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Cheng E, Shamavonian R, Mui J, Hayler R, Karpes J, Wijayawardana R, Barat S, Ahmadi N, Morris DL. Overall survival and morbidity are not associated with advanced age for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: a single centre experience. Pleura Peritoneum 2023; 8:83-90. [PMID: 37304160 PMCID: PMC10249755 DOI: 10.1515/pp-2022-0202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/18/2023] [Indexed: 06/13/2023] Open
Abstract
Objectives Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has enabled better prognosis for patients with peritoneal surface malignancies. However, in older age groups, short -and long-term outcomes are still perceived as poor. We evaluated patients aged 70 and over and determine if age is a predictor of morbidity, mortality and overall survival (OS). Methods A retrospective cohort analysis was performed on CRS/HIPEC patients and categorised by age. The primary outcome was overall survival. Secondary outcomes included morbidity, mortality, hospital and incentive care unit (ICU) stay and early postoperative intraperitoneal chemotherapy (EPIC). Results A total of 1,129 patients were identified with 134 aged 70+ and 935 under 70. There was no difference in OS (p=0.175) or major morbidity (p=0.051). Advanced age was associated with higher mortality (4.48 vs. 1.11 %, p=0.010), longer ICU stay (p<0.001) and longer hospitalisation (p<0.001). The older group was less likely to achieve complete cytoreduction (61.2 vs. 73 %, p=0.004) and receive EPIC (23.9 vs. 32.7 %, p=0.040). Conclusions In patients undergoing CRS/HIPEC, age of 70 and above does not impact OS or major morbidity but is associated with increased mortality. Age alone should not be a limiting factor in selecting CRS/HIPEC patients. Careful multi-disciplinary approach is needed when considering those of advanced age.
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Affiliation(s)
- Ernest Cheng
- Department of Surgery, Peritonectomy and Liver Cancer Unit, St George Hospital, Kogarah, NSW, Australia
- St George Hospital Clinical School, University of New South Wales, Kogarah, NSW, Australia
| | - Raphael Shamavonian
- Department of Surgery, Peritonectomy and Liver Cancer Unit, St George Hospital, Kogarah, NSW, Australia
| | - Jasmine Mui
- Department of Surgery, Peritonectomy and Liver Cancer Unit, St George Hospital, Kogarah, NSW, Australia
- St George Hospital Clinical School, University of New South Wales, Kogarah, NSW, Australia
| | - Raymond Hayler
- Department of Surgery, Peritonectomy and Liver Cancer Unit, St George Hospital, Kogarah, NSW, Australia
- St George Hospital Clinical School, University of New South Wales, Kogarah, NSW, Australia
| | - Josh Karpes
- Department of Surgery, Peritonectomy and Liver Cancer Unit, St George Hospital, Kogarah, NSW, Australia
- St George Hospital Clinical School, University of New South Wales, Kogarah, NSW, Australia
| | - Ruwanthi Wijayawardana
- Department of Surgery, Peritonectomy and Liver Cancer Unit, St George Hospital, Kogarah, NSW, Australia
| | - Shoma Barat
- Department of Surgery, Peritonectomy and Liver Cancer Unit, St George Hospital, Kogarah, NSW, Australia
| | - Nima Ahmadi
- Department of Surgery, Peritonectomy and Liver Cancer Unit, St George Hospital, Kogarah, NSW, Australia
| | - David L. Morris
- Department of Surgery, Peritonectomy and Liver Cancer Unit, St George Hospital, Kogarah, NSW, Australia
- St George Hospital Clinical School, University of New South Wales, Kogarah, NSW, Australia
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Carboni F, Valle M, Vaira M, Sammartino P, Federici O, Robella M, Deraco M, Framarini M, Macrì A, Sassaroli C, Lippolis PV, Di Giorgio A, Biacchi D, Martin-Roman L, Sperduti I, Baratti D. Complications and Mortality Rate of Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy: Italian Peritoneal Surface Malignancies Oncoteam Results Analysis. Cancers (Basel) 2022; 14. [PMID: 36497306 DOI: 10.3390/cancers14235824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy may significantly improve survival for selected patients with peritoneal surface malignancies, but it has always been criticized due to the high incidence of postoperative morbidity and mortality. METHODS Data were collected from nine Italian centers with peritoneal surface malignancies expertise within a collaborative group of the Italian Society of Surgical Oncology. Complications and mortality rates were recorded, and multivariate Cox analysis was used to identify risk factors. RESULTS The study included 2576 patients. The procedure was mostly performed for ovarian (27.4%) and colon cancer (22.4%). The median peritoneal cancer index was 13. Overall postoperative morbidity and mortality rates were 34% and 1.6%. A total of 232 (9%) patients required surgical reoperation. Multivariate regression logistic analysis identified the type of perfusion (p ≤ 0.0001), body mass index (p ≤ 0.0001), number of resections (p ≤ 0.0001) and colorectal resections (p ≤ 0.0001) as the strongest predictors of complications, whereas the number of resections (p ≤ 0.0001) and age (p = 0.01) were the strongest predictors of mortality. CONCLUSIONS Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy is a valuable option of treatment for selected patients with peritoneal carcinomatosis providing low postoperative morbidity and mortality rates, if performed in high-volume specialized centers.
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Weksler Y, Hoffman A, Green E, Kyzer M, Nevo N, Gerstenhaber F, Greenberg R, Klausner JM, Gutman M, Lahat G, Berger Y, Geva R, Nizri E. Long-term outcomes of elderly patients with peritoneal metastases of colorectal origin after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Surg Oncol 2022; 44:101848. [PMID: 36126349 DOI: 10.1016/j.suronc.2022.101848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 08/12/2022] [Accepted: 09/06/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) were reportedly safe for the elderly. However, long-term survival data in this subgroup of patients are scarce. Our aim was to evaluate the peri-operative and long-term outcomes of CRS + HIPEC in colorectal peritoneal metastases (CRC-PM) in patients ≥70 years of age. MATERIAL AND METHODS We retrospectively analyzed our combined institutional databases for patients who underwent CRS + HIPEC for CRC-PM. Clinical and pathological characteristics, as well as overall survival (OS) and progression-free survival (PFS) were compared between the groups. Tumor extent was measured by the peritoneal carcinomatosis index (PCI) and completeness of cytoreduction by the CCR score. Major morbidity was defined according to Clavien-Dindo classification. RESULTS The dataset of 159 patients included 33 elderly and 126 non-elderly patients. Clinical characteristics between the groups differed only in medical comorbidities (Charlson comorbidity index 10 vs. 7, P < 0.001) and delivery of post-HIPEC adjuvant treatment (12.5% vs. 43.8%, P = 0.004). Overall PCI and CCR0 rates were similar between the groups, as were length of stay and major morbidity and mortality rates. Long-term outcomes in the elderly group were lower than those of the non-elderly (median OS: 21.8 vs. 40.5 months, P < 0.001; median PFS: 6 vs. 8 months, P = 0.02, respectively). CONCLUSIONS CRS + HIPEC in selected elderly patients can be safe in terms of postoperative morbidity and mortality. However, despite the same surgical extents and radicality, their long-term outcomes are inferior, possibly due to under-usage of systemic chemotherapy.
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Lim PQ, Han IH, Seow KM, Chen KH. Hyperthermic Intraperitoneal Chemotherapy (HIPEC): An Overview of the Molecular and Cellular Mechanisms of Actions and Effects on Epithelial Ovarian Cancers. Int J Mol Sci 2022; 23:10078. [PMID: 36077477 DOI: 10.3390/ijms231710078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 08/15/2022] [Accepted: 08/31/2022] [Indexed: 12/04/2022] Open
Abstract
Most patients with epithelial ovarian cancers (EOCs) are at advanced stages (stage III–IV), for which the recurrence rate is high and the 5-year survival rate is low. The most effective treatment for advanced diseases involves a debulking surgery followed by adjuvant intravenous chemotherapy with carboplatin and paclitaxel. Nevertheless, systemic treatment with intravenous chemotherapeutic agents for peritoneal metastasis appears to be less effective due to the poor blood supply to the peritoneal surface with low drug penetration into tumor nodules. Based on this reason, hyperthermic intraperitoneal chemotherapy (HIPEC) emerges as a new therapeutic alternative. By convection and diffusion, the hyperthermic chemotherapeutic agents can directly contact intraperitoneal tumors and produce cytotoxicity. In a two-compartment model, the peritoneal–plasma barrier blocks the leakage of chemotherapeutic agents from peritoneal cavity and tumor tissues to local vessels, thus maintaining a higher concentration of chemotherapeutic agents within the tumor tissues to facilitate tumor apoptosis and a lower concentration of chemotherapeutic agents within the local vessels to decrease systemic toxicity. In this review, we discuss the molecular and cellular mechanisms of HIPEC actions and the effects on EOCs, including the progression-free survival (PFS), disease-free survival (DFS) and overall survival (OS). For primary advanced ovarian cancers, more studies are agreeing that patients undergoing HIPEC have better surgical and clinical (PFS; OS) outcomes than those not, although one study reported no differences in the PFS and OS. For recurrent ovarian cancers, studies have revealed better DFS and OS in patients undergoing HIPEC than those in patients not undergoing HIPEC, although one study reported no differences in the PFS. HIPEC appears comparable to traditional intravenous chemotherapy in treating advanced EOCs. Overall, HIPEC has demonstrated some therapeutic benefits in many randomized phase III trials when combined with the standard cytoreductive surgeries for advanced EOCs. Nevertheless, many unknown aspects of HIPEC, including detailed mechanisms of actions, along with the effectiveness and safety for the treatment of EOCs, warrant further investigation.
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Laks S, Bilik A, Schtrechman G, Adileh M, Mor E, Boursi B, Halpern N, Margalit O, Shacham-Shmueli E, Nissan A, Ben-Yaacov A. Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy in Elderly is Safe and Effective. J Surg Res 2022; 279:739-747. [PMID: 35940050 DOI: 10.1016/j.jss.2022.06.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 06/22/2022] [Accepted: 06/30/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION An increasing proportion of elderly patients (EP) are undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC). They have increased comorbidities and perioperative risk. Current literature is deficient in describing the outcomes of EP undergoing CRS/HIPEC. MATERIALS AND METHODS A retrospective review of our prospectively maintained CRS/HIPEC database analyzed perioperative and oncological outcomes of EP (>70 y) compared to younger patients (YP) (<60 y). RESULTS Of 500 CRS/HIPEC patients, 62 EP and 210 YP were included. Median age was 73 y in EP and 46 y in YP. Demographic, clinical, operative, and perioperative outcomes were similar between groups. American Society of Anesthesiologists > 3 was more prevalent in the EP with 88.2% versus 54.8% in the YP (P < 0.001). Comorbidities were higher in the EP with 87.1% versus 39.0% in the YP (P < 0.001). Peritoneal Cancer Index score was similar with a median of 9. All postoperative and severe complications were similar with 55.2% and 17.1% in the YP and 64.5% and 21.0% in the EP (P = 0.242; P = 0.448). Postoperative mortality was similar with 1.5% in the YP and 5.0% in the EP (P = 0.134). In colorectal primary patients, median overall and disease-free survival was 61.8 and 12.9 mo in the YP and 64.6 and 11.3 mo in the EP (P = 0.363; P = 0.845). CONCLUSIONS Despite a significant age difference, increased comorbidities, worse American Society of Anesthesiologists, and similar Peritoneal Cancer Index burden, we found no significant differences in perioperative complications or oncological benefit in elderly CRS/HIPEC patients. EP appear to have similar perioperative and oncological outcomes as YP.
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Affiliation(s)
- Shachar Laks
- Department of General Surgery C and Surgical Oncology, Sheba Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Ramat Gan, Israel.
| | - Alona Bilik
- Department of General Surgery C and Surgical Oncology, Sheba Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Ramat Gan, Israel
| | - Gal Schtrechman
- Department of General Surgery C and Surgical Oncology, Sheba Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Ramat Gan, Israel
| | - Mohammad Adileh
- Department of General Surgery C and Surgical Oncology, Sheba Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Ramat Gan, Israel
| | - Eyal Mor
- Department of General Surgery C and Surgical Oncology, Sheba Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Ramat Gan, Israel
| | - Ben Boursi
- Department of Oncology, Sheba Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Ramat Gan, Israel
| | - Naama Halpern
- Department of Oncology, Sheba Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Ramat Gan, Israel
| | - Ofer Margalit
- Department of Oncology, Sheba Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Ramat Gan, Israel
| | - Einat Shacham-Shmueli
- Department of Oncology, Sheba Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Ramat Gan, Israel
| | - Aviram Nissan
- Department of General Surgery C and Surgical Oncology, Sheba Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Ramat Gan, Israel
| | - Almog Ben-Yaacov
- Department of General Surgery C and Surgical Oncology, Sheba Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Ramat Gan, Israel
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