|Year : 2015 | Volume
| Issue : 4 | Page : 793-797
Video-assisted thoracoscopic lobectomy for elderly nonsmall cell lung cancer: Short-term and long-term outcomes
Guangliang Qiang, Chaoyang Liang, Yongqing Guo, Bin Shi, Yanchu Tian, Zhiyi Song, Deruo Liu
Department of Thoracic Surgery, China-Japan Friendship Hospital, Beijing, China
|Date of Web Publication||15-Feb-2016|
No. 2 Yinghua East road, Chaoyang District, Beijing - 100029
Source of Support: None, Conflict of Interest: None
Background: Lung cancer is the leading cause of cancer-related death worldwide, and the number of elderly patients with nonsmall-cell lung cancer (NSCLC) has risen with increasing life-expectancy.
Aims: To evaluate safety and efficacy of thoracoscopic lobectomy for NSCLC patients above 75 years old.
Patients and Methods: We reviewed the data of 795 consecutive patients with NSCLC, who underwent video-assisted thoracoscopic lobectomy from January 2006 to December 2013. Patients were divided into two groups: The elderly group aged at least 75 years old (n = 54), the contrast group aged <75 years old (n = 741). The general characteristic, comorbidity, intraoperative observations, complications, operative mortality and long-term survival were compared between the two groups.
Results: The elderly group had a higher incidence of squamous cell carcinoma (40.74% vs. 29.69%) and a lower incidence of adenocarcinoma (37.04% vs. 52.63%) than the contrast group (P = 0.083). The ratio of smoking (61.11% vs. 41.97%), preoperative comorbidities (62.96% vs. 38.06%), perioperative blood transfusion (25.93% vs. 13.50%) and thoracic intubation indwelling time (10.3 vs. 8.2 days) in the elderly group were higher (P < 0.01). There was no significant difference in duration of surgery (222.9 vs. 226.6 min), intraoperative blood loss (299.8 vs. 253.5 min), hospital stay (18.2 vs. 15.8 days) or postoperative hospital stay (10.3 vs. 8.4 days) between the two groups. Postoperative morbidities occurred more frequently in the elderly group than the contrast group (24.07% vs. 12.01%, P = 0.018). Thirty-day mortality rate of two groups showed no significant difference (1.85% vs. 0.40%, P = 0.246). The overall survival and recurrence-free survival in the elderly group were comparable with the contrast group (P = 0.114 and 0.092, respectively).
Conclusions: Video-assisted thoracoscopic lobectomy is a safe and reliable approach with acceptable short- and long-term outcome in the elderly.
Keywords: Elderly, lobectomy, nonsmall-cell lung cancer, thoracoscopic
|How to cite this article:|
Qiang G, Liang C, Guo Y, Shi B, Tian Y, Song Z, Liu D. Video-assisted thoracoscopic lobectomy for elderly nonsmall cell lung cancer: Short-term and long-term outcomes. J Can Res Ther 2015;11:793-7
|How to cite this URL:|
Qiang G, Liang C, Guo Y, Shi B, Tian Y, Song Z, Liu D. Video-assisted thoracoscopic lobectomy for elderly nonsmall cell lung cancer: Short-term and long-term outcomes. J Can Res Ther [serial online] 2015 [cited 2019 Sep 21];11:793-7. Available from: http://www.cancerjournal.net/text.asp?2015/11/4/793/140930
| > Introduction|| |
Lung cancer is responsible for approximately 1.59 million deaths in 2012.  In China, the registered lung cancer mortality rate increased by 464.84% in the past three decades, about 600,000 people die of lung cancer each year.  Although significant advances have been made with therapies, the outcome of patients with nonsmall-cell lung cancer (NSCLC) remains extremely poor. , Since the number of elderly patients with NSCLC has risen with increasing life-expectancy, in this study we retrospectively analyzed the clinicopathological feature of patients with NSCLC, who underwent lobectomy by video-assisted thoracic surgery (VATS), and evaluated the clinical outcome.
| > Patients and methods|| |
From January 2006 to December 2013, a total of 795 consecutive patients underwent lobectomy by VATS for histologically verified NSCLC were enrolled in this retrospective study. Patients who had received preoperative chemotherapy or thoracic radiotherapy were excluded. And patients who underwent a lesser resection (wedge or segmentectomy) or a more extensive operation (pneumonectomy, sleeve lobectomy, chest wall resection, bronchoplasty, or major vascular resection) were excluded. Patients were divided into two groups: The elderly group consisted of patients aged at least 75 years old, and the contrast group consisted of patients aged <75 years old. This study was conducted with the approval from the Ethics Committee of our hospital and written consent was given by the patients for their information to be stored in the hospital database and used for clinical research.
All patients received general anesthesia with double-lumen endotracheal intubation, and one-lung ventilation. Anatomic lobectomy followed by hilar and mediastinal lymph node dissection was performed through 2 or 3 ports. A 30° camera scope was applied, the observation port was located at the 7 th or the 8 th intercostal space on the mid-axillary line, the main operating port was located at the 4 th or the 5 th intercostal space on the anterior axillary line with a length of 3-4 cm. Another auxiliary operating port was made at the 8 th or the 9 th intercostal space on the scapular line when necessary. Ribs were not retracted. The sequence of thoracoscopic lobectomy was basically similar to that of the conventional lobectomy performed via thoracotomy. Pulmonary vascular and bronchus were divided individually by using endoscopic staplers. Systemic lymph node dissection was performed after lobectomy.
Patients were followed-up every 1-2 months and systemically checked every 3 months for first 2 years and then every 6 months thereafter. The postoperative systemic check included chest X-ray, electrocardiography, abdominal sonography (AS), chest computed tomography, serum levels of tumor marker, Tc-m99 whole body bone scan, and brain magnetic resonance imaging.
Patients' clinicopathologic characteristics were obtained from the hospital database. Baseline variables were collected including age, sex, pulmonary function, comorbidities, site of lesion. The intraoperative and postoperative variables were selected, including surgical approach, type of histology, duration of the operation, intraoperative blood loss, blood transfusion, duration of drainage, total hospital stay, postoperative hospital stay, intraoperative and postoperative complications. The pathological stages were determined according to the seventh edition of International Union against Cancer tumor node metastasis classification system.  Overall survival (OS) and recurrence-free survival (RFS) data were collected from hospital follow-up records, and unfollowed patients had been called in order to obtain information about their conditions. OS was defined as the duration from the date of surgery to the most recent follow-up contact or to the date of death, and RFS was defined as the duration from the date of surgery to the most recent follow-up contact or to the date of recurrence or death. Local recurrence included any recurrence within the ipsilateral lung, bronchial stump, mediastinal lymph node and the ipsilateral pleural space. Systemic recurrence included any recurrence in the contralateral lung, liver, adrenal glands, bone, brain or other locations.
Continuous variables were expressed as the mean value ± standard deviation. Categorical data were described as absolute frequencies and percentage. We used SPSS 20.0 software (IBM, Armonk, NY, USA) to perform statistical procedures. Statistical analyses were performed with the independent t-test and the Chi-square test or Fisher's exact test for continuous and categorical variables, respectively. Survival curves were drawn according to the Kaplan-Meier method, and differences between curves were analyzed by the log-rank test. Difference was considered statistically significant when the P < 0.05.
| > Results|| |
Comparison of baseline
The mean age in the elderly group was 76.67 ± 1.82 years, versus 60.08 ± 9.01 years in the contrast group. There were no significant differences in gender, side of the lesion, pulmonary function between the two groups. However, there was a statistically significant difference in the ratio of smoker, 61.11% in the elderly group versus 41.97% in the contrast group (P = 0.006). Moreover, the incidence of hypertension, coronary heart disease (CHD) and chronic obstructive pulmonary disease (COPD) in the elderly group were significantly higher than those of the contrast group [Table 1].
Comparison of intraoperative and postoperative characteristics
The operative procedures consisted of 221 right upper lobectomies (RUL), 13 right middle lobectomies (RML), 128 right lower lobectomies (RLL), 36 RUL and RML, 87 RLL and RML, 169 left upper lobectomies, and 141 left lower lobectomies. We did not see any significant difference between the two groups with respect to the operative procedures or operative duration [Table 2]. For intraoperative blood loss, the elderly group had similar statistical result comparing with the contrast group (299.81 ± 206.72 vs. 253.46 ± 222.86, P = 0.064). However, the ratio of perioperative blood transfusion in the elderly group was higher than in the contrast group (25.93% vs. 13.50%, P = 0.024). In addition, we found that the drainage time for the elderly group was significantly longer than that of the contrast group (10.31 ± 9.034 vs. 8.18 ± 5.550, P = 0.001). Elderly patients had a higher incidence of squamous cell carcinoma and a lower incidence of adenocarcinoma. However, the difference of pathological composition between groups was not statistically significant. No difference was observed between the two groups with respect to pathological stage. Hospital stay and postoperative hospital stay between the two groups were comparable. Postoperative morbidities occurred more frequently in the elderly group (24.07%) than in the contrast group (12.01%) (P = 0.018), and cardiopulmonary related complications were the main causes [Table 3]. Thirty days mortality rate of two groups were 1.85% and 0.4%, respectively, showed no significant difference (P = 0.246).
|Table 2: The comparison of intraoperative and postoperative characteristics|
Click here to view
Long-term survival analysis
Follow-up data were complete in all patients. The follow-up period ranged from 1 to 98 months, with a median of 42 months. At the end of the study, 462 patients were still alive, 356 of them were free from cancer recurrence. The 5 years OS rate and RFS rate of patients in the elderly group were 60.4% and 48.0%, respectively. In the contrast group, the 5 years OS rate and RFS rate were 79.0% and 68.6%, respectively. [Figure 1] and [Figure 2] illustrate the Kaplan-Meier plots for the two groups. There was no significant difference in OS (P = 0.114) or RFS (P = 0.092) between the two groups.
|Figure 2: Recurrence-free survival curve for different age group (P = 0.092)|
Click here to view
| > Discussion|| |
Lung cancer is the leading cause of cancer-related death worldwide, and NSCLC represents 85% of all lung cancer cases. For the patient with early stage or local NSCLC (I, II, and subsets of IIIa), complete surgical resection remains the treatment offering the best survival rates. As a result of the epidemiological changes related to the aging of the population, lung cancer incidence peaks in the 75-79 years old age group,  treatment in patients aged 75 years and over is likely to be a major issue of thoracic oncology in the forthcoming years. This study demonstrates that elderly patients with NSCLC following thoracoscopic lobectomy would get comparable safety and efficacy with younger ones.
Advances in anesthetic management and surgical techniques have enabled surgeons to include increasing numbers of elderly patients in surgical series. It is widely accepted that video-assisted thoracoscopic lobectomy is a minimally invasive surgical approach, associated with better postoperative outcomes, so that the elderly patients will most benefit from this technique.
However, high incidence of comorbidities presents a challenge in providing care to elderly. In our study, the ratio of preoperative comorbidities including hypertension, CHD and COPD in the elderly group patients were higher than those of the contrast group. Furthermore, postoperative morbidities occurred more frequently in elderly patients as well, and cardiopulmonary related complications were the main causes. These findings in our study are consistent with other published series. ,, Age-related deterioration of cardiopulmonary function does not usually produce symptoms in unstressed individuals before surgical intervention. However, in response to stress and surgery, reduction in respiratory or cardiac function could be an evident problem. Postoperative risks are higher in elderly particularly those with impaired performance status. Therefore selecting appropriate candidates for surgical resection is crucial to maximize the benefit derived from surgery. The cardiopulmonary evaluation of an elderly patient who will undergo lobectomy has to be carefully conducted. For patients with borderline spirometry or arterial blood gas analysis, further cardiopulmonary exercise test such as the 6 min walking test or the stair-climbing test is useful. High-risk patients should be treated preoperatively with anti-ischemic and anti-hypertensive therapy. After surgery, more intensive monitoring and treatment should be conducted. We attached importance to the increased risk of pulmonary embolism in the elderly, and intermittent pneumatic compression device was regularly used for the prevention of venous thromboembolism after surgery. Moreover, low molecular weight heparin was added from postoperative day 1 if there was no indication of active hemorrhage or other contraindications.
We also observed that the incidence of smoking in the elderly group was significantly higher than contrast group. The adverse effect of smoking in NSCLC patients is well-known, and it is suspected that the younger the age at which patients take up the habit, the more serious the postoperative complications will be. Smoking significantly increases the risk of postoperative pulmonary, cardiovascular, and other complications.  Smoking abstinence was shown to reduce the incidence of postoperative pulmonary complications such as pneumonia, respiratory distress, atelectasis, air leakage, bronchopleural fistula and re-intubation.  Data from several studies indicate that at least 4 weeks of smoking cessation before surgery are necessary in order to reduce the risk of postoperative complications.  Lung expansion maneuvers including incentive spirometry and deep breathing exercises were taught to the patients before surgery, and patient-controlled epidural analgesia was recommended for the elderly in pain management after surgery. These strategies promoted the ability to take a deep breath and enhanced expectoration of airway secretions in the postoperative period. Although incidence of postoperative complications was higher than contrast group, the elderly group had a comparable hospital stay, and postoperative hospital stay, 30 days mortality rate of two groups showed no significant difference as well. It might be due to a strict selection in the elderly patients for surgery, and improvements in patient care, both preoperatively and postoperatively, may have a contribution to minimize the adverse impact and improve the short-term result.
Due to the decline in organ function, elderly patients have a significantly increased postoperative infection rate and mortality compared with younger patients under the same condition of blood loss. , Evidence from observational studies suggest that elderly patients are less tolerant of blood loss and should therefore be transfused at a higher hemoglobin level, while in younger patients, mild degrees of anemia are well tolerated, and transfusion can be avoided.  These facts could explain elderly patients were more likely to receive blood transfusion in the current study, even though efforts were made to reduce bleeding during surgery, and intraoperative blood loss was comparable with that of the younger patients.
There is good evidence that age alone is not a significant prognostic factor in lung cancer, with performance status, the stage being of much greater importance.  Elderly patients with resectable NSCLC, who undergo curative surgery have similar postoperative survival to younger patients. The high survival rate of 82% at 5 years has been found in a cohort of Stage Ia elderly patients treated with anatomic resection for lung cancer. In conformity with the previous reports, , the long-term survival of the current study showed comparable between elderly patients and their younger counterparts.
There were some limitations for this study such as mismatched patient distribution between groups, small study population of the elderly cohort, mixed stage and potential selection bias due to concerning for morbidity and mortality in elderly patients. Further prospective studies with more accurate data are necessary to validate our findings. However, our experience demonstrates that older age is not a contraindication to curative surgical treatment for NSCLC. In carefully selected elderly patients with NSCLC, video-assisted thoracoscopic lobectomy is a safe and justifiable option, it can be performed with acceptable short-term result and long-term survival that compares favorably with younger patients. The results need to be considered when deciding if a patient aged above 75 years old should undergo surgery or other therapies.
| > References|| |
World Health Organization. Cancer: Fact sheet no. 297. World Health Organization; 2014. Available from: http://www.who.int/mediacentre/factsheets/fs297/en.
She J, Yang P, Hong Q, Bai C. Lung cancer in China: Challenges and interventions. Chest 2013;143:1117-26.
Tsim S, O'Dowd CA, Milroy R, Davidson S. Staging of non-small cell lung cancer (NSCLC): A review. Respir Med 2010;104:1767-74.
Lung cancer: A global scourge. Lancet 2013;382:659.
Sobin LH, Gospodarowicz MK, Wittekind C. International Union against Cancer (UICC) TNM Classification of Malignant Tumours. 7 th
ed. New York: Wiley-Liss; 2010.
Akgün KM, Crothers K, Pisani M. Epidemiology and management of common pulmonary diseases in older persons. J Gerontol A Biol Sci Med Sci 2012;67:276-91.
Coate LE, Massey C, Hope A, Sacher A, Barrett K, Pierre A, et al.
Treatment of the elderly when cure is the goal: The influence of age on treatment selection and efficacy for stage III non-small cell lung cancer. J Thorac Oncol 2011;6:537-44.
Voltolini L, Rapicetta C, Ligabue T, Luzzi L, Scala V, Gotti G. Short- and long-term results of lung resection for cancer in octogenarians. Asian Cardiovasc Thorac Ann 2009;17:147-52.
Okami J, Higashiyama M, Asamura H, Goya T, Koshiishi Y, Sohara Y, et al.
Pulmonary resection in patients aged 80 years or over with clinical stage I non-small cell lung cancer: Prognostic factors for overall survival and risk factors for postoperative complications. J Thorac Oncol 2009;4:1247-53.
Gritz ER, Fingeret MC, Vidrine DJ, Lazev AB, Mehta NV, Reece GP. Successes and failures of the teachable moment: Smoking cessation in cancer patients. Cancer 2006;106:17-27.
Zaman M, Bilal H, Mahmood S, Tang A. Does getting smokers to stop smoking before lung resections reduce their risk? Interact Cardiovasc Thorac Surg 2012;14:320-3.
Nakagawa M, Tanaka H, Tsukuma H, Kishi Y. Relationship between the duration of the preoperative smoke-free period and the incidence of postoperative pulmonary complications after pulmonary surgery. Chest 2001;120:705-10.
Dunne JR, Malone D, Tracy JK, Gannon C, Napolitano LM. Perioperative anemia: An independent risk factor for infection, mortality, and resource utilization in surgery. J Surg Res 2002;102:237-44.
Gruson KI, Aharonoff GB, Egol KA, Zuckerman JD, Koval KJ. The relationship between admission hemoglobin level and outcome after hip fracture. J Orthop Trauma 2002;16:39-44.
Carson JL, Duff A, Berlin JA, Lawrence VA, Poses RM, Huber EC, et al.
Perioperative blood transfusion and postoperative mortality. JAMA 1998;279:199-205.
Stanley KE. Prognostic factors for survival in patients with inoperable lung cancer. J Natl Cancer Inst 1980;65:25-32.
Schneider T, Pfannschmidt J, Muley T, Reimer P, Eberhardt R, Herth FJ, et al.
A retrospective analysis of short- and long-term survival after curative pulmonary resection for lung cancer in elderly patients. Lung Cancer 2008;62:221-7.
Chambers A, Routledge T, Pilling J, Scarci M. In elderly patients with lung cancer is resection justified in terms of morbidity, mortality and residual quality of life? Interact Cardiovasc Thorac Surg 2010;10:1015-21.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]