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Eur J Cardiothorac Surg 2003;23:446-450
© 2003 Elsevier Science NL

Surgical strategy for clinical stage I non-small cell lung cancer in octogenarians

^a Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Niigata 951-8510, Japan
^b Niigata Cancer Center Hospital, Niigata, Japan
^c National Nishi-Niigata Chuou Hospital, Niigata, Japan

Received 10 September 2002; received in revised form 2 January 2003; accepted 4 January 2003.

^* Corresponding author. Tel.: +81-25-227-2233; fax: +81-25-227-0780
e-mail: taoki{at}med.niigata-u.ac.jp

	Abstract

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Objective: The purpose of this study was to determine whether lobectomy without radical systematic mediastinal lymphadenectomy (LA) is a satisfactory alternative surgical treatment for octogenarians with clinical stage I non-small cell lung cancer (NSCLC). Methods: From April 1985 through December 2001, 49 patients aged 80 years and older who underwent surgical treatment for clinical stage I NSCLC were reviewed. Lobectomy without radical systematic mediastinal LA was performed for 27 patients (LA0 group) and lobectomy with radical systematic mediastinal LA was performed for 22 patients (LA group). Results: The mortality rate was 0% in the LA0 group and 4.5% in the LA group. Five-year survival rate according to the type of surgery was 44.8% in the LA0 group and 55.5% in the LA group, a difference that was not significant (P=0.88). Although there was no significant statistical difference, postoperative pulmonary complication was more frequent in the LA group than in the LA0 group (32% in the LA group versus 11% in the LA0 group P=0.07). Five-year survival rates according to serum carcinoembryonic antigen (CEA) levels were 0% for patients with elevated CEA levels (n=9) and 56.5% for patients with normal CEA levels (n=40) (P<0.01). Conclusion: Lobectomy without radical systematic mediastinal LA appears to be a satisfactory surgical procedure for octogenarians with clinical stage I NSCLC. However, mediastinoscopy is necessary in such octogenarians if their serum CEA level is elevated so that the precise clinical stage can be determined and an accurate prognosis can be given.

Key Words: Octogenarians • Stage I non-small cell lung cancer • Mediastinal lymphadenectomy

	1. Introduction

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
The population in Japan is aging, and mass screenings for lung cancer are increasing in the general public, as the proportion of elderly patients with lung cancer continues to increase. Several reports have documented that pulmonary resection can be performed safely in octogenarians with lung cancer [1–5], but surgical morbidity and mortality rates are higher among octogenarians than among younger patients [3,6]. Surgical treatment offers the best prospects for patient with non-small cell lung cancer (NSCLC), and this certainly applies to early-stage NSCLC; however, concern about excessive morbidity with pulmonary resection in octogenarians has led to the performance of surgeries apt to confer the least amount of surgical trauma as possible in this group. We compared survival rates and other factors related to outcome in a group of octogenarians who underwent lobectomy with or without radical systematic mediastinal lymphadenectomy (LA) in this retrospective study.

	2. Patients and methods

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
From April 1985 to December 2001, 98 consecutive patients aged 80 years and older underwent surgical resection of primary lung cancer at our institutions. Of these, we studied the records of 49 patients who underwent lobectomy with or without radical systematic mediastinal LA for clinical stage I NSCLC. Other 49 patients underwent limited resection such as wedge resection or segmental resection. Preoperative staging was determined in all patients by means of chest radiography, computed tomography of the chest, brain and upper abdomen, and whole body bone scintigraphy. The clinical characteristics of patients evaluated included smoking history, medical history, and blood tests including serum carcinoembryonic antigen (CEA) concentrations. A medical condition was defined as major if the patient received medical therapy with his past history. A CEA level of 5 ng/ml or more was considered elevated. Pulmonary function was also assessed preoperatively on the basis of spirometry and arterial blood gas measurements. Cardiac stress testing or echocardiography was added if the patient had risk factors for myocardial ischemia. Perioperative data consisted of surgical procedure, operation times, operative morbidity and mortality occurring within 30 days, and length of postoperative hospital stay. The operations were performed by six surgeons. The stages of lung cancer were determined according to TNM classification system, revised in 1997 [7]. Follow-up information was obtained for all survivors, either during office visits or by telephone interview with the patient or a relative. Since no autopsy was done on patients who died, metastatic disease was diagnosed on the basis of clinical and radiographic findings when pathologic confirmation was not available.

Statistical analysis was performed with ² or unpaired t-test, actuarial survival was assessed by the Kaplan–Meier method. Differences were significant at P values of less than 0.05.

2.1. Surgical procedure
Preoperative mediastinoscopy was not performed, since clinical staging of disease in all 49 patients was stage I. All patients underwent standard posterolateral thoracotomies, entering in the fourth or fifth intercostal space. In the LA group, radical systematic mediastinal LA was done [8]. The lymph nodes within the superior mediastinal compartment contained between trachea and superior vena cava from the level of right subclavian artery to the azygos vein were removed. The azygos vein was ligated. The right laryngeal recurrent nerve was generally exposed and dissected. The trachea, superior vena cava, and ascending aorta were completely free from all tissue. The subcarinal lymph nodes were dissected in the LA group patients. The paraesophageal and inferior pulmonary lymph nodes were dissected routinely in cancer of lower lobe. The mediastinum anterior to the superior vena cava was not routinely dissected. In cancer of the left side, the lymph nodes within the subaortic compartment contained between the left pulmonary artery, the aortic arch, the left recurrent laryngeal nerve, and the phrenic nerve were dissected. In the LA0 group, simple lobectomy was performed, radical systematic mediastinal LA or systematic lymph node sampling was not done.

	3. Results

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Lobectomy without radical systematic mediastinal LA was performed in 27 patients (LA0 group) and lobectomy with radical systematic mediastinal LA was performed in 22 patients (LA group). This is a non-randomized retrospective study. Surgeon and each institution preference influenced the selection process. The 27 patients in the LA0 group were considered on the basis of macroscopic operative findings to have N0 disease. As shown in Table 1, age, sex and preoperative staging did not differ statistically between the two groups. Preoperative pulmonary function determined by spirometry and arterial blood gas analysis did not differ statistically between the two groups.

The operation time was significantly longer in the LA group than in the LA0 group, and intraoperative blood loss was relatively more in the LA group than in the LA0 group (Table 1). There was no significant difference in postoperative hospital stay between the two groups (Table 1). The overall mortality rate was 2.0% (one of 49 patients) in this study. There were no deaths in the LA0 group, but one (4.5%) of the 22 patients in the LA group died within 30 days after the operation. The patient in the LA group died of acute respiratory distress syndrome (ARDS) at 25 postoperative days. It is not clear how much additional lymphadenectomy affects the occurrence of ARDS. The overall morbidity rate was 41%; 41% (11 of 27 patients) in the LA0 group and 41% (nine of 22 patients) in the LA group suffered operative complications. Most postoperative complications were pulmonary complications; two cases of bacterial pneumonia that was defined as the patient required reintubation and intensive sputum suctioning and one case of pulmonary embolism that was defined as the patient required intensive cardiopulmonary care with thrombolytic therapy and anticoagulation in the LA0 group and six cases of pneumonia and one case of ARDS in the LA group. Postoperative pulmonary complication was more frequent in the LA group than in the LA0 group (32% in the LA group versus 11% in the LA0 group), however, there was no significant statistical difference (Table 2). The mean postoperative hospital stay for patients with pulmonary complication was 26 days and that of patients without pulmonary complication was 18 days postoperatively (P<0.05). Median follow-up was 25 months. The overall all-cause mortality rate was 70.6% at 3 years and 52.5% at 5 years. We related overall long-term survival to the type of surgery; in the LA0 group, 3-year survival was 67.3% and 5-year survival was 44.8%; in the LA group, 3-year survival was 74.4% and 5-year survival was 55.5%. There was no significant difference between the two groups (Fig. 1 ). A total of 19 patients have died among the 49 patients, eight patients in the LA0 group and 11 patients in the LA group. Recurrent malignant disease was determined to be the cause of death in four (50%) of eight patients in the LA0 group and in seven (63.6%) of 11 patients in the LA group.

View larger version (15K): [in this window] [in a new window]   Fig. 1. Kaplan–Meier survival curves based on the type of surgery. The between-group difference was not significant. LA0, lobectomy without radical systematic mediastinal lymphadenectomy; LA, lobectomy with radical systematic mediastinal lymphadenectomy.

View larger version (17K): [in this window] [in a new window]   Fig. 2. Kaplan–Meier survival curves based on serum CEA levels. The between-group difference was significant (P<0.01).

	4. Discussion

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

The mortality rate we observed was very low (2.0%), and the morbidity rate was similar (41%) to that of other studies [1–5]. Common complications of radical systematic mediastinal LA such as recurrent nerve palsy, chylothorax, or bronchopleural fistula did not occur in our LA group. The overall morbidity rate was almost same between the LA group and the LA0 group, but pulmonary complication was relatively higher in the LA group than in the LA0 group (Table 2). However, previous reports have indicated that the relatively long operation time would increase the risk of postoperative pulmonary complications [1,9]. This study demonstrated same results of previous study, although the longer time operation in the LA group would be associated with radical systematic mediastinal LA. The previous reports indicated that the length of the postoperative hospital stay of octogenarians with NSCLC was associated with the occurring of the postoperative pulmonary complication and this study demonstrated same results of previous study [1,2,4]. Surgeon should prevent the occurrence of postoperative pulmonary morbidity and supply to the benefit for surgical treatment that was considered to be the shorter length of hospital stay compared to other treatment. Therefore, we believe that expeditious surgery should be performed in octogenarians, though pulmonary surgery has been performed safely.

Five-year survival rates associated with surgical treatment of clinical stage I NSCLC in octogenarians have been reported between 38 and 79%; our overall 5-year survival rate of 52.5% for stage I disease was similar [1–5]. The 5-year survival rate of 36.1% for stage IA disease in our octogenarians is lower than the 70.8% for stage IA disease including all ages [10]. This low survival rate is considered to result from the cause of death including all facts and making wrong diagnosis as stage I disease for advanced disease due to the absence of radical systematic mediastinal LA. Four of the eight patients in the LA0 group and four of the 11 patients in the LA group did not die of a cancer-related cause in this study. We showed previously that the major cause of death in long-term survivors in octogenarians was pneumonia, which derived from the poor pulmonary function due to extensive pulmonary resection [1] and Morandi et al. demonstrated that the incidence of non-cancer related death of elderly patients with pulmonary resection was higher than that of younger ones [11]. This condition would influence the results of this study that there was no significant difference in 5-year survival rate between patients in the LA and LA0 group. Takizawa et al. showed that surgeons could not detect metastases in 70% of patients with nodal involvement of small peripheral adenocarcinoma [12]. In the present study, three of 22 patients in the LA group were upstaged for postoperative pathological examination, although all these patients had normal CEA concentration. Radical systematic mediastinal LA would need to be performed in octogenarians with clinical stage I lung cancer if ‘true’ stage I NSCLC should be detected [13].

In actuality, if pulmonary resection with radical systematic mediastinal LA were to be performed in all octogenarians with clinical stage I NSCLC, it is likely that surgical mortality rates would increase. So, what are the indications for radical systematic mediastinal LA in octogenarians? In our study, only serum CEA levels posed a significant risk. Radical systematic mediastinal LA was not a predictor of long-term survive for octogenarians with clinical stage I NSCLC. Several reports have shown elevated preoperative serum CEA levels to be a predictor of a poor outcome and pathological N2 factor [14,15]. We believe that for accurate pathologic staging and a clear indication of prognosis, preoperative mediastinoscopy should be performed in octogenarians with clinical stage I NSCLC and CEA elevation. Octogenarians with stage I NSCLC and a normal CEA level can be treated with pulmonary resection without radical systematic mediastinal LA.

In conclusion, our findings suggest that pulmonary resection without complete radical systematic mediastinal LA is a satisfactory alternative surgical procedure for octogenarians with clinical stage I NSCLC because with radical systematic mediastinal LA, the risk of postoperative pulmonary morbidity may increase and there may be no impact on prolonging the survival. Preoperative mediastinoscopy is needed in octogenarians with clinical stage I NSCLC and serum CEA elevation if the precise pathological stage is to be determined and an accurate prognosis is to be made.

	References

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Masanori Tsuchida Jun-ichi Hayashi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Aoki, T. Articles by Hayashi, J.-i. Search for Related Content PubMed PubMed Citation Articles by Aoki, T. Articles by Hayashi, J.-i. Related Collections Lung - cancer Mediastinum