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Ann Thorac Surg 2008;85:406-411. doi:10.1016/j.athoracsur.2007.10.057
© 2008 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

Video-Assisted Thoracic Surgery for Clinical Stage I Lung Cancer in Octogenarians

Mingyon Mun, MD*, Tadasu Kohno, MD

Department of Thoracic Surgery, Toranomon Hospital, Tokyo, Japan

Accepted for publication October 15, 2007.

* Address correspondence to Dr Mun, Toranomon Hospital, 2-2-2 Toranomonn, Minatoku, Tokyo, 105-0001 Japan (Email: m.mun{at}nifty.com).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: The purpose of this retrospective study was to investigate the value of video-assisted thoracic surgery (VATS) for clinical stage I lung cancer in octogenarians.

Methods: From April 1999 to December 2006, 55 consecutive patients aged older than 80 years with clinical stage I lung cancer underwent VATS pulmonary resection. We reviewed preoperative and perioperative data, morbidity, and mortality occurring within 30 days or before discharge, and long-term survival.

Results: There were 35 men and 20 women with a mean age of 82.7 years (range, 80 to 89 years). The surgical procedures using VATS comprised 37 lobectomies, one bilobectomy, and 17 sublobar resections (7 segmentectomies, 10 wedge resections). Two lobectomies (3.6%) were converted to thoracotomy due to bleeding. The cancer was adenocarcinoma in 38 patients (62.3%), squamous cell carcinoma in 12 (19.7%), bronchioloalveolar carcinoma in 3 (4.9%), large-cell neuroendocrine carcinoma in 3 (4.9%), and others in 4 (6.6%). Postoperative complications occurred in 14 patients (25.6%), including bacterial pneumonia in 4 (7.3%), mild arterial arrhythmia in 3 (5.6%), air leak lasting more than 7 days in 3 (5.6%), pulmonary dysfunction that needed oxygen therapy in 2 (3.6%), aggressive interstitial pneumonia in 1 (1.8%), and six other minor complications. There were two operative deaths (3.6%), one due to bacterial pneumonia on postoperative day 132, and another due to aggressive interstitial pneumonia on postoperative day 105. Median hospital stay was 8.0 days. Median follow-up was 49 months. The actuarial survival rate of the 55 patients was 76.4% at 3 years and 65.9% at 5 years.

Conclusions: With appropriate selection of patients and procedures, VATS can be safely used for lung cancer in octogenarians with good prognostic results.


   Introduction
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 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
According to the 2006 statistical analysis of the Japanese Health and Welfare section, life expectancy in 80-year-olds was 8.45 years for men and 11.32 years for women. The population in Japan is aging, and mass screening of the general population for lung cancer is also increasing as the proportion of elderly patients with lung cancer continues to increase. Complete resection remains the treatment of choice for early non-small cell lung cancer (NSCLC) in octogenarians [1–5], but surgical morbidity and mortality rates are higher among octogenarians than in young patients because of the increased prevalence of coexisting cardiopulmonary or cerebrovascular disease [3, 6]. Surgeons are often faced with the critical decision of whether to operate. Recently, several authors have emphasized the efficacy of video-assisted thoracic surgery (VATS) lobectomy [7, 8]. To determine whether curative resection using VATS is feasible in elderly patients with clinical stage I lung cancer, we reviewed the early morbidity, mortality, and the long-term survival of patients aged older than 80 years who underwent VATS.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Patients
This study was approved by the Toranomon Hospital Institutional Review Board of Clinical Research, and the need for informed consent from patients was waived because of its retrospective design. From August 1999 to December 2006, 919 patients underwent pulmonary resection for primary lung cancer at the Toranomon Hospital, and 58 patients (6.0%) aged 80 years or older underwent surgical resection. As a rule, surgical treatment was used in lung cancer patients with clinical stage I or II disease.

Surgical treatment was performed in octogenarians with good performance status (PS 0 to 2), when the predicted postoperative forced expiratory volume in the first second (FEV1) was more than 1000 mL, or when patients did not have severe preoperative cardiopulmonary disease and delirium. Preoperative computed tomography (CT) showed that 55 patients had clinical stage I lung cancer with normal (<1 cm) mediastinal lymph nodes. All patients with clinical stage I lung cancer underwent thoracoscopic resection, and only three open posterolateral thoracotomies were planned preoperatively because of evident invasion of the chest wall on CT.

VATS Procedure
Surgical procedures using VATS were selected from an oncologic perspective, preoperative PS, and pulmonary function. All procedures were performed using three access ports (7-, 10- and 11.5-mm diameters) without minithoracotomy. The VATS wedge resection was performed using an endostapler or resection and suturing techniques. In VATS lobectomy or segmentectomy, the endostapler was used to staple the hilar bronchus and vessels after dissection. Finally, one of the three incisions was extended by 2 to 4 cm to remove specimens. A metal chest retractor was not used during this incision, but instead, a 2.5-cm diameter silicon rubber instrument (Lap-Protector, Hakko, Tokyo, Japan) was applied to maintain the wound and to allow access for one more instruments for mediastinal lymph node dissection. Tumor stage was described according to the TNM classification of 1997 [9].

A retrospective review of patient clinical variables included age, sex, PS, smoking history, pulmonary function, comorbidity, as well as perioperative data, consisting of surgical procedure, operation time, blood loss, duration of chest drainage, postoperative hospitalization, histopathologic type, pathologic stage, operative morbidity, and death within 30 days or before discharge. The patients were followed until their death or up to the time of analysis in June 2007.

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


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
Among 919 patients with primary NSCLC who underwent pathologically complete resection during the study period, 58 (6.0%) were 80 years or older; of these, 55 had clinical stage I lung cancer on preoperative CT, with normal (<1 cm) mediastinal lymph nodes. Preoperative mediastinoscopy was not performed in any patients because of its invasiveness for octogenarians. These 55 patients underwent thoracoscopic resection. Patient characteristics are listed in Table 1. Their mean age was 82.7 ± 2.3 years (range, 80 to 89 years), and 35 were men and 20 were women. Preoperatively, 38 patients (69%) had a documented history of smoking, with a mean smoking index of 878 ± 846, and 35 patients (63.6%) had a smoking index exceeding 600. In 54 of 55 patients, preoperative PS was 0 to 2, and only 1 patient, who had a leg fracture, had PS of 3. The average pulmonary function as measured by vital capacity (VC) was 2.68 ± 0.69 L (range, 2.63 to 4.25 L), with an average FEV1 of 1.73 ± 0.55 L (range, 0.81 to 3.45 L). The patient with the lowest FEV1 (0.81 L) underwent wedge resection for a small peripheral lesion. His postoperative course was uneventful.


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  		Table 1 Patient Demographics
 
Preoperative Comorbidity
Fifty of 55 patients (91%) had comorbidity. Pulmonary comorbidities included chronic obstructive pulmonary disease (FEV1 <70% predicted) in 13 patients (54.5%), of which 8 (65%) were receiving oral bronchodilators or inhaled medication; others were prior tuberculosis in 5 patients, pulmonary infarction in 1, and interstitial pneumonia in 1. The most common cardiac comorbidity was hypertension in 23 patients (42%), 13 (23.6%) had cardiac arrhythmia, 5 of whom (38%) were taking medication at the time of operation; 8 (27%) had a history of angina pectoris, 2 (3.6%) had a prior myocardial infarction, and 2 (3.6%) had percutaneous coronary intervention before operation. Two patients (3.6%) had abdominal aorta aneurysm that had not been treated. Twenty-four patients (43.6%) had previously been treated for malignant disease, including 6 with gastric cancer, 4 with prostate cancer, 3 each with colorectal, breast, and renal cancer; 1 each with uterine, thyroid, esophageal, and parotid gland cancer; and 1 with hepatoma. None of these patients had evidence of cancer recurrence at the time of operation for lung cancer.

Surgical Procedures and Operative Findings
All 55 patients with clinical stage I lung cancer were treated thoracoscopically (Table 2). Thirty-seven patients (67.3%) underwent VATS lobectomy with lymph node sampling or systemic dissection. One bilobectomy was performed in a patient with tumor located in a fused fissure. As a rule, VATS lobectomy or bilobectomy was undertaken in patients with PS 0 to 1 and a predicted postoperative FEV1 exceeding 1000 mL. However, in 1 patient with PS 3 because of preoperative fracture, VATS lobectomy was planned preoperatively because of oncologic considerations and good pulmonary reserve.


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  		Table 2 Surgery and Pathologic Findings
 
In 28 of 38 patients who underwent VATS major pulmonary resections, mediastinal node dissection was performed for accurate staging. In the other 10 patients, mediastinal node dissection was omitted because of preoperative severe cardiac comorbidity or intrathoracic adhesions.

Seven VATS segmentectomies (12.7%) were undertaken because of insufficient pulmonary reserve in 5 patients and peripherally located small lesions in 2. Wedge resection was done in 7 patients (18.2%) because of insufficient pulmonary reserve, and 3 underwent wedge resection for bronchioloalveolar carcinoma type A or B, according to the Noguchi classification [10].

Duration of operation was 174 ± 71 minutes (range, 27 to 385 minutes). Blood loss was 202 ± 219 mL (range, 0 to 669 mL). All patients received epidural tube insertion before the operation and were then intubated with a double-lumen tube for anesthesia. A continuous epidural infusion of 0.25% bupivacaine (4 or 2 mL/h) was used postoperatively until chest drainage tubes were removed.

Adhesion between lung and chest wall was seen in 25 patients (45.5%), which was partial in 11 and severe in 14. Two patients (3.6%) who underwent VATS lobectomy converted to thoracotomy due to bleeding from the pulmonary artery. No patients were given a blood transfusion perioperatively. The chest drainage tube was removed as soon as possible if air leak stopped and discharge was less than 200 mL/d. Median duration of chest drainage was 2.6 ± 2.4 days (range, 1 to 13 days). As a rule, antibiotics were used only on the day of operation. On the first postoperative day, 54 of 55 patients (98%) could walk by themselves; only one patient had bed rest because of a preoperative fracture. The median length of postoperative hospitalization was 8.0 days (range, 4 to 132 days).

Histopathologic Type and Pathologic Stage
Histopathologic diagnoses for the 61 lesions in the 55 patients are presented in Table 2. Final diagnoses were 38 adenocarcinomas (63%), 12 squamous cell carcinomas (19.6%), three bronchioloalveolar carcinomas (4.9%), and seven other types of carcinoma (11.6%), consisting of three large cell neuroendocrine carcinomas, two large cell carcinomas, one adenosquamous cell carcinoma, and one pleomorphic carcinoma. According to the criteria of Martini and Melamed, modified by Anakli for the diagnosis of synchronous multiple lung cancer [11], 6 of the 55 patients (10.9%) had synchronous double primary cancers. Single-stage surgical treatment was applied to these synchronous multiple lung cancers with comorbid physical conditions.

The pathologic stage of lung cancer was classified as I in 44 patients (80%), II in 6 (11%), and III in 5 (9%). Two patients with stage IIIA disease had malignant N2 lymphadenopathy and received postoperative radiation therapy. Three patients with stage IIIB disease had pulmonary metastasis in the resected lobe. No patients received postoperative adjuvant chemotherapy. All patients are still being followed up by CT every 6 months at our institute.

Morbidity and Mortality
Table 3 outlines the postoperative complications and outcome. One or more postoperative complications occurred in 14 patients (25.6%), and 41(74.4%) had no complications. The most common postoperative pulmonary complication was pneumonia in 4 patients (7.3%). Other pulmonary complications were prolonged air leaks persisting for more than 7 days in 3 patients (5.6%), respiratory failure requiring home oxygen therapy in 2 (3.6%), atelectasis in 1 (1.8%), and aggressive interstitial pneumonia in 1 (1.8%). Most of the pulmonary complications were manageable observationally. Nonpulmonary complications were transient delirium in 4 patients (7.3%) that occurred only on postoperative day 1, mild atrial arrhythmia that did not need medication in 3 (5.6%), epidural shock in 1 (1.8%), and arteriosclerosis obliterans that needed emergency intervention therapy in 1 (1.8%).


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  		Table 3 Postoperative Complications and Outcomes
 
There were two in-hospital deaths for an operative mortality rate of 3.6%. One patient died of bacterial pneumonia on day 132, and another died of aggressive interstitial pneumonia on postoperative day 105 (Table 3).

Long-Term Outcome
Median follow-up was 49 months. The actuarial survival rates of the 55 patients, including deaths from all causes, were 76.4% at 3 years and 65.9% at 5 years (Fig 1). At the time of analysis, 7 patients (12.7%) had died of the disease, 6 (10.9%) had died of late-phase pneumonia, and 40 (76.4%) patients were alive with or without disease.


Figure 1
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  		Fig 1. Overall survival analysis with Kaplan-Meier method.

 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
The population in Japan is aging; life expectancy in 80-year-olds exceeds 8 years. The average life expectancy of patients with untreated or palliated early-stage NSCLC is 1.5 years [12]; therefore, treatment for lung cancer in this age group should be strongly considered if it can be performed with acceptable morbidity and mortality. However, elderly patients with lung cancer have more underlying comorbidity than younger patients, increasing the risks associated with surgery. The mortality rate of patients aged 80 years and older who underwent surgical resection with thoracotomy for lung cancer was 8.1% to 21% in studies performed before 1995 [3–5, 13]. In more recent studies (Table 4), however, operative mortality was 0% to 8.8% in octogenarian patients undergoing appropriate surgical procedures [2, 8, 14–18]. According to these results, the operative mortality was 2.0% to 8.8% among patients undergoing lobectomy with standard thoracotomy.


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  		Table 4 Surgical Resection of Lung Cancer in Octogenarians
 
Although anatomic resection is more technically challenging than sublobar resection, it has been shown to have a two to three times lower incidence of local recurrence than sublobar resection; therefore, lobectomy is an ideal procedure for lung cancer in octogenarians. However, lobectomy with thoracotomy is an invasive procedure for elderly patients with concomitant cardiopulmonary diseases. Minimally invasive surgical procedures, which we also have used, are believed to substantially reduce early morbidity and mortality in octogenarians.

Several studies have looked at VATS in the elderly [8, 16, 18]. Koizumi and associates [16] have reported that operative mortality among 17 patients who underwent lobectomy by VATS was 5.9% and that analyses of postoperative conditions suggest the superiority of VATS lobectomy in terms of the small amount of blood loss, short period of chest drainage, and low level of maximal serum creatine phosphokinase postoperatively. Patients who undergo VATS lobectomy have a low incidence of postoperative complications compared with those who underwent lobectomy with thoracotomy [16].

MacVay and associates [7] reported in their large study that VATS anatomic pulmonary resection was performed on 159 octogenarians with clinical stage I lung cancer and their morbidity and mortality rates were 18% and 1.8%, respectively. Their rate of conversion to thoracotomy was a favorable 1%. However, their median follow-up period of 29 months was relatively short, and long-term outcome was not described.

In our study, 50 of 55 patients (91%) who underwent VATS had preoperative concomitant diseases, and half or more of these were cardiopulmonary diseases. However, our morbidity rate of 25.6%, operative mortality rate of 3.6%, and 5-year survival rate of 65.9% after median follow-up of 49 months confirm that VATS is a safe and acceptable procedure.

Some reports have revealed that the major cause of death in long-term-surviving octogenarians is pneumonia, which arises from the poor pulmonary function caused by extensive pulmonary resection [1, 15]. At the time of analysis, 6 patients (10.9%) in our study had died of pneumonia after discharge, and all of them had a smoking index exceeding 600. We propose to investigate further the relationship between smoking and long-term mortality in octogenarians. Pulmonary complications caused by increased bronchial secretion and difficulty in expectoration directly increase mortality, which makes the prevention of such complications essential. Postoperative drainage tubes and wound pain cause movement restriction and suppress coughing, which increases the risk of postoperative illness, and early postoperative mobilization is particularly important for elderly patients.

A previous study has revealed that operation duration is an independent risk factor for morbidity, and operative procedure is a risk factor for PS deterioration [1, 19]. Some previous studies have revealed that the length of postoperative hospital stay in octogenarians with lung cancer is associated with the occurrence of postoperative pulmonary complications [10, 20, 21]. Therefore, pulmonary resection using VATS is recommended for curative resection in octogenarians after considering PS and pulmonary reserve.

Although lobectomy with radical systemic lymphadenectomy is ideal in younger patients from the viewpoint of curative cancer resection, in octogenarians, this may sometimes be a risk factor for postoperative complications that can lead to operative death. Aoki and associates [15] have reported that the efficacy of radical systemic lymphadenectomy is controversial. The risk of postoperative pulmonary morbidity may increase, and there may be no impact on prolonging survival [15]. The surgical procedures they reported were done using standard posterolateral thoracotomies. Until recently, we had not persisted with lymph node dissection in octogenarians because of its invasiveness. However, since 2004, because a suitable technique had become established, lymphadenectomy with VATS was performed in low-risk octogenarians. As a result, there were no postoperative complications concerning lymphadenectomy with VATS in octogenarians and our long-term survival was favorable.

Recently, early experiences using radiofrequency ablation or stereotactic radiosurgery modalities have suggested that these procedures could serve as potential additions or alternatives to surgery for local treatment of peripheral small primary lung cancers. Fernando and associates [22] provide the longest patient follow-up, so far reported, of 14 months after radiofrequency ablation and demonstrated a radiographic local progression rate of 38% [22]. Thus, the long-term effectiveness of radiofrequency ablation needs to be further evaluated for high-risk patients such as octogenarians. If minimally invasive VATS were performed in high-risk patients, sublobar resections might effect a balance between local control of lung cancer and a low rate of complications.

Although the size of the subject population and duration of follow-up was insufficient to properly determine the effectiveness of VATS management in elderly patients, surgical treatment with VATS was an acceptable procedure. However, these patients also need careful follow-up after resection because of the possibility of pneumonia and recurrence of cancer in the longer term.

In conclusion, VATS pulmonary resection for clinical stage I lung cancer in octogenarians is a satisfactory alternative treatment. Although advanced age is not a contraindication for curative resection, we should decide on the proper selection of patients and surgical procedures.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

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