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The Intersection of Age and Tumor Biology with Postoperative Outcomes in Patients After Cytoreductive Surgery and HIPEC

  • Peritoneal Surface Malignancy
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Patient age is a significant factor in preoperative selection for major abdominal surgery. The association of age, tumor biology, and postoperative outcomes in patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) remains ill-defined.

Methods

Retrospective analysis was performed for patients who underwent a CCR0/1 CRS/HIPEC from the US HIPEC Collaborative Database (2000–2017). Age was categorized into < 65 or ≥ 65 years. Primary outcome was postoperative major complications. Secondary outcomes were non-home discharge (NHD) and readmission. Analysis was stratified by disease histology: non-invasive (appendiceal LAMN/HAMN), and invasive (appendiceal/colorectal adenocarcinoma).

Results

Of 1090 patients identified, 22% were ≥ 65 (n = 240), 59% were female (n = 646), 25% had non-invasive (n = 276) and 51% had invasive (n = 555) histology. Median PCI was 13 (IQR 7–20). Patients ≥ 65 had a higher rate of major complications (37 vs 26%, p = 0.02), NHD (12 vs 5%, p < 0.01), and readmission (28 vs 22%, p = 0.05), compared to those < 65. For non-invasive histology, age ≥ 65 was not associated with major complications or NHD on multivariable analysis. For invasive histology, when accounting for PCI and CCR, age ≥ 65 was associated with major complications (OR 2.04, 95% CI 1.16–3.59, p = 0.01). When accounting for major complications, age ≥ 65 was associated with NHD (OR 2.54, 95% CI 1.08–5.98, p = 0.03). Age ≥ 65 was not predictive of readmission for any histology when accounting for major complications.

Conclusions

Age ≥ 65 years is an independent predictor for postoperative major complications and non-home discharge for invasive histology, but not non-invasive histology. These data inform preoperative counseling, risk stratification, and early discharge planning.

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References

  1. Foster JM, Sleightholm R, Patel A, et al. Morbidity and mortality rates following cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy compared with other high-risk surgical oncology procedures. JAMA Netw Open. 2019;2(1):e186847.

    Article  Google Scholar 

  2. Cao C, Yan TD, Black D, Morris DL. A systematic review and meta-analysis of cytoreductive surgery with perioperative intraperitoneal chemotherapy for peritoneal carcinomatosis of colorectal origin. Ann Surg Oncol. 2009;16(8):2152–65.

    Article  Google Scholar 

  3. Omohwo C, Nieroda CA, Studeman KD, et al. Complete cytoreduction offers longterm survival in patients with peritoneal carcinomatosis from appendiceal tumors of unfavorable histology. J Am Coll Surg. 2009;209(3):308–12.

    Article  Google Scholar 

  4. Alexander HR, Hanna N, Pingpank JF. Clinical results of cytoreduction and HIPEC for malignant peritoneal mesothelioma. Cancer Treat Res. 2007;134:343–55.

    CAS  PubMed  Google Scholar 

  5. Spiliotis J, Halkia E, Lianos E, et al. Cytoreductive surgery and HIPEC in recurrent epithelial ovarian cancer: a prospective randomized phase III study. Ann Surg Oncol. 2015;22(5):1570–5.

    Article  CAS  Google Scholar 

  6. Desantis M, Bernard JL, Casanova V, et al. Morbidity, mortality, and oncological outcomes of 401 consecutive cytoreductive procedures with hyperthermic intraperitoneal chemotherapy (HIPEC). Langenbecks Arch Surg. 2015;400(1):37–48.

    Article  Google Scholar 

  7. Ceelen WP, Peeters M, Houtmeyers P, Breusegem C, De Somer F, Pattyn P. Safety and efficacy of hyperthermic intraperitoneal chemoperfusion with high-dose oxaliplatin in patients with peritoneal carcinomatosis. Ann Surg Oncol. 2008;15(2):535–41.

    Article  Google Scholar 

  8. Kusamura S, Younan R, Baratti D, et al. Cytoreductive surgery followed by intraperitoneal hyperthermic perfusion: analysis of morbidity and mortality in 209 peritoneal surface malignancies treated with closed abdomen technique. Cancer. 2006;106(5):1144–53.

    Article  Google Scholar 

  9. Beckert S, Struller F, Horvath P, Falcke A, Konigsrainer A, Konigsrainer I. Overall morbidity but not mortality is increased in elderly patients following cytoreductive surgery and HIPEC. Langenbecks Arch Surg. 2015;400(6):693–8.

    Article  Google Scholar 

  10. Melis M, Marcon F, Masi A, et al. The safety of a pancreaticoduodenectomy in patients older than 80 years: risk vs. benefits. HPB (Oxford). 2012;14(9):583–8.

    Article  Google Scholar 

  11. Ide T, Miyoshi A, Kitahara K, Noshiro H. Prediction of postoperative complications in elderly patients with hepatocellular carcinoma. J Surg Res. 2013;185(2):614–9.

    Article  Google Scholar 

  12. D’Amico TA. Outcomes after surgery for esophageal cancer. Gastrointest Cancer Res. 2007;1(5):188–96.

    PubMed  PubMed Central  Google Scholar 

  13. Huang Y, Alzahrani NA, Alzahrani SE, Zhao J, Liauw W, Morris DL. Cytoreductive surgery and perioperative intraperitoneal chemotherapy for peritoneal carcinomatosis in the elderly. World J Surg Oncol. 2015;13:262.

    Article  Google Scholar 

  14. Spiliotis JD, Halkia E, Boumis VA, Vassiliadou DT, Pagoulatou A, Efstathiou E. Cytoreductive surgery and HIPEC for peritoneal carcinomatosis in the elderly. Int J Surg Oncol. 2014;2014:987475.

    CAS  PubMed  PubMed Central  Google Scholar 

  15. Votanopoulos KI, Newman NA, Russell G, et al. Outcomes of cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in patients older than 70 years; survival benefit at considerable morbidity and mortality. Ann Surg Oncol. 2013;20(11):3497–503.

    Article  Google Scholar 

  16. Tabrizian P, Jibara G, Shrager B, et al. Outcomes for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the elderly. Surg Oncol. 2013;22(3):184–9.

    Article  Google Scholar 

  17. H. WLCSGDW. 65+ in the United States: 2010. US Government Printing Office. 2014:23-212.

  18. Yang R, Wolfson M, Lewis MC. Unique aspects of the elderly surgical population: an anesthesiologist’s perspective. Geriatr Orthop Surg Rehabil. 2011;2(2):56–64.

    Article  Google Scholar 

  19. Al-Refaie WB, Parsons HM, Henderson WG, et al. Major cancer surgery in the elderly: results from the American College of Surgeons National Surgical Quality Improvement Program. Ann Surg. 2010;251(2):311–8.

    Article  Google Scholar 

  20. Lin HS, Watts JN, Peel NM, Hubbard RE. Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatr. 2016;16(1):157.

    Article  Google Scholar 

  21. Buigues C, Juarros-Folgado P, Fernández-Garrido J, Navarro-Martínez R, Cauli O. Frailty syndrome and pre-operative risk evaluation: a systematic review. Arch Gerontol Geriatr. 2015;61(3):309–21.

    Article  Google Scholar 

  22. Govaerts K, Chandrakumaran K, Carr NJ, et al. Single centre guidelines for radiological follow-up based on 775 patients treated by cytoreductive surgery and HIPEC for appendiceal pseudomyxoma peritonei. Eur J Surg Oncol. 2018;44(9):1371–7.

    Article  Google Scholar 

  23. Lee RM, Zaidi MY, Gamboa AC, et al. What is the optimal preoperative imaging modality for assessing peritoneal cancer index? An analysis from the United States HIPEC Collaborative. Clin Colorectal Cancer. 2019;19:e1–7.

    Article  Google Scholar 

  24. Gamboa AC, Zaidi MY, Lee RM, et al. Optimal surveillance frequency after CRS/HIPEC for appendiceal and colorectal neoplasms: a multi-institutional analysis of the US HIPEC Collaborative. Ann Surg Oncol. 2020;27(1):134–46.

    Article  Google Scholar 

  25. Chiu H-C, Lin Y-C, Hsieh H-M, Chen H-P, Wang H-L, Wang J-Y. The impact of complications on prolonged length of hospital stay after resection in colorectal cancer: a retrospective study of Taiwanese patients. J Int Med Res. 2017;45(2):691–705.

    Article  Google Scholar 

  26. Khan NA, Quan H, Bugar JM, Lemaire JB, Brant R, Ghali WA. Association of postoperative complications with hospital costs and length of stay in a tertiary care center. J Gen Intern Med. 2006;21(2):177–180.

    Article  Google Scholar 

  27. Burguete D, Mokdad AA, Augustine MM, et al. Non-home discharge and prolonged length of stay after cytoreductive surgery and HIPEC. J Surg Res. 2019;233:360–7.

    Article  Google Scholar 

  28. Wong EYT, Tan GHC, Chia CSL, Kumar M, Soo KC, Teo MCC. Morbidity and mortality of elderly patients following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). Asia Pac J Clin Oncol. 2018;14(2):e193–202.

    Article  Google Scholar 

  29. Lee TC, Wima K, Sussman JJ, et al. Readmissions after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: a US HIPEC Collaborative Study. J Gastrointest Surg. 2020;24(1):165–76.

    Article  Google Scholar 

  30. Paredes AZ, Abdel-Misih S, Schmidt C, Dillhoff ME, Pawlik TM, Cloyd JM. Predictors of readmission after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. J Surg Res. 2019;234:103–9.

    Article  Google Scholar 

  31. Turrentine FE, Wang H, Simpson VB, Jones RS. Surgical risk factors, morbidity, and mortality in elderly patients. J Am Coll Surg. 2006;203(6):865–77.

    Article  Google Scholar 

  32. Saltzstein SL, Behling CA. 5- and 10-year survival in cancer patients aged 90 and older: a study of 37,318 patients from SEER. J Surg Oncol. 2002;81(3):113–6 (discussion 117).

    Article  Google Scholar 

  33. Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri SF. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study. Arch Surg. 1999;134(1):36–42.

    Article  CAS  Google Scholar 

  34. Ethun CG, Bilen MA, Jani AB, Maithel SK, Ogan K, Master VA. Frailty and cancer: implications for oncology surgery, medical oncology, and radiation oncology. CA Cancer J Clin. 2017;67(5):362–77.

    Article  Google Scholar 

  35. Konstantinidis IT, Chouliaras K, Levine EA, Lee B, Votanopoulos KI. Frailty correlates with postoperative mortality and major morbidity after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol. 2017;24(13):3825–30.

    Article  Google Scholar 

  36. Alyami M, Lundberg P, Kepenekian V, et al. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis in the elderly: a case-controlled, multicenter study. Ann Surg Oncol. 2016;23(Suppl 5):737–45.

    Article  Google Scholar 

  37. Kitai T, Yamanaka K, Miyauchi Y, Kawashima M. Indications for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in elderly patients with peritoneal malignancy. Int J Clin Oncol. 2017;22(3):519–25.

    Article  Google Scholar 

  38. Gagniere J, Veziant J, Pereira B, Pezet D, Le Roy B, Slim K. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for the elderly: is it reasonable? A Meta-Analysis. Ann Surg Oncol. 2018;25(3):709–19.

    Article  Google Scholar 

  39. Schneider MA, Eshmuminov D, Lehmann K. Major postoperative complications are a risk factor for impaired survival after CRS/HIPEC. Ann Surg Oncol. 2017;24(8):2224–32.

    Article  Google Scholar 

  40. Ihemelandu C, Mavros MN, Sugarbaker P. Adverse events postoperatively had no impact on long-term survival of patients treated with cytoreductive surgery with heated intraperitoneal chemotherapy for appendiceal cancer with peritoneal metastases. Ann Surg Oncol. 2016;23(13):4231–7.

    Article  Google Scholar 

  41. Squires MH, 3rd, Staley CA, Knechtle W, et al. Association between hospital finances, payer mix, and complications after hyperthermic intraperitoneal chemotherapy: deficiencies in the current healthcare reimbursement system and future implications. Ann Surg Oncol. 2015;22(5):1739–45.

    Article  Google Scholar 

Download references

Acknowledgements

This study was supported in part by the Katz Foundation and the National Center for Advancing Translational Science, Grant/Award Number: UL1TR002378/TL1TR002382.

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Authors and Affiliations

  1. Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA

    Michael K. Turgeon MD, Adriana C. Gamboa MD, Rachel M. Lee MD, MSPH, Mohammad Y. Zaidi MD, MS, Charles A. Staley MD, Shishir K. Maithel MD & Joshua H. Winer MD

  2. Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA

    Charles Kimbrough MD & Jordan M. Cloyd MD

  3. Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA

    Travis Grotz MD

  4. Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Keith Fournier MD

  5. Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA

    Benjamin Powers MD & Sean Dineen MD

  6. Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL, USA

    Benjamin Powers MD & Sean Dineen MD

  7. Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA, USA

    Jula Veerapong MD

  8. Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA

    Callisia Clarke MD & Harveshp Mogal MD

  9. Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA

    Sameer H. Patel MD

  10. Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA

    Laura Lambert MD

  11. Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA

    Sean Ronnekleiv-Kelly MD

  12. Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA

    Mustafa Raoof MD

  13. Department of Surgery, Johns Hopkins University, Baltimore, MD, USA

    Nadege Fackche MD & Jonathan B. Greer MD

Authors
  1. Michael K. Turgeon MD
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  14. Laura Lambert MD
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  18. Jonathan B. Greer MD
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  19. Charles A. Staley MD
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  20. Jordan M. Cloyd MD
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  21. Shishir K. Maithel MD
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  22. Joshua H. Winer MD
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Corresponding author

Correspondence to Joshua H. Winer MD.

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Turgeon, M.K., Gamboa, A.C., Lee, R.M. et al. The Intersection of Age and Tumor Biology with Postoperative Outcomes in Patients After Cytoreductive Surgery and HIPEC. Ann Surg Oncol 27, 4894–4907 (2020). https://doi.org/10.1245/s10434-020-08538-y

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  • DOI: https://doi.org/10.1245/s10434-020-08538-y

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