Perioperative outcomes of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy in elderly women with epithelial ovarian cancer: analysis of a prospective registry

Abstract

ObjectiveTo evaluate perioperative outcomes in elderly versus non-elderly women with advanced or recurrent epithelial ovarian cancer undergoing surgery with hyperthermic intraperitoneal chemotherapy (HIPEC).MethodsA single-institution prospective registry was analyzed for women with ovarian cancer who underwent surgery with HIPEC from January 2014 to December 2020. Elderly age was defined as ≥65 years at surgery. Complications were defined according to the Accordion scale. Univariate and multivariable analysis was used to compare progression-free survival and overall survival.ResultsOf 127 women who underwent surgery with HIPEC, 33.1% (n=42) were ≥65 and 17.3% (n=22) were ≥70 years old. The median age for non-elderly and elderly patients were 55.7±8.3 versus 72.0±5.4 years, respectively (p<0.001). The majority of non-elderly versus elderly patients underwent HIPEC at the time of interval cytoreductive surgery following neoadjuvant chemotherapy (52.9% vs 73.8%, p=0.024). There were no differences in moderate (15.3% vs 26.2%) or severe postoperative complications (10.6% vs 11.9%, p=0.08), acute kidney injury (7.1% vs 16.7%, p=0.12), and length of stay (5.0 vs 5.0 days, p=0.56) for non-elderly versus elderly patients. With a median follow-up of 20 months (95% CI 9.1 to 32.7 months), there was no difference in progression-free survival (18.8 vs 15.7 months, p=0.75) or overall survival (61.6 months vs not estimable, p=0.72) for non-elderly versus elderly patients. Comparing patients 65–69 versus ≥70 years, progression-free survival (33.0 vs 12.5 months, p=0.002) was significantly improved in patients aged 65–69, without difference in overall survival (not estimable vs 36.0 months, p=0.91). On multivariable analysis, age ≥65 did not impact progression-free survival (p=0.74).ConclusionsIn this prospective registry of women with ovarian cancer, perioperative morbidity is not increased for non-elderly versus elderly patients following surgery with HIPEC. While age should not exclude patients from surgery with HIPEC, additional research is needed regarding oncologic benefits in elderly women.

Is there a role for hyperthermic intraperitoneal chemotherapy in ovarian cancer?

“…Enhanced recovery after surgery is used postoperatively, and patients are cared for on the routine surgical floor. Other institutions have published guides to starting HIPEC protocols, most of which focus on perioperative care and considerations, as well as the multidisciplinary work needed to achieve a safe and efficacious HIPEC case [33–35,36 ▪ ,37–41].…”

Multi-Disciplinary Care Planning of Ovarian Cancer in Older Patients: General Statement—A Position Paper from SOFOG-GINECO-FRANCOGYN-SFPO

“…In a meta-analysis on cytoreductive surgery and HIPEC regardless of the indication which considered different cut-offs (65, 70, 75 years) to analyze the effect of age on patients’ outcomes and toxicities, the 70 year threshold appeared to be clinically relevant; the 30-day postoperative grade 3 morbidity and the 90-day postoperative mortality were significantly higher in patients ≥70 years, although this was not associated with a longer hospital stay [ 58 ]. In a recent single-institution prospective analysis of HIPEC in patients with gynecologic cancers, Chambers et al found that chronological age (<65 vs. ≥65 years) did not predict post-operative complications, progression-free survival or overall survival but that patients aged ≥70 years had a reduced progression-free survival following HIPEC compared to patients 65–69 years without any impact on overall survival [ 59 ]. However, the same group later reported that a composite index of 11 medical comorbidities (the modified frailty index, mFI) significantly predicted post-operative complications in multivariate analysis, with a more than 9-fold risk of grade ≥2 complications in those with mFI ≥ 2 vs. 0–1 (OR 9.4, 95% CI [3.3; 26.4], p < 0.001), whereas age did not [ 60 ].…”