Eur J Cardiothorac Surg 2007;32:445-448. doi:10.1016/j.ejcts.2007.06.014
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Management of esophageal cancer in patients aged over 80 years
Alberto Ruola,
Giuseppe Portaleb,
Carlo Castorob,*,
Stefano Meriglianoa,
Francesco Cavallina,
Giorgio Battagliab,
Silvia Michielettoa,
Ermanno Anconab
a Department of Surgery and Organ Transplant, Clinica Chirurgica III, University of Padova School of Medicine, Padova, Italy
b Istituto Oncologico Veneto (IOV-IRCCS), Padova, Italy
Received 28 March 2007;
received in revised form 9 June 2007;
accepted 11 June 2007.
* Corresponding author. Address: Istituto Oncologico Veneto (IOV-IRCCS), University of Padova School of Medicine, Via Giustiniani 2, 35128 Padova, Italy. Tel.: +39 049 821 8842; fax: +39 049 821 3151. (Email: carlo.castoro{at}unipd.it).
 |
Abstract
|
|---|
Background: Important advances in the management of cancer of the esophagus and esophagogastric junction have occurred in the last decades, making treatment possible even in elderly patients. Unfortunately there is little information on management of esophageal cancer in octogenarian patients. The aim of this study was to evaluate the treatment results of esophageal and esophagogastric junction cancer in a single institution over a 14-year period in patients 
80 years of age. Methods: Clinicopathological characteristics and management strategies were studied in patients 80 years old with cancer of the esophagus or esophagogastric junction, referred to our department and treated between 1992 and 2005. Results: There were 62 patients 80 years: 12 underwent surgical resection and 50 were not resected. There were no perioperative deaths. The morbidity rate was 33%. Most non-resected patients had an endoscopic prosthesis. The median survival for the overall group was 5.4 months: 14.6 and 5.1 in resected and non-resected patients, respectively. Conclusions: Even in octogenarian patients – with limited comorbidities and fit for surgery – esophagectomy may be regarded as a valid treatment option. Unfortunately this remains possible only in a small minority of 80–90-year old patients. In the remainder, endoscopic treatments – namely prosthesis placements, with chemoradiotherapy when possible – are the alternatives.
Key Words: Esophageal and esophagogastric junction cancer • Elderly • Octogenarians • Esophagectomy • Palliation
|
1. Introduction
|
|---|
The change in life expectancy, in recent decades, has led to neoplasms of the digestive tract in the elderly becoming a major issue in the public health system. The increasing number of elderly patients with cancer of the digestive tract has paralleled the advances which occurred in the management of these neoplasms. But, for many of them, in particular for esophageal cancer, surgery remains the mainstay of treatment. Undoubtedly, esophagectomy is a major surgical procedure and high postoperative morbidity and mortality rates are well recognized.
On the other side, despite developments in adjuvant treatments (with reduced recurrence rate and improved survival), these are felt as too toxic for most elderly patients. Further, most randomized studies assessing the advantage of neoadjuvant treatments in patients with locally advanced esophageal cancer before surgical resection, exclude patients in their eighties. Thus, there is paucity of data on treatments of proven efficacy in the elderly population. Recent reports would suggest that only a very small proportion of patients aged over eighty could be able to receive a curative resection [1].
The aim of this study was to evaluate the management of esophageal cancer in patients 80 years, at a single high-volume center.
|
2. Materials and methods
|
|---|
We evaluated all patients with cancer of the esophagus or esophagogastric junction – Siewert type I–II – presenting at our department between January 1992 and December 2005.
Preoperative evaluation included physical examination, standard laboratory tests, pulmonary function testing, cardiological and anesthesiological assessment. In selected cases, noninvasive cardiac evaluation (echocardiogram and/or dynamic tests to estimate patients’ ventricular function) was also performed. The ASA (American Society of Anesthesiology) classification was used to assess the operative risk. Barium swallow study and upper gastrointestinal endoscopy were performed to assess tumor characteristics; flexible bronchoscopy and otolaryngology evaluation was also added for tumors of the cervical, upper and middle esophagus. Computed tomography scans of the thorax and abdomen (with neck in selected cases) were done in all patients to exclude the presence of metastatic disease. Endoscopic ultrasound (EUS) was used since 2000 to provide additional information regarding tumor depth and lymph node status.
Complete tumor resection was defined as R0, and incomplete resections with microscopic or macroscopic residual disease were defined as R1 and R2, respectively.
Perioperative mortality was defined as in hospital (all deaths occurring at the hospital) and 30-day mortality (including all deaths occurring within 30 days from surgery).
Postoperative morbidity included any minor and major complications, both medical and surgical. Anastomotic leaks included both symptomatic and asymptomatic small leaks detected on radiological examination. No patient 80 years of age underwent chemotherapy or radiotherapy preoperatively. Patients were offered resection if they had potentially resectable tumors with no clear evidence of regional spreadout or disseminated disease and their general health conditions were good. Details on surgical techniques have been already published. Briefly, esophagectomy was performed using an Ivor–Lewis procedure, via a laparotomy and right thoracotomy, for tumors of the mid-lower esophagus and gastric cardia. A three-stage McKeown's procedure, with an additional left cervical incision, was reserved for tumors in the upper third of the esophagus. At least 6–8 cm of healthy esophagus was resected above the proximal edge of the tumor to avoid neoplastic involvement of the resection margins. In patients undergoing resection with a curative intent, en bloc lymph node dissection was performed, including the periesophageal, infracarinal, posterior mediastinal and paracardial lymph nodes, as well as those located along the lesser gastric curvature, the origin of the left gastric artery, the celiac trunk, the common hepatic artery and the splenic artery. The alimentary tract was reconstructed using the gastric pull-up technique; if the stomach was unavailable, either a jejunal loop or the left colon was used. Patients were followed by the operating surgeons at regularly scheduled intervals, after 1, 3, 6, 12 months, and every 6–12 months thereafter.
2.1 Statistical analysis
Data are expressed as medians and interquartile ranges. Proportions were compared using the Chi-square or Fisher's exact test. Continuous variables were compared using the Mann–Whitney test. Survival estimates were calculated by the Kaplan–Meier method and survival comparisons were performed using the log-rank test. A p value below 0.05 was considered significant.
|
3. Results
|
|---|
Of the 1400 patients with esophageal or GEJ cancer presenting at our department between January 1992 and December 2005, 62 (4.4%) were 80 years of age. Forty-five (72.6%) patients were between 80 and 84 years of age, 13 (21%) between 85 and 89, and 9 (6.4%) were 90 years old.
3.1 Clinicopathological characteristics
There were 40 males and 22 females, with a median age of 83 years [interquartile range (IQR) 81.6–85.2] at presentation. Clinical characteristics of patients at presentation are summarized in Table 1
. Twelve (19.3%) patients underwent surgical resection, 50 were not resected (Table 2
). Tumor characteristics in the two groups are presented in Table 3
. As expected, despite preoperative risk factors – namely cardiovascular and respiratory – being similarly distributed in both groups, nearly double of patients who did not undergo surgical resection had ASA score III or IV as compared to the resected ones (82.6 vs 41.7, p
= 0.01). The median follow-up for the overall study group was 5.4 months (IQR: 1.8–18.3).
3.2 Resected patients
There were 6 (6/40 = 15%) males and 6 (6/22 = 27%) females, with a median age of 81.6 years (80.8–84.6) at surgery. Table 3 summarizes the details of treatment approach and pathologic findings at operation in the 12 resected patients. There were no perioperative deaths. Morbidity rate was 33.3% (4/12): one cervical and one thoracic anastomotic leak (both successfully treated conservatively), one bronchopneumonia and one pulmonary embolism.
3.3 Non-resected patients
Details on treatment strategy in non-resected patients are reported in Table 2. The vast majority of patients in this group had an endoscopic prosthesis or YAG laser therapy. The morbidity rate was 10.6% (5/47, excluding three patients who only had supportive care management). They had either hemorrhage or perforation from prosthesis placement.
3.4 Survival
The median survival for the overall study group was 5.4 months (IQR: 1.8–18.3): 13.6 (IQR: 5–40.5) and 5.1 (IQR: 1.8–14) in resected and non-resected patients, respectively (p
= 0.009, Fig. 1
). Seven of 12 resected patients were alive at 12 months after surgery, 4 out of 12 at 36 months. Five of the eight deaths were due to cancer recurrence; the remaining three were not disease-related (Table 4
).
View larger version (12K):
[in this window]
[in a new window]
|
Fig. 1. Kaplan–Meier survival curves (including postoperative deaths) plotted for resected and non-resected patients (
2
= 6.73, p
= 0.009).
|
|
|
4. Conclusions
|
|---|
The number of elderly patients presenting with esophageal or cardiac cancer has paralleled the increased life expectancy in recent decades. This has led to a large – and constantly increasing – number of elderly patients with esophageal or cardiac cancer being referred for treatment. Reports on advances in perioperative care and similar morbidity and mortality rates in younger and elderly patients undergoing esophageal resection, have suggested that advanced age alone should not be regarded as an absolute contraindication for a major operation like esophagectomy [2–5].
As a consequence, the surgical community has considered it reasonable to change the historical attitude to merely palliate dysphagia, in patients with esophageal carcinoma in their seventies, towards a greater chance for cure with esophagectomy [6]. All this seems much more than a challenge in octogenarian patients, with several invalidating pulmonary and cardiovascular comorbidities. The high postoperative morbidity and mortality rates following esophagectomy parallel the high risks of cytoreductive treatments. The use of endoscopic treatments has been advocated in 80–90 year old patients with esophageal cancer [7].
There are only a few series, with small sample size, of reported data on different treatment options in octogenarian patients referred for treatment in a high volume center. The percentage of patients aged 80 years or older among esophageal cancer patients is quoted to be in the 5% range; in our department this figure was 4.4% [8].
Most of our elderly patients presented with advanced disease and/or poor general health condition, making surgical resection not advisable. The palliative treatment performed in this series was mainly the placement of an esophageal prosthesis, in order to allow patients to manage oral intake and maintain a discrete quality of life. Other palliative options, namely radiation therapy or chemotherapy, pose several problems when applied to very old patients [9].
As for radiotherapy, since advanced cancer is common in elderly patients, wide radiation fields should be used, with consequent risk of bone marrow suppression and radiation sickness. Complications such as pneumonia and pulmonary fibrosis can present at significantly lower doses than in younger patients and require discontinuation of the treatment. As for chemotherapy, the standard combination of cisplatin and 5-fluorouracil is often not possible in these patients because of the risk of severe adverse effects in already compromised organs (especially heart, kidney and liver). And the efficacy in case of reduced dosage is questionable, although some good responses have been reported.
Among all our octogenarian patients with cancer of the esophagus or esophagogastric junction, we carefully selected a subgroup suitable for esophagectomy. A thorough perioperative assessment was necessary: an important factor to keep in mind when dealing with elderly patients is that in case of normal laboratory and function tests, a poor organ function may still be present and affect the treatment (either surgical or cytoreductive) in old patients assumed in ‘general good health conditions’. Indications for surgery and choice of surgical approach were of course individualized for each patient.
The improved perioperative patient care, in recent decades, has contributed to reduce the related morbidity (especially pulmonary complications) and mortality rates, and all patients, irrespective of age, have benefited from this. In particular, epidural analgesia with a better pain control and less interference with pulmonary mechanics has helped mostly elderly patients with compromised pulmonary function. Frequent bronchoscopic suctioning and incentive spirometry pre- and postoperatively, performed routinely by patients or, preferably, by a respiratory therapist have all contributed to improve postoperative lung activity [10].
In such selected population (12/62 octogenarians), we had no perioperative deaths and the morbidity rate was 33%, in line (if not even better) with rates in septuagenarians and younger patients, in our experience. As already reported by our group, and similarly by others, increased multispecialty team experience over time and refinements in surgical technique have also contributed to these results [11–12]. Interestingly, one third of patients were alive at 36 months from surgical resection: this result is not different from that obtained in 50, 60, or 70 year old patients with esophageal cancer.
These results are quite different from those recently published by a cancer registry in France with just 1% (2/256 patients) and by a Japanese group with 0% (0/10) of curative resections in esophageal cancer occurring in octogenarian patients [1,13]. Of course, such an extensive procedure – esophagectomy – requires a careful selection of patients. Only 20% of patients in our series could benefit from surgical resection. This figure is in line with that of another Japanese group (Chino et al. [9]) who reported a 29% (13/45 patients) resection rate, although their mortality and morbidity rates were higher (7% and 60%, respectively). In the remaining 80% of our patients, as already said above, only a palliative treatment option was possible (mostly endoscopic prosthesis) with a median survival of 5 months. Octogenarian patients with esophageal cancer, who could survive the esophagectomy itself, had better survival rates than palliated patients (29% at 5 years, which is, again, in line with the 31% reported by Chino et al.), and, of course, a restored swallowing function and better quality of life.
In summary, even in octogenarian patients – with limited comorbidities and fit for surgery – esophagectomy may be regarded as a valid treatment option. Unfortunately this remains possible only in a small minority of 80–90 year old patients with esophageal and esophagogastric junction cancer and only after a careful surgical risk assessment. In the remainder, endoscopic treatments – namely prosthesis placements, with chemoradiotherapy when possible – are the alternatives.
|
References
|
|---|
- Bouvier AM, Launoy G, Lepage C, Faivre J. Trends in the management and survival of digestive tract cancers among patients aged over 80 years. Aliment Pharmacol Ther 2005;22:233-241.[CrossRef][Medline]
- Bonavina L, Incarbone R, Saino G, Clesi P, Peracchia A. Clinical outcome and survival after esophagectomy for carcinoma in elderly patients. Dis Esophagus 2003;16:90-93.[CrossRef][Medline]
- Rahamin JS, Murphy GJ, Awan Y, Junemann-Ramirez M. The effect of age on the outcome of surgical treatment for carcinoma of the oesophagus and gastric cardia. Eur J Cardiothorac Surg 2003;23:805-810.[Abstract/Free Full Text]
- Ellis FH, Williamson WA, Heatley GJ. Cancer of the esophagus and cardia: does age influence treatment selection and surgical outcomes. J Am Coll Surg 1998;187:345-351.[CrossRef][Medline]
- Merigliano S, Ruol A, Baldan N, Santi F, Petrin GF, Polo R, Bonaviba L, Peracchia A, Ancona E. Management and prognosis of esophageal cancer in elderly patients. J Chemotherapy 1996;8:72-74.
- Naunheim KS, Hanosh J, Zwischenberger J, Turrentine MW, Kesler KA, Reeder LB, Ferguson MK, Baue AE. Esophagectomy in the septuagenarian. Ann Thorac Surg 1993;56:880-884.[Abstract]
- Nozaki M, Murakami Y, Furuta M, Izawa Y, Iwasaki N. Radiation therapy for cancer in elderly patients over 80 years of age. Radiat Med 1998;16:491-494.[Medline]
- Bluett M, Sawyers J, Healy D. Esophageal carcinoma: improved quality of survival with resection. Am Surg 1987;53:126-132.[Medline]
- Chino O, Makuuchi H, Machimura T, Mizutani K, Shimada H, Kanno K, Nishi T, Tanaka H, Sasaki T, Tajima T, Mitomi T, Sugihara T. Treatment of esophageal cancer in patients over 80 years old. Surg Today 1997;27:9-16.[CrossRef][Medline]
- Shulman M, Sandler AN, Bradley JW, Young PS, Brebner J. Post-thoracotomy pain and pulmonary function following epidural and systemic morphine. Anesthesiology 1984;61:569-575.[Medline]
- Poon R, Law SY, Chu KM, Branicki GJ, Wong J. Esophagectomy for carcinoma of the esophagus in the elderly. Ann Surg 1998;227:357-364.[CrossRef][Medline]
- Kinugasa S, Tachibana M, Yoshimura H, Dhar DK, Shibakita M, Ohno S, Kubota H, Masunaga R, Nagasue N. Esophageal resection in elderly esophageal carcinoma patients: improvement in postoperative complications. Ann Thorac Surg 2001;71:414-418.[Abstract/Free Full Text]
- Gupta R, Kawashima T, Ryu M, Okada T, Cho A, Takayama W. Role of curative resection in octogenarians with malignancy. Am J Surg 2004;188:282-287.[CrossRef][Medline]
Top
Abstract
1. Introduction
