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Ann Thorac Surg 2009;88:1093-1099. doi:10.1016/j.athoracsur.2009.06.012
© 2009 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

Risk Factors for Morbidity After Lobectomy for Lung Cancer in Elderly Patients

Mark F. Berry, MDa, Jennifer Hanna, MDa, Betty C. Tong, MDa, William R. Burfeind, Jr, MDb, David H. Harpole, MDa, Thomas A. D'Amico, MDa, Mark W. Onaitis, MDa,*

a Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
b Department of Thoracic Surgery, St. Luke's Health Network, Bethlehem, Pennsylvania

Accepted for publication June 4, 2009.

* Address correspondence to Dr Onaitis, Box 3305, Duke University Medical Center, Durham, NC 27710 (Email: mark.onaitis{at}duke.edu).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: Studies evaluating risk factors for complications after lobectomy in elderly patients have not adequately analyzed the effect of using minimally invasive approaches.

Methods: A model for morbidity including published preoperative risk factors and surgical approach was developed by multivariable logistic regression. All patients aged 70 years or older who underwent lobectomy for primary lung cancer without chest wall resection or airway procedure between December 1999 and October 2007 at a single institution were reviewed. Preoperative, histopathologic, perioperative, and outcome variables were assessed using standard descriptive statistics. Morbidity was measured as a patient having any perioperative complication. The impact of bias in the selection of surgical approach was assessed using propensity scoring.

Results: During the study period, 338 patients older than 70 years (mean age, 75.7 ± 0.2) underwent lobectomy (219 thoracoscopy, 119 thoracotomy). Operative mortality was 3.8% (13 patients) and morbidity was 47% (159 patients). Patients with at least one complication had increased length of stay (8.3 ± 0.6 versus 3.8 ± 0.1 days; p < 0.0001) and mortality (6.9% [11 of 159] versus 1.1% [2 of 179]; p = 0.008). Significant predictors of morbidity by multivariable analysis included age (odds ratio, 1.09 per year; p = 0.01) and thoracotomy as surgical approach (odds ratio, 2.21; p = 0.004). Thoracotomy remained a significant predictor of morbidity when the propensity to undergo thoracoscopy was considered (odds ratio, 4.9; p= 0.002).

Conclusions: Patients older than 70 years of age can undergo lobectomy for lung cancer with low morbidity and mortality. Advanced age and the use of a thoracotomy increased the risk of complications in this patient population.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Lobectomy achieves the best long-term survival in patients with early-stage non–small cell lung cancer [1]. Lung cancer is generally a disease of older adults, and age has been shown to be an important risk factor for morbidity and mortality after lung resection [2–10]. Perhaps because of these increased risks, patients older than 75 years are offered curative surgery for lung cancer 22% less often than younger patients [10, 11]. In addition, older patients are more likely than younger patients to undergo lesser resections such as a wedge resection [7, 10, 12].

Several reports have shown that thoracoscopic lobectomy is safe and effective for resectable non–small cell lung cancer, with equivalent oncologic outcomes and lower overall complication rates and shorter hospital stays compared with thoracotomy [13–16]. In elderly patients, the use of thoracoscopic approaches to both anatomic and wedge resections has been associated with lower morbidity than that usually associated with thoracotomy [14, 15, 17–20]. Published models evaluating risk factors for complications after lobectomy have not considered the effect of using a minimally invasive approach [3, 21–25]. The purpose of this study was to test the hypothesis that a thoracoscopic approach independently predicts improved morbidity in elderly patients undergoing lobectomy for lung cancer.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
After local institutional review board approval was granted, the Duke University Medical Center Data Center was queried for current procedural terminology codes linked with pulmonary resection by either an open approach or by a thoracoscopic approach between December 1999 and October 2007. Careful attention was paid to individual operative notes and surgical pathology reports to identify all patients older than 70 years age who underwent anatomic lobectomy. Patients who had a completion lobectomy, sleeve resection, bronchoplasty, chest wall resection, pleurectomy, or diaphragm resection were excluded from the study.

Retrospective review of an institutional, prospective database maintained on all thoracic surgery patients documented and compared demographics, preoperative functional status, the use of induction therapy, smoking history, significant comorbidities, the histology and stage of disease, intraoperative details, and postoperative course. Chart review was used as necessary to complete data collection. Preoperative performance status was based on Zubrod, or Eastern Cooperative Oncology Group, scores that were included in the prospective database [26]. Any postoperative event prolonging or otherwise altering the postoperative course was recorded along with all operative deaths, which were defined as deaths that occurred within 30 days after operation or those that occurred later but during the same hospitalization. Deaths were captured both by chart review and use of the Social Security Death Index database. The definitions of postoperative events were based on The Society of Thoracic Surgeons General Thoracic Surgery Database [27]. Morbidity was defined as the occurrence of at least one postoperative event.

Thoracoscopic lobectomy was performed without any rib spreading with the thoracoscope placed in the eighth intercostal space in the midaxillary line and a 4- to 5-cm anterior utility incision in the fifth intercostal space [13]. Thoracotomy in most patients was by means of a standard posterolateral approach with sparing of the serratus muscle; 1 surgeon (30 of 119 cases) used an approach in which both the latissimus and serratus muscles were spared and notching of the sixth rib was performed. An epidural catheter for postoperative pain relief was offered to all patients regardless of planned operative approach. Chest tubes were routinely placed on water seal immediately postoperatively and removed when no air leak was present and drainage for 24 hours was less than 200 mL.

Univariate analyses were performed relating operative morbidity to the following 12 patient characteristics: age, American Society of Anesthesiology score (a marker of overall health status), Zubrod score (a measurement of performance status), the presence of diabetes, the presence of renal insufficiency, the use of induction chemotherapy, a history of smoking, preoperative pulmonary function tests (forced expiratory volume in 1 second and diffusion capacity of the lung to carbon monoxide), surgical approach, year of surgery, and pathologic stage. Unpaired Student's t tests were used to compare continuous data, Fisher's exact tests for dichotomous data, and {chi}2 for categoric variables. A two-tailed probability value of less than 0.05 was considered significant. The variables that were significant at a probability value less than 0.20 were entered into a multivariable logistic regression with morbidity as the dependent variable and significance set at the 0.05 level.

A propensity score analysis was then undertaken to minimize the effect of bias in the selection of patients to undergo a thoracoscopic approach. Univariate analyses were performed relating operative approach (thoracotomy or thoracoscopy) to surgeon, age, stage, previous thoracic surgery, forced expiratory volume in 1 second, diffusion capacity of the lung to carbon monoxide, year of surgery, and induction therapy. Variables significant at a probability value less than 0.20 were entered into multivariable logistic regression with approach as the outcome. Cancer stage, surgeon, and previous thoracic surgery were predictors of approach in both univariate and multivariate analyses. These predictors were reentered into a logistic regression model to calculate predicted scores. Patients with scores lower than 0.25 (high chance of undergoing thoracotomy) and higher than 0.75 (high chance of undergoing thoracoscopy) were then excluded, and the multivariable logistic regression model with morbidity as the dependent variable was repeated on the subgroup of patients who had propensity scores between 0.25 and 0.75 of undergoing a thoracoscopic approach. Data are presented as mean ± standard error of the mean unless otherwise noted. Survival was modeled using the Kaplan-Meier method. The SAS 9.0 statistical package (SAS Institute, Cary, NC) was used for statistical analyses.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
During the study period, 971 patients older than 70 underwent lung resection. Of these, 338 patients (median age of 75) underwent lobectomy for lung cancer: 119 patients underwent thoracotomy and 219 patients underwent thoracoscopy. The distribution performed per study year is depicted in Figure 1. Lobectomy was performed in 1,578 patients overall during the study period. Therefore, the number evaluated in this report represents approximately 21% of the total number of lobectomies.


Figure 1
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  		Fig 1. The number of open and thoracoscopic lobectomies performed in patients older than 70 years of age annually during the study period. Each bar is split by a line inside the bar to show the number of patients 75 years or younger (under the line) and those older than 75 (over the line). (Note, the year 1999 included only 1 month for analysis and the year 2007 included only 10 months for analysis).

 
Demographic, baseline characteristics, pathologic cancer stage, and comorbid conditions are shown in Table 1. Staging cervical mediastinoscopy was performed on 276 patients (82%); 221 during the same operation as lobectomy and 55 at a previous setting. The median chest tube duration for all patients was 3 days, and the median hospitalization was 4 days. Overall operative mortality was 3.8% (13 patients) and morbidity was 47% (159 patients). Patients with at least one complication had increased length of stay (8.3 ± 0.6 versus 3.8 ± 0.1 days; p < 0.0001) and mortality (6.9% [11 of 159] versus 1.1% [2 of 179]; p = 0.008). The 2-year and 5-year survival rates for the entire cohort were 69% and 44%, respectively (Fig 2A). The 2-year and 5-year survival rates for stage I non–small cell lung cancer were 75% and 53% (Fig 2B).


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  		Table 1 Demographics, Baseline Characteristics, and Comorbid Conditions
 

Figure 2
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  		Fig 2. A. Kaplan-Meier analysis of overall survival after lobectomy in all patients older than 70 years. B. Kaplan-Meier analysis of overall survival after lobectomy in patients with stage I lung cancer.

 
On univariate analysis using the predictors listed in Table 2, increasing age and thoracotomy as surgical approach were significantly associated with morbidity. Including age, approach, smoking history, percent-predicted forced expiratory volume in 1 second, and presence of diabetes as possible predictors in multivariable logistic regression with presence of at least one postoperative complication as the outcome, age (odds ratio per year, 1.09; p = 0.01) and thoracotomy as surgical approach (odds ratio, 2.21; p = 0.004) remained significant predictors of morbidity (Table 2).


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  		Table 2 Univariate Analysis and Logistic Regression Model of Risk Factors for Morbidity
 
To attempt to minimize the effect of selection bias on the model, logistic regression was performed using approach (thoracotomy or thoracoscopy) as the outcome. Possible predictors included in the model included surgeon, age, stage, previous thoracic surgery, forced expiratory volume in 1 second, diffusion capacity of the lung to carbon monoxide, year of surgery, and induction therapy. Of these, surgeon, clinical stage, and previous thoracic surgery independently predicted operative approach. Thus, these predictors were reentered into a logistic regression model and predicted scores calculated. This model showed a good predictive capacity (c = 0.82). The patients with scores lower than 0.25 (high chance of undergoing thoracotomy) and higher than 0.75 (high chance of undergoing thoracoscopy) were then excluded, leaving 125 patients with predicted preoperative chance of undergoing thoracoscopy between 25% and 75% (Table 3). In this subgroup of 125 patients, the mean propensity score of the patients who underwent thoracoscopy was 0.55 with a standard deviation of 0.14, and the mean propensity score of the patients who underwent thoracotomy was 0.45 with a standard deviation of 0.12. Performing multivariable logistic regression on these 125 patients using presence of complications as the outcome and approach, age, smoking history, percent-predicted forced expiratory volume in 1 second, and presence of diabetes as predictors demonstrates that age (odds ratio per year, 1.25; p = 0.002) and thoracotomy as surgical approach (odds ratio, 5.99; p = 0.001) remained significant predictors of morbidity (Table 2).


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  		Table 3 Complications According to Predicted Approach for Lobectomy a
 
Postoperative complications are listed in Table 4. The most common complications in the entire group were atrial arrhythmia (69 patients, 20%), need for chest tube more than 5 days (51 patients, 15%), postoperative transfusion (30 patients, 9%), delirium or mental status changes (27 patients, 8%), and need for postoperative bronchoscopy (19 patients, 6%). Because the multivariable analysis identified age and operative approach as independent significant predictors of morbidity, complications are also stratified by age (patients older and younger than the median age) and operative approach. As Figure 3 clearly demonstrates, use of thoracoscopy for lobectomy in elderly patients older than 75 reduces complications to a lower frequency than that of elderly patients younger than 75 years undergoing thoracotomy for lobectomy.


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  		Table 4 Postoperative Events
 

Figure 3
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  		Fig 3. Morbidity stratified by age and operative approach.

 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
This study demonstrates that lobectomy can be performed for non–small cell lung cancer in patients older than 70 with acceptable overall morbidity and mortality (3.8% and 47%, respectively). These results are in the range of those published from other multiinstitution and single-institution series [6, 12, 28–31]. Despite the significant comorbid conditions listed in Table 1, the majority of patients did not experience a postoperative complication. Our analysis demonstrates that age and surgical approach independently predict the occurrence of complications in this age group. When technically possible, we believe that thoracoscopy should be strongly considered as the approach of choice in these patients.

Our findings support those of previously published reports that have suggested that age should not be the sole determinant when considering surgery as a treatment option for lung cancer or other pulmonary diseases. Carefully selected elderly patients can undergo lung resection with similar morbidity and mortality to younger patients [32]. In addition, changes in health-related quality of life in the first year after lobectomy is not different between patients older than 70 years of age and younger patients [33]. Functional status, pulmonary function, and comorbid conditions should be considered more importantly than chronologic age as risk factors when considering patients for surgery [34]. We believe that the feasibility of thoracoscopic lobectomy further emphasizes these conclusions.

The main strength of this study is that, compared with other large series of lung resections in elderly patients, a significant number in this series underwent a minimally invasive approach, allowing assessment of its effect on outcomes. This allowed creation of a multivariable model of complications using previously published prognostic factors as well as an adequately powered approach variable. Because a randomized trial of thoracoscopic versus open lobectomy will likely never be performed, we are left to control selection bias through propensity scoring. Our propensity scoring is unique in that it includes surgeon preference, previous thoracic surgery, and clinical stage. Although it is impossible to completely control selection bias in a retrospective study, we attempted to control for all known contributors.

The main limitation of this study is the retrospective nature. The procedures in this report were also performed by several different surgeons, which introduces potential confounders such as different selection criteria for surgery, surgical techniques, and postoperative management. Finally, the positive effects of approach on outcome in this study cannot necessarily be immediately generalized to all thoracic surgeons, considering the extensive experience of the surgeons in this study with thoracoscopic lobectomy. However, surgeons comfortable with thoracoscopic lobectomy can achieve results similar or even better than those shown in this series and should consider this approach preferentially in older patients, even in the presence of adhesions from previous surgery or higher cancer stages.

Determining the specific age, set of comorbid conditions, and functional status to perform lobectomy in the individual elderly patient in comparison to lesser resection or no surgery at all is beyond the scope of this study. The survival benefit conferred by lobectomy in the surgical treatment of lung cancer has been shown to be a function of age, with patients older than 75 having no difference in overall survival between patients undergoing lobectomies and more limited resections for stage I or II lung cancer [10]. Patients with extensive comorbidities might not live long enough to realize the benefit of lobectomy over limited resection owing to an increased rate of noncancer deaths [35]. It must be noted that these conclusions result from studies that evaluated patients treated in the years 1989 to 1997, a period when thoracoscopic lobectomy was rarely used. Given that the present study demonstrates that a thoracoscopic approach reduces morbidity, the survival advantages of lobectomy over lesser resection may be able to be conferred to older patients, even those with significant comorbidities and marginal lung function. Future analyses are needed to evaluate this possibility further.

In conclusion, lobectomy is an appropriate and safe treatment for patients older than 70 with lung cancer, and a thoracoscopic approach reduces the morbidity and shortens both the duration of chest tube drainage and hospital length of stay. This study suggests a thoracoscopic approach to lobectomy should be the procedure of choice to minimize the risk of complications in elderly patients with a diagnosis of non–small cell lung cancer, especially those older than 75.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Ginsberg RJ, Rubenstein LV, LCSG Randomized trial of lobectomy versus limited resection for T1N0 non-small cell lung cancer Ann Thorac Surg 1995;60:615-623.[Abstract/Free Full Text]
  2. Ettinger DS, Akerly W, Bepler G, et al. National Comprehensive Cancer Network (NCCN). Non-small cell lung cancer clinical practice guidelines in oncology. J Natl Compr Canc Netw 2008;6:228-269.[Abstract]
  3. Harpole Jr DH, DeCamp Jr MM, Daley J, et al. Prognostic models of thirty-day mortality and morbidity after major pulmonary resection J Thorac Cardiovasc Surg 1999;117:969-979.[Abstract/Free Full Text]
  4. Deslauriers J, Ginsberg RJ, Piantadosi S, Fournier B. Prospective assessment of 30-day operative morbidity for surgical resections in lung cancer Chest 1994;106(Suppl):329S-330S.[Abstract/Free Full Text]
  5. Volpino P, Cangemi R, Fiori E, et al. Risk of mortality from cardiovascular and respiratory causes in patients with chronic obstructive pulmonary disease submitted to follow-up after lung resection for non-small cell lung cancer J Cardiovasc Surg (Torino) 2007;48:375-383.[Medline]
  6. Fan J, Wang XJ, Jiang GN, et al. Survival and outcomes of surgical treatment of the elderly NSCLC in China: a retrospective matched cohort study Eur J Surg Oncol 2007;33:639-643.[Medline]
  7. Hanna N, Brooks JA, Fyffe J, Kesler K. A retrospective analysis comparing patients 70 years or older to patients younger than 70 years with non-small-cell lung cancer treated with surgery at Indiana university: 1989–1999 Clin Lung Cancer 2002;3:200-204.[Medline]
  8. Birim O, Kappetein AP, Waleboer M, et al. Long-term survival after non-small cell lung cancer surgery: development and validation of a prognostic model with a preoperative and postoperative mode J Thorac Cardiovasc Surg 2006;132:491-498.[Abstract/Free Full Text]
  9. Birim O, Kappetein AP, Bogers AJ. Charlson comorbidity index as a predictor of long-term outcome after surgery for nonsmall cell lung cancer Eur J Cardiothorac Surg 2005;28:759-762.[Abstract/Free Full Text]
  10. Mery CM, Pappas AN, Bueno R, et al. Similar long-term survival of elderly patients with non-small cell lung cancer treated with lobectomy or wedge resection within the surveillance, epidemiology, and end results database Chest 2005;128:237-245.[Abstract/Free Full Text]
  11. Owonikoko TK, Ragin CC, Belani CP, et al. Lung cancer in elderly patients: an analysis of the surveillance, epidemiology, and end results database J Clin Oncol 2007;25:5570-5577.[Abstract/Free Full Text]
  12. Sirbu H, Schreiner W, Dalichau H, Busch T. Surgery for non-small cell carcinoma in geriatric patients: 15-year experience Asian Cardiovasc Thorac Ann 2005;13:330-336.[Abstract/Free Full Text]
  13. Onaitis MW, Petersen RP, Balderson SS, et al. Thoracoscopic lobectomy is a safe and versatile procedure: experience with 500 consecutive patients Ann Surg 2006;244:420-425.[Medline]
  14. Park BJ, Zhang H, Rusch VW, Amar D. Video-assisted thoracic surgery does not reduce the incidence of postoperative atrial fibrillation after pulmonary lobectomy J Thorac Cardiovasc Surg 2007;133:775-779.[Abstract/Free Full Text]
  15. Cattaneo SM, Park BJ, Wilton AS, et al. Use of video-assisted thoracic surgery for lobectomy in the elderly results in fewer complications Ann Thorac Surg 2008;85:231-235.[Abstract/Free Full Text]
  16. D'Amico TA. Long-term outcomes of thoracoscopic lobectomy Thorac Surg Clin 2008;18:259-262.[Medline]
  17. Jaklitsch MT, DeCamp Jr MM, Liptay MJ, et al. Video-assisted thoracic surgery in the elderly: a review of 307 cases Chest 1996;110:751-758.[Abstract/Free Full Text]
  18. Atkins BZ, Harpole DH, Mangum JH, Toloza EM, D'Amico TA, Burfeind WR. Pulmonary segmentectomy by thoracotomy or thoracoscopy: reduced hospital length of stay with a minimally-invasive approach Ann Thorac Surg 2007;84:1107-1113.[Abstract/Free Full Text]
  19. Koren JP, Bocage JP, Geis WP, Caccavale RJ. Major thoracic surgery in octogenarians: the video-assisted thoracic surgery (VATS) approach Surg Endosc 2003;17:632-635.[Medline]
  20. Tovar EA. One-day admission for major lung resections in septuagenarians and octogenarians: a comparative study with a younger cohort Eur J Cardiothorac Surg 2001;20:449-453.[Abstract/Free Full Text]
  21. Wright CD, Gaissert HA, Grab JD, O'Brien SM, Peterson ED, Allen MS. Predictors of prolonged length of stay after lobectomy for lung cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database risk-adjustment model Ann Thorac Surg 2008;85:1857-1865.[Abstract/Free Full Text]
  22. Gagarine A, Urschel JD, Miller JD, Bennett WF, Young JE. Preoperative and intraoperative factors predictive of length of hospital stay after pulmonary lobectomy Ann Thorac Cardiovasc Surg 2003;9:222-225.[Medline]
  23. Martin J, Ginsberg RJ, Abolhoda A, et al. Morbidity and mortality after neoadjuvant therapy for lung cancer: the risks of right pneumonectomy Ann Thorac Surg 2001;72:1149-1154.[Abstract/Free Full Text]
  24. Myrdal G, Gustafsson G, Lambe M, Hörte LG, Ståhle E. Outcome after lung cancer surgery. Factors predicting early mortality and major morbidity. Eur J Cardiothorac Surg 2001;20:694-699.[Abstract/Free Full Text]
  25. Duque JL, Ramos G, Castrodeza J, et al. Early complications in surgical treatment of lung cancer: a prospective, multicenter study. Grupo Cooperativo de Carcinoma Broncogénico de la Sociedad Española de Neumología y Cirugía Torácica. Ann Thorac Surg 1997;63:944-950.[Abstract/Free Full Text]
  26. Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group Am J Clin Oncol 1982;5:649-655.[Medline]
  27. Society of Thoracic Surgeons 2009http://www.sts.org/sections/stsnationaldatabase 1982accessed March 5, 2009.
  28. Allen MS, Darling GE, Pechet TT, et al. ACOSOG Z0030 Study Group Morbidity and mortality of major pulmonary resections in patients with early-stage lung cancer: initial results of the randomized, prospective ACOSOG Z0030 trial Ann Thorac Surg 2006;81:1013-1019.[Abstract/Free Full Text]
  29. Pagni S, McKelvey A, Riordan C, Federico JA, Ponn RB. Pulmonary resection for malignancy in the elderly: is age still a risk factor? Eur J Cardiothorac Surg 1998;14:40-44.[Abstract/Free Full Text]
  30. Thomas P, Piraux M, Jacques LF, Grégoire J, Bédard P, Deslauriers J. Clinical patterns and trends of outcome of elderly patients with bronchogenic carcinoma Eur J Cardiothorac Surg 1998;13:266-274.[Abstract/Free Full Text]
  31. Conti B, Brega Massone PP, Lequaglie C, Magnani B, Cataldo I. Major surgery in lung cancer in elderly patients?. Risk factors analysis and long-term results. Minerva Chir 2002;57:317-321.[Medline]
  32. Cerfolio RJ, Bryant AS. Survival and outcomes of pulmonary resection for non-small cell lung cancer in the elderly: a nested case-control study Ann Thorac Surg 2006;82:424-430.[Abstract/Free Full Text]
  33. Burfeind Jr WR, Tong BC, O'Branski E, et al. Quality of life outcomes are equivalent after lobectomy in the elderly J Thorac Cardiovasc Surg 2008;136:597-604.[Abstract/Free Full Text]
  34. Bernard A, Ferrand L, Hagry O, Benoit L, Cheynel N, Favre JP. Identification of prognostic factors determining risk groups for lung resection Ann Thorac Surg 2000;70:1161-1167.[Abstract/Free Full Text]
  35. Landreneau RJ, Sugarbaker DJ, Mack MJ, et al. Wedge resection versus lobectomy for stage 1 (T1 N0 M0) non-small-cell lung cancer J Thorac Cardiovasc Surg 1997;113:691-700.[Abstract/Free Full Text]

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S. Paul, N. K. Altorki, S. Sheng, P. C. Lee, D. H. Harpole, M. W. Onaitis, B. M. Stiles, J. L. Port, and T. A. D'Amico
Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS database.
J. Thorac. Cardiovasc. Surg., February 1, 2010; 139(2): 366 - 378.
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S. C. Yang
Invited Commentary
Ann. Thorac. Surg., October 1, 2009; 88(4): 1099 - 1099.
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