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Interact CardioVasc Thorac Surg 2009;9:274-277. doi:10.1510/icvts.2008.199455 © 2009 European Association of Cardio-Thoracic Surgery
Surgical treatment for non-small cell lung cancer in octogenarians – the usefulness of video-assisted thoracic surgeryDepartment of Thoracic Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki-shi, Okayama 710-8602, Japan Received 25 November 2008; received in revised form 9 April 2009; accepted 20 April 2009
*Corresponding author. Tel.: +81-86-422-0210; fax: +81-86-421-3424.
The purpose of this study was to investigate whether surgical treatment for non-small cell lung cancer (NSCLC) confers a survival benefit in octogenarians, and whether video-assisted thoracic surgery (VATS) is effective in terms of postoperative morbidity, mortality, and quality of life (QOL). Among 1684 patients with primary NSCLC who underwent pathologically complete resection, 95 were octogenarians. Operation was performed by the VATS approach (VATS group, n=58) or the standard thoracotomy (ST group, n=37). Although postoperative cardiopulmonary complications occurred in 20 cases (21.1%), all were manageable. In the ST group cardiopulmonary complications occurred more frequently than in the VATS group (P=0.030). The overall 5-year survival rate of the 95 octogenarians, including deaths from all causes, was 54.4%. The overall 5-year survival rate of patients with stage IA disease was 65.2%. These outcome data were not significantly worse than those for patients aged 79 years or under (P=0.136). There was no significant difference in overall 5-year survival rates between the ST group and the VATS group (P=0.144). The VATS approach for pulmonary resection is recommended for octogenarians with NSCLC. Surgical resection is the optimal treatment for stage IA NSCLC, and therefore, advanced age is not a contraindication for curative resection.
Key Words: Lung cancer; Thoracoscopy/VATS
Thoracic surgery in octogenarians has several problematic aspects, including low pulmonary function, a high-frequency of postoperative morbidity and mortality, and postoperative deterioration in quality of life (QOL). However, due to the aging population and increased incidence of lung cancer, the number of surgical resections for lung cancer in octogenarians has increased. The average life expectancy of patients with untreated or palliated early-stage non-small cell lung cancer (NSCLC) is 1.5 years [1]. Therefore, treatment for NSCLC in this elderly group should be seriously considered whether it can be performed with acceptable morbidity, mortality and deterioration in QOL, because complications caused by surgical treatment might reduce their remaining days adversely. However, if surgical treatment for NSCLC could confer a survival benefit even in octogenarians, this invasive form of therapy could be selected as an optimal treatment. In recent years, many reports have demonstrated acceptable results of surgical treatment for NSCLC in octogenarians [2–4]. Additionally, several authors have emphasized the efficacy of video-assisted thoracic surgery (VATS) in view of its less invasive nature, leading to a lower frequency of postoperative complications [5–7]. In the present study, we retrospectively investigated whether surgical treatment for NSCLC conferred a survival benefit for octogenarians, and assessed the efficacy of VATS in terms of postoperative morbidity, mortality, and QOL.
Data were obtained from the medical records of patients with NSCLC who underwent pathologically complete resection between April 1982 and March 2008 at Kurashiki Central Hospital. The preoperative assessment included medical history, physical examination, routine blood tests, electrocardiography (ECG), and pulmonary function tests. Clinical staging was based on computed tomography scan of the head, chest and abdomen, bone scintigraphy, brain magnetic resonance imaging (MRI), and positron emission tomography with [18F]fluoro-2-deoxy-[cp6,8]D[cp9,11]-glucose (FDG-PET), based on the TNM classification 1997. We reviewed clinical features including age, gender, pulmonary function, clinical staging, and perioperative data including surgical procedure, histopathological type, pathological staging, operative morbidity and mortality (defined as death at any time during the initial hospitalization or within 30 days following the operation), and actuarial survival rates. Follow-up information was obtained from outpatient clinic or telephone contact with patients, relatives, or physicians. Statistical analysis was performed using the Mann–Whitney rank sum test or Fisher's exact test for comparison of variables. Actuarial survival rate was assessed by the Kaplan–Meier method. Results were considered significant at P<0.05. Pulmonary resection was performed under general anesthesia using one-lung ventilation with the patient in the lateral decubitus position. The cases as a whole were divided into two groups, comprising a VATS group and a standard thoracotomy (ST) group. In the VATS group, one mini-thoracotomy and two access ports were employed. A vertical 4.5 cm skin incision was made at the 4th or 5th intercostal space on the midaxillary line. Two access ports were established for insertion of a thoracoscope or an endoscopic stapler. In the ST group, an anteroaxillary or posterolateral skin incision, ranging in length from 15 to 25 cm, was performed with separation of the anterior serratus muscle, or cutting of the broadest muscle of back. Among 1684 patients with primary NSCLC who underwent pathologically complete resection during the study period, 95 (5.6%) were octogenarians. The patient characteristics and surgery of these cases are shown in Table 1. There were 55 men (57.9%) and 40 women (42.1%), and the mean age was 82.6±2.4 years. The clinical stage was IA in 59 cases, IB in 22, IIA in 1, IIB in 3, IIIA in 8, and IIIB in 2. There were no stage IV cases.
2.2. Surgical procedure The VATS group comprised 58 cases (61.1%), whereas the ST group comprised 37 (38.9%). In three cases, VATS was converted to standard anteroaxillar thoracotomy because of difficulty with dissection of severe adhesion or hemostasis. Operation time in VATS group was 232±91 min, whereas 275±108 min in ST group. There were no significant differences between these groups (P=0.153). We performed pneumonectomy in two cases, bilobectomy in one, and standard lobectomy in 49, which were defined as the standard or extended resection group (54.7%), and segmentectomy in 22, and wedge resection in 21, which were defined as the limited resection group (45.3%). There was no significant difference in the proportion of standard or extended resection between the VATS group and the ST group (P=0.058). Radical systemic ND2a lymphadenectomy was performed in 48 cases (50.5%), whereas ND1 was in 23 cases (24.2%) and ND0 was in 24 cases (25.3%).
3.1. Histopathological type and pathological stage Pathological data are shown in Table 2.
Mean tumor size was 26.1±12.1 mm. The histopathological types were adenocarcinoma in 66 patients, squamous cell carcinoma in 22, large cell carcinoma in 3, adenosquamous cell carcinoma in 2, and pleomorphic carcinoma in 2. The pathological stage was IA in 51 patients, IB in 22, IIA in 3, IIB in 8, IIIA in 8, and IIIB in 3. There were no stage IV cases. Lymphnode stagings were N0-disease in 79 cases, N1-disease in 8 and N2-disease in 8. Postoperative complications are shown in Table 3.
There were no perioperative deaths. Although in 20 cases (21.1%), 22 postoperative cardiopulmonary complication events occurred (pulmonary embolism in 1, atrial fibrillation in 2, mild arrhythmia in 1, prolonged air leakage in 4, prolonged pleural discharge in 3, postoperative hypoxemia in 2, chylothorax in 1, bacterial pneumonia in 2, interstitial pneumonia in 1, sputum retention in 1, atrial fibrillation and prolonged air leakage in 1, and atrial fibrillation and bacterial pneumonia in 1), all of them were manageable. Cardiopulmonary complications occurred in 12 cases (32.4%) in the ST group, and in 8 cases (13.8%) in the VATS group. The difference was statistically significant (P=0.030). Cardiopulmonary complications occurred in 17 cases (32.7%) in the standard or extended resection group, and in 3 cases (7.0%) in the limited resection group. The difference was statistically significant (P=0.002). The mean and median follow-up periods for the survivors were 28.2 and 20.0 months, respectively. In octogenarians, the overall 5-year survival rate, including deaths from all causes, was 54.4%, which was not significantly worse than for patients under 79 years of age (P=0.066). The overall 5-year survival rate for patients with stage IA disease was 65.2% in octogenarians (Fig. 1), which was not significantly worse than for patients under 79 years of age (P=0.136).
For octogenarians, there was no significant difference in the overall 5-year survival rates between the ST group (48.0%) and the VATS group (57.4%) (P=0.144, Fig. 2).
The mean postoperative hospital stay was 19.5 days in the ST group and 8.5 days in the VATS group (P<0.0001). Additionally, after 2000 April, the mean postoperative hospital stay was 12.7 days in the ST group and 8.2 days in the VATS group (P=0.0015).
In reports published from the 1980s to 1990s, the mortality rate of octogenarians who underwent surgical treatment for lung cancer ranged from 3.7 to 17.6% [8–10]. On the other hand, among reports published after 2000, several demonstrated acceptable results resulting from progress in peri- and postoperative care, and surgical techniques [2, 3, 11]. In younger patients, lobectomy with radical systemic lymphadenectomy is ideal from the viewpoint of curative cancer resection. However, in octogenarians, this standard surgical procedure may sometimes be a risk factor for operative morbidity or mortality, which makes surgeons select limited resection rather than standard lobectomy with ND2a lymphadenectomy. However, in a randomized controlled study, Ginsberg et al. reported that limited resection resulted in a higher local recurrence rate and poorer outcome than lobectomy, and therefore, recommended lobectomy as the standard operation for lung cancer [12]. In our department, if cardiopulmonary function is acceptable for surgery, we select standard lobectomy except for peripheral small lesions (maximum diameter 10 mm or less). Although the present study showed that cardiopulmonary complications occurred more frequently in the standard or extended resection group than in the limited resection group, there were no perioperative deaths. This result suggested that proper selection of operative candidates can ensure that lobectomy for NSCLC is as safe as the standard operation even in octogenarians. Nagahiro et al. reported that VATS generates less pain and cytokine production, and offers better preservation of pulmonary function in the early postoperative phase [13]. Similarly, Yim et al. reported that VATS lobectomy is associated with reduced postoperative release of both proinflammatory and anti-inflammatory cytokines compared with the open approach [14]. These reports demonstrated that VATS is less invasive than open thoracotomy. Recently, several authors have reported the efficacy of VATS, which were lower incidence of morbidity and mortality, and acceptable 5-year survival rate, in octogenarians [6, 7]. Our present study also demonstrated that cardiopulmonary complications in the ST group occurred significantly more frequently than in the VATS group, and that there was no significant difference in overall 5-year survival rates between the two groups. Additionally, the mean postoperative hospital stay in the VATS group was significantly shorter than in the ST group. We consider that this shorter postoperative hospitalization in the VATS group may be indicative of maintenance of postoperative QOL in octogenarians who have undergone surgery although progress in peri- and postoperative care, and surgical techniques may affect it. These results suggest that the VATS approach is a favorable procedure in octogenarians from the viewpoints of oncology and QOL in patients who undergo surgical treatment for lung cancer. The present study revealed that the overall 5-year survival rate in octogenarians was not significantly worse than that of patients under 79 years of age (P=0.066), and the overall 5-year survival rate for patients with stage IA disease was 65.2%, which again was not significantly worse than for younger patients (P=0.136). These results suggest that surgical treatment confers a survival benefit for patients with lung cancer, even octogenarians. In conclusion, the VATS approach for pulmonary resection is recommended for octogenarians with NSCLC because of its lower frequency of postoperative morbidity and mortality, and maintenance of postoperative QOL. As surgical resection has been the optimal treatment for stage IA NSCLC [15], advanced age is not a contraindication for curative resection if this invasive treatment is performed safely, and can confer a survival benefit.
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Abstract
1. Introduction
