metrics for patient selection was key for prolonged survival.…”

“…Their results showed similar encouraging numbers for various forms of PC: median survivals of 31.8 months for appendiceal cancer, 41.5 months for mesothelioma, 54 months for ovarian cancer and 13.2 months for colon cancer. 48 Wu et al evaluated the combination of HIPEC and CRS in women with Krukenberg ovarian tumors that had metastasized to the peritoneum. Their analysis shows that HIPEC with surgery improves survival by 5 months when compared with CRS alone.…”

Morbidity and mortality of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy in advanced gastric cancer

“…Larger scale studies are still needed to establish specific risk factors of morbidity and mortality in CRS-HIPEC in GC patients. On the other hand, we believe it remains reasonable to carefully evaluate and select the patients with the common risk factors of CRS-HIPEC morbidity including advanced age, smoking, high disease burden (such as PC index) and poor completeness of cytoreduction (CC) (6,11,12) before more specific data regarding GC are available.…”

Causes and Palliation of Transfusion-Associated Vaginal Bleeding in Patients With Metastatic Cancer

“…The 3-month interval, referred to above, was chosen because of its precedent in defining the success of interventions in other cancer settings. 5,19,20 The decision to seek information on the morbidities of coronary artery disease and bleeding diathesis was based on a high likelihood of lowering the thresholds of transfusion and bleeding, respectively. Finally, overall survival, as calculated from the time of vaginal bleeding to death, was also reported.…”