1
|
Kuwabara S, Kobayashi K, Sudo N. Outcomes of elderly patients following thoracoscopic esophagectomy for esophageal cancer. Langenbecks Arch Surg 2023; 408:56. [PMID: 36689075 DOI: 10.1007/s00423-023-02797-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 11/22/2022] [Indexed: 01/24/2023]
Abstract
PURPOSE Thoracoscopic esophagectomy (TE) is widely used for esophageal cancer treatment. However, the short- and long-term outcomes of TE in older patients remain unknown. Thus, we investigated those outcomes as well as the effectivity of TE in this patient cohort. METHODS A total of 228 consecutive patients who underwent TE for esophageal cancer from 2002 to 2015 were included in the study and categorized into the elderly (≥ 75 years) and non-elderly (< 75 years) groups. The background was adjusted by propensity score matching. The short- and long-term outcomes were then compared between the two groups. RESULTS There was no difference in the short-term outcomes between the two groups. The elderly group had significantly lower overall survival (OS) and relapse-free survival (RFS) than the non-elderly group. When pulmonary complications occurred, the OS and RFS were significantly decreased in the elderly group but not in the non-elderly group. Without pulmonary complications, the OS and RFS in the elderly group did not differ from those in the non-elderly group. The multivariate analysis showed that pulmonary complications were independent poor prognostic factors for OS and RFS in the elderly group but not in the non-elderly group. CONCLUSION TE is safe and feasible for older patients. However, the OS and RFS of the elderly group were significantly worse than those of the non-elderly group, especially when pulmonary complications occurred. Therefore, perioperative management to prevent pulmonary complications is essential to improve the long-term outcomes of older patients receiving TE.
Collapse
Affiliation(s)
- Shirou Kuwabara
- Department of Digestive Surgery, Niigata City General Hospital, 463-7 Shumoku, Chuo-Ku, Niigata prefecture, 950-1197, Niigata city, Japan.
| | - Kazuaki Kobayashi
- Department of Digestive Surgery, Niigata City General Hospital, 463-7 Shumoku, Chuo-Ku, Niigata prefecture, 950-1197, Niigata city, Japan
| | - Natsuru Sudo
- Department of Digestive Surgery, Niigata City General Hospital, 463-7 Shumoku, Chuo-Ku, Niigata prefecture, 950-1197, Niigata city, Japan
| |
Collapse
|
2
|
Hamamoto Y, Murakami K, Kato K, Kitagawa Y. Management of elderly patients with esophageal squamous cell cancer. Jpn J Clin Oncol 2022; 52:816-824. [PMID: 35511482 PMCID: PMC9354502 DOI: 10.1093/jjco/hyac067] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 04/07/2022] [Indexed: 12/02/2022] Open
Abstract
This review focuses on the treatment about elderly esophageal cancer to clarify the current situation regarding our clinical question. Although there are several reviews about elderly esophageal cancer treatment, there are fundamental differences between Japan and the rest of the world. Two main differences are raised: histological differences and treatment strategies for resectable patients. We overview each status according to following clinical questions. First, there are no established evaluation criteria for frail. Second, selection criteria for surgery or non-surgery are not established. Third, few specific treatments for elderly patients (EPs) are investigated. In conclusion, there are many reports about treatment of esophageal squamous cell carcinoma for EPs, although treatment strategy is still controversial. We have to consider well-designed prospective trial to confirm specific treatment strategy according to each stage.
Collapse
Affiliation(s)
- Yasuo Hamamoto
- Keio Cancer Center, Keio University Hospital, School of Medicine, Tokyo, Japan
| | - Kentaro Murakami
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Ken Kato
- Department of Head and Neck, Esophageal Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| |
Collapse
|
3
|
Preoperative Thoracic CT Findings Associated With Postoperative Mechanical Ventilation in Patients Undergoing Major Abdominal or Pelvic Surgery: A Matched Case-Control Study. AJR Am J Roentgenol 2021; 218:279-288. [PMID: 34467781 DOI: 10.2214/ajr.21.26411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Postoperative prolonged mechanical ventilation is associated with increased morbidity and mortality. Reliable predictors of postoperative mechanical ventilation after abdominal or pelvic surgeries are lacking. Objective: To explore associations between preoperative thoracic CT findings and need for postoperative mechanical ventilation after major abdominal or pelvic surgeries. Methods: This retrospective case-control study included patients who underwent abdominal or pelvic surgeries (01/01/2014-12/31/2018) and underwent preoperative thoracic CT. Cases were patients who required postoperative mechanical ventilation. Control and case patients were matched at a 3:1 ratio based on age, sex, body mass index, chronic obstructive pulmonary disease, smoking status, and surgery type. Two radiologists (R1, R2) reviewed CT images. Findings were compared between groups. Results: The study included 165 patients (70 female, 95 male; mean age 67.0±9.7 years; 42 cases, 123 matched controls). Bronchial wall thickening and pericardial effusion were more frequent in cases than controls for R2 (10% vs 2%, p=.03; 17% vs 5%, p=.01), but not R1. Pulmonary artery diameter was greater in cases than controls for R2 (2.9±0.5 cm vs 2.8±0.5 cm, p=.045) but not R1. Right lung height was lower in cases than controls for R1 (18.4±2.9 cm vs 19.9±2.7 cm, p=.01) and R2 (18.3±2.9 cm vs 19.8±2.7 cm, p=.01). Left lung height was lower in cases than controls for R1 (19.5±3.1 cm vs 21.1±2.6 cm, p=.01) and R2 (19.6±2.4 cm vs 20.9±2.6 cm, p=.01). Anteroposterior chest diameter was greater for cases than controls for R1 (14.0±2.3 cm vs 12.9±3.7 cm, p=.02) and R2 (14.2±2.2 cm vs 13.2±3.6 cm, p=.04). In multivariable regression model using pooled reader data, bronchial wall thickening exhibited odds ratio (OR) of 4.6 (95% CI: 1.3, 16.5; p=.02); pericardial effusion, OR 5.1 (95% CI: 1.7, 15.5; p=.004); pulmonary artery diameter, OR 1.4 (95% CI: 0.7, 3.0; p=.32); mean lung height, OR 0.8 (95% CI: 0.7, 1.001; p=.05); anteroposterior chest diameter, OR 1.2 (95% CI: 1.013, 1.4; p=.03). Conclusion: CT features are associated with the need for postoperative mechanical ventilation following abdominal or pelvic surgery. Clinical Impact: Many patients undergo thoracic CT before abdominal or pelvic surgery; the CT findings may complement preoperative clinical risk factors.
Collapse
|
4
|
Feasibility of esophagectomy for esophageal cancer in elderly patients: a case-control study. Langenbecks Arch Surg 2021; 406:2687-2697. [PMID: 34258676 DOI: 10.1007/s00423-021-02271-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/08/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE Surgery in elderly patients with esophageal cancer is challenging due to high mortality and limited survival. This study aimed to evaluate the safety and effectiveness of curative esophagectomy in elderly patients with esophageal cancer. METHODS This study included 77 and 112 patients with esophageal cancer aged ≥ 70 and 40-64 years, respectively, who underwent R0 esophagectomy between January 1998 and December 2016. Patient characteristics, intraoperative outcomes, postoperative complications, and long-term survival were compared. RESULTS The proportions of comorbid diseases (85.7% vs. 57.1%; P < 0.001), the American Society of Anesthesiologists score (1/2/3; 2.6%/94.8%/2.6% vs. 42.9%/57.1%/0%; P < 0.001), the preoperative systemic inflammation score (SIS) (0/1/2; 20.8%/48.1%/31.2% vs. 38.4%/38.4%/23.2%; P = 0.036), and postoperative complications (Clavien-Dindo grade ≥ III) (33.8% vs. 20.5%; P = 0.041) were significantly higher in the elderly group than those in the non-elderly group. However, long-term overall survival (OS) and relapse-free survival were not significantly different between the groups. On multivariate analysis, SIS (hazard ratio, 3.06; P = 0.037) and severe postoperative complications (hazard ratio, 2.01; P = 0.039) were significantly correlated with OS in the elderly group. CONCLUSIONS As SIS and severe postoperative complications lead to poor prognosis after R0 esophagectomy in elderly patients, selecting appropriate patients for esophagectomy and preventing severe postoperative complications is essential.
Collapse
|
5
|
Qiu G, Zhang H, Wang F, Zheng Y, Wang Z, Wang Y. Metastasis Patterns and Prognosis of Elderly Patients With Esophageal Adenocarcinoma in Stage IVB: A Population-Based Study. Front Oncol 2021; 11:625720. [PMID: 34123784 PMCID: PMC8193932 DOI: 10.3389/fonc.2021.625720] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 04/30/2021] [Indexed: 02/05/2023] Open
Abstract
Background Esophageal adenocarcinoma (EAC) is the most common kind of esophageal cancer. Age at diagnosis of advanced EAC is greater. Studies about practice patterns for elderly EAC patients with distant metastasis (DM) in stage IVB are limited. This retrospective, population-based study was conducted using data from the Surveillance, Epidemiology, and End Results (SEER) to evaluate 855 elderly EAC patients with DM in stage IVB from 2010 to 2015. Methods 855 elderly EAC patients with DM in stage IVB between 2010 and 2015 were included in this study. Univariate and multivariate Cox-regression and Kaplan-Meier analyses were used to assess prognosis. These patients were classified to bone-only, brain-only, lung-only, liver-only, and multiple (patients with two or more organs in metastasis)-site group according to the site of metastasis. Overall survival (OS), cancer-specific survival (CSS), median survival time (MST), and survival rate (SR) were evaluated to analyze the survival outcomes. Results The most common metastasis site was the liver among the single-organ metastasis population, followed by lung, bone, and brain. Compared with the bone-only group, the multiple-site group was associated with worst OS (HR: 1.037, 95% CI: 0.811–1.327, p = 0.770) and CSS (HR: 1.052, 95% CI: 0.816–1.357, p = 0.695). The multiple-site group also had the lowest MST in the population (MST: 2 months in OS and 3 months in CSS) and SR (6-month SR: 27.1% in OS, 29.9% in CSS, 1-year SR: 10.7% in OS, 12.0% in CSS, 3-year SR: 2.5% in OS, 2.8% in CSS). Compared to untreated patients (N) in the total population, other patients who were treated with surgery (S), radiotherapy (R), and chemotherapy (C) are beneficial for the prognosis (OS and CSS: p < 0.001). Conclusion This population-based study was conducted to ascertain metastasis patterns and survival outcomes of EAC patients with DM in stage IVB. Elderly patients with multiple-site metastasis exhibited the worst OS and CSS among all the populations, and patients with bone-only metastasis had the worst OS and CSS among single-organ metastasis populations. Active treatment is beneficial for elderly EAC patients with DM in stage IVB, especially chemotherapy. This study also shows that more than one third of the patients had not received any therapy.
Collapse
Affiliation(s)
- Guanghao Qiu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Hanlu Zhang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Fuqiang Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yu Zheng
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zihao Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yun Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
6
|
Esophageal Cancer in Elderly Patients, Current Treatment Options and Outcomes; A Systematic Review and Pooled Analysis. Cancers (Basel) 2021; 13:cancers13092104. [PMID: 33925512 PMCID: PMC8123886 DOI: 10.3390/cancers13092104] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/17/2021] [Accepted: 04/21/2021] [Indexed: 12/26/2022] Open
Abstract
Simple Summary Any given treatment may provide improve survival for elderly patients with oesophageal cancer compared to best supportive care. Although surgery may be related to a higher rate of complications in these patients, it also offers the best chance for survival, especially when combined with perioperative chemo-or chemoradiation. Definitive chemoradiation remains also a valid and widely used curative approach in this population. Quality of life after oesophageal cancer treatment does not seem to be particularly compromised in elderly patients, although the risk of loss of autonomy after the disease is higher. Based on the available data, excluding a priori elderly patients from curative treatment based on age alone cannot be supported. A thorough general health status and geriatric assessment is necessary to offer the optimal treatment, tailored to the individual patient. Abstract Esophageal cancer, despite its tendency to increase among younger patients, remains a disease of the elderly, with the peak incidence between 70–79 years. In spite of that, elderly patients are still excluded from major clinical trials and they are frequently offered suboptimal treatment even for curable stages of the disease. In this review, a clear survival benefit is demonstrated for elderly patients treated with neoadjuvant treatment, surgery, and even definitive chemoradiation compared to palliative or no treatment. Surgery in elderly patients is often associated with higher morbidity and mortality compared to younger patients and may put older frail patients at increased risk of autonomy loss. Definitive chemoradiation is the predominant modality offered to elderly patients, with very promising results especially for squamous cell cancer, although higher rates of acute toxicity might be encountered. Based on the all the above, and although the best available evidence comes from retrospective studies, it is not justified to refrain from curative treatment for elderly patients based on their age alone. Thorough assessment and an adapted treatment plan as well as inclusion of elderly patients in ongoing clinical trials will allow better understanding and management of esophageal cancer in this heterogeneous and often frail population.
Collapse
|
7
|
Sugita Y, Nakamura T, Sawada R, Takiguchi G, Urakawa N, Hasegawa H, Yamamoto M, Kanaji S, Matsuda Y, Yamashita K, Matsuda T, Oshikiri T, Suzuki S, Kakeji Y. Safety and feasibility of minimally invasive esophagectomy for elderly esophageal cancer patients. Dis Esophagus 2021; 34:5902470. [PMID: 32895704 DOI: 10.1093/dote/doaa083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/27/2020] [Accepted: 07/23/2020] [Indexed: 12/11/2022]
Abstract
The number of elderly patients with esophageal cancer has increased in recent years. The use of thoracoscopic esophagectomy has also increased, and its minimal invasiveness is believed to contribute to postoperative outcomes. However, the short- and long-term outcomes in elderly patients remain unclear. This study aimed to elucidate the safety and feasibility of minimally invasive esophagectomy in elderly patients. This retrospective study included 207 patients who underwent radical thoracoscopic esophagectomy for thoracic esophageal squamous cell carcinoma at Kobe University Hospital between 2005 and 2014. Patients were divided into non-elderly (<75 years) and elderly (≥75 years) groups. A propensity score matching analysis was performed for sex and clinical T and N stage, with a total of 29 matched pairs. General preoperative data, surgical procedures, intraoperative data, postoperative complications, in-hospital death, cancer-specific survival, and overall survival were compared between groups. The elderly group was characterized by lower preoperative serum albumin levels and higher American Society of Anesthesiologists grade. Intraoperative data and postoperative complications did not differ between the groups. The in-hospital death rate was 4% in the elderly group, which did not significantly differ from the non-elderly group. Cancer-specific survival was similar between the two groups. Although overall survival tended to be poor in the elderly group, it was not significantly worse than that of the non-elderly group. In conclusion, the short- and long-term outcomes of minimally invasive esophagectomy in elderly versus non-elderly patients were acceptable. Minimally invasive esophagectomy is a safe and feasible modality for elderly patients with appropriate indications.
Collapse
Affiliation(s)
- Y Sugita
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - T Nakamura
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - R Sawada
- Colorectal Surgery Department, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - G Takiguchi
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - N Urakawa
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - H Hasegawa
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - M Yamamoto
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - S Kanaji
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Y Matsuda
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - K Yamashita
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - T Matsuda
- Division of Minimally Invasive Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - T Oshikiri
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - S Suzuki
- Division of Community Medicine and Medical Network, Department of Social Community Medicine and Health Science, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Y Kakeji
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| |
Collapse
|
8
|
Madhavan A, Kamarajah SK, Navidi M, Wahed S, Immanuel A, Hayes N, Griffin SM, Phillips AW. The impact of age on patients undergoing transthoracic esophagectomy for cancer. Dis Esophagus 2021; 34:5859088. [PMID: 32556151 DOI: 10.1093/dote/doaa056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/18/2020] [Accepted: 05/23/2020] [Indexed: 12/11/2022]
Abstract
To compare long-term and short-term outcomes in patients <70 years old with those ≥ 70 years old, who underwent transthoracic esophagectomy for carcinoma. With an ageing population more patients, with increasing co-morbidities are being diagnosed with potentially curable esophageal cancer. Concerns exist regarding offering older patients esophagectomy, conversely undue prejudice may exists that may prevent surgery being offered. Consecutive patients from a single unit between January 2000 and July 2016 that underwent trans-thoracic esophagectomy with or without neoadjuvant treatment for carcinoma were included. Short-term outcomes including morbidity, mortality, length of stay and long-term survival were compared between those <70 and those ≥ 70. This study identified 992 patients who underwent esophagectomy during the study period, of which 302 (30%) ≥ 70 years old. Greater proportion ≥ 70 years old had SCC (squamous cell carcinoma) (23%) than <70 (18%) (p = 0.07). Patients ≥ 70 years old were noted to have higher ASA Grade 3 (34% vs 25%, p = 0.004) and were less likely to receive neoadjuvant treatment (64% vs 45% p<0.001). Length of stay was longer in ≥ 70 (14 vs 17 days p<0.001), and there were more complications (63% vs 75% p<0.001). In hospital mortality was higher in ≥ 70 (2% vs 5% p = 0.026). Overall survival was 50 months in <70 vs 36 months in ≥ 70 (p = <0.001). In <70s with adenocarcinoma, overall survival was 52 months vs 35 months in the ≥ 70 (p<0.001). No significant difference in survival in patients with SCC, 49 months in <70 vs 54 months in ≥ 70 (p = 0.711). Increased peri-operative morbidity and mortality combined with the reduction in the long term survival in the over 70s cohort should be addressed when counselling patients undergoing curative resection for oesophageal cancer.
Collapse
Affiliation(s)
- Anantha Madhavan
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Sivesh K Kamarajah
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Maziar Navidi
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - S Wahed
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Arul Immanuel
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Nick Hayes
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - S Michael Griffin
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | | |
Collapse
|
9
|
Lagergren J, Bottai M, Santoni G. Patient Age and Survival After Surgery for Esophageal Cancer. Ann Surg Oncol 2020; 28:159-166. [PMID: 32468352 PMCID: PMC7752878 DOI: 10.1245/s10434-020-08653-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Indexed: 01/01/2023]
Abstract
Background Esophagectomy for esophageal cancer is associated with a substantial risk of life-threatening complications and a limited long-term survival. This study aimed to clarify the controversial questions of how age influences short-term and long-term survival. Methods This population-based cohort study included almost all patients who underwent curatively intended esophagectomy for esophageal cancer in Sweden in 1987–2010, with follow-up through 2016. The exposure was age, analyzed both as a continuous and categorical variable. The probability of mortality was computed using a novel flexible parametric model approach. The reported probabilities are proper measures of the risk of dying, and the related odds ratios (OR) are therefore more suitable measures of association than hazard ratios. The outcomes were 90-day all-cause mortality, 5-year all-cause mortality, and 5-year disease-specific mortality. A novel flexible parametric model was used to derive the instantaneous probability of dying and the related OR along with 95% confidence intervals (CIs), adjusted for sex, education, comorbidity, tumor histology, pathological tumor stage, and resection margin status. Results Among 1737 included patients, the median age was 65.6 years. When analyzed as a continuous variable, older age was associated with slightly higher odds of 90-day all-cause mortality (OR 1.05, 95% CI 1.02–1.07), 5-year all-cause mortality (OR 1.02, 95% CI 1.01–1.03), and 5-year disease-specific mortality (OR 1.01, 95% CI 1.01–1.02). Compared with patients aged < 70 years, those aged 70–74 years had no increased risk of any mortality outcome, while patients aged ≥ 75 years had higher odds of 90-day mortality (OR 2.85, 95% CI 1.68–4.84), 5-year all-cause mortality (OR 1.56, 95% CI 1.27–1.92), and 5-year disease-specific mortality (OR 1.38, 95% CI 1.09–1.76). Conclusions Patient age 75 years or older at esophagectomy for esophageal cancer appears to be an independent risk factor for higher short-term mortality and lower long-term survival. Electronic supplementary material The online version of this article (10.1245/s10434-020-08653-w) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Jesper Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Matteo Bottai
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Giola Santoni
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
| |
Collapse
|
10
|
Han Y, Liu S, Guo W, Zhang Y, Li H. Clinical outcomes of oesophagectomy in elderly versus relatively younger patients: a meta-analysis. Interact Cardiovasc Thorac Surg 2020; 29:897-905. [PMID: 31765482 DOI: 10.1093/icvts/ivz208] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 07/03/2019] [Accepted: 08/01/2019] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES The surgical efficacy of oesophagectomy for elderly patients (>80 years old) is still unclear. The aim of this meta-analysis was to compare the clinical outcomes of oesophagectomy between elderly and relatively younger patients. METHODS PubMed, EMBASE and the Cochrane Library were searched for relevant studies comparing the clinical outcomes of oesophagectomy for elderly and relatively younger patients. Odds ratios were extracted to obtain pooled estimates of the perioperative effect, and hazard ratios were extracted to compare survival outcomes between the 2 cohorts. RESULTS Nine studies involving 4946 patients were included in this meta-analysis. For patients older than 80 years of age, in-hospital mortality [odds ratio (OR) 2.00, 95% confidence interval (CI) 1.28-3.13; P = 0.002] and the incidence rates of cardiac (OR 1.55, 95% CI 1.10-2.20; P = 0.01) and pulmonary (OR 1.57, 95% CI 1.11-2.22; P = 0.01) complications were higher than those of relatively younger patients. The overall postoperative complication rate (OR 1.40, 95% CI 0.82-2.40; P = 0.22) and the incidence of anastomotic leak (OR 0.92, 95% CI 0.58-1.47; P = 0.73) were not significantly different between the 2 groups. Elderly patients had a worse overall 5-year survival rate (HR 2.66, 95% CI 1.65-4.28; P < 0.001) than that of relatively younger patients. The cancer-related 5-year survival rate of elderly patients was also lower than that of relatively younger patients (HR 3.37, 95% CI 2.36-4.82; P < 0.001). CONCLUSIONS Compared with relatively younger patients, elderly patients with oesophageal cancer undergoing oesophagectomy are at higher risk of in-hospital mortality and have lower survival rates. However, there is no conclusive evidence that the overall rate of complications is elevated in elderly patients.
Collapse
Affiliation(s)
- Yu Han
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shengjun Liu
- Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wei Guo
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yajie Zhang
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hecheng Li
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| |
Collapse
|
11
|
Bakhos CT, Salami AC, Kaiser LR, Petrov RV, Abbas AE. Outcomes of octogenarians with esophageal cancer: an analysis of the National Cancer Database. Dis Esophagus 2019; 32:1-8. [PMID: 30596899 DOI: 10.1093/dote/doy128] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 10/26/2018] [Indexed: 12/11/2022]
Abstract
The optimal treatment of esophageal cancer in octogenarians is controversial. While the safety of esophagectomy has been demonstrated in elderly patients, surgery and multimodality therapy are still offered to a select group. Additionally, the long-term outcomes in octogenarians have not been thoroughly compared to those in younger patients. We sought to compare the outcomes of esophageal cancer treatment between octogenarians and non-octogenarians in the National Cancer Database (2004-2014). The major endpoints were early postoperative mortality and long-term survival. A total of 107,921 patients were identified [octogenarian-16,388 (15.2%)]. Compared to non-octogenarians, octogenarians were more likely to be female, of higher socioeconomic status, and had more Charlson comorbidities (p < 0.001 for all). Octogenarians were significantly less likely to undergo esophagectomy (11.5% vs. 33.3%; p < 0.001) and multimodality therapy (2.0% vs. 18.5%; p < 0.001), a trend that persisted following stratification by tumor stage and Charlson comorbidities. Both 30-day and 90-day mortality were higher in the octogenarian group, even after multivariable adjustment (p ≤ 0.001 for both). Octogenarians who underwent multimodality therapy had worse long-term survival when compared to younger patients, except for those with stage III tumors and no comorbidities (HR: 1.29; p = 0.153). Within the octogenarian group, postoperative mortality was lower in academic centers, and the long-term survival was similar between multimodality treatment and surgery alone (HR: 0.96; p = 0.62). In conclusion, octogenarians are less likely to be offered treatment irrespective of tumor stage or comorbidities. Although octogenarians have higher early mortality and poorer overall survival compared to younger patients, outcomes may be improved when treatment is performed at academic centers. Multimodality treatment did not seem to confer a survival advantage compared to surgery alone in octogenarians, and more prospective studies are necessary to better elucidate the optimal treatment in this patient population.
Collapse
Affiliation(s)
- C T Bakhos
- Department of Thoracic Medicine and Surgery, Temple University Hospital.,Department of Surgery, Albert Einstein Healthcare Network, Philadelphia, USA
| | - A C Salami
- Department of Surgery, Albert Einstein Healthcare Network, Philadelphia, USA
| | - L R Kaiser
- Department of Thoracic Medicine and Surgery, Temple University Hospital
| | - R V Petrov
- Department of Thoracic Medicine and Surgery, Temple University Hospital
| | - A E Abbas
- Department of Thoracic Medicine and Surgery, Temple University Hospital
| |
Collapse
|
12
|
Kanda M, Koike M, Tanaka C, Kobayashi D, Hayashi M, Yamada S, Nakayama G, Omae K, Kodera Y. Feasibility of subtotal esophagectomy with systematic lymphadenectomy in selected elderly patients with esophageal cancer; a propensity score matching analysis. BMC Surg 2019; 19:143. [PMID: 31615499 PMCID: PMC6792188 DOI: 10.1186/s12893-019-0617-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 09/30/2019] [Indexed: 11/10/2022] Open
Abstract
Background The global increase in elderly populations is accompanied by an increasing number of candidates for esophagectomy. Here we aimed to determine the postoperative outcomes after subtotal esophagectomy in elderly patients with esophageal cancer. Methods Patients (n = 432) with who underwent curative-intent transthoracic subtotal esophagectomy with 2- or 3-field lymphadenectomies for thoracic esophageal cancer were classified as follows: non-elderly (age < 75 years, n = 373) and elderly (age ≥ 75 years, n = 59) and groups. To balance the essential variables including neoadjuvant treatment and stage of progression, we conducted propensity score analysis, and clinical characteristics, perioperative course and prognosis were compared. Results After two-to-one propensity score matching, 100 and 50 patients were classified in the non-elderly and elderly groups. The elderly group had more comorbidities and lower preoperative cholinesterase activities and prognostic nutrition indexes. Although incidences of postoperative pneumonia, arrhythmia and delirium were slightly increased in the elderly group, no significant differences were observed in overall incidence of postoperative complications, rates of repeat surgery and death caused by surgery, and length of postoperative hospital stay between the two groups. There were no significant differences in disease-free and disease-specific survival as well as overall survival between the two groups. Conclusion Older age (≥75 years) had limited impact on morbidity, disease recurrence, and survival after subtotal esophagectomy. Therefore, age should not prevent older patients from benefitting from surgery.
Collapse
Affiliation(s)
- Mitsuro Kanda
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Masahiko Koike
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Chie Tanaka
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Daisuke Kobayashi
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Masamichi Hayashi
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Suguru Yamada
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Goro Nakayama
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Kenji Omae
- Department of Innovative Research and Education for Clinicians and Trainees (DiRECT), Fukushima Medical University Hospital, 1 Hikariga-oka, Fukushima, 960-1295, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| |
Collapse
|
13
|
Motoori M, Ito Y, Miyashiro I, Sugimura K, Miyata H, Omori T, Fujiwara Y, Yano M. Impact of Age on Long-Term Survival in Patients with Esophageal Cancer Who Underwent Transthoracic Esophagectomy. Oncology 2019; 97:149-154. [DOI: 10.1159/000500604] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 04/13/2019] [Indexed: 01/16/2023]
|
14
|
Schlottmann F, Strassle PD, Nayyar A, Herbella FAM, Cairns BA, Patti MG. Postoperative outcomes of esophagectomy for cancer in elderly patients. J Surg Res 2018; 229:9-14. [PMID: 29937021 DOI: 10.1016/j.jss.2018.03.050] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/09/2018] [Accepted: 03/20/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND The number of elderly patients with esophageal cancer is expected to increase. We aimed to determine the postoperative outcomes of esophagectomy for esophageal cancer in elderly patients. MATERIAL AND METHODS A retrospective, population-based analysis was performed using the National inpatient sample for the period 2000-2014. Adult patients ≥18 years old (yo) diagnosed with esophageal cancer who underwent esophagectomy during their inpatient hospitalization were included. Patients were categorized into <70 yo and ≥70 yo. Multivariable linear and logistic regressions were used to assess the potential effect of age on postoperative complications, inpatient mortality, and hospital charges. RESULTS Overall, 5243 patients were included, with 3699 (70.6%) <70 yo and 1544 (29.5%) ≥70 yo. The yearly rate of esophagectomies among patients ≥70 yo did not significantly changed during the study period (28.4% in 2000 and 26.3% in 2014, P = 0.76). Elderly patients were significantly more likely to have postoperative cardiac failure (odds ratio 1.59, 95% confidence interval [CI] 1.21, 2.09, P = 0.0009) and inpatient mortality (odds ratio 1.84, 95% CI 1.39, 2.45, P < 0.0001). Among the elderly patients, hospital charges were, on average, $16,320 greater (95% CI $3110, $29,530) than patients <70 yo (P = 0.02). The predicted probability of mortality increased consistently across age (1.5% in 40 yo, 2.5% in 50 yo, 3.6% in 60 yo, 5.4% in 70 yo, and 7.0% in 80 yo). CONCLUSIONS Elderly patients undergoing esophagectomy for cancer have a significantly higher risk of postoperative mortality and pose a higher financial burden on the health care system. Elderly patients with esophageal cancer should be carefully selected for surgery.
Collapse
Affiliation(s)
- Francisco Schlottmann
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina; Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina.
| | - Paula D Strassle
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Apoorve Nayyar
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Bruce A Cairns
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Marco G Patti
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina; Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| |
Collapse
|
15
|
Zeng Y, Liang W, Liu J, He J, Ng CSH, Liu CC, Petersen RH, Rocco G, D'Amico T, Brunelli A, Chen H, Zhi X, Dong X, Wang W, Cui F, Xiao D, Wang W, Yang W, Pan H, He J. Esophageal cancer in elderly patients: a population-based study. J Thorac Dis 2018; 10:448-457. [PMID: 29600077 DOI: 10.21037/jtd.2018.01.89] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background As the aging issue and increased elderly esophageal cancer (EC) patients, we sought to study the clinical characteristics, treatment modality and outcomes of EC patients 70 years or older compared with those younger than 70 years old. Methods The national surveillance, epidemiology, and end results (SEER) database for the period from 1973 to 2013 was analyzed. The patient and treatment characteristics were compared between the age groups. Multivariate Cox proportional hazard regression analyses were also performed to identify independent prognostic factors. Propensity-score matching analyses (PSA) regarding survival after different treatments were also performed in locoregional EC. Results Compared with the younger group, patients 70 years or older were characterized by having a higher proportion of patients with female gender, white race, localized disease, non-adenocarcinoma and without any treatment, as well as inferior overall survival (OS) [hazard ratio (HR), 1.324] and EC-specific survival (HR, 1.270). In addition, older patients shared same independent prognostic factors with younger patients, including age, histology and race. Specifically, compared with those receiving no intensive treatments, surgery alone (HR, 0.342), both surgery and RT (HR, 0.323) and RT only (HR, 0.525) were favorable among elderly patients, as confirmed by both multivariate adjustment and PSA. Conclusions Compared to younger EC patients, those 70 years or older showed distinctive clinical characteristics and inferior survival. Despite showing a higher proportion of localized disease, patients 70 years or older were less likely to be subjected to surgery or/and RT. Thus, the role of intensive treatments, which were identified as favorable factors among elderly patients in this study, warrants further investigation.
Collapse
Affiliation(s)
- Yuan Zeng
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Wenhua Liang
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Jun Liu
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Jiaxi He
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Calvin S H Ng
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Chia-Chuan Liu
- Division of thoracic surgery, Sun Yat-Sen Cancer Center, Taipei
| | - René Horsleben Petersen
- Department of Cardiothoracic Surgery, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Gaetano Rocco
- Division of Thoracic Surgical Oncology, Department of Thoracic Surgery and Oncology, Istituto Nazionale Tumori, IRCCS, Fondazione Pascale, Naples, Italy
| | - Thomas D'Amico
- Section of General Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Haiquan Chen
- Department of Thoracic Surgery, Fudan University Shanghai, china Cancer Center, Shanghai 200032, China
| | - Xiuyi Zhi
- Department of Thoracic Surgery, Beijing Xuanwu Hospital of Capital Medical University, Beijing 100053, China
| | - Xiao Dong
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang 330008, China
| | - Wei Wang
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,Research Center for Translational Medicine, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Fei Cui
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Dakai Xiao
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,Research Center for Translational Medicine, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Wenjun Wang
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,Research Center for Translational Medicine, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Wei Yang
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang 330008, China
| | - Hui Pan
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Jianxing He
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | | |
Collapse
|
16
|
|
17
|
Münch S, Heinrich C, Habermehl D, Oechsner M, Combs SE, Duma MN. Primary radio(chemo)therapy for esophageal cancer in elderly patients: are efficiency and toxicity comparable with younger patients? Eur J Med Res 2017; 22:24. [PMID: 28683820 PMCID: PMC5501408 DOI: 10.1186/s40001-017-0265-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 06/26/2017] [Indexed: 12/12/2022] Open
Abstract
Purpose In elderly patients with esophageal cancer (EC), esophagectomy is associated with an increased mortality, and therefore these patients are often treated with definite (chemo)radiation. The purpose of this study was to assess the toxicity and efficiency of definite radio(chemo)therapy in patients >75 years compared with definite radio(chemo)therapy in patients <75 years. Methods 32 patients >75 years were treated with definite radio(chemo)therapy for EC. We compared baseline parameters, efficiency and toxicity rates of these patients to 39 patients <75 years. Results Patients <75 years were more likely to receive simultaneous chemotherapy, and had a lower age-adjusted Charlson comorbidity index (ACCI). 25% of elderly patients were treated in palliative intent. There was no significant difference in progression-free survival between patient groups. No significant differences were seen for overall survival (15.7 months vs. 19.9 months; p = 0.102) and progression-free survival (10.5 months vs. 9.2 months, p = 0.470) between older patients treated with curative intent and younger patients. In addition, there were no significant differences for dysphagia and hematological side effects between elderly patients and younger patients. Conclusion Definite (chemo)radiation is a feasible therapy for elderly patients. OS and PFS in elderly patients with a curative treatment approach are comparable to younger patients and it is not associated with higher toxicity rates.
Collapse
Affiliation(s)
- Stefan Münch
- Department of Radiation Oncology, Klinik für RadioOnkologie und Strahlentherapie, Klinikum rechts der Isar/TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Christine Heinrich
- Department of Radiation Oncology, Klinik für RadioOnkologie und Strahlentherapie, Klinikum rechts der Isar/TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Practice for Radiotherapy, Norbert-Kerkel-Platz 1, 83734, Hausham, Germany
| | - Daniel Habermehl
- Department of Radiation Oncology, Klinik für RadioOnkologie und Strahlentherapie, Klinikum rechts der Isar/TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Klinik für RadioOnkologie und Strahlentherapie, Klinikum rechts der Isar/TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinik für RadioOnkologie und Strahlentherapie, Klinikum rechts der Isar/TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Oberschleißheim, Germany
| | - Marciana-Nona Duma
- Department of Radiation Oncology, Klinik für RadioOnkologie und Strahlentherapie, Klinikum rechts der Isar/TU München, Ismaninger Str. 22, 81675, Munich, Germany. .,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Oberschleißheim, Germany.
| |
Collapse
|
18
|
Liu Q, Chen J, Wen J, Yang H, Hu Y, Luo K, Tan Z, Fu J. Comparison of right- and left-approach esophagectomy for elderly patients with operable thoracic esophageal squamous cell carcinoma: a propensity matched study. J Thorac Dis 2017; 9:1883-1890. [PMID: 28839986 DOI: 10.21037/jtd.2017.06.22] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND the right- and left-approach open esophagectomies remain the general procedures among patients with operable thoracic esophageal squamous cell carcinoma (ESCC). The choice between the two approaches for elderly patients is controversial. METHODS we performed a 1:1 propensity score matching (PSM) analysis to compare the impact of right- and left-approach esophagectomies on survival and perioperative complications of elderly ESCC patients. Patients aged over 70 receiving esophagectomy to treat the thoracic ESCC were retrospectively retrieved. RESULTS a total of 276 patients were included in the study. Among them, 75 (27.2%) patients received right-approach esophagectomy. After match, 114 patients (57 pairs) undertook right or left-approach esophagectomy displayed no difference among clinicopathological characteristics. Both the overall survival (54.6% vs. 32.6%, P=0.036) and disease-free survival (52.7% vs. 20.2%, P=0.021) were significant better in right-approach group, along with better lymph node resection, and lower incidence of recurrence. However, increased incidences of postoperative pneumonia (P=0.040), respiratory failure (P=0.028), and sub-clinical anastomotic leak (P=0.032) were found in right-approach group as well, although the perioperative mortality was similar between groups. CONCLUSIONS Right-approach esophagectomy should be accepted as a preferential surgical approach for elderly patients with ESCC.
Collapse
Affiliation(s)
- Qianwen Liu
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Guangdong Esophageal Cancer Institute, Guangzhou, China
| | - Junying Chen
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Guangdong Esophageal Cancer Institute, Guangzhou, China
| | - Jing Wen
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Guangdong Esophageal Cancer Institute, Guangzhou, China
| | - Hong Yang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Guangdong Esophageal Cancer Institute, Guangzhou, China
| | - Yi Hu
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Guangdong Esophageal Cancer Institute, Guangzhou, China
| | - Kongjia Luo
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Guangdong Esophageal Cancer Institute, Guangzhou, China
| | - Zihui Tan
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Guangdong Esophageal Cancer Institute, Guangzhou, China
| | - Jianhua Fu
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Guangdong Esophageal Cancer Institute, Guangzhou, China
| |
Collapse
|
19
|
The impact of prophylactic administration of a neutrophil elastase inhibitor on the postoperative course in older patients undergoing esophagectomy for esophageal cancer: a propensity score-matched analysis. Esophagus 2017. [DOI: 10.1007/s10388-017-0571-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
|
20
|
Cavallin F, Pinto E, Saadeh LM, Alfieri R, Cagol M, Castoro C, Scarpa M. Health related quality of life after oesophagectomy: elderly patients refer similar eating and swallowing difficulties than younger patients. BMC Cancer 2015; 15:640. [PMID: 26391127 PMCID: PMC4578681 DOI: 10.1186/s12885-015-1647-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 09/11/2015] [Indexed: 01/12/2023] Open
Abstract
Background Oesophagectomy for cancer could be safe and worthwhile in selected older patients, but less is known about the effect of oesophagectomy on perceived quality of life of such delicate class of cancer patients. The aim of this study was to evaluate the impact of oesophagectomy for cancer in elderly patients in term of health-related quality of life. Methods We retrospectively evaluated all consecutive patients who underwent oesophagectomy for cancer at the Surgical Oncology Unit of the Veneto Institute of Oncology between November 2009 and March 2014. Quality of life was evaluated using EORTC C-30 and OES-18 questionnaires at admission, at discharge and 3 months after surgery. Adjusted multivariable linear mixed effect models were estimated to assess mean score differences (MDs) of selected aspects in older (≥70 years) and younger (<70 years) patients. Results Among 109 participating patients, 23 (21.1 %) were at least 70 years old and 86 (78.9 %) were younger than 70 years. Global quality of life was clinically similar between older and younger patients over time (MD 4.4). Older patients reported clinically and statistically significantly worse swallowing saliva (MD 17.4, 95 % C.I. 3.6 to 31.2), choking when swallowing (MD 13.8, 95 % C.I. 5.8 to 21.8) and eating difficulties (MD 20.1 95 % C.I. 7.4 to 32.8) than younger patients only at admission. Conclusions Early health-related quality of life perception after surgery resulted comparable in older and younger patients. This result may also be due to some predisposition of the elderly to adapt to the new status. Electronic supplementary material The online version of this article (doi:10.1186/s12885-015-1647-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Francesco Cavallin
- Surgical Oncology Unit, Regional Centre for Oesophageal Disease, Veneto Institute of Oncology IOV IRCCS, Via Gattamelata 64, 35128, Padua, Italy.
| | - Eleonora Pinto
- Surgical Oncology Unit, Regional Centre for Oesophageal Disease, Veneto Institute of Oncology IOV IRCCS, Via Gattamelata 64, 35128, Padua, Italy.
| | - Luca M Saadeh
- Surgical Oncology Unit, Regional Centre for Oesophageal Disease, Veneto Institute of Oncology IOV IRCCS, Via Gattamelata 64, 35128, Padua, Italy.
| | - Rita Alfieri
- Surgical Oncology Unit, Regional Centre for Oesophageal Disease, Veneto Institute of Oncology IOV IRCCS, Via Gattamelata 64, 35128, Padua, Italy.
| | - Matteo Cagol
- Surgical Oncology Unit, Regional Centre for Oesophageal Disease, Veneto Institute of Oncology IOV IRCCS, Via Gattamelata 64, 35128, Padua, Italy.
| | - Carlo Castoro
- Surgical Oncology Unit, Regional Centre for Oesophageal Disease, Veneto Institute of Oncology IOV IRCCS, Via Gattamelata 64, 35128, Padua, Italy.
| | - Marco Scarpa
- Surgical Oncology Unit, Regional Centre for Oesophageal Disease, Veneto Institute of Oncology IOV IRCCS, Via Gattamelata 64, 35128, Padua, Italy.
| |
Collapse
|
21
|
Liu HC, Huang WC, Chen CH, Chan ML. Radical esophagectomy in elderly patients with esophageal cancer. FORMOSAN JOURNAL OF SURGERY 2015. [DOI: 10.1016/j.fjs.2015.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
22
|
Is minimally invasive esophagectomy beneficial to elderly patients with esophageal cancer? Surg Endosc 2014; 29:925-30. [DOI: 10.1007/s00464-014-3753-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 07/11/2014] [Indexed: 10/24/2022]
|
23
|
Is surgery in the elderly for oesophageal cancer justifiable? Results from a single centre. ISRN SURGERY 2013; 2013:609252. [PMID: 24205444 PMCID: PMC3800610 DOI: 10.1155/2013/609252] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 08/14/2013] [Indexed: 12/19/2022]
Abstract
Aims. Advanced age is an identified risk factor for patients undergoing oncological surgical resection. The surgery for oesophageal cancer is associated with significant morbidity and mortality. Our aim was to study the operative management of elderly patients (≥70 years) at a single institute. Methods. The data was collected from 206 patients who have undergone operative resection of oesophageal cancer. The demographic, operative, histological, and postoperative follow-up of all patients were analysed. Results. A total of 46 patients of ≥70 years who had surgical resection for oesophageal cancer were identified. Patients ≥70 years had poor overall survival (P = 0.00). Also elderly patients with nodal involvement had poor survival (P = 0.04). Age at the time of surgery had no impact on the incidence of postoperative complication and inpatient mortality. Both the univariate and multivariate analyses showed age, nodal stage, and positive resection margins as independent prognostic factors for patients undergoing surgery for oesophageal cancer. Conclusions. Advanced age is associated with poor outcome following oesophageal resection. However, the optimisation of both preoperative and postoperative care can significantly improve outcomes. The decision of operative management should be individualised. Age should be considered as one of the factors in surgical resection of oesophageal cancer in the elderly patients.
Collapse
|
24
|
Impact of subcarinal dissection on short-term outcome and survival following esophagectomy. Am J Surg 2013; 206:314-9. [DOI: 10.1016/j.amjsurg.2012.10.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Revised: 10/26/2012] [Accepted: 10/26/2012] [Indexed: 11/21/2022]
|
25
|
Assessment of morbidity and mortality after esophagectomy using a modified frailty index. Ann Thorac Surg 2013; 96:1240-1245. [PMID: 23915593 DOI: 10.1016/j.athoracsur.2013.05.051] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 05/09/2013] [Accepted: 05/14/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Esophagectomy is associated with significant morbidity and mortality. This retrospective study examined use of a modified frailty index as a potential predictor of morbidity and mortality in esophagectomy patients. METHODS National Surgical Quality Improvement Program Participant Use Files were reviewed for 2005 through 2010. Patients undergoing esophagectomy were selected based on CPT codes. A modified frailty index with 11 variables was used to determine correlation between frailty and postesophagectomy morbidity and mortality. Data were analyzed using χ(2) test and logistic regression. RESULTS A total of 2,095 patients were included in the analysis. Higher frailty scores were associated with a statistically significant increase in morbidity and mortality. A frailty score of 0, 1, 2, 3, 4, and 5 had associated morbidity rates of 17.9% (142 of 795 patients), 25.1% (178 of 710 patients), 31.4% (126 of 401 patients), 34.4% (48 of 140 patients), 44.4% (16 of 36 patients), and 61.5% (8 of 13 patients), respectively. A frailty score of 0, 1, 2, 3, 4, and 5 had associated mortality rates of 1.8% (14 of 795 patients), 3.8% (27 of 710 patients), 4% (16 of 401 patients), 7.1% (10 of 140 patients), 8.3% (3 of 36 patients), and 23.1% (3 of 13 patients), respectively. When using multivariate logistic regression for mortality comparing age, functional status, prealbumin, emergency surgery, wound class, American Society of Anesthesiologists score, and sex, only age and frailty were statistically significant. The odds ratio was 31.84 for frailty (p = 0.015) and 1.05 (p = 0.001) for age. CONCLUSIONS Using a large national database, a modified frailty index was shown to correlate with postesophagectomy morbidity and mortality. Such an index may be used to aid in improving risk assessment and patient selection for esophagectomy.
Collapse
|
26
|
Markar SR, Karthikesalingam A, Thrumurthy S, Ho A, Muallem G, Low DE. Systematic review and pooled analysis assessing the association between elderly age and outcome following surgical resection of esophageal malignancy. Dis Esophagus 2013; 26:250-62. [PMID: 22591068 DOI: 10.1111/j.1442-2050.2012.01353.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The incidence of esophageal malignancy continues to increase worldwide. At the same time, average life expectancy levels continue to climb, ensuring that more patients will present in their 70s, 80s, and 90s. The aim of this pooled analysis is to compare short- and long-term outcomes for elderly and younger patients undergoing esophagectomy for malignancy. Studies comparing the outcomes of esophagectomy for malignancy in elderly and young cohorts of patients were included. The minimum threshold age used to define the elderly cohort was 70 years. Primary outcomes were in-hospital mortality, overall and cancer-related 5-year survival. Secondary outcomes were the length of hospital stay, the incidence of anastomotic leak, conduit ischemia, cardiac and pulmonary complications, and the use of neoadjuvant therapy. Twenty-five publications comprising 9531 and 2573 operations on younger and elderly cohorts of patients respectively were analyzed. Elderly patients were less likely to receive neoadjuvant therapy (14.6% vs. 29.47%; pooled odds ratio [POR]= 0.48; 95% confidence interval [C.I.]= 0.35-0.65; P < 0.05). Esophagectomy in elderly patients was associated with increased in-hospital mortality (7.83% vs. 4.21%; POR = 1.87; 95% C.I. = 1.54-2.26; P < 0.05), as well as increased pulmonary (21.77% vs. 19.49%) and cardiac (18.7% vs. 13.17%) complications. Subset analysis of studies using an age threshold of 80 years showed an even more significant association between in-hospital mortality and elderly age (pooled odds ratio = 3.19; 95% C.I. = 1.6-6.35; P < 0.05). There were no significant differences between the groups in length of hospital stay, incidence of anastomotic leak, or conduit ischemia. The elderly group showed reduced overall 5-year survival (21.23% vs. 29.01%; pooled odds ratio = 0.73; 95% C.I. = 0.62-0.87; P < 0.05) and reduced cancer-free 5-year survival (34.4% vs. 41.8%; POR = 0.75; 95% C.I. = 0.64-0.89; P < 0.05). Elderly patients are at increased risk of pulmonary and cardiac complications, and perioperative mortality following esophagectomy, and show reduced cancer-related 5-year survival compared with younger patients. These patients represent a high-risk cohort, who requires thorough assessment of medical comorbidity, targeted counseling, and optimized treatment pathways.
Collapse
Affiliation(s)
- S R Markar
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA 98111, USA
| | | | | | | | | | | |
Collapse
|
27
|
Tapias LF, Muniappan A, Wright CD, Gaissert HA, Wain JC, Morse CR, Donahue DM, Mathisen DJ, Lanuti M. Short and long-term outcomes after esophagectomy for cancer in elderly patients. Ann Thorac Surg 2013; 95:1741-8. [PMID: 23500043 DOI: 10.1016/j.athoracsur.2013.01.084] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 01/13/2013] [Accepted: 01/28/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND As worldwide life expectancy rises, the number of candidates for surgical treatment of esophageal cancer over 70 years will increase. This study aims to examine outcomes after esophagectomy in elderly patients. METHODS This study is a retrospective review of 474 patients undergoing esophagectomy for cancer during 2002 to 2011. A total of 334 (70.5%) patients were less than 70 years old (group A), 124 (26.2%) 70 to 79 years (group B), and 16 (3.4%) 80 years or greater (group C). We analyzed the effect of age on outcome variables including overall and disease specific survival. RESULTS Major morbidity was observed to occur in 115 (35.6%) patients of group A, 58 (47.9%) of group B, and 10 (62.5%) of group C (p = 0.010). Mortality, both 30-day and 90-day was observed in 2 (0.6%) and 7 (2.2%) of group A, 4 (3.2%) and 7 (6.1%) of group B, and 1 (6.3%) and 2 (14.3%) of group C, respectively (p = 0.032 and p = 0.013). Anastomotic leak was observed in 16 (4.8%) patients of group A, 6 (4.8%) of group B, and 0 (0%) of group C (p = 0.685). Anastomotic stricture (defined by the need for ≥ 2 dilations) was observed in 76 (22.8%) of group A, 13 (10.5%) of group B, and 1 (6.3%) of group C (p = 0.005). Five-year overall and disease specific survival was 64.8% and 72.4% for group A, 41.7% and 53.4% for group B, 49.2% and 49.2% for group C patients (p = 0.0006), respectively. CONCLUSIONS Esophagectomy should be carefully considered in patients 70 to 79 years old and can be justified with low mortality. Outcomes in octogenarians are worse suggesting esophagectomy be considered on a case by case basis. Stricture rate is inversely associated to age.
Collapse
Affiliation(s)
- Luis F Tapias
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Markar SR, Low DE. Physiology, Not Chronology, Dictates Outcomes after Esophagectomy for Esophageal Cancer: Outcomes in Patients 80 Years and Older. Ann Surg Oncol 2012; 20:1020-6. [DOI: 10.1245/s10434-012-2703-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Indexed: 11/18/2022]
|
29
|
Karakurt Z, Fanfulla F, Ceriana P, Carlucci A, Grassi M, Colombo R, Karakurt S, Nava S. Physiologic determinants of prolonged mechanical ventilation in patients after major surgery. J Crit Care 2012; 27:221.e9-16. [DOI: 10.1016/j.jcrc.2011.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Revised: 08/08/2011] [Accepted: 08/09/2011] [Indexed: 11/30/2022]
|
30
|
Patient Selection according to General Condition and Associated Disease. Updates Surg 2012. [DOI: 10.1007/978-88-470-2330-7_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
31
|
Abstract
Elderly patients constitute the largest group in oncologic medical practice, despite the fact that in solid cancers treated operatively, many patients are denied standard therapies and where such decision making is based solely on age. The “natural” assumptions that we have are often misleading; namely, that the elderly cannot tolerate complex or difficult procedures, chemotherapy, or radiation schedules; that their overall predictable medical health determines survival (and not the malignancy); or that older patients typically have less aggressive tumors. Clearly, patient selection and a comprehensive geriatric assessment is key where well-selected cases have the same cancer-specific survival as younger cohorts in a range of tumors as outlined including upper and lower gastrointestinal malignancy, head and neck cancer, and breast cancer. The assessment of patient fitness for surgery and adjuvant therapies is therefore critical to outcomes, where studies have clearly shown that fit older patients experience the same benefits and toxicities of chemotherapy as do younger patients and that when normalized for preexisting medical conditions,that older patients tolerate major operative procedures designed with curative oncological intent. At present, our problem is the lack of true evidence-based medicine specifically designed with age in mind, which effectively limits surgical decision making in disease-based strategies. This can only be achieved by the utilization of more standardized, comprehensive geriatric assessments to identify vulnerable older patients, aggressive pre-habilitation with amelioration of vulnerability causation, improvement of patient-centered longitudinal outcomes, and an improved surgical and medical understanding of relatively subtle decreases in organ functioning, social support mechanisms and impairments of health-related quality of life as a feature specifically of advanced age.
Collapse
Affiliation(s)
- Andrew P Zbar
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Tel-Aviv, Israel 52621.
| | | | | |
Collapse
|