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Ann Thorac Surg 1997;63:785-789
© 1997 The Society of Thoracic Surgeons

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Original Article: General Thoracic

Pulmonary Resection for Lung Cancer in Octogenarians

Division of Cardiothoracic Surgery, Hospital of St. Raphael and Yale-New Haven Hospital, New Haven, Connecticut

Accepted for publication October 17, 1996.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Octogenarians often present with potentially resectable bronchogenic carcinoma. Older reports noting prohibitive mortality and recent surveys documenting continued substantial risk raise concerns about the applicability of operation in this age group.

Methods. We reviewed the short-term and long-term results of pulmonary resection for intended cure of lung cancer in patients 80 years and older operated on from 1980 through 1995. Our surgical philosophy favored lobectomy over lesser resection and generally avoided pneumonectomy in the elderly.

Results. Fifty-four octogenarians underwent resection: 43 lobectomies, 2 extended lobectomies, 2 bilobectomies, 3 segmentectomies, 3 wedge excisions, and 1 pneumonectomy. There were two perioperative deaths (3.7%). The overall nonfatal complication rate was 42%, with a major complication rate of 11%. Postoperative stay decreased from 8.1 days overall to 6.3 days in the last 3 years. Only 3 patients required temporary convalescent care after discharge. Actuarial survival at 1, 3, and 5 years was 86%, 62%, and 43%, respectively, for all discharged patients (n = 52) and 97%, 78%, and 57% for stage I cases (n = 39). Patients with tumors beyond stage I fared poorly.

Conclusions. Advanced age per se is neither a contraindication to curative resection nor a routine indication for nonanatomic operations in healthy octogenarians with stage I lung cancer. With proper selection, acute risk should be low. Pneumonectomy, extended resection, and operation for stage II or III disease should be considered only in exceptional cases.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
As life expectancy rises, surgeons are faced with growing numbers of elderly patients who present with anatomically and oncologically correctable pathology. In one series, the proportion of septuagenarians admitted to a large surgical service tripled over an 18-year period, and the fraction of octogenarians increased more than tenfold [1]. For thoracic surgeons, an aging population coupled with the rising incidence of bronchogenic carcinoma results in the frequent clinical scenario of a patient diagnosed later in life with potentially resectable disease. Previous reports of surgical treatment for lung cancer in the elderly have presented mixed results. Long-term survival has been generally, but not universally, acceptable. Operative mortality and morbidity, in contrast, often have been substantial, thereby complicating analysis of risk versus benefit. Further, the inclusion in some series of cases of benign pathology, simple biopsy, and nonresective thoracotomy relates to diagnostic and staging practices and does not address directly the issue of operative treatment of lung cancer. As emphasized by Eiseman [2], quality of life and maintenance of the premorbid level of independence are important considerations for the elderly and should be addressed in assessing results.

Concern about excessive morbidity and mortality from pulmonary resection in the elderly has led some to advocate nonoperative treatment or lesser resections in this age group [3, 4]. In practice, the latter approach most often substitutes wedge excision for lobectomy when gross disease can be encompassed by the smaller operation. Segmentectomy may be oncologically equivalent to lobectomy in some cases, but the term is commonly misapplied to nonanatomic procedures.

The present report summarizes a 16-year experience with pulmonary resection for intended cure of lung cancer in octogenarians based on a policy of avoiding pneumonectomy and favoring standard lobectomy or anatomic segmentectomy over lesser resections.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
We reviewed the records of our patients aged 80 years and older who underwent intended curative lung resection for bronchogenic carcinoma between 1980 and 1995, inclusive. All operations were performed by residents under the direction of attending staff at two teaching hospitals. Cases of suspected cancer but final benign pathology, nonresective thoracotomies, diagnostic procedures, and thoracoscopic operations were excluded. Abstracted demographic and clinical data included age, gender, cardiopulmonary functional assessment, and comorbidity. Perioperative data consisted of extent of resection, operative morbidity and mortality occurring within 30 days or during the same hospitalization, length of postoperative hospital stay, venue of care after discharge, adjuvant treatment, clinical stage, and pathologic stage. Follow-up information was obtained from office visits or telephone contact with patients, relatives, or physicians. Statistical analysis was performed using ² and two-tailed tests for comparison of variables. Actuarial survival was assessed by the Kaplan-Meier method. Results were considered significant at p values less than 0.05.

Functional assessment of octogenarians was similar to our practice with younger patients and in most cases was derived entirely from the medical history, physical examination, basic blood tests, electrocardiogram, and standard pulmonary function data. Stress testing and other assays of myocardial function and blood supply were performed when indicated by a history of coronary artery disease, suspicious symptoms, or electrocardiographic abnormality. Clinical staging was based on computed tomography of the chest and upper abdomen in all cases and selective, but liberal, application of mediastinoscopy and extrathoracic imaging. Routine multilevel pathologic mediastinal nodal assessment was begun in 1986. For this study, staging for earlier cases was based on a synthesis of pathology reports, operative notes, and preoperative radiographic studies.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Pulmonary resection was performed in 54 octogenarians, representing 4% of 1,328 therapeutic operations for lung cancer during the study period. It is notable that 44 of the group underwent operation in the second half of the study period; only 10 cases were performed during the first 8 years. There were 28 women and 26 men, ranging in age from 80 to 88 years (mean, 82 years). Seventeen patients (31%) had a diagnosis of chronic obstructive pulmonary disease, but only 7 (13%) were taking oral bronchodilators or inhaled medications. No patients were being treated with oral corticosteroids for emphysema at the time of operation. Thirteen patients (24%) had a history of angina pectoris, myocardial infarction, or cardiac arrhythmia requiring treatment. One man underwent percutaneous transluminal coronary angioplasty to allow subsequent pulmonary resection. Ten patients (19%) had previous treatment for malignant disease, including colon (4), uterus/cervix (3), breast (1), prostate (1), and retroperitoneal sarcoma (1). All were free of evidence of recurrence of these neoplasms at the time of operation for lung cancer. Despite the expected degree of comorbidity for this age group, all patients met standard cardiopulmonary criteria for the proposed resections. In cases with poor or borderline measured lung function, the records indicate that the operating surgeon believed the tests underestimated true capacity. With the exception of 2 patients treated early in the series with "preoperative" radiation therapy (4,000 cGy) for what would now be defined as clinical nodal stage IIIA disease, all other cases were considered clinical stage I, stage II, or T3 N0 stage IIIA. No patients were treated with induction chemotherapy or chemoradiotherapy. Application of mediastinoscopy for clinical staging increased markedly over the study period. In recent years, preresection operative mediastinal biopsy was performed in the majority of cases.

The procedures performed included 43 standard lobectomies, two extended lobectomies (one sleeve, one en bloc chest wall), two bilobectomies, three lower-lobe superior segmentectomies, three wedge resections, and one left pneumonectomy. Adenocarcinoma was the histology in two thirds of the cases (36 patients), along with 14 squamous cancers, 2 large cell carcinomas, one carcinosarcoma, and one small cell cancer. Forty-one patients (76%) had stage I tumors, 5 had stage II cancers, and 8 had stage IIIA disease. The stage III group was defined by a malignant N2 lymphadenopathy in 6 cases and T3 (parietal pleural/chest wall involvement) without nodal metastases in 2 cases. Postoperative adjuvant therapy was given in 9 stage II and III cases and consisted of radiation alone in 7 and combined radiation and chemotherapy in 2 patients.

Morbidity and mortality are summarized as follows. There were two perioperative deaths, yielding an operative mortality rate of 3.7%. An 81-year-old could not be resuscitated after a cardiopulmonary arrest that occurred suddenly 48 hours after right upper lobectomy. The clinical impression of the cause of death was massive pulmonary embolism, but there was no postmortem examination. A second 81-year-old died of a myocardial infarction incurred during reexploration for hemorrhage from a bronchial artery a few hours after left upper lobectomy. Twenty-three patients had nonlethal complications (42%). Cardiac problems comprised the majority and consisted mainly of supraventricular tachycardias that were hemodynamically well tolerated and easily controlled pharmacologically. Six of the nonfatal problems (11%) were considered major complications because they required unusual treatment, significantly extended hospital stay, or produced a long-term adverse effect. In this category were 2 cases of parenchymal air leak persisting beyond 7 days and one instance each of congestive heart failure, reoperation for evacuation of hemothorax, bacterial pneumonia, and recurrent laryngeal nerve injury. Minor complications (17, 31%) included atrial arrhythmia (11), urinary retention (3), and depression or confusion (3). There was no significant difference in risk when the patients were stratified by age, gender, extent of resection, comorbidity, or year of operation.

The mean postoperative length of stay for the 52 surviving patients was 8.1 ± 3.5 days, with a range of 3 to 23 days. Patients without major complications were discharged 7.3 ± 2.3 days after the operation. Length of stay decreased significantly over time (p = 0.02), with a mean of 10.2 ± 2.8 days during the first 8 years and 7.4 ± 3.6 days thereafter. During the last 3 years, the stay for all cases (n = 21) fell to 6.35 ± 1.7 days. Forty-nine of the 52 surviving patients were discharged home after operation; only 3 patients required temporary care at a convalescent facility.

Long-term survival is presented in Figure 1. Including death from all causes, the actuarial survival of the 52 discharged patients at 1, 3, and 5 years was 86%, 62%, and 43%, respectively. In cases of stage I disease, survival at the same time intervals was 97%, 78%, and 57%. Patients with more advanced lung cancer, on the other hand, fared poorly. Of the 13 in this group, only 2 were alive, at 8 and 27 months after operation. The remainder died between 4 and 40 months postoperatively. Equally dismal long-term survival was noted in both stage II and stage III cases, and the latter category included the two T3 N0 patients as well as those octogenarians with N2 disease. The median survival for the combined stage II and III cohort was only 15 months.

View larger version (20K): [in this window] [in a new window]   Fig 1. . Actuarial survival for all discharged patients (n = 52), stage I patients (n = 39), and stage II/III patients (n = 13).

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

Recent decades have witnessed a dramatic increase in longevity and in the proportion of elderly people living active and independent lives. The current life expectancy is 6.7 years for an 80-year-old American man and 8.8 years for an 80-year-old woman. At age 85, life expectancy is 5.3 years for men and 6.7 years for women [5]. Further, a 75-year-old can expect that 75% of his or her remaining years will be spent in active life, as opposed to dependency; at age 85, about 50% of the remaining years will be independent [6]. This degree of potential quality longevity exceeds the expected survival of untreated or palliatively treated lung cancer patients [7]. Although nonoperative treatment regimens yield some long-term survivorship and should not be discounted, the results are inferior to definitive resection for limited disease. For example, Haffty and associates [8] found a 5-year survival of 21% with radical radiation in stage I non–small cell cancer when resection was not performed for medical or psychological reasons.

The late results of resection for lung cancer in octogenarian operative survivors have been good. Although several series focused on patients over 65 or 70 years of age, only a few dealt exclusively with octogenarians or presented separately identifiable data for this subset [9–14]. These reports are presented in Table 1. Five-year survival including all stages was between 30% and 55%, and reached 65% to 79% for stage I disease. Our experience confirms that octogenarians with lung cancer of limited extent who survive operation benefit from resection. Although our stage I 5-year survival rate of 57% is lower than that reported in some series, it falls within an acceptable range. The discrepancy may be due to understaging before routine nodal assessment, as well as inclusion of deaths from all causes.

Yellin and Benfield [20] pointed out that the early results of resection in patients older than 70 years have improved in the past 3 decades, with an operative mortality rate commonly in the range of 15% to 20% in the 1960s and 1970s, as compared with rates as low as 3% to 6% in some later reports. Despite this trend, the acute risk for elderly patients in general, and octogenarians in particular, remains variable. As shown in Table 1, operative mortality including all in-hospital deaths is between 3.7% and 21%. With the exception of the Lung Cancer Study Group [9] and our experience, as well as an allusion by Yellin [21] to 12 cases over 10 years with no deaths, reported mortality is more than 10%. Harvey and colleagues [14], for example, contrasted a 1.6% risk for septuagenarians with a 17% rate for octogenarians. Naunheim and associates [12] found that even within the octogenarian group, increasing age was a negative factor.

Quality of life as related to cancer treatment is rarely addressed in the surgical literature. Although our review lacks formal assessment of this factor, we did not identify any prolonged disability. The only permanent complication was a single instance of recurrent nerve paralysis. Taking venue of care after discharge as an estimate of ability to resume the preoperative lifestyle, we noted that 94% of the group was discharged directly home. The absence of chronic morbidity suggests that there were no unusual ongoing expenses. Similarly, pulmonary resection in our octogenarian patients was not associated with excessive inpatient costs, as there were no instances of prolonged ventilator support, multiple organ failure, or other sources of increased expenditure. Postoperative stay compared favorably with that of contemporaneous younger patients and continues to decrease.

Two factors that are sometimes related, advanced tumor stage and the need for resection of more than a pulmonary lobe, are associated with particularly poor results in older patients. With some exceptions [22, 23], the reported acute mortality rate is substantial in elderly people having extended resection [12, 16, 17, 24] or pneumonectomy, particularly right-sided pneumonectomy [25, 26]. For this reason, the number of such operations in most recent series, including the present report, is low. In the category of extended resection, extensive chest wall operations carry the highest risk. Sleeve lobectomy, in contrast, should be well tolerated in octogenarians. Tumors beyond stage I appear to constitute a second limitation. Long-term survival in our patients with cancer extending beyond the lung parenchyma was insufficient to justify operation. Disappointing results were noted for stage II as well as for both nodal and T3 N0 stage III cases. Similarly, Riquet and colleagues [13] achieved no 5-year survival and a median survival of only 11 months in N2 patients over 75 years of age, in contrast to 20% 5-year and 18-month median survivals in those younger than 75. In reports documenting better survival, only about half the older patients with advanced tumors survived for 1 year after resection [10, 14].

In conclusion, age in the 80s per se is neither a contraindication to operative treatment nor a routine indication for lesser resection. Our experience demonstrates that healthy octogenarians with lung cancer can be offered operation with low early risk and worthwhile late survival. Although operative risk in younger people is largely predictable by an algorithm factoring in quantifiable assays of functional status, tumor extent, and required resection, advancing age is an independent risk factor. In assessing the elderly for operation, surgeons must look beyond measured indices to the subjective qualities of vitality and motivation. Complete clinical staging must be stressed because older patients with disease beyond T1-2 N0 do poorly. Pneumonectomy and extended operations should generally be avoided. With proper selection, mortality should be well below 10%. At the other end of the spectrum, the risk for octogenarians with limited pulmonary function or substantial comorbidity is compounded by age. Operation in the high-risk elderly is rarely prudent. Finally, we stress that our report does not assess the relative merits of lobectomy versus lesser resection, but does show that anatomic resection can be performed safely.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Ponn, 330 Orchard St, Suite 107, New Haven, CT 06511.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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This Article Abstract 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): Ronald B. Ponn Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pagni, S. Articles by Ponn, R. B. Search for Related Content PubMed PubMed Citation Articles by Pagni, S. Articles by Ponn, R. B.