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Eur J Cardiothorac Surg 2005;28:380-383
© 2005 Elsevier Science NL

Original articles

Complications and outcomes after pulmonary resection for cancer in patients 80 to 89 years of age

^a Department of Surgery, Hyogo Prefectural Kaibara Hospital, Kaibara 5208-1, Kaibara-cho, Tanba city, Hyogo 669-3395, Japan
^b Department of Thoracic Surgery, Hyogo Medical Center for Adults, Akashi city, Hyogo, Japan

Received 2 May 2005; received in revised form 13 June 2005; accepted 15 June 2005.

^* Corresponding author. Tel.: +81 795 72 0524; fax: +81 795 72 1276. (Email: hmatsuoka1{at}mac.com).

Abstract

Objective: Patients 80 years or older often present with potentially resectable cases of non-small cell lung cancer. Whether such patients should undergo surgical treatment is becoming increasingly important in this rapidly aging society. Methods: From April 1997 through March 2004, 40 consecutive patients with non-small cell lung cancer who were 80–88 years of age underwent complete resection of their tumors, as confirmed pathologically. We reviewed preoperative data including gender, age, history of smoking, pulmonary function, co-morbidity, and induction/adjuvant therapy. Perioperative data consisted of surgical procedure, operative morbidity and mortality, histopathologic type, pathologic stage, and outcome. Results: The procedures comprised 16 lobectomies (40%), 12 segmentectomies (30%), and 12 wedge resections (30%). The histopathologic diagnosis was adenocarcinoma in 22 patients, squamous cell carcinomas in 11, large cell carcinomas in 4, adenosquamous cell carcinomas in 2, and neuro-endocrine cell carcinoma in 1. The disease stage was IA in 21 patients, IB in 14, IIB in 3, and IIIA in 2. There was no perioperative mortality. Eight patients had non-lethal complications (20%), including five with cardiopulmonary complications (parenchymal air leaks persisting for more than 7 days in two patients, interstitial pneumonia in one, bacterial pneumonia in one, and moderate arrhythmias in one) and three with minor complications (depression or confusion). The actuarial survival rates of the 40 patients, including deaths from all causes, were 92.4, 71.6, and 56.9% at 1, 3, and 5 years, respectively. In patients with stage I disease, the respective survival rates were 94.3, 74.3, and 57.3%. Conclusions: Advanced age is not a contraindication to curative resection in patients 80–89 years of age with stage I non-small cell lung cancer.

Key Words: Lung cancer • Elderly patients • Operation

Abbreviations: FEV1 = Forced expiratory volume per one second

1. Introduction

The life expectancy in Japan in 2003 is 7.95 years in 85 years old woman and 8.26 years in 85 years old man. The population of Japan is rapidly aging like this, resulting in increased numbers of elderly patients with lung cancer. Complete resection remains the treatment of choice for early non-small cell lung cancer, but the risks of surgery in elderly patients are higher than those in younger patients because of the increased prevalence of coexisting cardiopulmonary or cerebrovascular disease. Surgeons are often faced with the critical decision of whether or not to perform surgery. To determine whether curative resection is feasible in elderly patients with non-small cell lung cancer, we reviewed the early morbidity and mortality and the late survival of patients 80 years or older who underwent surgery for this indication.

2. Materials and methods

Data were obtained from the medical records of patients with non-small cell lung cancer 80 years or older who underwent pathologically complete resection between April 1997 and March 2004 at Hyogo Prefectural Kaibara Hospital and Hyogo Medical Center for Adults. We reviewed demographic and clinical data, including gender, age, smoking history, pulmonary function, concomitant disease, and induction/adjuvant therapy, as well as perioperative data, consisting of surgical procedure, histopathologic type, pathologic stage, and operative morbidity and mortality, occurring within 30 days or before discharge. Follow-up information was obtained at the time of office visits or by contacting the patients or their relatives or physicians by mail.

3. Statistical analysis

Actuarial survival curves were constructed by the Kaplan–Meier method, using Statview 5.0 software (SAS Institute; Cary, NC, USA).

4. Results

4.1 Preoperative characteristics of patients
Among 1212 patients with primary non-small cell carcinoma who underwent pathologically complete pulmonary resection during the study period, 40 (3.3%) were 80 years or older. They comprised 30 men and 10 women 80–88 years of age (mean, 82.0±2.0 years). Twenty-two patients (55%) had a documented history of smoking (mean Brinkmann index, 1176±594). Pulmonary function as measured by vital capacity ranged 1.82–3.97 L, averaging 2.62±0.59 L (predicted%, 100.0±16.3). Forced expiratory volume per second (FEV1) ranged from 0.97 to 2.78 L, averaging 1.76±0.45 L (mean FEV1/forced vital capacity, 0.694±0.13). Preoperative mediastinoscopy was not performed in any patient. No patient received induction or postoperative adjuvant chemotherapy or radiation (Table 1 ).

4.3 Surgical procedure
We performed muscle sparing posterolateral thoracotomy/VATS for 34 cases (85% of all cases). The others were standard posterolateral thoracotomies.

Sixteen patients (40%) underwent standard lobectomies with lymph node sampling or systematic dissection. Segmentectomies were done in 12 patients (30%) with peripherally located small lung cancers who had a diagnosis of N0 on frozen-section examination. The other 12 patients (30%) underwent wedge resection because their pulmonary function was evaluated to be severely impaired by their physicians (Table 2 ).

4.4 Histopathologic type and pathologic stage
The histopathologic diagnosis was adenocarcinoma in 22 patients, squamous cell carcinoma in 11, large cell carcinoma in four, adenosquamous cell carcinoma in two, and neuro-endocrine cell carcinoma in one. The disease stage was IA in 21 patients (52.5%), IB in 14 (35.0%), IIB in three (7.5%), and IIIA in two. The two patients with stage IIIA disease had malignant N2 lymphadenopathy (Table 2).

4.5 Morbidity and mortality
Blood loss was 170±195ml (ranged 20–860ml). Two patients were given blood transfusion (0.5% of all cases).

There were no perioperative deaths. Eight patients had non-lethal complications (20%), including five with cardiopulmonary complications (parenchymal air leaks persisting for more than 7 days in two patients, interstitial pneumonia in one, bacterial pneumonia in one, and moderate arrhythmia in one) and three with minor complications (depression or confusion) (Table 2).

4.6 Long-term survival
Mean and median follow-up periods for the survivors were 35.4 and 28.3 months, respectively. The actuarial survival rates of the 40 patients, including deaths from all causes, were 92.4, 71.6, and 56.9% at 1, 3, and 5 years, respectively (Fig. 1 ). The respective survival rates in patients with stage I disease were 94.3, 74.3, and 57.3% (Fig. 2 ). Patients with more advanced lung cancer had poorer outcomes. Of the five with stage II or III disease, only two were alive as of 8 and 28 months after operation. The three other patients had disease recurrence 6, 9, and 27 months after operation and died at 9, 19, and 69 months, respectively.

View larger version (11K): [in this window] [in a new window]   Fig. 1. Overall postoperative survival of patients 80 years or older with non-small cell lung cancer.

View larger version (11K): [in this window] [in a new window]   Fig. 2. Overall postoperative survival of patients 80 years or older with stage I non-small cell lung cancer.

Elderly patients generally have more underlying co-morbidities than younger patients, increasing the risks associated with surgery. The mortality rate of patients 80 years or older who underwent surgical resection for lung cancer ranged from 8.1 to 21% in reports published before 1995 [1–5]. Harvey and co-authors reported that operative mortality did not significantly increase until 80 years of age in patients surgically treated for non-small cell lung cancer. In that report, operative mortality was 1.4% for patients younger than 70 years, 1.6% for patients 70–79 years old, and 17.6% for patients 80 years or older [5]. However, more encouraging results have been obtained during the past 10 years [6–10] (Table 3 ). In our series, surgical resection of non-small cell lung cancer in patients 80–88 years of age was not associated with an excessive increase in complications or mortality. Most complications were predictable and did not lead to mortality because they were effectively managed according to previously reported recommendations.

In addition to routine measures of pulmonary function, e.g. vital capacity or forced expiratory volume per second, cardiopulmonary function should be comprehensively evaluated in patients at risk for cardiovascular complications. Cardiac catheterization has been found to be useful for cardiopulmonary evaluation to assess the risk of postoperative complications [12]. However, cardiac catheterization is not commonly performed because of its invasive nature. Brunelli and associates reported that a symptom-limited stair-climbing test was a safe and simple procedure for predicting the risk of cardiopulmonary complications in elderly patients after lung resection [13]. We previously reported that the treadmill exercise test can simply and effectively assess the degree of operative invasion [14]. Modified procedures for wedge resection or segmentectomy are recommended in patients in whom exercise consistently decreases the arterial blood oxygen concentration.

Video-assisted thoracoscopic surgery has become popular for the treatment of lung cancer. Jaklitsch and associates reported that one case of pneumonia and three minor morbid events, including supraventricular dysrhythmia, confusion, and other symptoms, developed among 33 patients 80 years or older who underwent video-assisted thoracic surgery [15]. There was no operative death. Asamura and associates reported that only two prolonged air leaks and no serious complications occurred among six patients 78–85 years of age who underwent video-assisted lobectomy [16]. This minimally invasive procedure, which we also have used, is believed to substantially reduce morbidity and mortality in elderly patients.

Some reports concluded that standard lobectomy is the procedure of choice even in elderly patients, because the risk of major complications or operative death is not necessarily related to age [10,17,18]. In our study, 40% of the patients underwent standard lobectomy and 60% limited resection. Extended segmentectomy for low-risk patients might strike a balance between curability and a low rate of complications. Pneumonectomy, especially right-sided, is strongly associated with an increased risk of complications as compared with standard lobectomy or limited resection [19–21]. Mizushima and associates reported that operative mortality after pneumonectomy was 22.2% in patients 70 years or older and significantly differ from with that in patients younger than 70 years (3.2%) [22]. Bronchoplasty should be performed whenever possible even in elderly patients to avoid pneumonectomy [23].

Pathologic stage has proven to be the most important prognostic factor for long-term survival. In our study, patients with stages IA and IB disease had good outcomes.

In conclusion, advanced age is not a contraindication to curative resection in patients 80–89 years of age with stage I non-small cell lung cancer. Most serious complications and operative deaths can be avoided by careful evaluation of cardiopulmonary function, careful selection of the surgical procedure, and meticulous postoperative management.

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