Surgical treatment of non-small cell lung cancer in octogenarians

Olivia Fanucchi 0 Marcello Carlo Ambrogi 0 Paolo Dini 0 Marco Lucchi 0 Franca Melfi 0 Federico Davini 0 Alfredo Mussi 0 0 Division of Thoracic Surgery, Department of Cardiac Thoracic and Vascular Surgery, University of Pisa , Via Paradisa 2, 56124 Pisa, Italy As the European population ages, surgeons are regularly faced with octogenarians with resectable early stage non-small cell lung cancer (NSCLC). We compared our experience with those reported in the literature to comprehend the feasibility, outcomes and lessons learned regarding surgical treatment. We reviewed octogenarians who underwent lung resection for NSCLC in the past nine years in our Department. The purpose of this paper is to retrospectively analyse postoperative surgical and oncological outcomes of our series, trying to find possible correlations between mortality, morbidity, survival and preoperative oncological and functional assessment, surgical approach and extent of resection. Eighty-two patients (MyFs63y19), with a mean age 81.0 years (range 80-87 years) underwent lung resection for NSCLC: 63 lobectomies, one inferior bilobectomy, three segmentectomies, and 15 wedge resections. There were two perioperative deaths (2.4%). The overall complication rate was 30.0%, with a major complication rate of 2.5%. Actuarial cancer-related survival rates at one, three and five years were 90%, 44% and 36%, respectively, with a statistically-significant correlation with pathological stage. Octogenarians may benefit from surgical treatment of NSCLC with an acceptable morbidity and mortality rate, if an accurate preoperative selection is pursued. 2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. 1. Introduction In recent decades health care has improved, and at the same time the elderly population has increased w1x. Even the definition of the elderly population has changed, with a cut-off rising from 65 years to 70 years or more w2, 3x, and lung cancer incidence in older patients has increased also w4x. Despite several studies regarding lung resection in the older population having dismissed previous accounts of prohibitively high mortality rates, and having suggested that surgical resection is associated with a reasonable perioperative risk, only a few of them deal with patients over 80 years old w510x. To better understand the real benefit of surgical treatment in octogenarians with nonsmall cell lung cancer (NSCLC), and to determine what should be done or avoided during the selection course, we retrospectively analysed our recent nine-year experience and compared it with those of the literature. 2. Materials and methods 2.1. Study design and definitions From our surgical database (Ormawind 2000, Avelco SRL., Genova, Italy) we retrospectively selected all patients aged 80 years or more who underwent surgical resection for NSCLC in the period 20012009. *Corresponding author. Tel.: q39-050-995211; fax: q39-050-995352. E-mail address: (M.C. Ambrogi). 2011 Published by European Association for Cardio-Thoracic Surgery The main aim of this study was to evaluate postoperative surgical and oncological outcomes, investigating their relationship with data from the preoperative evaluation course, surgical management and pathological findings. All cases were re-staged according to the seventh edition of the TNM classification w11x. To identify the individual comorbid ailments and define the severity of comorbid health, in such a limited number of patients, we utilised a new 27-item validated comorbidity index for use in patients with cancer (ACE-27)1 w12x. For the evaluation of preoperative and postoperative quality of life, we utilised the Karnofsky Performance Status (KPS) scale. Treatment-related complications were defined as those occurring within 30 days of treatment. Minor complications were those resulting in no sequelae or in a short hospital stay for observation (-10 days). Major complications were those resulting in re-admission to the hospital for treatment, an unplanned increase in the level of care, extended hospitalisation ()10 days), permanent adverse sequelae, or death. 2.2. Statistical analysis Statistical analysis was performed using Statistica software version 6.0 for the personal computer (PC) (Stat-Soft, 1 Adult Comorbidity Evaluation 27 (ACE-27). Available at: http:yy www.rtog.orgymembersyprotocolsy0815yACE-27.pdf. Accessibility verified December 19, 2010. O. Fanucchi et al. / Interactive CardioVascular and Thoracic Surgery 12 (2011) 749753 Inc, Tulsa, OK, USA). Analysis of continuous and categorical variables was done by Students t-test and x2-test, respectively. Actuarial survival and disease-free survival were estimated by KaplanMeiers method, and the log-rank test was used to assess statically significant differences. We analysed possible correlations between morbidity, mortality, duration of hospitalisation, overallycancer specific survival rates and gender, preoperative forced expiratory volume in 1 s (FEV1) () vs. -1.5 l), ACE-27 grade (grade 01 vs. grade 23), histology (squamous cell carcinoma vs. other tumour cell types), pathologic stage (stage IyII vs. stage III), extent of resection (lobectomyybilobectomy vs. sub-lobar resection), and type of surgical approach (thoracotomy vs. VATS), both by univariate and multivariate analysis (logit and Cox proportional regression models). A P-value -0.05 was considered statistically significant. 3. Results 3.1. Demographics and clinical data During the period, of the )3000 patients that underwent pulmonary resection of NSCLC at our Institute, 82 were older than 80 years of age. There were 63 males and 19 females with a mean age of 81.1 years (range 8087 years). Most of the patients were asympomatic and lung cancer was revealed on an occasional chest X-ray. Preoperative performance status, according to the Karnofsky scale, was 82% on average (range 70%100%). The mean preoperative FEV1 value was 1.74 l (range 1.12.4). In 28 cases (34.1%), estimation of TLCO and quantitative perfusion scan were performed in addition to routine lung function test. Most patients (77.8%) exhibited comorbidities, and 25 patients (30.5%) had two or more comorbid conditions (Table 1). Based on the ACE-27 scoring system, 18 patients were evaluated to be grade 0, 38 patients grade 1, 19 patients grade 2, and seven patients grade 3. Routine staging included chest radiograph, bronchoscopy, blood tumour markers, CT of the chest and upper abdomen in all cases. In nine cases, brain CT or bone scintigraphy excluded disseminate disease. Mediastinoscopy (ns7) or TBNA (ns10) were negative in 17 patients with enlarged mediastinal nodes ()1 cm). Preoperative pathological COPD, chronic obstructive pulmonary disease; coronary artery disease was defined as a positive exercise testing or prior myocardial infarction or prior coronary bypass. diagnosis was obtained in 35 (42.6%) cases: seven adenocarcinomas, eight squamous cell carcimanomas an (...truncated)