Resection for lung cancer in the elderly patient

Are Extensive Open Lung Resections for Elderly Patients with Lung Cancer Justified?

BACKGROUND

Older patients with malignancies are more comorbid than younger ones and are usually undertreated only because of their age. The aim of this study is to investigate the safety of open anatomical lung resections for lung cancer in elderly patients.

METHODS

We retrospectively analyzed all patients who underwent lung resection for lung cancer in our institution and categorized them into two groups: the elderly group (≥70 years old) and the control (<70).

RESULTS

In total, 135 patients were included in the elderly group and 375 in the control. Elderly patients were more frequently diagnosed with squamous cell carcinoma (59.3% vs. 51.5%, p = 0.037), higher differentiated tumors (12.6% vs. 6.4%, p = 0.014), and at an earlier stage (stage I: 55.6% for elderly vs. 36.6%, p = 0.002). Elderly patients were more vulnerable to postoperative pneumonia (3.7% vs. 0.8%, p = 0.034), lung atelectasis (7.4% vs. 2.9%, p = 0.040), and pleural empyema (3.2% vs. 0%, p = 0.042), however, with no increased 30-day-mortality (5.2% for elderly vs. 2.7%, p = 0.168). Survival was comparable in both groups (43.4 vs. 45.3 months, p = 0.579).

CONCLUSIONS

Elderly patients should not be excluded from open major lung resections as the survival benefit is not reduced in selected patients.

Management of Lung Cancer in the Elderly

Lung cancer is the leading cause of cancer-associated mortality in the USA. The median age at diagnosis of lung cancer is 70 years, and thus, about one-half of patients with lung cancer fall into the elderly subgroup. There is dearth of high level of evidence regarding the management of lung cancer in the elderly in the three broad stages of the disease including early-stage, locally advanced, and metastatic disease. A major reason for the lack of evidence is the underrepresentation of elderly in prospective randomized clinical trials. Due to the typical decline in physical and physiologic function associated with aging, most elderly do not meet the stringent eligibility criteria set forth in age-unselected clinical trials. In addition to performance status, ideally, comorbidity, cognitive, and psychological function, polypharmacy, social support, and patient preferences should be taken into account before applying prevailing treatment paradigms often derived in younger, healthier patients to the care of the elderly patient with lung cancer. The purpose of this chapter was to review the existing evidence of management of early-stage, locally advanced disease, and metastatic lung cancer in the elderly.

Comparison of short and long-term results between sleeve resection and pneumonectomy in lung cancer patients over 70 years old: 10 years experience from a single institution in China

BACKGROUND

The aim of this study was to compare the short and long-term results between sleeve resection (SR) and pneumonectomy (PN) in lung cancer patients over 70 years of age.

METHODS

We retrospectively reviewed 105 lung cancer patients over 70 years of age who had undergone SR or PN at Shanghai Chest Hospital from January 2003 to December 2012.

RESULTS

The SR group showed a higher frequency of airway clearance via bronchoscopy (48.6% vs. 25.7%, P = 0.04), longer surgical time (162.7 vs. 140.9 minutes, P = 0.01), and shorter postoperative stay (13.7 vs. 18.1 days, P = 0.02) than the PN group. There was no difference in hospital mortality (P = 1.00) or morbidity (P = 0.40) between the two groups. A logistic regression model showed that preoperative predicted forced expiratory volume in 1 second was the only independent risk factor for overall morbidity (P = 0.04). In survival analysis, SR showed better prognosis than PN (median 50.0 vs. 20.0 months, P < 0.01). In subgroup analysis, SR showed better survival in N0 (P = 0.03) and N1 (P < 0.01) cases, but not in N2 cases (P = 0.36). It also showed better survival in stage I + II patients (P = 0.03), but not in stage III patients (P = 0.10).

CONCLUSIONS

Although PN could be carried out as safely as SR in patients over 70 years of age with a good pulmonary reservoir, SR is still recommended as a less traumatic procedure, sparing lung parenchyma with better long-term results.

Surgical considerations in older adults with cancer

PURPOSE

The aging of the population is a real concern for surgical oncologists, who are increasingly being asked to treat patients who would not have been considered for surgery in the past. In many cases, decisions are made with relatively little evidence, most of which was derived from trials in which older age was a limiting factor for recruitment.

METHODS

This review focuses on risk assessment and perioperative management. It describes the relationship between age and outcomes for colon, lung, hepatobiliary, and head and neck cancer, which are predominantly diseases of the elderly and are a major cause of morbidity and mortality.

RESULTS

Effective surgery requires safe performance as well as reasonable postoperative life expectancy and maintenance of quality of life. Treatment decisions for potentially vulnerable elderly patients should take into account data obtained from the evaluation of geriatric syndromes, such as frailty, functional and cognitive limitations, malnutrition, comorbidities, and polypharmacy, as well as social support. Postoperative care should include prevention and treatment of complications seen more frequently in the elderly, including postoperative delirium, functional decline, and the need for institutionalization.

CONCLUSION

Surgery remains the best modality for treatment of solid tumors, and chronologic age alone should not be a determinant for treatment decisions. With adequate perioperative risk stratification, functional assessment, and oncologic prognostication, elderly patients with cancer can do as well in terms of morbidity and mortality as their younger counterparts. If surgery is determined to be the appropriate treatment modality, patients should not be denied this option because of their age.

Thoracic surgery in octogenarians: CVTSA/Inova Fairfax hospital experience, 1990 to 2009

With an increasing proportion of U.S. individuals 80 years of age or older, the authors examined their surgical experience with octogenarians undergoing major, curative-intent thoracic surgery. Between January 1, 1990, and September 1, 2009, 102 octogenarians underwent curative-intent resection for nonsmall cell carcinoma of the lung (NSCCL), esophageal carcinoma (EC), or related surgery for thoracic esophageal perforation (EP). Analysis and reporting followed the guidelines of the Nationwide Inpatient Sample database study (1994 to 2003). Eighty-six patients underwent curative-intent resection for NSCCL, 12 for EC, and four for surgery for EP. Hospital and 30-day mortalities were 0 per cent. Overall 1-, 2-, and 5-year survival rates were: 78, 58, and 32 per cent. Within the NSCCL cohort, minimally invasive exposures (video-assisted thoracic surgery [VATS] and video thoracoscopy [VT]) were associated with fewer and shorter duration of air leaks, leading to shorter length of stay. Since we began using minimally invasive exposure for NSCCL in 2007, the percentage of octogenarians discharged within 5 days of surgery has increased from 35.5 to 66.7 per cent (P = 0.01), and the percentage of patients discharged within 3 days of surgery has increased from 8.1 to 33.3 per cent (P = 0.006). Of 24 patients undergoing surgery for NSCCL since 2007, 18 (75%) underwent minimally invasive (VATS or VT) exposures, of which 15 patients (83.3%) were discharged home within 5 days and eight (44.4%) within 3 days of their procedure. Excellent, short- and longer-term results can be achieved in elderly patients if risks, exposures, and resections are appropriately matched to patient performance.

The Surgical Management of Lung Cancer

Since the introduction of the pneumonectomy as a technically feasible strategy for the treatment of lung cancer, surgical resection has played a pivotal role in the management of early stage non-small cell lung carcinoma (NSCLC). In the last two decades, surgical, medical, and radiation oncologists have produced a growing body of evidence to support the combination of neoadjuvant or adjuvant treatments with standard surgical resection, to improve disease-free and overall survival for specific patient subgroups. Furthermore, alternatives to aggressive surgical management have evolved for patients who are medically inoperable due to compromised pulmonary function or other comorbidities. In this review, surgical options and multimodal treatment strategies are discussed, as well as completed and ongoing clinical trials addressing the surgical management of NSCLC.

Carbon ion radiotherapy for elderly patients 80 years and older with stage I non-small cell lung cancer

Surgical resection is the standard treatment for stage I non-small cell lung cancer (NSCLC). However, elderly patients with NSCLC often suffer from other conditions, such as chronic obstructive pulmonary disease (COPD) or cardiovascular disease, and are not suitable candidates for surgery. Different modalities to treat stage I NSCLC have been developed, such as stereotactic radiotherapy (SRT), proton beam radiotherapy and carbon ion radiotherapy (CIRT). Between April 1999 and November 2003, we treated 129 patients with stage I NSCLC using CIRT. In this study, we focused on 28 patients aged 80 years and older who underwent CIRT, and analyzed the effectiveness of CIRT in treating their lung cancer and the impact on their activity of daily life (ADL). The 5-year local control rate for these patients was 95.8%, and the 5-year overall survival rate was 30.7%, but there were no patients who started home oxygen therapy or had decreased ADL. Our data demonstrate that CIRT was effective in treating elderly patients with stage I NSCLC.

Comorbidity in older surgical cancer patients: influence on patient care and outcome

Evidence is scarce about the influence of comorbidity on outcome of surgery, whereas this information is highly relevant for estimating the surgical risk of cancer patients, and for optimising pre-, peri- and postoperative care. In this paper, the prognostic role of increasing age and comorbid conditions in patients diagnosed with stage I-III colorectal, stage I-II NSCLC or stage I-III breast cancer between 1995 and 2004 in the southern part of the Netherlands is summarised. Almost all patients with stage I-III colon cancer or rectal cancer underwent surgery regardless of age or comorbidity. In contrast, the resection rate among elderly patients with stage I-II NSCLC was clearly lower than among younger patients and was significantly lower when COPD, cardiovascular diseases or diabetes were present. Among patients with stage I-III breast cancer, those aged 80 or older underwent less surgery, and the resection rate appeared to be lower when cardiovascular diseases or diabetes were present. Among patients with resected colorectal cancer, postoperative morbidity and mortality were higher among those undergoing emergency surgery, and also among those with reduced pulmonary function, cardiovascular disease or neurological comorbidity. Among those with resected NSCLC, postoperative morbidity and mortality were related to reduced pulmonary function or cardiovascular disease. Since surgery for breast cancer is low risk, elective surgery, morbidity and mortality were not higher for elderly or those with comorbidity. Among patients with colorectal or breast cancer, comorbidity in general, cardiovascular diseases, COPD, diabetes (only colon and breast cancer) and venous thromboembolism had a negative effect on overall survival, whereas the effect of comorbidity on survival of stage I-II NSCLC was less clear. Elderly and those with comorbidity (especially cardiovascular diseases and COPD) among colorectal cancer and NSCLC patients had more postoperative morbidity and mortality. Prospective randomised studies are needed for refining selection criteria for surgery in elderly cancer patients and for anticipation and prevention of complications.

Surgery of non-small cell lung cancer in the elderly

PURPOSE OF REVIEW

The aim of this review is to analyze recent evidence for optimal treatment of elderly patients with non-small cell lung cancer, focusing on surgery, and possibly to foresee the future strategies to apply in these patients.

RECENT FINDINGS

Surgery in elderly patients affected by non-small cell lung cancer is safe and feasible when careful preoperative respiratory and cardiac studies have been carried out and the disease has been properly staged. The surgical treatment is not to be denied in elderly patients due to age per se, but when a major contraindication to surgery has been recognized. Long term survival for elderly patients with early stage lung cancer treated by anatomical pulmonary resection is comparable to the survival rate of younger patients. Pneumonectomy, extended surgical procedure or preoperative induction chemotherapy are major risk factors for an increased postoperative morbidity and mortality rate. When co-morbidities are present or a patient is 80 years or older, there is evidence that a non-anatomical resection can be performed without affecting long-term results.

SUMMARY

Due to the aging of the general population, elderly patients will become a large percentage of the cases of non-small cell lung cancer to be treated. Implementing preoperative cardiologic studies and redefining selective respiratory criteria specifically could dramatically improve results.

Problems in pathologic staging of lung cancer

CONTEXT

Tumor stage is the most important prognostic and predictive factor for patients with lung cancer, the most lethal neoplasm in the United States. It is used by thoracic surgeons, radiation therapists, and oncologists to determine whether patients with these neoplasms will be treated surgically with curative intent or with palliative radiation therapy and/or chemotherapy.

OBJECTIVE

To review the variety of practical problems that can arise during the assessment of the pathologic stage and other prognostic/predictive factors included in the College of American Pathologist checklist for evaluation of resected lung neoplasms.

DATA SOURCES

Potential practical difficulties that can arise during the pathologic staging of lung cancer patients include the distinction between pT1, pT2, and pT3 lesions based on their location and the presence of visceral pleura and/or parietal pleura invasion; the differential diagnosis between multiple synchronous or metachronous primary lung neoplasms (pT1m) and intrapulmonary metastasis of non-small cell carcinoma of the lung (pT4 or pM1 according to their location); and the role of the recent American Joint Committee on Cancer terminology for the classification of lymph nodes (isolated tumor cells, micrometastases, and metastases).

CONCLUSIONS

The variety of practical problems that can arise during the assessment of important prognostic and predictive features such as resection margin status and evaluation of lymphovascular invasion are reviewed. A brief discussion of the assessment of the effects of neoadjuvant therapy on resected lung neoplasms is also included.