Advanced age does not exclude lobectomy for non-small cell lung carcinoma

[Immediate results of angio- and bronchoplastic lobectomies for non-small cell lung carcinoma in patients over 70 years old]

OBJECTIVE

To study the immediate results of angio- and bronchoplastic lobectomies for non-small cell lung carcinoma (NSCLC) in patients over 70 years old.

MATERIAL AND METHODS

Thirty-one extended angio- and/or bronchoplastic lobectomies were performed in patients with NSCLC over 70 years old between January 2015 and December 2020. Mean age of patients was 74.5 ± 3.2 years. NSCLC stage IA was found in 5 (16.1%) cases, IB - 11 (35.5%), IIA - 12 (38.7%), IIB - 3 (9.7%) patients. Squamous cell carcinoma was diagnosed in 19 (61.3%) patients, adenocarcinoma - in other ones (n=12). All patients had concomitant diseases with predominance of cardiorespiratory pathology. Severity of postoperative complications was assessed according to the Clavien - Dindo grading system.

RESULTS

Mean Charlson index was 5.34 ± 1.46 scores. ASA grade III was observed in 21 patients, grade IV - in 10 patients. Postoperative complications occurred in 12 (38.7%) patients, mortality rate was 6.4%. Prolonged air discharge through pleural drainage tubes (12.9%) and paroxysms of atrial fibrillation (16.1%) were the most common complications. Cardiac arrhythmia is a serious and fatal complication.

CONCLUSION

Anatomical lung resections for NSCLC in patients over 70 years old have certain features of surgical technique and postoperative management. Prevention and prediction of postoperative complications along with rational perioperative management are of priority importance for increasing the safety of these interventions. Angio- and/or bronchoplastic lobectomy should be considered as the only surgical option characterized by high quality and satisfactory immediate results. This procedure is an adequate alternative to pneumonectomy.

Oncologic Outcomes of Surgery Versus SBRT for Non-Small-Cell Lung Carcinoma: A Systematic Review and Meta-analysis

BACKGROUND

The optimal treatment of stage I non-small-cell lung carcinoma is subject to debate. The aim of this study was to compare overall survival and oncologic outcomes of lobar resection (LR), sublobar resection (SR), and stereotactic body radiotherapy (SBRT).

METHODS

A systematic review and meta-analysis of oncologic outcomes of propensity matched comparative and noncomparative cohort studies was performed. Outcomes of interest were overall survival and disease-free survival. The inverse variance method and the random-effects method for meta-analysis were utilized to assess the pooled estimates.

RESULTS

A total of 100 studies with patients treated for clinical stage I non-small-cell lung carcinoma were included. Long-term overall and disease-free survival after LR was superior over SBRT in all comparisons, and for most comparisons, SR was superior to SBRT. Noncomparative studies showed superior long-term overall and disease-free survival for both LR and SR over SBRT. Although the papers were heterogeneous and of low quality, results remained essentially the same throughout a large number of stratifications and sensitivity analyses.

CONCLUSION

Results of this systematic review and meta-analysis showed that LR has superior outcomes compared to SBRT for cI non-small-cell lung carcinoma. New trials are underway evaluating long-term results of SBRT in potentially operable patients.

Sublobar resection versus lobectomy in Surgical Treatment of Elderly Patients with early-stage non-small cell lung cancer (STEPS): study protocol for a randomized controlled trial

Background

The appropriateness of lobectomy for all elderly patients is controversial. Meanwhile, sublobar resection is associated with reduced operative risk, better preservation of pulmonary function, and a better quality of life, constituting a potential alternative to standard lobectomy for elderly patients with early-stage non-small cell lung cancer (NSCLC). To date, no randomized trial comparing sublobar resection and lobectomy focusing on elderly patients has been reported. We hypothesized that for patients at least 70 years old with clinical stage T1N0M0 NSCLC, sublobar resection is non-inferior to lobectomy for 3-year disease-free survival (DFS).

Methods/design

This is a prospective, randomized, controlled multicenter non-inferiority trial with two study arms: sublobar resection and lobectomy groups. Comprehensive geriatric assessments will be acquired for each patient. A total of 339 subjects will be enrolled on the basis of power calculations, and participants followed up every 6 months post-operation for 3 years. In case of relapse, survival follow-up will be continued until 5 years or death. Pulmonary function testing will be performed at 6, 12, and 36 months post-operation. The primary outcome is 3-year DFS; secondary endpoints include peri-operative complications and mortality, hospitalization time, post-operative ventilator time, overall survival, 3-year recurrence rates, post-operative pulmonary function, quality of life, geriatric assessment data, and 4-year mortality index.

Discussion

The present study is the only prospective, multicenter, randomized controlled trial comparing sublobar resection and lobectomy for elderly patients. The therapeutic outcomes of sublobar resection will be evaluated in comparison with lobectomy for elderly patients (≥70 years) with early-stage NSCLC.

Trial registration number

NCT02360761: 01/24/2015 (ClinicalTrials.gov)

Influence of Pulmonary Rehabilitation on Lung Function Changes After the Lung Resection for Primary Lung Cancer in Patients with Chronic Obstructive Pulmonary Disease

Influence of physiotherapy on the outcome of the lung resection is still controversial. Study aim was to assess the influence of physiotherapy program on postoperative lung function and effort tolerance in lung cancer patients with chronic obstructive pulmonary disease (COPD) that are undergoing lobectomy or pneumonectomy. The prospective study included 56 COPD patients who underwent lung resection for primary non small-cell lung cancer after previous physiotherapy (Group A) and 47 COPD patients (Group B) without physiotherapy before lung cancer surgery. In Group A, lung function and effort tolerance on admission were compared with the same parameters after preoperative physiotherapy. Both groups were compared in relation to lung function, effort tolerance and symptoms change after resection. In patients with tumors requiring a lobectomy, after preoperative physiotherapy, a highly significant increase in FEV1, VC, FEF50 and FEF25 of 20%, 17%, 18% and 16% respectively was registered with respect to baseline values. After physiotherapy, a significant improvement in 6-minute walking distance was achieved. After lung resection, the significant loss of FEV1 and VC occurred, together with significant worsening of the small airways function, effort tolerance and symptomatic status. After the surgery, a clear tendency existed towards smaller FEV1 loss in patients with moderate to severe, when compared to patients with mild baseline lung function impairment. A better FEV1 improvement was associated with more significant loss in FEV1. Physiotherapy represents an important part of preoperative and postoperative treatment in COPD patients undergoing a lung resection for primary lung cancer.

Outcome of VATS Lobectomy for Elderly Non-Small Cell Lung Cancer: A Propensity Score-Matched Study

PURPOSE

To analyze the short-term and long-term outcome of video-assisted thoracic surgery (VATS) lobectomy for elderly patients with non-small cell lung cancer.

METHODS

105 patients aged ≥75 years with resected non-small cell lung cancer were matched with 105 younger patients by propensity score. Survival rates were calculated by the Kaplan-Meier method. The cumulative incidence functions of conditional survival rate according to the age of the patients were calculated by competing risk analysis.

RESULTS

patients ≥75 years was associated with higher postoperative complication rate (p <0.001), but similar perioperative death rate (p = 0.006). Patients ≥75 years were less likely to receive adjuvant chemotherapy (p <0.001). The 5-year overall survival rates were 54.6% for patients ≥75 years and 74.1% for patients <75 years (p = 0.001). No difference was seen in disease-free survival rate (59.5% vs. 71.9% respectively = 0.117). The cumulative incidence functions of 5-year cancer-specific death were similar between the two groups (28.7% vs. 24.6% respectively, p = 0.106). The cumulative incidence functions of 5-year non-cancer-specific death was significantly higher in the elderly group (18.7% vs. 1.0%, p <0.001).

CONCLUSIONS

VATS lobectomy for non-small-cell lung cancer in patients ≥75 years were feasible with increased morbidity but similar mortality. The resected elderly patients were more frequently associated with non-cancer-specific death.

Resolution of a life-threatening complication after lung radiofrequency ablation

Lung radiofrequency ablation (RFA) is an option for the treatment of unresectable lung cancer. Clinical investigators have previously warned against severe complications associated with this procedure. We report a case of life-threatening complication after lung RFA for non-operable non-small-cell lung cancer consisting of pulmonary abscess evolving into a bronchopleural fistula, severe pneumothorax and septic pleuritis, which was successfully treated with a multimodal conservative approach.

Evaluation and management of elderly patients with lung cancer

Most patients diagnosed with lung cancer are older than 65 years. Advancing age is associated with increased medical and psychosocial issues that increase the complexity of care. This article provides a summary and update of work-up and management of elderly patients with lung cancer. Patient-related prognostic factors with attention to assessment of comorbidity in lung cancer patients are reviewed. Recent literature regarding toxicity and advances in locoregional and systemic therapies are reviewed, with recommendations for management.

Short-term outcomes after thoracoscopic lobectomy in elderly compared to younger patients

OBJECTIVE

: As the population continues to age, more benign and malignant lung lesions requiring surgical intervention are being identified in elderly patients. Historically, advanced age has been used to justify performing wedge resection rather than a lobectomy in elderly patients. The introduction of thoracoscopic surgery has resulted in improved short-term outcomes compared with thoracotomy. The objective of this study is to compare short-term outcomes of thoracoscopic lung resection in elderly patients to that in younger patients.

METHODS

: A retrospective review was performed of all patients undergoing thoracoscopic anatomic lobectomy without previous chemotherapy or radiation between April 2006 and April 2009. Patient charts were reviewed to determine risk factors, perioperative complications, and length of stay. Student's t test was used for comparison between groups.

RESULTS

: Over the period studied, 86 patients underwent thoracoscopic lobectomy. Forty of them were 70 years or older. Baseline pulmonary function testing showed an average FEV1 of 85% predicted (81% younger vs 90% older, P = nonsignificant). Median chest tube duration was 3 days and median length of stay was 4 days in both groups. The overall incidence of perioperative complications was 21% and was not different in the two groups (20% younger vs 22% older).

CONCLUSIONS

: Elderly patients with good baseline pulmonary function tolerate thoracoscopic lobectomy as well as younger patients. Advanced age alone should not be considered a contraindication to lobectomy in the era of thoracoscopy. Elderly patients should be offered lobectomy rather than wedge resection on the basis of the same criteria used in younger patients.

Are we treating enough elderly patients with early stage non-small cell lung cancer?

Despite the fact that non-small-cell lung cancer (NSCLC) is very common in the older population, these patients are frequently underrepresented in clinical trials evaluating new anti-cancer agents, and thus it is difficult to reach evidence-based recommendations for this special population. The purpose of the present paper is to present the currently available evidence regarding treatment of early-stages of NSCLC in older patients. Although, age is still considered as a negative factor influencing treatment decisions and curative cancer-directed surgery is often omitted in the older population several studies support that surgical resection is feasible in the older patient and that age per se is not a contraindication for various surgical procedures. Pneumonectomy is associated with a higher mortality in the older population and this issue should be taken into account when deciding whether a patient is suitable for pneumonectomy. Older patients should be considered for adjuvant chemotherapy after surgical resection although little information is available regarding the real benefit and tolerability of these regimens for patients over 75 years of age. Given the lack of demonstrated benefit for the use of adjuvant RT it is also not recommended in older population.

Lung function changes and complications after lobectomy for lung cancer in septuagenarians

BACKGROUND:

In septuagenarians, lobectomy is the preferable operation, with lower morbidity than for pneumonectomy. However, the 1-year impact of lobectomy on lung function has not been well studied in elderly patients.

MATERIALS AND METHODS:

Retrospective study including 30 patients 70 years or older (study group), 25 patients with chronic obstructive pulmonary disease (COPD) under 70 years (control group 1), and 22 patients under 70 years with normal lung function (control group 2) operated for lung cancer in a 2-year period. The study and control groups were compared related to lung function changes after lobectomy, operative morbidity, and mortality.

RESULTS:

Postoperative lung function changes in the elderly followed the similar trend as in patients with COPD. There were no significant differences between these two groups related to changes in forced expiratory volume in the first second (FEV₁) and vital capacity (VC). Unlike that, the pattern of the lung function changes in the elderly was significantly different compared with patients with normal lung function. The mean postoperative decrease in FEV₁ was 14.16% in the elderly, compared with a 29.23% decrease in patients with normal lung function (P < 0.05). In the study and control groups, no patients died within the first 30 postoperative days. The operative morbidity in the elderly group was significantly lower than in patients with COPD (23.3% vs. 60%).

CONCLUSIONS:

The lung function changes after lobectomy in the elderly are similar to those in patients with COPD. The explanation for such a finding needs further investigation. Despite a high proportion of concomitant diseases, the age itself does not carry a prohibitively high risk of operative mortality and morbidity.

EORTC Elderly Task Force and Lung Cancer Group and International Society for Geriatric Oncology (SIOG) experts' opinion for the treatment of non-small-cell lung cancer in an elderly population

Non-small-cell lung cancer (NSCLC) represents a common health issue in the elderly population. Nevertheless, the paucity of large, well-conducted prospective trials makes it difficult to provide evidence-based clinical recommendations for these patients. The present paper reviews the currently available evidence regarding treatment of all stages of NSCLC in elderly patients. Surgery remains the standard for early-stage disease, though pneumonectomy is associated with higher incidence of postoperative mortality in elderly patients. Given the lack of demonstrated benefit for the use of adjuvant radiotherapy, it is also not recommended in elderly patients. Elderly patients seem to derive the same benefit from adjuvant chemotherapy as younger patients do, with no significant increase in toxicity. For locally advanced NSCLC, concurrent chemoradiotherapy may be offered to selected elderly patients as there is a higher risk for toxicity reported in the elderly population. Third-generation single-agent treatment is considered the standard of care for patients with advanced/metastatic disease. Platinum-based combination chemotherapy needs to be evaluated in prospective trials. Unfortunately, with the exception of advanced/metastatic NSCLC, prospective elderly-specific NSCLC trials are lacking and the majority of recommendations made are based on retrospective data, which might suffer from selection bias. Prospective elderly-specific trials are needed.

Inadequate access to surgeons: reason for disparate cancer care?

OBJECTIVE

To compare the likelihood of seeing a surgeon between elderly dually eligible non-small-cell lung cancer (NSCLC) and colon cancer patients and their Medicare counterparts. Surgery rates between dually eligible and Medicare patients who were evaluated by a surgeon were also assessed.

METHODS

We used statewide Medicaid and Medicare data merged with the Michigan Tumor Registry to extract a sample of patients with a first primary NSCLC (n = 1100) or colon cancer (n = 2086). The study period was from January 1, 1997 to December 31, 2000. We assessed the likelihood of a surgical evaluation using logistic models that included patient characteristics, tumor stage, and census tracts. Among patients evaluated by a surgeon, we used logistic regression to predict if a resection was performed.

RESULTS

Dually eligible patients were nearly half as likely to be evaluated by a surgeon as Medicare patients (odds ratio [OR] = 0.49; 95% confidence interval = 0.32, 0.77 and odds ratio = 0.59; 95% confidence interval = 0.41, 0.86 for NSCLC and colon cancer patients, respectively). Among patients who were evaluated by a surgeon, the likelihood of resection was not statistically significantly different between dually eligible and Medicare patients.

CONCLUSIONS

This study suggests that dually eligible patients, in spite of having Medicaid insurance, are less likely to be evaluated by a surgeon relative to their Medicare counterparts. Policies and interventions aimed toward increasing access to specialists and complete diagnostic work-ups (eg, colonoscopy, bronchoscopy) are needed.

Treatment and survival differences in older Medicare patients with lung cancer as compared with those who are dually eligible for Medicare and Medicaid

PURPOSE

This study compares non-small-cell lung cancer (NSCLC) treatments provided to older patients (age > or = 66 years) who are dually eligible for Medicare and Medicaid with treatments provided to similar patients who are insured by Medicare. We extend the analysis to include a comparison of survival rates between Medicare and dually eligible patients. Dual eligibility is associated with low socioeconomic status. However, Medicaid coverage in addition to Medicare removes many financial barriers to care.

PATIENTS AND METHODS

The sample included 2,626 older patients with local and regional stage NSCLC diagnosed between 1997 and 2000. Four outcomes were studied: the likelihood of receiving resection, chemotherapy, radiation therapy, and survival (perioperative and longer-term). Logistic regression was used to predict the likelihood of treatment, and stratified and multivariate analyses were used to evaluate differences in survival.

RESULTS

Dually eligible patients were half as likely to undergo resection as Medicare patients (P < .001) and were more likely to receive radiation than Medicare patients. Stratified and multivariate analyses showed that surgically treated dually eligible patients had slightly inferior survival as compared with that of Medicare patients. Survival was equivalent among patients who did not undergo resection, regardless of insurance coverage.

CONCLUSION

Older dually eligible patients with NSCLC had a lower likelihood of undergoing resection despite controls for socioeconomic factors and comorbidities. However, if such patients were surgically treated, survival improved substantially, but it remained inferior to the survival of Medicare patients. Additional research is needed to understand why resection rates were substantially lower among dually eligible patients.

A retrospective analysis of short and long-term survival after curative pulmonary resection for lung cancer in elderly patients

In this retrospective study we analyzed the age-related mortality and the long-term survival of a total of 2021 subjects (male: n=1509; female: n=512) who underwent major pulmonary resections (lobectomy, pneumonectomy) in curative intention for primary non-small cell lung cancer (NSCLC). As controls, patients were divided into three groups of age: subjects >75 years of age (n=119), subjects 65-75 years of age (n=587) and subjects <65 years of age (n=1315). Overall mortality after lobectomy was 1.4% (21/1505 patients); age-related mortality was 0.9% (n=8/919) in subjects aged <65 years, 1.9% (n=9/486) in subjects aged 65-75 years, and 4.0% (n=4/100) in subjects aged >75 years. Overall mortality after pneumonectomy was 4.3% (22/516 patients); age-related mortality was 3.0% (n=12/396) in subjects aged <65 years, 7.9% (n=8/101) in subjects aged 65-75 years, 10.5% (n=2/19) in subjects aged >75 years. The overall 5-year survival rates were 52.5% (age: <65 years), 45.8% (age: 65-75 years), and 50% (age: >75 years). There was no significant difference in overall survival between age groups. However, an impaired performance status (ECOG status grades 1-3) had a significant negative impact on survival in subjects >65 years (p=0.017), and in subjects >75 years (p=0.002). We conclude, medically fit elderly patients should not be denied surgery of resectable non-small cell lung cancer based on their chronologic age alone. Curative pulmonary resections due to lung cancer can be performed safely in those elderly patients that are fulfilling the common criteria of operability.

Complications after lung radiofrequency ablation: risk factors for lung inflammation

This retrospective study was conducted to review the complications of lung radiofrequency (RF) ablation and to clarify the effects of inflammation after lung RF ablation on mortality and morbidity. Complications were evaluated by reviewing medical records on an RF session basis. The C-reactive protein (CRP) value was used as an indicator of inflammation and was measured before and every 1-2 days during the hospital stay after RF ablation. The relationships between CRP values and patient baselines were evaluated to identify factors affecting lung inflammation. 130 patients who underwent 327 lung RF ablation sessions were enrolled in this study. The major complication rate was 18.3% (60/327). Inflammation-related complications such as interstitial pneumonia (n = 2) and aseptic pleuritis (n = 2) developed in four sessions (1.2%). Death occurred in two patients with interstitial pneumonia (0.6%). The mean CRP value increased significantly from 1.3+/-2.6 mg dl(-1) to 3.4+/-5.6 mg dl(-1) (p<0.01) after RF ablation. Large tumour size (>or=2 cm) and previous external-beam radiotherapy were significant factors associated with an increased CRP value in both univariate and multivariate analyses. In conclusion, although the incidence rate is low, fatal lung inflammation may develop after lung RF ablation. Large tumour size and previous external-beam radiotherapy are risk factors for severe lung inflammation.

Treatment of lung cancer in older patients

Lung cancer is a disease of older persons. It is the most common cause of cancer death in men and women in the United States. A comprehensive evaluation of medical comorbidities and functional status is important in all patients but perhaps more so in older adults, and it should be included in the assessment of older patients who have lung cancer. Age, per se, should not be a limiting factor to treatment, because a large body of evidence demonstrates that fit older patients who have lung cancer can safely undergo the same treatments as their younger counterparts with equally good results.

Open lobectomy for patients with stage I non-small cell lung cancer

Until additional multi-institutional, randomized, controlled trials provide evidence to the contrary, open lobectomy with mediastinal lymphadenectomy should be considered the gold standard for treating patients with stage I NSCLC with sufficient cardiopulmonary reserve, including older patients. It is the operation with which alternative pulmonary resections, including video-assisted thoracoscopic lobectomy and sublobar resection, should be compared. In treating stage I NSCLC patients, sublobar resection should be reserved for patients with inadequate physiologic reserve to tolerate lobectomy and for those enrolled in clinical trials.

Pulmonary resection in the elderly

PURPOSE OF REVIEW

With increasing longevity, altered demographics of the lung cancer population, and preoperative interventions to enhance the efficacy of surgical therapy, increasing numbers of elderly people will present for anesthesia and pulmonary resection.

RECENT FINDINGS

The geriatric population often exhibits wide disparity between chronologic and physiologic senescence which is underscored by data indicating that outcome following lung resection for cancer is influenced more by tumor stage, preoperative functional status and comorbidities than age alone. Nonetheless, the normal process of cardiopulmonary aging can limit the physiological reserve necessary to compensate for perioperative stress even in otherwise healthy elderly patients. Data indicate a relatively favorable risk-benefit relationship for lung resection in the elderly given the poor prognosis for patients undergoing palliative care or chemotherapy or radiation alone. Emerging experience now suggests that minimally invasive surgical techniques for the treatment of lung cancer may parallel conventional thoracotomy in terms of oncologic efficacy while decreasing perioperative morbidity in the elderly.

SUMMARY

The combination of an aging population, recent advances in neoadjuvant therapies, data supporting the oncologic efficacy of resection, and minimally invasive surgical techniques strongly suggests that more elderly patients will be candidates for surgical management of their lung cancer, thus presenting anesthesiologists with unique challenges.