- Email: [email protected]
Surgical treatment of lung cancer in patients over the age of 70 years
Surgical treatment of lung cancer in 'patients over the age of 70 years Eighty patients of 70 years of age with lung cancer have been treated since 1964. Forty-eight received no therapy or chemotherapy and/or irradiation. Mean survival was 3.5 to 10 months, and only three (6 percent) survived for 2 years. Twenty-two of 32 patients selected for thoracotomy underwent resection for cure (70 percent). The operative mortality rate was 18 percent for resection, and 64 percent of the patients survived for at least 2 years. The incidence of exploratory thoracotomy decreased in the last 5 years of the study with the introduction of more rigorous preoperative evaluation. The poor survival rate without resection and the favorable survival rate following recovery from resection support the continued use of surgical resection for lung cancer in elderly patients, despite an increased operative risk.
J. Duncan Harviel, M.D., J. Judson McNamara, M.D., and Clifford J. Straehley, M.D., Honolulu, Hawaii
BronchOgeniC carcinoma is a disease for which surgery is nearly the only potentially curative form of treatment. Yet, results of surgical treatment remain disappointingly poor. 1-3 The impact of surgical therapy on the over-all cure rate of bronchogenic carcinoma has changed very little during the past 15 to 20 years.v 5 By contrast, the results of surgical resection for lung cancer have steadily improved during this period owing to both a decrease in the operative mortality rate and improved patient selection. 1-3, 6 A variety of factors are now being considered in the preoperative selection of patients treated for lung cancer, and advanced age of the patient is one factor which recently has been suggested as a contraindication to resectional therapy. 7 This paper is based on a retrospective study of 80 patients over the age of 70 years with a tissue-proved diagnosis of carcinoma of the lung. The study was undertaken to investigate the influence of surgical resection on long-term survival of patients with cancer of the lung. Patients All patients seen at Queen's Medical Center or Kaiser Foundation Hospital, from 1964 to 1972 inclusive, who were older than 70 years of age and had a From the Department of Surgery, University Integrated Surgical Residency Program, Queen's Medical Center, Honolulu, Hawaii 96813. Read at the Third Annual Meeting of The Samson Thoracic Surgical Society, Colorado Springs, Colorado, June 4-7,1977.
802
tissue diagnosis of bronchogenic carcinoma, are included in the present study. Patients who were moribund on admission or in whom the diagnosis was established at autopsy were excluded. Patients referred for treatment were included only if the date of tissue diagnosis was after the seventieth birthday. Eighty-one patients met the criteria and were surveyed-63 men and 18 women. Since one patient was lost to follow-up, he was excluded from the series. Diagnostic procedures were not uniform for two reasons: because a number of different surgeons were involved in the care of the patients and because new diagnostic procedures have been introduced, i.e., fiberoptic bronchoscopy, transbronchial biopsy, thin needle biopsy, gallium and bone scanning, and cervical mediastinal exploration. In the past 5 years diagnostic procedures have included chest roentgenography, tomography, bronchoscopy, cervical mediastinoscopy, cytologic examination of sputum and pleural fluid, transpleural needle biopsy, transbronchial biopsy, and liver, lung, and bone scanning as indicated. Cell types for all 81 patients are listed in Table I. Thirteen patients were not treated, because of either the stage of disease or the patient's refusal of further treatment. Thirty-five patients received chemotherapy or irradiation, all but five because the disease was beyond resectionallimits when first evaluated. Thirty-two patients underwent thoracotomy: Ten had unresectable disease and 22 underwent resection for cure. The procedures performed are listed in Table II.
0022-5223178/0675-0802$00.40/0 © 1978 The C. V. Mosby Co.
Volume 75
Lung cancer in elderly patients
Number 6 June. 1978
Results Five patients died within 30 days of their surgical procedure, one after exploration alone (10 percent) and four after resection (18 percent). Patients who had chemotherapy or irradiation after exploratory thoracotomy are included in this group, because they had been exposed to the same operative risk. Seven of 10 patients (including the one who died) had exploratory thoracotomy during the first 4 years of the survey. Only three patients of 19 having thoracotomy were found to have unresectable lesions during the past 5 years, because of the more rigorous preoperative evaluation of all patients with lung cancer by most surgeons in this community. The mean survival period of patients who were not treated was 3.5 months, although one patient survived for I year. The mean survival period for patients receiving chemotherapy or irradiation was 9.8 months, three patients (8 percent) surviving for 2 years. Patients with unresectable tumors at thoracotomy had an 18.3 month mean survival period, three (30 percent) surviving 2 years (all nine surviving patients had irradiation therapy). Patients undergoing resection had a mean survival of 30.6 months, and 14 (64 percent) survived for 2 years. Nine patients have been alive for periods ranging from 27 to 66 months from the time of review. For purposes of determining survival rate, all patients who died were considered to have died from their disease, although a number of patients died from other causes. One patient who underwent resection was lost to follow-up. Discussion Since Graham's" first successful pulmonary resection for cancer in 1933, surgical removal of lung cancer has been the mainstay of therapy. The mortality rates for thoracotomy and pulmonary resection have generally improved, although the death rate for lung cancer has remained relatively stable for the past several years.v 5 The improvement in survival after surgical resection is the result of a number of factors. Appreciation of the generally poor results from resection of oat cell carcinema': a and from resection in patients with extensive involvement of mediastinal nodes,': a as well as a movement away from pneumonectomy when more limited resections will suffice, has decreased the mortality rate from needless or unnecessarily extensive surgery. I-a. 6 Improved methods of patient selection, including more sophisticated cardiopulmonary evaluation and improved techniques for identifying cell type, local extent of disease, and the presence of distant metastasis,
803
Table I. Cell types Squamous cell Adenocarcinoma Large cell Alveolar cell Undifferentiated
33
Total
81
20 7
5 16
Table II. Types of operation Exploration Pneumonectomy Lobectomy Wedge/segmental resection
10 2 17
Total
32
3
have also contributed to improved results of resectional therapy.P"!' The age of the patient at the time of diagnosis has also been bandied about as a potential contraindication to surgical resection. Although Kirsh and co-workers, 12 treating elderly patients, have reported results of resectional therapy nearly comparable to those seen in other age groups, Weiss? in 1974 argued against resection in male patients older than 70 years of age because of the high operative mortality rate (19.4 percent). The present series is notable because of the relatively low operability rate (40 percent) as compared to the 50 to 60 percent operability rates generally quoted in the literature. I-to We believe this reflects, in part, selection against surgery owing to other underlying diseases related to the advanced age of the patients. Furthermore, more rigorous preoperative evaluation appears to have decreased the incidence of exploratory thoracotomy in recent years. The over-all resectability rate of nearly 70 percent is reasonably high when compared to those in many published reports, but, it is not as high, for reasons previously mentioned, as that which currently can be obtained with appropriate preoperative evaluation. The reduced incidence of exploratory thoracotomies in the past 5 years (three of 19 operations) has increased the resectability rate to a more respectable 85 percent. The resectability rate of 28 percent (22 of 80) in the group as a whole is a figure comparable to that reported by others." These figures generally support the importance of a careful patient selection process in reducing the incidence of unnecessary thoracotomy in this elderly group of patients. The major factor indicting age as a contraindication to surgery has been the high operative mortality noted with both exploratory thoracotomy alone and resection
The Journalof Thoracic and Cardiovascular Surgery
804 Harviel, McNamara, Straehley
for cure. Although the numbers in the present series are small, the one death in 10 patients who underwent exploration alone (10 percent) is consistent with figures given in the literature. I, 13 This is particularly true in elderly patients, in whom the operative mortality rates for a variety of major surgical procedures, i.e., colon and rectal cancer, 14 major surgery in general, 15 thoracic procedures;" major abdominal surgery, and cardiac procedures," are all reported to be significantly increased. The 15 percent over-all surgical mortality reported in the present series with resection for cure is somewhat less than that reported by Weiss" but is considerably higher than the operative mortality for similar surgical procedures in large series of patients unselected for age. 1-3, 6. 10 Two-year survival was arbitrarily selected as a definition for long-term survival because the majority of patients with lung cancer will have died by that time and yet death from other causes in this group of elderly patients will be minimized. After resection, the 2 year survival rate of 64 percent is slightly higher than that generally reported in the literature.I-3. 4. 10. 16. 18 Thus far, in considering resection in elderly patients, it is apparent that the increased risks of surgery are weighed against a chance for long-term survival which is at least as good as, if not better than, that seen in an unselected group of patients having resection for lung cancer. The third element in this equation is a consideration of the probabilities of long-term survival for the 32 patients undergoing thoracotomy if nonsurgical treatment had been selected instead. Although the groups are not comparable because of preselected differences in extent of disease, the mean survival of 3.5 to 10 months and the 6 percent 2 year survival in patients having nonsurgical therapy suggest that the outlook would be much less favorable if resection had not been undertaken when possible. This theory is supported by data from Roswit and co-workers" on survival of patients with inoperable lung cancer. Resection must be weighed further in the context of the lingering and incapacitating illness which frequently occurs prior to death in patients with unresectable carcinoma of the lung. Avoiding this miserable situation is an important consideration in weighing the advantages and disadvantages of a surgical procedure. Because of these considerations, it appears reasonable to offer surgical resection to carefully selected elderly patients with carcinoma of the lung. They should be informed both of the relatively favorable long-term results of resection and of the increased operative risks.
2 Shields TW, Yee J, Conn JH, Robinette CD: Relationship of cell type and lymph node metastasis to survival after resection of bronchial carcinoma. Ann Thorac Surg 20:50 I, 1975 3 Kirsh MM, Rotman H, Argenta L, Bove E, Cimmino V, Tashian J, Ferguson P, Sloan H: Carcinoma of the lung. Results of treatment over ten years. Ann Thorac Surg 21:371, 1976 4 Miller AB: Recent trends in lung cancer mortality in Canada. Can Med Assoc J 116:28, 1977 5 Perez C: Radiation therapy in the management of carcinoma of the lung. Cancer 39:901, 1977 6 Overhold RH, Neptune WB, Ashraf MM: Primary cancer of the lung. A 42 year experience. Ann Thorac Surg 20:511, 1975 7 Weiss W: Operative mortality and five year survival rates in patients with bronchogenic carcinoma. Am J Surg 28:799, 1974 8 Graham EA, Singer JJ: Successful removal of an entire lung for carcinoma of the bronchus. JAMA 101:1371, 1933 9 Paulson DL, Urschel HL: Selectivity in the surgical treatment of bronchogenic carcinoma. J THORAC CARDIOVASC SURG 62:554, 1971 10 Stanford W, Spivey CG Jr, Larsen GL, Alexander JA, Besich WJ: Results of treatment of primary carcinoma of the lung. J THORAC CARDIOVASC SURG 72:441-449, 1976 II Yashar J and Yashar JJ: Factors affecting long-term survival of patients with bronchogenic carcinoma. Am J Surg 129:386, 1975 12 Kirsh MM, Rotman H, Bove E, Argenta L, Cimmino V, Tashian J, Ferguson P, Sloan H: Major pulmonary resection for bronchogenic carcinoma in the elderly. Ann Thorac Surg 22:369, 1976 13 Beattie E: Editorial. Chest 66:469, 1974 14 Kragelund E, Balslev I, Bardram L, Jensen HE, Nielsen J: Resectability, operative mortality and survival of patients in old age with carcinoma of the colon and rectum. Dis Colon Rectum 17:617, 1974 15 Brander P, Kjellberg M, Tammisto T: The effects of anesthesia and general surgery on geriatric patients. Ann Chir Gynaecol Fenn 59:138, 1970 16 Santos AL, Gelperin A: Surgical mortality in the elderly. J Am Geriatr Soc 23:42, 1975 17 Arkins R, Smessoret AA, Hiche RG: Mortality and morbidity of surgical patients with coronary artery disease. JAMA 190:485, 1964 18 Brock L: Long survival after operation for cancer of the lung. Br J Surg 62: I, 1975 19 Roswit B, Liberson S, Ohanian M, Kusik M. Petrovich Z: Survival with inoperable lung cancer. NY State J Med 1970, p 560
Discussion DR. HAROLD C. URSCHEL, JR.
REFERENCES
Dallas. Texas
Paulson DL: Carcinoma of the lung. CUff Probl Surg 1967, pp 1-64
Generalizations such as "all persons over 70 should have resection" or "no persons over 70 should have resection" are
Volume 75 Number 6 June, 1978
not appropriate as rigid dictums, and I agree with the authors that each individual should be evaluated carefully regardless of age. Over the age of 70 or under the age of 70, the ideal goal for treatment of cancer of the lung is to provide for the patient the best chance for cure with the least morbidity. Selectivity is a sine qua non for achievement of this goal. The same techniques used for persons under 70 are used for persons over 70, i.e., mediastinoscopy, pulmonary angiography, etc. The purpose of selectivity is to reduce the morbidity and mortality of exploratory thoracotomy to a minimum regardless of age. With this objective, the authors' exploratory thoracotomy rate of 32 percent or resection rate of only 68 percent, particularly in patients over the age of 70, would not seem ideal. Major thoracotomies have been performed on 126 patients over the age of 70 years (exploratory thoracotomy or resection) from our series. The over-all mortality rate is 8 percent, but in the past 10 years it has been only 4 percent. Resectability in the past 10 years has been 94 percent. Seven of the 126 patients survived 5 years. I do not think anybody knows what this means. Certainly at that age, without actuarial table comparison, no one knows what 5 year survival means. Radiation certainly has some hazards in the elderly. We would recommend employing all the diagnostic and staging techniques to improve resectability to at least 90 percent and to reduce exploratory thoracotomy to less than 10 percent, particularly in patients over 70 years old. DR. RICHARD M. PETERS San Diego, Calif.
The death of one of these elderly patients after an exploratory thoracotomy for a nonmalignant lesion is a tragedy which must be avoided. More care is required in the work-up of these patients because they do not have to have a resection to have a high morbidity and mortality following operation. Recently, a radiologist very skilled in doing needle biop-
Lung cancer in elderly patients
805
sies has joined us. Although one may not get enthusiastic support from this group by talking about needle biopsies, the procedure has been an added part of our armamentarium, particularly in our very high-risk patients. It avoids exploratory thoracotomies, but perhaps equally important, when the patient has carcinoma, the risks are more acceptable to the patient and referring physician. Also, a quick, planned resection can be done, and we do not have to worry about any other procedures before we proceed with the resection itself. Properly selected elderly patients can have pulmonary resections with a reasonable mortality rate. When we advocate such a treatment, we must consider Dr. Urschel's comment. If only seven of 126 patients have a 5 year survival, we must wonder what the total life years would have been without any resection? DR. McNAMARA(Closing) There are two serious comments that I want to make. One has to do with the fact that the series spanned a long period of time prior to the advent of surgical mediastinal exploration and fiberoptic bronchoscopy, which I think have greatly improved the selectivity in the patient in terms of obviating the need for exploratory thoracotomy. The other factor is that the larger percentage in the series, in fact, the large majority of the patients, are from the Queen's Hospital series. Queen's is a large community hospital, and I think that it probably is representative of most community hospitals across the country. The setup is different from what Dr. Urschel would see in his practice. Dr. Urschel has a small number of highly skilled thoracic surgeons doing these procedures. We have not only a few highly skilled thoracic surgeons, but also a large number of general surgeons doing pulmonary surgery. I think that our series probably is fairly representative. Despite the limitations in a community hospital, the outlook in carefully selected patients with resectional therapy is still superior to what one would see without resection. The purpose of the paper was to make it clear that age is not an absolute contraindication to pulmonary resection.
J. Duncan Harviel, M.D., J. Judson McNamara, M.D., and Clifford J. Straehley, M.D., Honolulu, Hawaii
BronchOgeniC carcinoma is a disease for which surgery is nearly the only potentially curative form of treatment. Yet, results of surgical treatment remain disappointingly poor. 1-3 The impact of surgical therapy on the over-all cure rate of bronchogenic carcinoma has changed very little during the past 15 to 20 years.v 5 By contrast, the results of surgical resection for lung cancer have steadily improved during this period owing to both a decrease in the operative mortality rate and improved patient selection. 1-3, 6 A variety of factors are now being considered in the preoperative selection of patients treated for lung cancer, and advanced age of the patient is one factor which recently has been suggested as a contraindication to resectional therapy. 7 This paper is based on a retrospective study of 80 patients over the age of 70 years with a tissue-proved diagnosis of carcinoma of the lung. The study was undertaken to investigate the influence of surgical resection on long-term survival of patients with cancer of the lung. Patients All patients seen at Queen's Medical Center or Kaiser Foundation Hospital, from 1964 to 1972 inclusive, who were older than 70 years of age and had a From the Department of Surgery, University Integrated Surgical Residency Program, Queen's Medical Center, Honolulu, Hawaii 96813. Read at the Third Annual Meeting of The Samson Thoracic Surgical Society, Colorado Springs, Colorado, June 4-7,1977.
802
tissue diagnosis of bronchogenic carcinoma, are included in the present study. Patients who were moribund on admission or in whom the diagnosis was established at autopsy were excluded. Patients referred for treatment were included only if the date of tissue diagnosis was after the seventieth birthday. Eighty-one patients met the criteria and were surveyed-63 men and 18 women. Since one patient was lost to follow-up, he was excluded from the series. Diagnostic procedures were not uniform for two reasons: because a number of different surgeons were involved in the care of the patients and because new diagnostic procedures have been introduced, i.e., fiberoptic bronchoscopy, transbronchial biopsy, thin needle biopsy, gallium and bone scanning, and cervical mediastinal exploration. In the past 5 years diagnostic procedures have included chest roentgenography, tomography, bronchoscopy, cervical mediastinoscopy, cytologic examination of sputum and pleural fluid, transpleural needle biopsy, transbronchial biopsy, and liver, lung, and bone scanning as indicated. Cell types for all 81 patients are listed in Table I. Thirteen patients were not treated, because of either the stage of disease or the patient's refusal of further treatment. Thirty-five patients received chemotherapy or irradiation, all but five because the disease was beyond resectionallimits when first evaluated. Thirty-two patients underwent thoracotomy: Ten had unresectable disease and 22 underwent resection for cure. The procedures performed are listed in Table II.
0022-5223178/0675-0802$00.40/0 © 1978 The C. V. Mosby Co.
Volume 75
Lung cancer in elderly patients
Number 6 June. 1978
Results Five patients died within 30 days of their surgical procedure, one after exploration alone (10 percent) and four after resection (18 percent). Patients who had chemotherapy or irradiation after exploratory thoracotomy are included in this group, because they had been exposed to the same operative risk. Seven of 10 patients (including the one who died) had exploratory thoracotomy during the first 4 years of the survey. Only three patients of 19 having thoracotomy were found to have unresectable lesions during the past 5 years, because of the more rigorous preoperative evaluation of all patients with lung cancer by most surgeons in this community. The mean survival period of patients who were not treated was 3.5 months, although one patient survived for I year. The mean survival period for patients receiving chemotherapy or irradiation was 9.8 months, three patients (8 percent) surviving for 2 years. Patients with unresectable tumors at thoracotomy had an 18.3 month mean survival period, three (30 percent) surviving 2 years (all nine surviving patients had irradiation therapy). Patients undergoing resection had a mean survival of 30.6 months, and 14 (64 percent) survived for 2 years. Nine patients have been alive for periods ranging from 27 to 66 months from the time of review. For purposes of determining survival rate, all patients who died were considered to have died from their disease, although a number of patients died from other causes. One patient who underwent resection was lost to follow-up. Discussion Since Graham's" first successful pulmonary resection for cancer in 1933, surgical removal of lung cancer has been the mainstay of therapy. The mortality rates for thoracotomy and pulmonary resection have generally improved, although the death rate for lung cancer has remained relatively stable for the past several years.v 5 The improvement in survival after surgical resection is the result of a number of factors. Appreciation of the generally poor results from resection of oat cell carcinema': a and from resection in patients with extensive involvement of mediastinal nodes,': a as well as a movement away from pneumonectomy when more limited resections will suffice, has decreased the mortality rate from needless or unnecessarily extensive surgery. I-a. 6 Improved methods of patient selection, including more sophisticated cardiopulmonary evaluation and improved techniques for identifying cell type, local extent of disease, and the presence of distant metastasis,
803
Table I. Cell types Squamous cell Adenocarcinoma Large cell Alveolar cell Undifferentiated
33
Total
81
20 7
5 16
Table II. Types of operation Exploration Pneumonectomy Lobectomy Wedge/segmental resection
10 2 17
Total
32
3
have also contributed to improved results of resectional therapy.P"!' The age of the patient at the time of diagnosis has also been bandied about as a potential contraindication to surgical resection. Although Kirsh and co-workers, 12 treating elderly patients, have reported results of resectional therapy nearly comparable to those seen in other age groups, Weiss? in 1974 argued against resection in male patients older than 70 years of age because of the high operative mortality rate (19.4 percent). The present series is notable because of the relatively low operability rate (40 percent) as compared to the 50 to 60 percent operability rates generally quoted in the literature. I-to We believe this reflects, in part, selection against surgery owing to other underlying diseases related to the advanced age of the patients. Furthermore, more rigorous preoperative evaluation appears to have decreased the incidence of exploratory thoracotomy in recent years. The over-all resectability rate of nearly 70 percent is reasonably high when compared to those in many published reports, but, it is not as high, for reasons previously mentioned, as that which currently can be obtained with appropriate preoperative evaluation. The reduced incidence of exploratory thoracotomies in the past 5 years (three of 19 operations) has increased the resectability rate to a more respectable 85 percent. The resectability rate of 28 percent (22 of 80) in the group as a whole is a figure comparable to that reported by others." These figures generally support the importance of a careful patient selection process in reducing the incidence of unnecessary thoracotomy in this elderly group of patients. The major factor indicting age as a contraindication to surgery has been the high operative mortality noted with both exploratory thoracotomy alone and resection
The Journalof Thoracic and Cardiovascular Surgery
804 Harviel, McNamara, Straehley
for cure. Although the numbers in the present series are small, the one death in 10 patients who underwent exploration alone (10 percent) is consistent with figures given in the literature. I, 13 This is particularly true in elderly patients, in whom the operative mortality rates for a variety of major surgical procedures, i.e., colon and rectal cancer, 14 major surgery in general, 15 thoracic procedures;" major abdominal surgery, and cardiac procedures," are all reported to be significantly increased. The 15 percent over-all surgical mortality reported in the present series with resection for cure is somewhat less than that reported by Weiss" but is considerably higher than the operative mortality for similar surgical procedures in large series of patients unselected for age. 1-3, 6. 10 Two-year survival was arbitrarily selected as a definition for long-term survival because the majority of patients with lung cancer will have died by that time and yet death from other causes in this group of elderly patients will be minimized. After resection, the 2 year survival rate of 64 percent is slightly higher than that generally reported in the literature.I-3. 4. 10. 16. 18 Thus far, in considering resection in elderly patients, it is apparent that the increased risks of surgery are weighed against a chance for long-term survival which is at least as good as, if not better than, that seen in an unselected group of patients having resection for lung cancer. The third element in this equation is a consideration of the probabilities of long-term survival for the 32 patients undergoing thoracotomy if nonsurgical treatment had been selected instead. Although the groups are not comparable because of preselected differences in extent of disease, the mean survival of 3.5 to 10 months and the 6 percent 2 year survival in patients having nonsurgical therapy suggest that the outlook would be much less favorable if resection had not been undertaken when possible. This theory is supported by data from Roswit and co-workers" on survival of patients with inoperable lung cancer. Resection must be weighed further in the context of the lingering and incapacitating illness which frequently occurs prior to death in patients with unresectable carcinoma of the lung. Avoiding this miserable situation is an important consideration in weighing the advantages and disadvantages of a surgical procedure. Because of these considerations, it appears reasonable to offer surgical resection to carefully selected elderly patients with carcinoma of the lung. They should be informed both of the relatively favorable long-term results of resection and of the increased operative risks.
2 Shields TW, Yee J, Conn JH, Robinette CD: Relationship of cell type and lymph node metastasis to survival after resection of bronchial carcinoma. Ann Thorac Surg 20:50 I, 1975 3 Kirsh MM, Rotman H, Argenta L, Bove E, Cimmino V, Tashian J, Ferguson P, Sloan H: Carcinoma of the lung. Results of treatment over ten years. Ann Thorac Surg 21:371, 1976 4 Miller AB: Recent trends in lung cancer mortality in Canada. Can Med Assoc J 116:28, 1977 5 Perez C: Radiation therapy in the management of carcinoma of the lung. Cancer 39:901, 1977 6 Overhold RH, Neptune WB, Ashraf MM: Primary cancer of the lung. A 42 year experience. Ann Thorac Surg 20:511, 1975 7 Weiss W: Operative mortality and five year survival rates in patients with bronchogenic carcinoma. Am J Surg 28:799, 1974 8 Graham EA, Singer JJ: Successful removal of an entire lung for carcinoma of the bronchus. JAMA 101:1371, 1933 9 Paulson DL, Urschel HL: Selectivity in the surgical treatment of bronchogenic carcinoma. J THORAC CARDIOVASC SURG 62:554, 1971 10 Stanford W, Spivey CG Jr, Larsen GL, Alexander JA, Besich WJ: Results of treatment of primary carcinoma of the lung. J THORAC CARDIOVASC SURG 72:441-449, 1976 II Yashar J and Yashar JJ: Factors affecting long-term survival of patients with bronchogenic carcinoma. Am J Surg 129:386, 1975 12 Kirsh MM, Rotman H, Bove E, Argenta L, Cimmino V, Tashian J, Ferguson P, Sloan H: Major pulmonary resection for bronchogenic carcinoma in the elderly. Ann Thorac Surg 22:369, 1976 13 Beattie E: Editorial. Chest 66:469, 1974 14 Kragelund E, Balslev I, Bardram L, Jensen HE, Nielsen J: Resectability, operative mortality and survival of patients in old age with carcinoma of the colon and rectum. Dis Colon Rectum 17:617, 1974 15 Brander P, Kjellberg M, Tammisto T: The effects of anesthesia and general surgery on geriatric patients. Ann Chir Gynaecol Fenn 59:138, 1970 16 Santos AL, Gelperin A: Surgical mortality in the elderly. J Am Geriatr Soc 23:42, 1975 17 Arkins R, Smessoret AA, Hiche RG: Mortality and morbidity of surgical patients with coronary artery disease. JAMA 190:485, 1964 18 Brock L: Long survival after operation for cancer of the lung. Br J Surg 62: I, 1975 19 Roswit B, Liberson S, Ohanian M, Kusik M. Petrovich Z: Survival with inoperable lung cancer. NY State J Med 1970, p 560
Discussion DR. HAROLD C. URSCHEL, JR.
REFERENCES
Dallas. Texas
Paulson DL: Carcinoma of the lung. CUff Probl Surg 1967, pp 1-64
Generalizations such as "all persons over 70 should have resection" or "no persons over 70 should have resection" are
Volume 75 Number 6 June, 1978
not appropriate as rigid dictums, and I agree with the authors that each individual should be evaluated carefully regardless of age. Over the age of 70 or under the age of 70, the ideal goal for treatment of cancer of the lung is to provide for the patient the best chance for cure with the least morbidity. Selectivity is a sine qua non for achievement of this goal. The same techniques used for persons under 70 are used for persons over 70, i.e., mediastinoscopy, pulmonary angiography, etc. The purpose of selectivity is to reduce the morbidity and mortality of exploratory thoracotomy to a minimum regardless of age. With this objective, the authors' exploratory thoracotomy rate of 32 percent or resection rate of only 68 percent, particularly in patients over the age of 70, would not seem ideal. Major thoracotomies have been performed on 126 patients over the age of 70 years (exploratory thoracotomy or resection) from our series. The over-all mortality rate is 8 percent, but in the past 10 years it has been only 4 percent. Resectability in the past 10 years has been 94 percent. Seven of the 126 patients survived 5 years. I do not think anybody knows what this means. Certainly at that age, without actuarial table comparison, no one knows what 5 year survival means. Radiation certainly has some hazards in the elderly. We would recommend employing all the diagnostic and staging techniques to improve resectability to at least 90 percent and to reduce exploratory thoracotomy to less than 10 percent, particularly in patients over 70 years old. DR. RICHARD M. PETERS San Diego, Calif.
The death of one of these elderly patients after an exploratory thoracotomy for a nonmalignant lesion is a tragedy which must be avoided. More care is required in the work-up of these patients because they do not have to have a resection to have a high morbidity and mortality following operation. Recently, a radiologist very skilled in doing needle biop-
Lung cancer in elderly patients
805
sies has joined us. Although one may not get enthusiastic support from this group by talking about needle biopsies, the procedure has been an added part of our armamentarium, particularly in our very high-risk patients. It avoids exploratory thoracotomies, but perhaps equally important, when the patient has carcinoma, the risks are more acceptable to the patient and referring physician. Also, a quick, planned resection can be done, and we do not have to worry about any other procedures before we proceed with the resection itself. Properly selected elderly patients can have pulmonary resections with a reasonable mortality rate. When we advocate such a treatment, we must consider Dr. Urschel's comment. If only seven of 126 patients have a 5 year survival, we must wonder what the total life years would have been without any resection? DR. McNAMARA(Closing) There are two serious comments that I want to make. One has to do with the fact that the series spanned a long period of time prior to the advent of surgical mediastinal exploration and fiberoptic bronchoscopy, which I think have greatly improved the selectivity in the patient in terms of obviating the need for exploratory thoracotomy. The other factor is that the larger percentage in the series, in fact, the large majority of the patients, are from the Queen's Hospital series. Queen's is a large community hospital, and I think that it probably is representative of most community hospitals across the country. The setup is different from what Dr. Urschel would see in his practice. Dr. Urschel has a small number of highly skilled thoracic surgeons doing these procedures. We have not only a few highly skilled thoracic surgeons, but also a large number of general surgeons doing pulmonary surgery. I think that our series probably is fairly representative. Despite the limitations in a community hospital, the outlook in carefully selected patients with resectional therapy is still superior to what one would see without resection. The purpose of the paper was to make it clear that age is not an absolute contraindication to pulmonary resection.