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Ann Thorac Surg 1997;64:193-198
© 1997 The Society of Thoracic Surgeons
First Department of Internal Medicine and First Department of Surgery, Toyama Medical and Pharmaceutical University, Toyama, Japan
Accepted for publication December 27, 1996.
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentReferences |
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Methods. Twenty-seven patients 70 years old or older (elderly group) and 95 patients younger than 70 years (younger group) who underwent pneumonectomy between January 1985 and March 1996 formed the study group. In the elderly group, 22 patients had squamous cell carcinoma, 2 had adenocarcinoma and 3, small cell carcinoma; 1 patient was in postoperative stage I, 4 patients were in stage II, 14 in stage IIIA, 5 in stage IIIB, and 3 in stage IV of the disease. The only significant differences in patient characteristics between the two groups were the percentage of patients undergoing right pneumonectomy and the percentage of patients receiving chemotherapy or radiotherapy within 3 months before or after operation or both times.
Results. The prognosis for the elderly group was comparable to that of the younger group for all stages of the disease; the overall 5-year survival rate was 30.5% for the younger group and 11.5% for the elderly group. However, operation-associated mortality was significantly higher in the elderly group (22.2% versus 3.2%; p < 0.005). The prognosis was better for patients with a centrally located tumor than a peripheral tumor in both groups [13.5% versus 2.0% in the elderly group and 46.7% versus 5.2% (p < 0.01) in the younger group] and significantly better for patients having a left pneumonectomy than a right pneumonectomy in the younger group (46.7% versus 5.2%; p < 0.01) but not in the elderly group (13.7% versus 22.2%). Adjuvant treatment did not have any beneficial effect on the prognosis in either group.
Conclusions. Pneumonectomy for lung cancer in elderly patients appears to be justified because the outcome in our study was comparable with that for the younger patients. However, it should be performed only in carefully selected patients because of the increased operative risk.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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The incidence of lung cancer is high for men and increases with age. The number of elderly people has been growing in Japan, and since 1993, lung cancer has become the leading cause of death in men. Oncologists see an increasing number of elderly patients with lung cancer, and treatment of such patients is becoming very important in many countries [1–5]. Pulmonary resection is still the most effective treatment of lung cancer and is associated with long-term survival. Lobectomy is now the most frequently performed surgical procedure for lung cancer. Most surgeons prefer not to do a pneumonectomy, especially on elderly patients, because of the resulting impairment of pulmonary function, but this operation is often necessary for lung cancer. There are several reports [2,6–10] on the surgical treatment of lung cancer in the elderly, but we could find none published in the past decade specifically dealing only with patients having pneumonectomy. In this study, the clinical features of patients 70 years old or older who underwent pneumonectomy were analyzed, and the validity of pneumonectomy for the treatment of lung cancer in the elderly was assessed.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Operation-associated mortality included deaths within 30 days after operation and in-hospital deaths.
Data are shown as the mean ± the standard error. A survival curve was constructed by the Kaplan-Meier method and statistically evaluated by the Cox-Mantel test. Time zero was the date of operation, and June 30, 1996, was the closing date for the analysis. One patient was lost to follow-up; therefore, all patients except 1 were included in the analysis. Other factors were evaluated by the 
2test or Student's t test, and a pvalue of less than 0.05 was considered significant.
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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. Forced vital capacity and forced expiratory volume in 1 second were significantly lower in the elderly group, but arterial oxygen tension was similar in the two groups. The percentage of patients undergoing a right pneumonectomy was significantly lower in the elderly group (22% versus 43%; p< 0.05). The percentage of patients receiving adjuvant treatment within 3 months before or after operation or both times was significantly lower in the elderly group (30% versus 68%; p < 0.005). There were no other significant differences between the two groups.
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). There were no significant differences in prognosis by any stage of the disease (Fig 1), location (right or left, central or peripheral), and adjuvant treatment. Concerning histologic type, a comparison was made only for squamous cell carcinoma, and no difference was observed.
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). The prognosis for patients undergoing left pneumonectomy compared with right pneumonectomy was significantly better in the younger group (40.9% versus 17.1%; p< 0.01) but not in the elderly group (13.7% versus 22.2%).
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). The percentage of patients in stages I or II was significantly lower among those having a right pneumonectomy in the younger group (10% versus 26%; p< 0.05).
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). There was no reduction in arterial oxygen tension at rest after pneumonectomy in either group. There were also no significant differences in forced vital capacity and forced expiratory volume in 1 second after pneumonectomy between the two groups.
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). Of the 9 patients who died, 7 had a peripheral location of the tumor.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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In their retrospective study of 80 patients older than 70 years, Harviel and associates [7] reported that the mean survival was 3.5 months for the untreated group (n = 13), 9.8 months for the chemotherapy or radiotherapy group (n = 35), and 30.6 months for the resection group (n = 22) with an operative mortality rate of 18.2% (4/22). Berggren and co-workers [13] obtained similar results; the 5-year survival rate was 34% for the group having resection with a hospital mortality rate of 15.9% versus 0% for the group without resection. Both groups of authors stated that surgical resection is worthwhile for the treatment of lung cancer in the elderly, despite an increased operative risk. We support this assertion because favorable long-term survival was observed in our study. However, the 5-year survival rate was not high for patients with an advanced stage of the disease: 69% for stage II, 38% for stage IIIA, and only less than 4% for stage IIIB. Therefore, detection of lung cancer at an early stage will be necessary to produce a better outcome.
In our study, the 30-day operative mortality rate after pneumonectomy was 4.1% (5/122) for all patients, which is comparable to the 6.2% (44/569) reported by Ginsberg and associates [14], the 6.9% (20/287) of Deneffe and colleagues [15], and the 6.8% (13/191) of Kadri and Dussek [16]. In our study, the mortality rate increased with the age of the patients (5/27 or 11.1% for the elderly group), which is comparable to the mortality rate in a similar group reported by Suemasu and co-workers [9] (4/25 or 16.0%). The finding that operative mortality increases with age has been well reported [14, 15].
However, others [2, 8, 13, 16] have found that the risk of a major complication or operative death is not related to age. Harvey and coauthors [10] reported that significantly increased operative mortality did not occur until age 80 years in 370 patients with non–small cell lung cancer treated surgically: the rates were 1.4% (4/289) for patients younger than 70 years, 1.6% (1/64) for patients 70 to 79 years old, and 17.6% (3/17) for patients 80 years old or older. The authors suggested that heparin sodium prophylaxis might be especially important in this last patient group. We agree that more attention should be given to careful preoperative staging, selection of surgical procedure, and routine preoperative and postoperative physical therapy to reduce operative mortality. In a study by Nagasaki and associates [17], the 4 patients who died after pneumonectomy (4/72 or 5.6%) all had a right pneumonectomy (4/30 or 13.3%). In our study, this tendency was not observed; 4 of the patients who died had a right pneumonectomy and 5, a left pneumonectomy. However, 7 of the 9 patients who died had a peripheral location of tumor.
Two clinical features were noted to be different between the younger and elderly groups. The first feature is that the percentage of patients undergoing a right pneumonectomy was significantly lower in the elderly group (22% versus 43%; p < 0.05). As the reduction in pulmonary function is greater after a right pneumonectomy than a left pneumonectomy (see Table 4
), most surgeons tend to avoid performing right pneumonectomy. The second feature is that the percentage of patients receiving adjuvant treatment within 3 months before or after operation or both times was significantly lower in the elderly group (30% versus 68%; p < 0.005). This may be due to the fact that doctors and elderly patients tended to avoid chemotherapy or radiotherapy because of the adverse effects. In our study, adjuvant treatment did not have any beneficial effect on the prognosis. The median survival times were almost the same for the patients receiving adjuvant treatment and the patients who did not in both age groups. On this point, the Lung Cancer Study Group [18] in the United States has reported that postoperative mediastinal irradiation was not beneficial for patients with completely resected stage II and stage III epidermoid lung cancer in their randomized trial. There is a clear need of adjuvant treatment for resectable lung cancer, and thus a new strategy will be required.
Recently, video-assisted thoracic surgery [19] has become popular for the treatment of lung cancer in Japan. This less invasive procedure may be more beneficial than pneumonectomy in select elderly patients. However, pneumonectomy often is necessary. We have shown in this study that pneumonectomy is justified for the treatment of lung cancer in elderly patients, but it should be done only in carefully selected patients because of the increased operative risk.
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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References |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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70) and younger (70>) age groups. Jpn J Clin Oncol 1986;16:319–23.Related Article
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