peritoneal carcinomatosis ( pc ) is associated with a poor prognosis , and , once it is diagnosed , survival is generally less than 6 months [ 1 , 2 ] . peritoneal carcinomatosis represents a devastating form of cancer progression and the pathogenesis of this clinical entity can be explained by several biological models and a better understanding of underlying tumor kinetics and cellular dissemination mechanisms . a considerable number of patients presenting with peritoneal carcinomatosis from digestive or gynecological cancers are aged 70 or older . offering a safe and appropriate treatment to elderly patients with pc presents a challenge for healthcare resources . the combination of cytoreductive surgery ( crs ) and hyperthermic intraperitoneal chemotherapy ( hipec ) plays an important therapeutic role in patients with pc . on the other hand , elderly patients are traditionally associated more frequently with comorbidities and a reduced capacity to recover or tolerate aggressive surgery [ 5 , 6 ] . several recent results have shown that age alone does not influence the outcome of surgery and cancer - specific survival in these patients is similar to that of younger patients [ 79 ] . as for the management of pc nowadays , many patients are treated in specialized centers around the world with extensive crs with peritonectomy procedures combined with hipec   and encouraging disease - free and overall survival results have been reported . in the past , in the few randomized trials that were performed , age was used as a selection criterion , investigating the outcomes in patients younger than 70 or 65 years [ 10 , 11 ] . however , patients with peritoneal carcinomatosis stemming from any tumor site are 70 years old or older at the time of diagnosis . the risks and benefits of crs and hipec in elderly patients using prospectively collected data from our institution with specialized interest in peritoneal surface malignancies , we examined the outcomes in the elderly patients who underwent crs and hipec . from a pool of 100 patients with a diagnosis of pc who underwent crs and hipec in our center in greece , in this study we have included patients at an age of 70 years or older and the results were compared to the patients younger than 70 years . data regarding patient characteristics , surgical procedures , perioperative outcomes , and survival outcomes were prospectively collected . regular followup was performed every three months for the first year and at six - month interval thereafter . the eligibility for crs and hipec procedures is decided after physical examination and double contrast - enhanced ct scans of the chest , abdomen , and pelvis . in addition , a positron emission tomography ( pet ) scan was performed to assess the extent of disease if necessary . each case was put to discussion at a multidisciplinary team meeting attended by surgical oncologists , medical oncologists , radiation oncologists , anaesthesiologists , cancer care nurses , and research staff . in all patients a jugular or subclavian central venous catheter was placed and they received prophylactic antibiotic treatment with cefazolin 200  mg and metronidazole 500  mg every six hours during surgery and postoperatively . procedures were performed by a specialized surgical team , led by the same surgeon ( js ) . patient position was supine ; a midline laparotomy was performed , followed by assessment of the extent of disease with the use of the peritoneal cancer index ( pci ) . the pci is a combined assessment of thickness of the lesion , size and distribution of tumor deposits in different abdominal regions , resulting in a numerical score which represents a quantification of the extent of the disease . the macroscopic result of cytoreduction was assessed and recorded using the completeness of cytoreduction ( cc ) score . after cytoreduction , hipec was performed by infusion of a heated chemoperfusate into the abdomen using either the coliseum technique or the closed abdomen technique at approximately 42.5c for 90 minutes . the drug protocol that was used has been described previously by our team , with a 30% dose reduction in the aged group . overall survival was defined as the time between the crs and hipec and the date of death or last followup . disease - free survival was defined as the time between the crs and hipec and the date of recurrence thirty patients of 70 years or older ( mean age 74.5 years ) underwent combined treatment with crs and hipec . details on concomitant disease and medical history are given in table 1 . in all patients , median time between the primary tumor resection and crs + hipec was 18 months ( 6180 ) . in the older group , the mean pci was 25 ( 439 ) and a complete removal of the peritoneal disease ( ccs0 ) was achieved in 16 patients ( 53.3% ) , while in the younger group ( < 70 years ) the mean pci was 24 ( 339 ) and a ccs0 was achieved in 55.7% . all the data concerning the intraperitoneal procedures are presented in table 2 . in fifteen patients ( 50% ) of the aged group , the crs and hipec were uncomplicated . in the group under 70 years , in 41 patients ( 58.5% ) no complications were observed . the mortality rate was 1/30 ( 3.3% ) in the older group versus 1/70 ( 1.4% ) in the younger group , respectively ( ns ) . three patients from the older group ( 10% ) required surgical intervention in order to deal with acute and severe complications compared to five patients ( 7.1% ) from the younger group . age plays a role in the overall survival rates three years after the initial operation . univariate analysis was performed to assess the influence on overall survival of the following factors : age > 75 , histologic type of tumor ( mucinous adenocarcinoma versus adenocarcinoma ) , peritoneal cancer index ( pci ) , completeness of cytoreduction score ( ccs ) , amount of blood transfused , duration of crs + hipec , and occurrence of postoperative complications . low pci ( < 10 ) , completeness of cytoreduction ( ccs0 ) , and tumor histology were the factors that influenced overall survival . over the past 30 years the global burden of cancer has more than doubled , so the ageing population and the associated rise in cancer prevalence lead to an increase in demand of cancer treatment . these factors together with the availability of modern surgical equipment , new antibiotic regimens , and the high standards of anesthetic and icu care may reduce the risk of age as a preoperative selection criterion . studies from other centers confirm that crs + hipec can be safely performed in elderly patients , including octogenarians [ 17 , 18 ] . in the past , age has been regarded as a limiting factor for aggressive or curative therapies . in the last decade , reports have shown acceptable outcomes in terms of morbidity and mortality in patients older than 70 years of age undergoing gastrectomy for gastric cancer , pancreatectomy for pancreatic cancer , or liver metastasectomies . our study shows that crs + hipec can be performed safely in patients aged 70 years or older with an acceptable morbidity and mortality , comparable to patients younger than 70 years . primary outcomes in our study were overall survival , which is 52% in five years for the younger group versus the older group , in which it is 30% . this result demonstrates that three years after the initial operation there is a survival benefit in the younger population . to optimize the outcomes of elderly patients undergoing crs + hipec low pci ( < 10 ) , completeness of cytoreduction ( ccs0 ) , and tumor histology were the factors that influenced overall survival . demonstrates equal results concerning the morbidity and mortality in elderly colorectal patients undergoing crs + hipec . the study presents the results in twenty - four patients aged > 70 years , but they did not compare their results against adults < 70 years . also foster et al . presented a retrospective analysis of twenty patients over the age of 65 who presented for consideration of crs + hipec and suggested that crs + hipec can be safely performed in elderly patients including octogenarians . other studies in the past have evaluated the safety , effectiveness , and feasibility of other major abdominal operations in the elderly , such as liver , pancreatic , gastric , and ovarian cancer surgery , showing a low mortality and acceptable morbidity with a careful patient selection process [ 1922 ] . the role of hipec in the management of peritoneal carcinomatosis worldwide remains unclear with excellent result in well selected patients and especially in those of colorectal and ovarian origin . over the past ten years , randomized controlled trials have shown prolongation of survival with the combination treatment as compared with standard care of conventional surgery and systemic chemotherapy . the studies in elderly population have a bias concerning the quality of life and the influence of this aggressive approach of treatment in the comorbidities and its role in long - term survival . this factor may play a role in the survival of aged patients in our study , who , after a three - year period , have statistically significant lower survival rates compared to the younger group . votanopoulos et al . recently reported a series of 81 patients older than 70 years who underwent cytoreductive surgery and hipec . the 30-day mortality was 13.8% and severe postoperative complications occurred in 38% of the patients , results which are similar to ours . in conclusion , more data are needed to assess the survival rates and to identify factors of influence on morbidity , mortality , and quality of life of patients receiving crs + hipec . also the treatment is feasible in patients over 70 years with good performance status and is well selected after consideration of the tumor volume , grading , and the type of resection . these factors must be the inclusion criteria for elderly patients in clinical trials to determine the best results .
background . 
 the combined treatment of peritoneal carcinomatosis with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is a rigorous surgical treatment , most suitable for young and good performance status patients . 
 we evaluated the outcomes of elderly patients undergoing crs and hipec for peritoneal carcinomatosis with careful perioperative care . 
 methods . 
 all consecutive patients 70 years of age or older who were treated for peritoneal carcinomatosis over the past five years were included . 
 primary outcomes were perioperative morbidity and mortality . 
 secondary outcomes were disease - free survival and overall survival .   results . from a pool of 100 patients , with a diagnosis of pc who underwent crs and hipec in our center , 
 we have included 30 patients at an age of 70 years or older and the results were compared to the patients younger than 70 years . 
 the total morbidity rate was 50% versus 41.5% in the group younger than 70 years ( nss ) . 
 the mortality rate was 3.3% in the elderly group versus 1.43% in the younger group ( nss ) . 
 median overall survival was 30 months in the older group versus 38 months in the younger group . 
 conclusion . 
 cytoreductive surgery and hipec for peritoneal carcinomatosis may be safely performed with acceptable morbidity in selected elderly patients .