title: 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 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.
authors.affiliation: Surgical Oncology Service, Department of General Surgery, Wake Forest University, Winston-Salem, NC, USA. kvotanop@wakehealth.edu
authors.forename: Konstantinos I
authors.initials: KI
authors.lastname: Votanopoulos
authors.forename: Naeem A
authors.initials: NA
authors.lastname: Newman
authors.forename: Greg
authors.initials: G
authors.lastname: Russell
authors.forename: Chukwuemeka
authors.initials: C
authors.lastname: Ihemelandu
authors.forename: Perry
authors.initials: P
authors.lastname: Shen
authors.forename: John H
authors.initials: JH
authors.lastname: Stewart
authors.forename: Edward A
authors.initials: EA
authors.lastname: Levine
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D017024:Chemotherapy, Adjuvant; D010478:Chemotherapy, Cancer, Regional Perfusion / Q000401:mortality*; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006979:Hyperthermia, Induced / Q000401:mortality*; D008297:Male; D009017:Morbidity; D009367:Neoplasm Staging; D009369:Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery / Q000628:therapy; D011379:Prognosis; D011446:Prospective Studies; D012189:Retrospective Studies; D015996:Survival Rate