Asian Cardiovasc Thorac Ann 2007;15:297-302
© 2007 Asia Publishing EXchange Ltd
Influence of Comorbidity on Outcome after Pulmonary Resection in the Elderly
Morris Beshay, FRCS,
Patrick Dorn, MD,
Hans-Beat Ris, MD,
Ralph A Schmid, MD
Division of General Thoracic Surgery, University Hospital of Berne, Berne, Switzerland
For reprint information contact: Morris Beshay, FRCS, Tel: 49 521 7727 7410, Fax: 49 521 7727 7407, Email: morris.beshay{at}evkb.de, Division of General Thoracic Surgery, Evangelic Hospital Bielefeld, 33605 Bielefeld, Germany.
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ABSTRACT
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The aim of this study was to determine the influence of comorbidity on outcome after pulmonary resection in patients over 75 years old. Three hundred and thirty-three patients with non-small-cell lung cancer operated on between 1998 and 2002 were divided into 3 age groups: < 60 years (group 1), 60–75 years (group 2), > 75 years (group 3). Overall operative mortality was 0.3%; 30-day mortality was 1%. There were more major complications with re-operation in groups 1 and 2, but minor complications occurred significantly more frequently in group 3 (36% vs 16%). Overall mean hospital stay was 12 days, with no significant difference among groups. Three-year survival rates were: 80%, 70%, and 65% in groups 1, 2, and 3, respectively, with no significant difference among groups. Age or the presence of comorbidity should not be considered contraindications for lung resection. With proper patient selection and careful preoperative evaluation, many major complications after pneumonectomy are avoidable.
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INTRODUCTION
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Non-small-cell lung cancer (NSCLC) is one of the most common tumors in the elderly, representing 80% of all lung cancers, with a grave prognosis. Half of the affected patients are over 65 years old.1 As life expectancy is increasing, the number of patients over 80 years old with lung cancer at a curative stage is also growing. Surgery remains the only potentially curative option for treatment of NSCLC in the early stages.2 Ischemic heart disease and right-sided tumors were reported to be associated with high perioperative morbidity and mortality in elderly patients undergoing lung resection.3–5 Elderly patients undergoing pneumonectomy for lung cancer have a higher risk of developing postoperative cardiopulmonary complications, which are associated with a high mortality rate.4,5 However, with advances in surgical techniques, anesthetic management, and perioperative care, lung resection may now be performed more safely in the elderly. Only a few studies have reported the operative risk and effect of comorbidity in patients over 80 years old.5,6 Comorbidity, defined as diseases requiring one or more additional investigations before surgery, are naturally more frequent in elderly patients. These patients need careful assessment as well as proper selection of the operative procedure.7,8 We retrospectively analyzed the results in our patients over a period of 5 years to assess early outcome in relation to pre-existing comorbidity, based on our algorithm of patient selection.
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PATIENTS AND METHODS
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We performed a retrospective review of the clinical records of all patients operated on for NSCLC between 1998 and 2002. Patients with lung metastases and benign lesions and those lost during the follow-up period were excluded. To identify factors predicting a complicated postoperative course, the patients were divided into 3 groups according to age: < 60 years (group 1), 60–75 years (group 2), and > 75 years (group 3). All patients underwent a preoperative evaluation that included medical history, physical examination, routine blood tests, chest radiography, electrocardiography, pulmonary function tests, and arterial blood gas analysis. Exercise spirometry was also performed. Concomitant diseases such as ischemic heart disease, arrhythmia, peripheral vascular disease, other lung disease, diabetes mellitus, renal failure, other malignant tumors, and gastrointestinal diseases were systematically evaluated. We adopt an interdisciplinary approach to assessing any concomitant disease, with the necessary investigations undertaken before or during hospitalization. Echocardiography and myocardial isotope scans were carried out in patients with known or suspected coronary artery disease, if these showed abnormal findings, coronary angiography was performed. In cases of significant coronary stenosis, the required intervention (balloon dilatation, coronary stenting, or coronary artery bypass) was completed before lung resection. Patients with relevant previous history underwent a Doppler study of the carotid arteries. Those with chronic renal failure or other known renal functional impairment were evaluated and treated preoperatively (renal dialysis, nephrostomy, or rehydration and stabilization of renal function). The staging protocol was performed in all cases with a computed tomography (CT) scan of the chest including the upper abdominal organs, and/or abdominal ultrasound, brain CT scan, skeletal isotope scan (since 2003, we have performed 18F-fluorodeoxyglucose positron-emission tomography). If pneumonectomy was anticipated, a lung ventilation perfusion scan was performed if the first-second forced expiratory volume (FEV1) was less than 2,000 mL. Patients with impaired pulmonary function with positive inhalation tests were re-evaluated after 2 weeks of oral steroids (prednisone 0.5 mg·kg–1 daily) combined with bronchodilator (albuterol and ipratropium) inhalation therapy. Smoking cessation before surgery was not routinely instructed.
Preoperative diagnosis was obtained by sputum cytology, bronchial biopsy, or transthoracic needle biopsy. Video-assisted thoracoscopic surgery (VATS) or open biopsies were used if other methods failed to deliver the diagnosis. Mediastinal lymph node assessment was carried out in all patients using video-assisted mediastinoscopy or VATS in cases of isolated aortopulmonary lymph node enlargement. In N2 situations, neoadjuvant chemotherapy was administered prior to lung resection. The operative procedure was selected according to the stage of the disease, endoscopic presentation of the tumor, postoperative predicted FEV1, local intraoperative findings, and local control of any other cancer. After careful re-evaluation of patients by the attending anesthesiologist, lung resection was performed. All patients met the standard cardiopulmonary criteria for elective surgery. Operative mortality was defined as death within 30 days postoperatively.
Preoperative and postoperative data were obtained retrospectively from clinical records. Follow-up data were obtained by contacting the patients themselves or their family doctors. The chi-squared or Pearson chi-squared test was used to assess the differences in postoperative morbidity and mortality among all groups. The Kruskal-Wallis and Wilcoxon rank-sum tests were used to assess the difference in hospital stay (as hospitalization does not follow a normal distribution). Results were considered significant if the p value was less than 0.05.
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RESULTS
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During the study period, 333 patients with potentially curable NSCLC were operated on. Of these, 310 (93%) had a history of tobacco smoking (mean, 36 packs per year), but 25% of them had not consumed tobacco for more than one year. Group 1 consisted of 92 patients aged 37–59 years, group 2 was 188 patients aged 60–75 years, and group 3 was 53 patients aged 76–85 years. The mean FEV1 was 2.4 L·m–1 (78%) in group 1, 1.9 L·m–1 (70%) in group 2, and 1.6 L·m–1 (60%) in group 3. Mean vital capacity was 3.2 L·m–1 (85%) in group 1, 2.8 L·m–1 (74%) in group 2, and 2.3 L·m–1 (68%) in group 3. There was history of coronary heart disease in all groups, but the incidence was higher in group 3. Two patients in group 1 and 4 in group 2 had to have coronary stenting before surgery, whereupon lung resection was performed 2 months later. There was no history of myocardial infarction or atrial fibrillation in group 1. The incidence of chronic obstructive pulmonary disease was significantly higher in group 3 ( p = 0.032). Other concomitant diseases are listed in Table 1
. Preoperative chemotherapy and/or radiotherapy in 18 patients did not affect the perioperative morbidity or mortality in any group. The operative procedures are listed in Table 2. Video-assisted thoracoscopic surgery (2 patients in group 1, 4 in group 2, and 3 in group 3) was performed when the postoperative predicted FEV1 was not good enough to allow an anatomical resection.
Minor bleeding occurred in 1 (1%) patient in group 1 and 3 (2%) in group 2. In one patient, uncontrollable major bleeding occurred due to tumor infiltration of the right main pulmonary artery. The intraoperative course was uneventful in all cases in group 3. All patients were admitted to the intensive care unit postoperatively. Some were moved to the ward after a few hours of monitoring, with no significant difference among groups. Two patients in group 1, 4 in group 2, and 3 in group 3 had a tracheotomy on the 2nd or 3rd postoperative day to ensure sufficient suction of secretions (no significant difference among groups).
The overall perioperative mortality rate (< 30 days) was 1.5% (5 patients). One patient in group 1 died from respiratory insufficiency after pneumonectomy. In group 2, one died from major intraoperative bleeding, another from respiratory insufficiency after pulmonary embolism, and a third from sepsis due to ischemic colitis followed by multiple organ failure. One patient in group 3 died on the 26th postoperative day due to respiratory insufficiency after a central pulmonary embolism. There was no significant difference among the groups in terms of perioperative mortality (p = 0.34).
There were no major postoperative cardiac complications. Dysrhythmia in the form of atrial fibrillation was less frequent in groups 1 and 2 than group 3 (Table 3). Prolonged mechanical ventilation (> 48 hr) was needed in 2 patients in group 1, 8 in group 2, and 1 in group 3. Re-operation was required in 5 (5%) patients in group 1; 3 of them had stump insufficiency, one had luxation of the heart after intrapericardial pneumonectomy, and one had bleeding from a bronchial artery. Nine (5%) patients in group 2 needed re-operation; 3 had stump insufficiency, 3 had delayed post-pneumonectomy empyema (45 to 180 days), one had an encapsulated seropneumothorax that was drained thoracoscopically, and one had a thrombectomy of the caval graft after pneumonectomy with partial resection of the superior vena cava. One patient had heart luxation due to loosening of the Prolene mesh from the diaphragm, which needed refixation. Two (4%) patients in group 3 underwent re-operation: to evacuate an infected subcutaneous hematoma in one, and for persistent air leak (> 3 weeks) in the other. There was a higher rate of minor complications (pulmonary, cardiovascular, renal, gastrointestinal) as well as other postoperative morbidity in the older patients (p = 0.014; Table 3).
Histological examinations showed a predominance of squamous cell carcinoma in elderly patients (Table 4). Carcinoid tumors were found only in groups 1 and 2. The majority of patients in all groups (mean, 51%; median, 50%) had tumors in stage IIB. Stage IIIB was due to either an N3 situation after neoadjuvant chemotherapy (4 in group 1, 3 in group 2, 1 in group 3) or a T4 situation (5 in group 1) due to recurrent nerve infiltration in 2, superior vena caval infiltration in 2, and double tumors in the same lobe in one patient. Stage IV was found in 4 patients in group 1 and 6 in group 2 due to solitary cerebral and suprarenal metastasis (Table 5, Figure 1).
Median hospital stay was 13 days in group 1 (range, 3–34 days), 15 days in group 2 (range, 3–68 days), and 10 days in group 3 (range, 6–26 days). The differences among groups were not statistically significant (p = 0.31), but hospital stay was significantly shorter after VATS than after thoracotomy for lobectomy or pneumonectomy in all groups (p = 0.024). Eighteen (18%) patients in group 1, 41 (22%) in group 2, and 24 (45%) in group 3 had rehabilitation after hospital discharge, which was a significantly higher rate in older patients (p = 0.007). The mean and median survival rates were 72% and 70%, respectively. The median follow-up of survivor was 36 months for stage I, 29 months for stage II, 20 months for stage IIIA, 16 months for stage IIIB, and 12 months for stage IV. The actuarial survival rates at 3 years were 80% for group 1, 70% for group 2, and 65% for group 3.
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DISCUSSION
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As a result of perceived high risks of perioperative mortality and postoperative complications, many elderly patients who are active and socially well integrated receive suboptimal treatment for potentially curable NSCLC. Although nonsurgical treatment improves the quality of life and slightly increases long-term survival, and thus should not be underestimated, the results are vastly inferior to surgical resection in the early stages.9 In previous reports, the 5-year survival rate for patients over 70 years was between 30% and 55%, which is comparable to the absolute survival rate in younger patients.5,10,11 This encouraged us to adopt an aggressive policy for treating patients over 80 years of age with potentially curative NSCLC. There have been few reports of the operative risk in patients over 75 years, but concomitant ischemic heart disease or right-sided lesions in elderly patients are considered to be major adverse factors influencing postoperative outcome, with a mortality rate of 20%.12,13 Operative mortality rates have declined over the last two decades, ranging from 4%–7%.14,15 The majority of reports suggest that age at the time of diagnosis is not an adverse prognostic factor.8 In contrast to other series, our results showed lower operative and perioperative mortality rates of 0.3% and 1.5% respectively.16,17 A previous study showed that mortality correlated neither with age nor with the extent of resection.16,18 Therefore, elderly patients should be carefully evaluated for concomitant diseases before deciding against resection, and they should have the same chance of optimal treatment for lung cancer as younger patients.
Postoperative major cardiac complications are frequent in elderly patients, but this study revealed no major cardiovascular complications after lung resection in any age group, including patients over 75 years.16,19 Those who had coronary dilatation, stent placement, or bypass before lung resection did not display a higher rate of complications. Dysrhythmias, especially atrial fibrillation, were less common in groups 1 and 2 than in group 3. Nevertheless, 10% of patients who had postoperative atrial fibrillation in group 3 had this condition before surgery. Pneumonectomy was performed at a similar rate in each group. Pulmonary complications, especially pneumonia, were uncommon, in contrast to previous studies that showed rates of up to 21%, and did not lead to any death in the present series.15,17 There was no stump insufficiency or atelectases in group 3.
Prolonged air leak and seropneumothorax were more frequent in groups 2 and 3, but re-operations were more frequent in the younger age groups. We normally perform anatomical segmentectomy or nonanatomical resection if the postoperative predicted FEV1 is 800 mL or less, lobectomy if it is 1,000 mL or more, and pneumonectomy if > 1,500 mL. We used to calculate postoperative predicted FEV1 based on the percentage of lung function values. Intraoperative findings and radical excision have to be considered when deciding the extent of lung resection. This was applied in 3 patients in whom lobectomy was anticipated but pneumonectomy was performed because of extensive local lesions, to ensure radical resection. Two of them had FEV1 < 1,500 mL. In this series, 4% had inadequate predicted postoperative FEV1 for anatomical resection, due to advanced chronic obstructive pulmonary disease or silicosis. Most had stage I disease, thus sublobar resection was performed, as reported by others.20
A careful review of group 3 showed that quality of life and the ability to go back to former activities were not adversely affected by surgery; moreover, no patient in this group needed long-term oxygen therapy, in contrast to groups 1 and 2 (1% and 2%, respectively). Hospital stay was shorter in the oldest age group, but a greater proportion of older patients needed rehabilitation after hospital discharge. Three-year survival rates were not significantly different among groups, and sex did not affect the postoperative outcome. Eight patients with N3 disease underwent pulmonary resection, however, we only operate on selected patients who meet the following criteria: 30% or more regression after chemotherapy or radiochemotherapy, no metastasis on re-staging, age 
75 years, no or low risk from concomitant diseases, good lung function, and suitable physical, mental, and psychological state.
We think that strict patient selection by thorough evaluation of preoperative cardiac and respiratory function and comorbidity, with further investigations or treatment before surgery, is essential. Selection of the type of resection should be based on lung function values. Patients who are still at high risk after the appropriate treatment for concomitant diseases should not be offered surgery. Routine preoperative and postoperative physiotherapy, good postoperative pain control, low-dose heparin, bronchodilators, proton-pump inhibitors, and antibiotic prophylaxis all played an important role in reducing morbidity and mortality rates in this series. Our experience reflects the fact that preoperative cardiopulmonary evaluation, strict patient selection, and close postoperative care, especially after major resections, are important factors in detection or prevention of complications.18 We conclude that the final decision to resect lung carcinoma should not be based only on age or concomitant diseases, and every effort should be made to give active older patients their chance of surgery. With proper selection, good surgical skills in a specialized center, and close postoperative follow-up, perioperative morbidity and mortality rates in the elderly, even after pneumonectomy and in the presence of concomitant diseases, are comparable to those of younger patients. Stage, histological type, and extent of the tumor are still the main prognostic factors that affect survival in the young as well as in the elderly. As in any retrospective study, we must also consider that selection bias may have played a role in our favorable results. Prospective studies are needed to confirm these conclusions.
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REFERENCES
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- Nugent WC, Edney MT, Hammerness PG, Dain BJ, Maurer LH, Rigas JR. Non-small cell lung cancer at the extremes of age: impact on diagnosis and treatment. Ann Thorac Surg 1997;63:193–7.[Abstract/Free Full Text]
- Morandi U, Stefani A, Golinelli M, Ruggiero C, Brandi L, Chiapponi A, et al. Results of surgical resection in patients over the age of 70 years with non small-cell lung cancer. Eur J Cardiothorac Surg 1997;11:432–9.[Abstract]
- Oliaro A, Leo F, Filosso PL, Rena O, Parola A, Maggi G. Resection for bronchogenic carcinoma in the elderly. J Cardiovasc Surg (Torino) 1999;40:715–9.[Medline]
- Pagni S, McKelvey A, Riordan C, Federico JA, Ponn RB. Pulmonary resection for malignancy in the elderly: is age still a risk factor? Eur J Cardiothorac Surg 1998;14:40–5.[Medline]
- Shirakusa T, Tsutsui M, Iriki N, Matsuba K, Saito T, Minoda S, et al. Results of resection for bronchogenic carcinoma in patients over the age of 80. Thorax 1989;44:189–91.[Abstract/Free Full Text]
- Osaki T, Shirakusa T, Kodate M, Nakanishi R, Mitsudomi T, Ueda H. Surgical treatment of lung cancer in the octogenarian. Ann Thorac Surg 1994;57:188–93.[Abstract]
- Ferguson MK, Reeder LB, Mick R. Optimizing selection of patients for major lung resection. J Thorac Cardiovasc Surg 1995;109:275–83.[Abstract/Free Full Text]
- Oliaro A, Leo F, Filosso PL, Rena O, Parola A, Maggi G. Resection for bronchogenic carcinoma in the elderly. J Cardiovasc Surg (Torino) 1999;40:715–9.[Medline]
- Lonardi F, Coeli M, Pavanato G, Adami F, Gioga G, Campostrini F. Radiotherapy for non-small cell lung cancer in patients aged 75 and over: safety, effectiveness and possible impact on survival. Lung Cancer 2000;28:43–50.[Medline]
- Harvey JC, Erdman C, Pisch J, Beattie EJ. Surgical treatment of non-small cell lung cancer in patients older than seventy years. J Surg Oncol 1995;60:247–9.[Medline]
- Shirakusa T, Tsutsui M, Iriki N, Matsuba K, Saito T, Minoda S, et al. Results of resection for bronchogenic carcinoma in patients over the age of 80. Thorax 1989;44:189–91.[Abstract/Free Full Text]
- Weiss W. Operative mortality and five year survival rates in patients with bronchogenic carcinoma. Am J Surg 1974;128:799–804.[Medline]
- Mizushima Y, Noto H, Sugiyama S, Kusajima Y, Yamashita R, Kashii T, et al. Survival and prognosis after pneumonectomy for lung cancer in the elderly. Ann Thorac Surg 1997;64:193–8.[Abstract/Free Full Text]
- Deslauriers J, Ginsberg RJ, Piantadosi S, Fournier B. Prospective assessment of 30-day operative morbidity for surgical resections in lung cancer. Chest 1994;106(6 Suppl):329S–30S.[Medline]
- Massard G, Moog R, Wihlm JM, Kessler R, Dabbagh A, Lesage A, et al. Bronchogenic cancer in the elderly: operative risk and long-term prognosis. Thorac Cardiovasc Surg 1996;44:40–5.[Medline]
- Bernet F, Brodbeck R, Guenin MO, Schupfer G, Habicht JM, Stulz PM, et al. Age does not influence early and late tumor-related outcome for bronchogenic carcinoma. Ann Thorac Surg 2000;69:913–8.[Abstract/Free Full Text]
- Rostad H, Naalsund A, Strand TE, Jacobsen R, Talleraas O, Norstein J. Results of pulmonary resection for lung cancer in Norway, patients older than 70 years. Eur J Cardiothorac Surg 2005;27:325–8.[Abstract/Free Full Text]
- Matsuoka H, Okada M, Sakamoto T, Tsubota N. Complications and outcomes after pulmonary resection for cancer in patients 80 to 89 years of age. Eur J Cardiothorac Surg 2005;28:380–3.[Abstract/Free Full Text]
- Putnam JB Jr, Lammermeier DE, Colon R, McMurtrey MJ, Ali MK, Roth JA. Predicted pulmonary function and survival after pneumonectomy for primary lung carcinoma. Ann Thorac Surg 1990;49:909–15.[Abstract]
- Ishida T, Yokoyama H, Kaneko S, Sugio K, Sugimachi K. Long-term results of operation for non-small cell lung cancer in the elderly. Ann Thorac Surg 1990;50:919–22.[Abstract]
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ABSTRACT
INTRODUCTION
