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Ramos-Fresnedo A, Phillips AL, Cantrell MC, Mobley EM, Awad ZT. Cancer recurrence and survival among patients who underwent neoadjuvant treatment and surgery for esophageal cancer: A single-institution 10-year experience. Surgery 2025; 179:108901. [PMID: 39490255 DOI: 10.1016/j.surg.2024.07.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 07/08/2024] [Accepted: 07/31/2024] [Indexed: 11/05/2024]
Abstract
BACKGROUND Standard of care for locally advanced esophageal cancer is neoadjuvant therapy followed by surgical resection. The objective of this study is to explore perioperative factors associated with recurrence and survival among patients with locally advanced esophageal cancer. METHODS A retrospective analysis of prospectively collected data on all consecutive minimally invasive Ivor Lewis esophagectomy cases for esophageal cancer performed from September 2013 to September 2023 was performed. Univariable and multivariable Cox proportional hazard regression models were used explore the risk and protective factors associated with recurrence-free and overall survival. RESULTS In total, 222 consecutive patients who underwent neoadjuvant chemoradiation followed by minimally invasive Ivor Lewis esophagectomy were included. On univariable analysis, hypertension, Eastern Cooperative Oncologic Group, N stage, number of positive lymph nodes, lymphovascular invasion, cellular differentiation, and positive margins were associated with recurrence. Age, N stage, number of positive lymph nodes, lymphovascular invasion, and cellular differentiation were associated with a worse overall survival. On multivariable analysis, N stage (1.911 [1.295-2.819], P = .009) and worsening cellular differentiation (2.042 [1.036-4.025], P = .039) remained risk factors for recurrence, whereas older age (1.056 [1.013-1.102], P = .011) and cellular differentiation (1.949 [1.004-3.782], P = .049) remained significantly associated with a greater risk of death. CONCLUSION Our data suggest that older age and cellular differentiation are strong independent risk factors associated with overall survival. N stage and age are strong independent risk factors associated with both recurrence and survival. These findings may help guide treatment options and shared decision-making among patients with locally advanced esophageal cancer on the basis of their risk and protective factors to maximize recurrence-free and overall survival.
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Affiliation(s)
| | | | | | - Erin M Mobley
- Department of Surgery, University of Florida, Jacksonville, FL
| | - Ziad T Awad
- Department of Surgery, University of Florida, Jacksonville, FL.
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The Role of Age and Comorbidities in Esophagogastric Cancer Chemoradiation of the Frail Elderly (>70 Years): An Analysis from a Tertiary High Volume-Center. Cancers (Basel) 2022; 15:cancers15010106. [PMID: 36612103 PMCID: PMC9817865 DOI: 10.3390/cancers15010106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/12/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022] Open
Abstract
Elderly patients > 70 years of age with esophageal cancer (EC) represent a challenging group as frailty and comorbidities need to be considered. The aim of this retrospective study was to evaluate the efficacy and side effects of curative chemoradiation therapy (CRT) with regard to basic geriatric screening in elderly patients in order to elucidate prognostic factors. Thirty-four elderly patients > 70 years with EC treated at our cancer center between May 2014 and October 2018 fulfilled the selection criteria for this retrospective analysis. Treatment consisted of intravenous infusion of carboplatin/paclitaxel or fluorouracil (5-FU)/cisplatin with the intention of neoadjuvant or definite chemoradiation. Clinicopathological data including performance status (ECOG), (age-adjusted) Charlson comorbidity index (CCI), Frailty-scale by Fried, Mini Nutritional Assessment Short Form, body mass index, C-reactive protein to albumin ratio, and treatment-related toxicity (CTCAE) were assessed. Data were analyzed as predictors of overall survival (OS) and progression-free survival (PFS). All patients (ten female, 24 male) received combined CRT (22 patients in neoadjuvant, 12 patients in definite intent). Median age was 75 years and the ECOG index between 0 and 1 (52.9% vs. 35.3%); four patients were rated as ECOG 3 (11.8%). Median follow-up was 24 months. Tumors were mainly located in the lower esophagus or esophagogastric-junction with an T3 stage (n = 25; 75.8%) and N1 stage (n = 28; 90.3%). 15 patients (44.1%) had SCC, 19 patients (55.9%) AC. 26 of the patients (76.5%) were scored as prefrail and 50% were in risk for malnutrition (n = 17). In relation to the BMI, ten patients (29.4%) were ranked as overweight, and 15 patients were presented in a healthy state of weight (44.1%). Grade 3 acute toxicity (or higher) occured in nine cases (26.5%). Most of the patients did not show any late toxicities (66.7%). Trimodal therapy provides a significant prolonged OS (p = 0.049) regardless of age, but without impact on PFS. Our analysis suggests that chemoradiation therapy is feasible for elderly patients (>70 years) with tolerable toxicity. Trimodal therapy of EC shows a positive effect on OS and PFS. Further studies are needed to elucidate benefitting subgroups within the elderly. In addition to age, treatment decisions should be based on performance status, nutritional condition and multidisciplinary validated geriatric screening tools.
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Aoyama T, Atsumi Y, Kawahara S, Tamagawa H, Tamagawa A, Ozawa Y, Maezawa Y, Kano K, Murakawa M, Kazama K, Segami K, Hara K, Numata M, Oshima T, Yukawa N, Masuda M, Rino Y. The Clinical Impact of the Age-adjusted Charlson Comorbidity Index on Esophageal Cancer Patients Who Receive Curative Treatment. In Vivo 2021; 34:2783-2790. [PMID: 32871815 DOI: 10.21873/invivo.12103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 06/22/2020] [Accepted: 06/24/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND/AIM We investigated the impact of the age-adjusted Charlson comorbidity index (ACCI) on esophageal cancer survival and recurrence after curative treatment. PATIENTS AND METHODS This study included 122 patients who underwent curative surgery followed by adjuvant chemotherapy for esophageal cancer between 2005 and 2017. The risk factors for the overall survival (OS) and recurrence-free survival (RFS) were identified. RESULTS An ACCI of 5 was regarded as the optimal critical point of classification considering the survival rates. The OS rates at 3 and 5 years after surgery were 64.2% and 54.4% in the low-ACCI group, respectively, and 42.3% and 29.2% in high-ACCI group, respectively (p=0.035). The RFS rates at 3 and 5 years after surgery were 50.2% and 43.6% in the low-ACCI group, respectively, and 28.5% and 21.3% in high-ACCI group, respectively (p=0.021). A multivariate analysis demonstrated that ACCI was a significant independent risk factor for both the OS and RFS. CONCLUSION ACCI is a risk factor for survival in patients who undergo curative treatment for esophageal cancer. An effective plan for the perioperative care and surgical strategy should be developed according to ACCI.
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Affiliation(s)
- Toru Aoyama
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Yosuke Atsumi
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | | | - Hiroshi Tamagawa
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Ayako Tamagawa
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Yukihiro Ozawa
- Department of Surgery, Miura City Hospital, Miura, Japan
| | - Yukio Maezawa
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Kazuki Kano
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Masaaki Murakawa
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Keisuke Kazama
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Kenki Segami
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Kentaro Hara
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Masakatsu Numata
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Takashi Oshima
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Norio Yukawa
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Munetaka Masuda
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Yasushi Rino
- Department of Surgery, Yokohama City University, Yokohama, Japan
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Esophageal Cancer in Elderly Patients, Current Treatment Options and Outcomes; A Systematic Review and Pooled Analysis. Cancers (Basel) 2021; 13:cancers13092104. [PMID: 33925512 PMCID: PMC8123886 DOI: 10.3390/cancers13092104] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/17/2021] [Accepted: 04/21/2021] [Indexed: 12/26/2022] Open
Abstract
Simple Summary Any given treatment may provide improve survival for elderly patients with oesophageal cancer compared to best supportive care. Although surgery may be related to a higher rate of complications in these patients, it also offers the best chance for survival, especially when combined with perioperative chemo-or chemoradiation. Definitive chemoradiation remains also a valid and widely used curative approach in this population. Quality of life after oesophageal cancer treatment does not seem to be particularly compromised in elderly patients, although the risk of loss of autonomy after the disease is higher. Based on the available data, excluding a priori elderly patients from curative treatment based on age alone cannot be supported. A thorough general health status and geriatric assessment is necessary to offer the optimal treatment, tailored to the individual patient. Abstract Esophageal cancer, despite its tendency to increase among younger patients, remains a disease of the elderly, with the peak incidence between 70–79 years. In spite of that, elderly patients are still excluded from major clinical trials and they are frequently offered suboptimal treatment even for curable stages of the disease. In this review, a clear survival benefit is demonstrated for elderly patients treated with neoadjuvant treatment, surgery, and even definitive chemoradiation compared to palliative or no treatment. Surgery in elderly patients is often associated with higher morbidity and mortality compared to younger patients and may put older frail patients at increased risk of autonomy loss. Definitive chemoradiation is the predominant modality offered to elderly patients, with very promising results especially for squamous cell cancer, although higher rates of acute toxicity might be encountered. Based on the all the above, and although the best available evidence comes from retrospective studies, it is not justified to refrain from curative treatment for elderly patients based on their age alone. Thorough assessment and an adapted treatment plan as well as inclusion of elderly patients in ongoing clinical trials will allow better understanding and management of esophageal cancer in this heterogeneous and often frail population.
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Lu HW, Chen CC, Chen HH, Yeh HL. The clinical outcomes of elderly esophageal cancer patients who received definitive chemoradiotherapy. J Chin Med Assoc 2020; 83:906-910. [PMID: 32889988 PMCID: PMC7526572 DOI: 10.1097/jcma.0000000000000419] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (CRT) followed by an esophagectomy is the standard treatment for locally advanced esophageal cancer, but remains a great challenge for elderly patients. Therefore, we aim to evaluate the efficacy of definitive CRT in elderly patients with esophageal cancer. METHODS From December 2007 to October 2017, 40 esophageal cancer patients aged ≥70 years receiving definitive CRT were retrospectively analyzed. All patients received cisplatin-based chemotherapy. Ten patients received standard doses of cisplatin 20 mg/m and fluorouracil (5-FU) 800 mg/m for 4 days, during the first and fifth weeks of radiotherapy. Eighteen patients received modified doses of cisplatin 16 to 18 mg/m and 5-FU 600 to 800 mg/m. Twelve patients received lower doses of cisplatin 10 to 12 mg/m and 5-FU 400 to 600 mg/m. The endpoints were overall survival (OS), tumor response rate, and treatment compliance. RESULTS The 3-year OS rate was 28.8% The 3-year OS rates for patients receiving standard, modified, and lower doses were 12.5%, 53.8%, and 0.0%, respectively (p = 0.05). There were 87.5% of patients completing the scheduled radiotherapy dose, along with two cycles of concurrent chemotherapy. The response rate (clinical complete response and partial response rate) was 70.0%. Multivariate analysis revealed that no statistical difference was found in the OS among three groups of chemotherapy dosage. The treatment response was the only independent prognostic factor to OS (p < 0.001). CONCLUSION Definitive CRT with dose modification is a feasible, safe, and reasonable treatment for elderly esophageal cancer patients. Achieving a better compliance to CRT via an optimal dose modification of chemotherapy may provide better clinical outcomes and would be the treatment goal for elderly esophageal cancer patients.
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Affiliation(s)
- Hao-Wei Lu
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Chien-Chih Chen
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- PhD Program in Translational Medicine, National Chung-Hsing University, Taichung, Taiwan, ROC
| | - Hsin-Hua Chen
- PhD Program in Translational Medicine, National Chung-Hsing University, Taichung, Taiwan, ROC
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Institute of Biomedical Science and Rong Hsing Research Center for Translational Medicine, Chung-Hsing University, Taichung, Taiwan, ROC
- School of Medicine, Chung-Shan Medical University, Taichung, Taiwan, ROC
- Institute of Public Health and Community Medicine Research Center, National Yang-Ming University, Taipei, Taiwan. ROC
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan, ROC
| | - Hui-Ling Yeh
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Address correspondence. Dr. Hui-Ling Yeh, Department of Radiation Oncology, Taichung Veterans General Hospital, 1650, Section 4, Taiwan Boulevard, Taichung 407, Taiwan, ROC. E-mail address: (H.-L. Yeh)
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Lagergren J, Bottai M, Santoni G. Patient Age and Survival After Surgery for Esophageal Cancer. Ann Surg Oncol 2020; 28:159-166. [PMID: 32468352 PMCID: PMC7752878 DOI: 10.1245/s10434-020-08653-w] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Indexed: 01/01/2023]
Abstract
Background Esophagectomy for esophageal cancer is associated with a substantial risk of life-threatening complications and a limited long-term survival. This study aimed to clarify the controversial questions of how age influences short-term and long-term survival. Methods This population-based cohort study included almost all patients who underwent curatively intended esophagectomy for esophageal cancer in Sweden in 1987–2010, with follow-up through 2016. The exposure was age, analyzed both as a continuous and categorical variable. The probability of mortality was computed using a novel flexible parametric model approach. The reported probabilities are proper measures of the risk of dying, and the related odds ratios (OR) are therefore more suitable measures of association than hazard ratios. The outcomes were 90-day all-cause mortality, 5-year all-cause mortality, and 5-year disease-specific mortality. A novel flexible parametric model was used to derive the instantaneous probability of dying and the related OR along with 95% confidence intervals (CIs), adjusted for sex, education, comorbidity, tumor histology, pathological tumor stage, and resection margin status. Results Among 1737 included patients, the median age was 65.6 years. When analyzed as a continuous variable, older age was associated with slightly higher odds of 90-day all-cause mortality (OR 1.05, 95% CI 1.02–1.07), 5-year all-cause mortality (OR 1.02, 95% CI 1.01–1.03), and 5-year disease-specific mortality (OR 1.01, 95% CI 1.01–1.02). Compared with patients aged < 70 years, those aged 70–74 years had no increased risk of any mortality outcome, while patients aged ≥ 75 years had higher odds of 90-day mortality (OR 2.85, 95% CI 1.68–4.84), 5-year all-cause mortality (OR 1.56, 95% CI 1.27–1.92), and 5-year disease-specific mortality (OR 1.38, 95% CI 1.09–1.76). Conclusions Patient age 75 years or older at esophagectomy for esophageal cancer appears to be an independent risk factor for higher short-term mortality and lower long-term survival. Electronic supplementary material The online version of this article (10.1245/s10434-020-08653-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jesper Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Matteo Bottai
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Giola Santoni
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
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Han Y, Liu S, Guo W, Zhang Y, Li H. Clinical outcomes of oesophagectomy in elderly versus relatively younger patients: a meta-analysis. Interact Cardiovasc Thorac Surg 2020; 29:897-905. [PMID: 31765482 DOI: 10.1093/icvts/ivz208] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 07/03/2019] [Accepted: 08/01/2019] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES The surgical efficacy of oesophagectomy for elderly patients (>80 years old) is still unclear. The aim of this meta-analysis was to compare the clinical outcomes of oesophagectomy between elderly and relatively younger patients. METHODS PubMed, EMBASE and the Cochrane Library were searched for relevant studies comparing the clinical outcomes of oesophagectomy for elderly and relatively younger patients. Odds ratios were extracted to obtain pooled estimates of the perioperative effect, and hazard ratios were extracted to compare survival outcomes between the 2 cohorts. RESULTS Nine studies involving 4946 patients were included in this meta-analysis. For patients older than 80 years of age, in-hospital mortality [odds ratio (OR) 2.00, 95% confidence interval (CI) 1.28-3.13; P = 0.002] and the incidence rates of cardiac (OR 1.55, 95% CI 1.10-2.20; P = 0.01) and pulmonary (OR 1.57, 95% CI 1.11-2.22; P = 0.01) complications were higher than those of relatively younger patients. The overall postoperative complication rate (OR 1.40, 95% CI 0.82-2.40; P = 0.22) and the incidence of anastomotic leak (OR 0.92, 95% CI 0.58-1.47; P = 0.73) were not significantly different between the 2 groups. Elderly patients had a worse overall 5-year survival rate (HR 2.66, 95% CI 1.65-4.28; P < 0.001) than that of relatively younger patients. The cancer-related 5-year survival rate of elderly patients was also lower than that of relatively younger patients (HR 3.37, 95% CI 2.36-4.82; P < 0.001). CONCLUSIONS Compared with relatively younger patients, elderly patients with oesophageal cancer undergoing oesophagectomy are at higher risk of in-hospital mortality and have lower survival rates. However, there is no conclusive evidence that the overall rate of complications is elevated in elderly patients.
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Affiliation(s)
- Yu Han
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shengjun Liu
- Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wei Guo
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yajie Zhang
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hecheng Li
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Vlacich G, Samson PP, Perkins SM, Roach MC, Parikh PJ, Bradley JD, Lockhart AC, Puri V, Meyers BF, Kozower B, Robinson CG. Treatment utilization and outcomes in elderly patients with locally advanced esophageal carcinoma: a review of the National Cancer Database. Cancer Med 2017; 6:2886-2896. [PMID: 29139215 PMCID: PMC5727236 DOI: 10.1002/cam4.1250] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 10/06/2017] [Accepted: 10/09/2017] [Indexed: 11/30/2022] Open
Abstract
For elderly patients with locally advanced esophageal cancer, therapeutic approaches and outcomes in a modern cohort are not well characterized. Patients ≥70 years old with clinical stage II and III esophageal cancer diagnosed between 1998 and 2012 were identified from the National Cancer Database and stratified based on treatment type. Variables associated with treatment utilization were evaluated using logistic regression and survival evaluated using Cox proportional hazards analysis. Propensity matching (1:1) was performed to help account for selection bias. A total of 21,593 patients were identified. Median and maximum ages were 77 and 90, respectively. Treatment included palliative therapy (24.3%), chemoradiation (37.1%), trimodality therapy (10.0%), esophagectomy alone (5.6%), or no therapy (12.9%). Age ≥80 (OR 0.73), female gender (OR 0.81), Charlson-Deyo comorbidity score ≥2 (OR 0.82), and high-volume centers (OR 0.83) were associated with a decreased likelihood of palliative therapy versus no treatment. Age ≥80 (OR 0.79) and Clinical Stage III (OR 0.33) were associated with a decreased likelihood, while adenocarcinoma histology (OR 1.33) and nonacademic cancer centers (OR 3.9), an increased likelihood of esophagectomy alone compared to definitive chemoradiation. Age ≥80 (OR 0.15), female gender (OR 0.80), and non-Caucasian race (OR 0.63) were associated with a decreased likelihood, while adenocarcinoma histology (OR 2.10) and high-volume centers (OR 2.34), an increased likelihood of trimodality therapy compared to definitive chemoradiation. Each treatment type demonstrated improved survival compared to no therapy: palliative treatment (HR 0.49) to trimodality therapy (HR 0.25) with significance between all groups. Any therapy, including palliative care, was associated with improved survival; however, subsets of elderly patients with locally advanced esophageal cancer are less likely to receive aggressive therapy. Care should be taken to not unnecessarily deprive these individuals of treatment that may improve survival.
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Affiliation(s)
- Gregory Vlacich
- Department of Radiation OncologyWashington UniversitySt. LouisMissouri
| | - Pamela P. Samson
- Department of Radiation OncologyWashington UniversitySt. LouisMissouri
| | | | - Michael C. Roach
- Department of Radiation OncologyWashington UniversitySt. LouisMissouri
| | - Parag J. Parikh
- Department of Radiation OncologyWashington UniversitySt. LouisMissouri
| | | | - A. Craig Lockhart
- Department of MedicineDivision of OncologyWashington UniversitySt. LouisMissouri
| | - Varun Puri
- Department of SurgeryDivision of Cardiothoracic SurgeryWashington UniversitySt. LouisMissouri
| | - Bryan F. Meyers
- Department of SurgeryDivision of Cardiothoracic SurgeryWashington UniversitySt. LouisMissouri
| | - Benjamin Kozower
- Department of SurgeryDivision of Cardiothoracic SurgeryWashington UniversitySt. LouisMissouri
| | - Cliff G. Robinson
- Department of Radiation OncologyWashington UniversitySt. LouisMissouri
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The clinical and economic costs of delirium after surgical resection for esophageal malignancy. Ann Surg 2013; 258:77-81. [PMID: 23426343 DOI: 10.1097/sla.0b013e31828545c1] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The aim of this study was to identify preoperative risk factors and postoperative consequences that are associated with the occurrence of delirium after esophagectomy for malignancy. BACKGROUND Delirium is an underdiagnosed, serious complication after major surgery, particularly in the elderly population. METHODS All patients undergoing esophagectomy for cancer (1991-2011) were included. Patients with and without delirium were compared with respect to medical comorbidities, use of neoadjuvant therapy, operative outcomes, postoperative complications, overall cost, and survival. RESULTS Of the 500 patients included in this analysis, 46 (9.2%) patients developed postoperative delirium. Patients with delirium had higher ASA and Charlson comorbidity index scores. Delirium was associated with a longer hospital (14 ± 7.5 vs 10.9 ± 5.7; P < 0.05) and intensive care unit stay (3.6 ± 3.8 vs 2.7 ± 16.9; P < 0.05) and an increased incidence of pulmonary complications and increased hospital costs. Delirium was preceded by another complication in 32.6% of cases but by a septic complication in only 19.6% of cases. Age was the only preoperative predictor of postoperative delirium in multivariate modeling (P < 0.05). No differences were noted in the use of neoadjuvant chemoradiotherapy or survival. CONCLUSIONS This study demonstrates that postoperative delirium is associated with a more complicated and costly recovery after esophagectomy and that age is independently predictive of its development. Delirium has often been thought to be the sequela of other complications; however, this study demonstrates that it presents in isolation or precedes other complications in 67.4% of cases. Focused screening will likely allow targeted preventative strategies to be used in the perioperative period to reduce complications and costs associated with delirium.
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Abstract
BACKGROUND Several researchers have determined the tumor length to be an important prognostic indictor of esophageal cancer (EC). However, controversy exists concerning the optimal cut-off points for tumor length to predict overall survival. The aim of this study was to determine the prognostic value of tumor length and propose the optimum cut-off point for tumor length in predicting survival difference in elderly patients with esophageal squamous cell carcinoma (ESCC). METHODS From January 2001 to December 2009, a retrospective analysis of 132 consecutive patients older than 70 years with ESCC was conducted. A receiver-operating characteristic (ROC) curve for survival prediction was plotted to verify the optimum cut-off point for tumor length. Univariate and multivariate analyses were performed to evaluate prognostic parameters for survival. RESULTS A ROC curve for survival prediction was plotted to verify the optimum cut-off point for tumor length, which was 4.0 cm. Patients with tumor length ≤ 4.0 cm had significantly better 5-year survival rate than patients with a tumor length >4.0 cm (60.7% versus 31.6%, P = 0.007). Multivariate analyses showed that tumor length (>4.0 cm versus ≤ 4.0 cm, P = 0.036), differentiation (poor versus well/moderate, P = 0.032), N staging (N1-3 versus N0, P = 0.018), and T grade (T3-4 versus T1-2, P = 0.002) were independent prognostic factors. CONCLUSION Tumor length is a predictive factor for long-term survival in elderly patients with ESCC, especially in T3-4 grade or nodal-negative patients. We conclude that 4.0 cm may be the optimum cut-off point for tumor length in predicting survival in elderly patients with ESCC.
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Affiliation(s)
- Ji-Feng Feng
- Department of Thoracic Surgery, Zhejiang Cancer Hospital, No. 38 Guangji Road, Banshan Bridge, Hangzhou 310022, China
- Key Laboratory Diagnosis and Treatment Technology on Thoracic Oncology, Zhejiang Province, Hangzhou 310022, China
| | - Ying Huang
- Department of Nursing, Zhejiang Cancer Hospital, Hangzhou 310022, China
| | - Qiang Zhao
- Department of Thoracic Surgery, Zhejiang Cancer Hospital, No. 38 Guangji Road, Banshan Bridge, Hangzhou 310022, China
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Markar SR, Karthikesalingam A, Thrumurthy S, Ho A, Muallem G, Low DE. Systematic review and pooled analysis assessing the association between elderly age and outcome following surgical resection of esophageal malignancy. Dis Esophagus 2013; 26:250-62. [PMID: 22591068 DOI: 10.1111/j.1442-2050.2012.01353.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The incidence of esophageal malignancy continues to increase worldwide. At the same time, average life expectancy levels continue to climb, ensuring that more patients will present in their 70s, 80s, and 90s. The aim of this pooled analysis is to compare short- and long-term outcomes for elderly and younger patients undergoing esophagectomy for malignancy. Studies comparing the outcomes of esophagectomy for malignancy in elderly and young cohorts of patients were included. The minimum threshold age used to define the elderly cohort was 70 years. Primary outcomes were in-hospital mortality, overall and cancer-related 5-year survival. Secondary outcomes were the length of hospital stay, the incidence of anastomotic leak, conduit ischemia, cardiac and pulmonary complications, and the use of neoadjuvant therapy. Twenty-five publications comprising 9531 and 2573 operations on younger and elderly cohorts of patients respectively were analyzed. Elderly patients were less likely to receive neoadjuvant therapy (14.6% vs. 29.47%; pooled odds ratio [POR]= 0.48; 95% confidence interval [C.I.]= 0.35-0.65; P < 0.05). Esophagectomy in elderly patients was associated with increased in-hospital mortality (7.83% vs. 4.21%; POR = 1.87; 95% C.I. = 1.54-2.26; P < 0.05), as well as increased pulmonary (21.77% vs. 19.49%) and cardiac (18.7% vs. 13.17%) complications. Subset analysis of studies using an age threshold of 80 years showed an even more significant association between in-hospital mortality and elderly age (pooled odds ratio = 3.19; 95% C.I. = 1.6-6.35; P < 0.05). There were no significant differences between the groups in length of hospital stay, incidence of anastomotic leak, or conduit ischemia. The elderly group showed reduced overall 5-year survival (21.23% vs. 29.01%; pooled odds ratio = 0.73; 95% C.I. = 0.62-0.87; P < 0.05) and reduced cancer-free 5-year survival (34.4% vs. 41.8%; POR = 0.75; 95% C.I. = 0.64-0.89; P < 0.05). Elderly patients are at increased risk of pulmonary and cardiac complications, and perioperative mortality following esophagectomy, and show reduced cancer-related 5-year survival compared with younger patients. These patients represent a high-risk cohort, who requires thorough assessment of medical comorbidity, targeted counseling, and optimized treatment pathways.
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Affiliation(s)
- S R Markar
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA 98111, USA
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Tapias LF, Muniappan A, Wright CD, Gaissert HA, Wain JC, Morse CR, Donahue DM, Mathisen DJ, Lanuti M. Short and long-term outcomes after esophagectomy for cancer in elderly patients. Ann Thorac Surg 2013; 95:1741-8. [PMID: 23500043 DOI: 10.1016/j.athoracsur.2013.01.084] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 01/13/2013] [Accepted: 01/28/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND As worldwide life expectancy rises, the number of candidates for surgical treatment of esophageal cancer over 70 years will increase. This study aims to examine outcomes after esophagectomy in elderly patients. METHODS This study is a retrospective review of 474 patients undergoing esophagectomy for cancer during 2002 to 2011. A total of 334 (70.5%) patients were less than 70 years old (group A), 124 (26.2%) 70 to 79 years (group B), and 16 (3.4%) 80 years or greater (group C). We analyzed the effect of age on outcome variables including overall and disease specific survival. RESULTS Major morbidity was observed to occur in 115 (35.6%) patients of group A, 58 (47.9%) of group B, and 10 (62.5%) of group C (p = 0.010). Mortality, both 30-day and 90-day was observed in 2 (0.6%) and 7 (2.2%) of group A, 4 (3.2%) and 7 (6.1%) of group B, and 1 (6.3%) and 2 (14.3%) of group C, respectively (p = 0.032 and p = 0.013). Anastomotic leak was observed in 16 (4.8%) patients of group A, 6 (4.8%) of group B, and 0 (0%) of group C (p = 0.685). Anastomotic stricture (defined by the need for ≥ 2 dilations) was observed in 76 (22.8%) of group A, 13 (10.5%) of group B, and 1 (6.3%) of group C (p = 0.005). Five-year overall and disease specific survival was 64.8% and 72.4% for group A, 41.7% and 53.4% for group B, 49.2% and 49.2% for group C patients (p = 0.0006), respectively. CONCLUSIONS Esophagectomy should be carefully considered in patients 70 to 79 years old and can be justified with low mortality. Outcomes in octogenarians are worse suggesting esophagectomy be considered on a case by case basis. Stricture rate is inversely associated to age.
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Affiliation(s)
- Luis F Tapias
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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13
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Outcomes assessment of the surgical management of esophageal cancer in younger and older patients. Ann Thorac Surg 2013; 94:1652-8. [PMID: 23098941 DOI: 10.1016/j.athoracsur.2012.06.067] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 06/26/2012] [Accepted: 06/28/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND The aim of this study was to assess the influence of age on disease presentation, clinical and pathologic staging, postoperative outcomes, costs, and long-term survival after esophagectomy for esophageal malignancy. METHODS All patients undergoing esophagectomy for cancer between 1991 and 2011 were prospectively enrolled in an Institutional Review Board approved database. RESULTS A total of 493 patients underwent surgical resection during the study period; 58 (11.76%) of these patients were 50 years or less (44 ± 4.7) and 435 patients were greater than 50 years (67 ± 8.44). There was no difference in clinical stage; however, patients 50 years or less were more likely to have adenocarcinoma and reduced Charlson comorbidity index and younger patients tended to have a more delayed presentation as manifested by an increased period of dysphagia and a greater degree of weight loss. In the 50 or less age group there was a significantly greater use of neoadjuvant therapy in stage II patients and the use of neoadjuvant chemotherapy significantly decreased with increasing age. Surgery in the 50 or less age group was associated with significantly reduced intensive care unit stay, incidence of postoperative complications, and overall costs. Multivariate analysis also confirmed associations between increasing age and increased incidence of postoperative complications and cost. There were no significant differences in pathologic stage, positive resection margins, incidence of complete response to neoadjuvant therapy, or in overall survival. CONCLUSIONS This study demonstrates younger patients have fewer complications and lower overall treatment costs after esophagectomy. In spite of having a more delayed presentation, younger patients presented with a similar stage and demonstrated similar overall survival.
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Donohoe CL, MacGillycuddy E, Reynolds JV. The impact of young age on outcomes in esophageal and junctional cancer. Dis Esophagus 2011; 24:560-8. [PMID: 21385286 DOI: 10.1111/j.1442-2050.2011.01183.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
It is not known whether patients diagnosed with esophageal and junctional cancer aged younger than 50 years have a more aggressive disease phenotype and thus poorer outcomes following treatment. Prospectively maintained database records of all patients diagnosed with esophageal carcinoma (n= 2129) over a 20-year period (1990-2009) in a single institution were analyzed. Patients aged less than 50 years at diagnosis (n= 170) were compared with those over 50 years with respect to clinicopathological stage and oncological outcomes. There was a significantly greater proportion of male patients (77.4 vs. 64.7%) among the younger group (P= 0.001). Patients were more likely to be diagnosed with an esophagogastric junction tumor (P= 0.002) and to have symptoms for a longer period prior to diagnosis (24.0 vs. 17.8 weeks, P= 0.03) if they were aged less than 50 years old. There was no significant difference in clinicopathological staging including Tumor-Nodal-Metastasis (TNM) stage, differentiation, and lymphatic and perineural invasion other than a greater likelihood of venous invasion in the older group (P= 0.002). Younger patients were more likely to be treated with curative rather than palliative intent (66.9 vs. 51.1%, P < 0.001). The disease-specific survival of patients younger than 50 years treated with curative intent was significantly greater than older patients (median 35 vs. 21 months, P= 0.04), except for the subgroup of patients aged less than 35 years (n= 18) who have reduced survival. Multivariate analysis revealed independent factors related to the difference in survival included sex, age, advanced T stage, and nodal metastases (P < 0.05). A consistent proportion of esophageal cancer patients are diagnosed aged less than 50 years old over time (1990-2009). Few phenotypic tumor differences were noted between the groups. With an aggressive approach to management, survival is significantly greater than in the older cohort, although outcomes are poorer in those aged below 35 years.
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Affiliation(s)
- C L Donohoe
- Department of Surgery, Trinity Centre for Health Sciences, Trinity College Dublin/St James' Hospital, Dublin 8, Ireland
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Alibakhshi A, Aminian A, Mirsharifi R, Jahangiri Y, Dashti H, Karimian F. The effect of age on the outcome of esophageal cancer surgery. Ann Thorac Med 2011; 4:71-4. [PMID: 19561928 PMCID: PMC2700490 DOI: 10.4103/1817-1737.49415] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2008] [Accepted: 02/15/2009] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Surgery is still the best way for treatment of esophageal cancer. The increase in life expectancy and the rising incidence of esophageal tumors have led to a great number of elderly candidates for complex surgery. The purpose of this study was to evaluate the effects of advanced age (70 years or more) on the surgical outcome of esophagectomy for esophageal cancer at a single high-volume center. MATERIALS AND METHODS: Between January 2000 and April 2006, 480 cases with esophageal cancer underwent esophagectomy in the referral cancer institute. One hundred sixty-five patients in the elderly group (70 years old or more) were compared with 315 patients in the younger group (< 70 years). All in-hospital morbidity and mortality were studied. RESULTS: The range of age was 38–84 years, with a mean of 58.7. The mean age of the elderly and younger groups was 74 and 53.2, respectively. In the younger group, 70 patients (22.2%) and in the elderly group, 39 patients (23.6%) were complicated (P 0.72).The most common complications in the two groups were pulmonary complications (9.8% in younger and 10.3% in elderly) (P 0.87). Rates of anastomotic leakage and cardiac complications were also similar between the two groups. Hospital mortality rates in younger and elderly patients were 2.8% and 3%, respectively. There was no significant difference between the two groups in morbidities and mortality (P-value > 0.05). CONCLUSIONS: With increased experience and care, the outcomes of esophagectomy in elderly patients are comparable to young patients. Advanced age alone is not a contraindication for esophagectomy.
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Affiliation(s)
- Abbas Alibakhshi
- Department of General Surgery, Tehran University of Medical Sciences, Tehran, Iran
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Cijs TM, Verhoef C, Steyerberg EW, Koppert LB, Tran TK, Wijnhoven BP, Tilanus HW, de Jonge J. Outcome of Esophagectomy for Cancer in Elderly Patients. Ann Thorac Surg 2010; 90:900-7. [DOI: 10.1016/j.athoracsur.2010.05.039] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2008] [Revised: 05/10/2010] [Accepted: 05/17/2010] [Indexed: 10/19/2022]
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Davies L, Lewis W, Arnold D, Escofet X, Blackshaw G, Gwynne S, Evans M, Roberts S, Appadurai I, Crosby T. Prognostic Significance of Age in the Radical Treatment of Oesophageal Cancer with Surgery or Chemoradiotherapy: a Prospective Observational Cohort Study. Clin Oncol (R Coll Radiol) 2010; 22:578-85. [DOI: 10.1016/j.clon.2010.05.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2009] [Revised: 03/22/2010] [Accepted: 04/08/2010] [Indexed: 11/29/2022]
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Elsayed H, Whittle I, McShane J, Howes N, Hartley M, Shackcloth M, Page R. The influence of age on mortality and survival in patients undergoing oesophagogastrectomies. A seven-year experience in a tertiary centre. Interact Cardiovasc Thorac Surg 2010; 11:65-9. [PMID: 20378697 DOI: 10.1510/icvts.2009.223826] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The aim of this study was to evaluate the effects of advanced age on the outcome and survival of patients undergoing oesophagectomy for oesophageal cancer at a single high-volume centre. We retrospectively reviewed the hospital survival of 326 patients in oesophagogastrectomies (OGs) in a period from May 2001 to April 2008. We divided the patients into two groups. Group A (n=218) consisted of patients younger than 70 years of age, while Group B (n=108) consisted of patients 70 years of age or older. The two groups were comparable. In-hospital mortality for Group A was 11 out of 218 (5%), while in-hospital mortality for Group B was 13 out of 108 (12%). This difference was statistically significant (P=0.024). Multivariate analysis showed that risk factors for in-hospital mortality after OG included age over 70 years [odds ratio (OR)=2.79], reduced % of predicted FEV(1) (OR=0.13) and cardiac co-morbidity (OR=2.53). Despite age over 70 years proving not to be predictive of survival (P=0.21), significant independent predictors were advancing age [hazard ratio (HR)=1.03] and stage of disease (HR=1.84). P-values were 0.0278 and 0.018, respectively. Increasing age is a significant risk factor for mortality and survival after oesophageal resection operations. This mortality is particularly high if associated with a preoperative cardiac or respiratory morbidity.
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Affiliation(s)
- Hany Elsayed
- Department of Thoracic Surgery, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK.
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Yang HX, Ling L, Zhang X, Lin P, Rong TH, Fu JH. Outcome of elderly patients with oesophageal squamous cell carcinoma after surgery. Br J Surg 2010; 97:862-7. [DOI: 10.1002/bjs.7005] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Oesophagectomy may have morbidity and mortality rates that severely compromise long-term survival in elderly patients. The aim of this study was to compare clinical outcomes in elderly patients with oesophageal squamous cell carcinoma (SCC) with those of younger controls.
Methods
Elderly patients at least 70 years old with oesophageal SCC were matched 1 : 1 with controls aged less than 70 years according to sex, tumour stage, tumour location, histological grade, surgical approach, completeness of resection and surgical period. Co-morbidities, surgical complications, surgical mortality and long-term survival were compared.
Results
One hundred and thirty-six patients were included in each group. Surgical mortality was greater in the elderly group (5·9 versus 0·7 per cent; P = 0·036). Overall and disease-specific 5-year survival rates were worse among patients aged at least 70 years (30·0 versus 41·8 per cent, and 31·5 versus 44·7 per cent respectively), as were 10-year rates (13·7 versus 26·4 per cent, and 20·2 versus 29·0 per cent). Disease-free survival rates after 5 years (24·0 versus 35·5 per cent) and 10 years (12·3 versus 24·3 per cent) were not statistically significant (P = 0·076).
Conclusion
Poor functional status may account for higher morbidity and mortality rates in elderly patients with oesophageal SCC. Acceptable perioperative mortality rates and substantial long-term survival can still be achieved. Elderly patients should not be denied oesophagectomy.
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Affiliation(s)
- H-X Yang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong Province, China
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong Province, China
| | - L Ling
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - X Zhang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong Province, China
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong Province, China
| | - P Lin
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong Province, China
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong Province, China
| | - T-H Rong
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong Province, China
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong Province, China
| | - J-H Fu
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong Province, China
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong Province, China
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Pultrum BB, Bosch DJ, Nijsten MWN, Rodgers MGG, Groen H, Slaets JPJ, Plukker JTM. Extended esophagectomy in elderly patients with esophageal cancer: minor effect of age alone in determining the postoperative course and survival. Ann Surg Oncol 2010; 17:1572-80. [PMID: 20180031 PMCID: PMC2868167 DOI: 10.1245/s10434-010-0966-7] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Indexed: 12/30/2022]
Abstract
BACKGROUND Elderly patients who undergo esophagectomy for cancer often have a high prevalence of coexisting diseases, which may adversely affect their postoperative course. We determined the relationship of advanced age (i.e., > or =70 years) with outcome and evaluated age as a selection criterion for surgery. METHODS Between January 1991 and January 2007, we performed a curative-intent extended transthoracic esophagectomy in 234 patients with cancer of the esophagus. Patients were divided into two age groups: <70 years (group I; 170 patients) and > or =70 years (group II; 64 patients). RESULTS Both groups were comparable regarding comorbidity (American Society of Anesthesiologists classification), and tumor and surgical characteristics. The overall in-hospital mortality rate was 6.2% (group I, 5%, vs. group II, 11%, P = 0.09). Advanced age was not a prognostic factor for developing postoperative complications (odds ratio, 1.578; 95% confidence interval, 0.857-2.904; P = 0.143). The overall number of complications was equal with 58% in group I vs. 69% in group II (P = 0.142). Moreover, the occurrence of complications in elderly patients did not influence survival (P = 0.174). Recurrences developed more in patients <70 years (58% vs. 42%, P = 0.028). The overall 5-year survival was 35%, and, when included, postoperative mortality was 33% in both groups (P = 0.676).The presence of comorbidity was an independent prognostic factor for survival (P = 0.002). CONCLUSIONS Advanced age (> or =70 years) has minor influence on postoperative course, recurrent disease, and survival in patients who underwent an extended esophagectomy. Age alone is not a prognostic indicator for survival. We propose that a radical resection should not be withheld in elderly patients with limited frailty and comorbidity.
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Affiliation(s)
- B B Pultrum
- Department of Surgery/Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Presentation and prognosis of esophageal adenocarcinoma in patients below age 50. Dig Dis Sci 2009; 54:1708-12. [PMID: 19030991 DOI: 10.1007/s10620-008-0565-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2008] [Accepted: 09/26/2008] [Indexed: 12/09/2022]
Abstract
Esophageal adenocarcinoma (EAC), one of the fastest growing cancers in the United States, is increasingly recognized in younger patients in whom the clinicopathologic features have been poorly described. We aim to compare clinical presentation between early (i.e., <or=50 years of age) and later onset EAC, and to evaluate factors associated with survival. All patients diagnosed with EAC at our hospital between 1994 and 2004 were evaluated. Demographics, social history, family history of cancer, clinical presentation, diagnosis during Barrett's surveillance, endoscopic and histologic findings, treatment, and survival were compared between patients older than 50 and <or=50 years of age. Thirty-one of 242 (12.8%) patients were <or=50 years at diagnosis. Patients <or=50 were more likely to present with dysphagia (80% vs. 60%, P = 0.003) and have lymphatic spread at diagnosis (48% vs. 31%, P = 0.015). Median survival was 21.1 months (range 13.1-31.4) for younger patients and 22.0 months (range 20.0-28.1) for older patients (P = NS). Factors associated with shortened survival were dysphagia at presentation, advanced histologic grade, lymphatic spread, and esophagectomy. By multivariable analysis, shortened survival was associated with histologic grade (P = 0.03) and lymphatic spread (P = 0.01). Younger patients comprise a considerable proportion of newly diagnosed EAC. Diagnosis is delayed in younger patients presenting with dysphagia which contributes to adverse outcomes and advanced stage at time of diagnosis. Early endoscopy should be performed in the evaluation of gastroesophageal reflux disease (GERD) and dysphagia, particularly for patients younger than 50 years.
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Heimann DM, Kemeny MM. Surgical Management of the Older Patient with Cancer. GERIATRIC ONCOLOGY 2009:157-200. [DOI: 10.1007/978-0-387-89070-8_8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Morita M, Egashira A, Yoshida R, Ikeda K, Ohgaki K, Shibahara K, Oki E, Sadanaga N, Kakeji Y, Maehara Y. Esophagectomy in patients 80 years of age and older with carcinoma of the thoracic esophagus. J Gastroenterol 2008; 43:345-51. [PMID: 18592152 DOI: 10.1007/s00535-008-2171-z] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2007] [Accepted: 02/12/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND The purpose of this study was to clarify the indications for an esophagectomy in elderly patients (especially patients over 80 years of age) with esophageal cancer. METHODS A total of 668 patients with thoracic esophageal cancer who underwent an esophagectomy by the transthoracic approach were divided into three groups according to age, namely, groups I (>80 years, n=16), II (70-79 years, n=158), and III (<or=69 years, n=494). In group I, surgery was only done in patients with PS 0 or 1, as well as normal cardiac and pulmonary functions. RESULTS The incidence of preoperative pulmonary risk was 16% and 7% in groups II and III, respectively (P<0.01). The morbidity rates of group II and III were 42% and 32%, respectively (P<0.05). Pulmonary complications occurred in 18% and 10%, respectively, and cardiovascular complications occurred in 11% and 4%, respectively (P<0.01). In group I, the morbidity and 30-day mortality rates were 25% and 0%, respectively, and pulmonary and cardiovascular complications occurred only in one patient each (6%). No significant differences were observed in cause-specific survival. CONCLUSIONS In the elderly, preoperative pulmonary risk is frequently present, and careful perioperative management is needed while paying special attention to pulmonary and cardiovascular complications. However, when the indications for surgery can be strictly determined, an esophagectomy is considered a viable treatment alternative with satisfactory prognosis even in patients 80 years of age and older without any increased morbidity or mortality.
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Affiliation(s)
- Masaru Morita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
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Ruol A, Portale G, Castoro C, Merigliano S, Cavallin F, Battaglia G, Michieletto S, Ancona E. Management of esophageal cancer in patients aged over 80 years. Eur J Cardiothorac Surg 2007; 32:445-8. [PMID: 17643999 DOI: 10.1016/j.ejcts.2007.06.014] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2007] [Revised: 06/09/2007] [Accepted: 06/11/2007] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Important advances in the management of cancer of the esophagus and esophagogastric junction have occurred in the last decades, making treatment possible even in elderly patients. Unfortunately there is little information on management of esophageal cancer in octogenarian patients. The aim of this study was to evaluate the treatment results of esophageal and esophagogastric junction cancer in a single institution over a 14-year period in patients>or=80 years of age. METHODS Clinicopathological characteristics and management strategies were studied in patients>or=80 years old with cancer of the esophagus or esophagogastric junction, referred to our department and treated between 1992 and 2005. RESULTS There were 62 patients>or=80 years: 12 underwent surgical resection and 50 were not resected. There were no perioperative deaths. The morbidity rate was 33%. Most non-resected patients had an endoscopic prosthesis. The median survival for the overall group was 5.4 months: 14.6 and 5.1 in resected and non-resected patients, respectively. CONCLUSIONS Even in octogenarian patients--with limited comorbidities and fit for surgery--esophagectomy may be regarded as a valid treatment option. Unfortunately this remains possible only in a small minority of 80-90-year old patients. In the remainder, endoscopic treatments--namely prosthesis placements, with chemoradiotherapy when possible--are the alternatives.
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Affiliation(s)
- Alberto Ruol
- Department of Surgery and Organ Transplant, Clinica Chirurgica III, University of Padova School of Medicine, Padova, Italy
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Ruol A, Portale G, Castoro C, Merigliano S, Cagol M, Cavallin F, Chiarion Sileni V, Corti L, Rampado S, Costantini M, Ancona E. Effects of Neoadjuvant Therapy on Perioperative Morbidity in Elderly Patients Undergoing Esophagectomy for Esophageal Cancer. Ann Surg Oncol 2007; 14:3243-50. [PMID: 17713823 DOI: 10.1245/s10434-007-9455-z] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2006] [Accepted: 03/09/2007] [Indexed: 11/18/2022]
Abstract
BACKGROUND The use of cytoreductive therapy followed by surgery is preferred by many centers dealing with locally advanced esophageal cancer. However, the potential for increase in mortality and morbidity rates has raised concerns on the use of chemoradiation therapy, especially in elderly patients. The aim of this study was to assess the effects of induction therapy on postoperative mortality and morbidity in elderly patients undergoing esophagectomy for locally advanced esophageal cancer at a single institution. METHODS Postoperative mortality and morbidity of patients > or = 70 years old undergoing esophagectomy after neoadjuvant therapy, between January 1992 and October 2005 for cancer of the esophagus or esophagogastric junction, were compared with findings in younger patients also receiving preoperative cytoreductive treatments. RESULTS 818 patients underwent esophagectomy during the study period. The study population included 238 patients < 70 years and 31 > or = 70 years old undergoing esophageal resection after neoadjuvant treatment. Despite a significant difference in comorbidities (pulmonary, cardiological and vascular), postoperative mortality and morbidity were similar irrespective of age. CONCLUSIONS Elderly patients receiving neoadjuvant therapies for cancer of the esophagus or esophagogastric junction do not have a significantly increased prevalence of mortality and major postoperative complications, although cardiovascular complications are more likely to occur. Advanced age should no longer be considered a contraindication to preoperative chemoradiation therapy preceding esophageal resection in carefully selected fit patients.
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Affiliation(s)
- Alberto Ruol
- Department of Gastroenterological and Surgical Sciences, Clinica Chirurgica III, University of Padova School of Medicine, Via Giustiniani 2, 35128, Padova, Italy
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Ruol A, Portale G, Zaninotto G, Cagol M, Cavallin F, Castoro C, Sileni VC, Alfieri R, Rampado S, Ancona E. Results of esophagectomy for esophageal cancer in elderly patients: Age has little influence on outcome and survival. J Thorac Cardiovasc Surg 2007; 133:1186-92. [PMID: 17467427 DOI: 10.1016/j.jtcvs.2006.12.040] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2006] [Revised: 11/15/2006] [Accepted: 12/12/2006] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The aging of the population and a longer life expectancy have led to an increased number of elderly patients with esophageal cancer being referred for surgical treatment. The aim of this study was to assess the effects of age on the outcome of surgery for esophageal cancer at a single institution. METHODS Perioperative outcome and long-term survival of patients at least 70 years old undergoing esophagectomy between 1992 and 2005 for cancer of the esophagus or esophagogastric junction were compared with findings in younger patients. Patients who underwent an abdominal procedure only were excluded from the analysis. RESULTS The analysis considered 580 patients younger than 70 years and 159 at least 70 years old. Clinical presentation in the two groups was similar, as were postoperative morbidity and mortality, despite significant differences in perioperative risk factors. Irrespective of age, overall survival was 34% at 5 years for all patients and 37% for patients with R0 resection. CONCLUSIONS Increased experience and refinements in perioperative care explain the better results of esophagectomy in elderly patients in recent years. Short- and long-term outcomes after esophagectomy for carcinoma in patients older than 70 years are comparable with those of their younger counterparts. Advanced age per se thus should not be considered a contraindication to esophageal resection.
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Affiliation(s)
- Alberto Ruol
- Department of Medical and Surgical Sciences, Clinica Chirurgica III, University of Padova School of Medicine, Padova, Italy
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Al-Sarira AA, David G, Willmott S, Slavin JP, Deakin M, Corless DJ. Oesophagectomy practice and outcomes in England. Br J Surg 2007; 94:585-91. [PMID: 17443856 DOI: 10.1002/bjs.5805] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Abstract
Background
The 2001 UK National Health Service guidance on improving outcomes recommended centralization of oesophageal resection. The aim of this study was to analyse national trends in oesophageal resection in England to determine whether centralization has occurred and its impact on outcomes.
Methods
The study used data from Hospital Episode Statistics for 1997–1998 to 2003–2004 and included patients who had resection for oesophageal cancer. The annual hospital volume was grouped into five categories based on the recommendation for annual volume for a designated centre.
Results
A total of 11 838 oesophageal resections were performed. The total number of hospitals performing resections decreased, mainly owing to a fall in the number of very low-volume hospitals (117 in 1997 to 45 in 2003). The proportion of resections performed in very high-volume hospitals increased from 17·8 per cent during 1997–1999 to 21·9 per cent during 2002–2003 (P < 0·001). The overall in-hospital mortality rate was 10·1 per cent, with a significant reduction over time (from 11·7 to 7·6 per cent; P < 0·001). The decline in mortality rate may be due to increased numbers of patients undergoing surgery in higher-volume hospitals. There was an increase in the annual number of new patients from 5672 to 6230 during the study, although a fall in the proportion of resections from 31·5 to 26·0 per cent (P < 0·001).
Conclusion
Centralization and multidisciplinary team expertise partly explain the improvement in mortality rate, but changes in preoperative selection also play a part.
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Affiliation(s)
- A A Al-Sarira
- Leighton Research Unit, Department of Surgery, Leighton Hospital, Mid Cheshire NHS Trust, Crewe, UK
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Hodgson T. Oesophageal cancer: Experiences of patients and their partners. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2006; 15:1157-60. [PMID: 17170688 DOI: 10.12968/bjon.2006.15.21.22372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Oesophageal cancer (OC) is a debilitating disease with significant social, psychological and physical impacts on health and lifestyle (Mills and Sullivan, 2000). The research presented in this paper uses a survey method, and reveals that patients require honest communication and more help with everyday living from nurses to facilitate recovery. Each patient is unique but commonalities can be established that improve experience and outcome. Three themes emerged from the data: food, activity and positivity. To meet long-term needs, the Oesophageal Patients Association is fundamental for patients and carers in order adapt to this major life-changing event.
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Ma JY, Wu Z, Wang Y, Zhao YF, Liu LX, Kou YL, Zhou QH. Clinicopathologic characteristics of esophagectomy for esophageal carcinoma in elderly patients. World J Gastroenterol 2006; 12:1296-9. [PMID: 16534889 PMCID: PMC4124447 DOI: 10.3748/wjg.v12.i8.1296] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the risk of esophagectomy for carcinoma of the esophagus in the elderly (70 years or more) compared with younger patients (<70 years) and to determine whether the short-term outcomes of esophagectomy in the elderly have improved in recent years.
METHODS: Preoperative risks, postoperative morbidity and mortality in 60 elderly patients (≥70 years) with esophagectomy for carcinoma of the esophagus were compared with the findings in 1 782 younger patients (<70 years) with esophagectomy between January 1990 and December 2004. Changes in perioperative outcome and short-time survival in elderly patients between 1990 to 1997 and 1998 to 2004 were separately analyzed.
RESULTS: Preoperatively, there were significantly more patients with hypertension, pulmonary dysfunction, cardiac disease, and diabetes mellitus in the elderly patients as compared with the younger patients. No significant difference was found regarding the operation time, blood loss, organs in reconstruction and anastomotic site between the two groups, but elderly patients were more often to receive blood transfusion than younger patients. Significantly more transhiatal and fewer transthoracic esophagectomies were performed in the elderly patients as compared with the younger patients. Resection was considered curative in 71.66% (43/60) elderly and 64.92% (1 157/1 782) younger patients, which was not statistically significant (P > 0.05). There were no significant differences in the prevalence of surgical complications between the two groups. Postoperative cardiopulmonary medical complications were encountered more frequently in elderly patients. The hospital mortality rate was 3.3% (2/60) for elderly patients and 1.1% (19/1 782) for younger patients without a significant difference. When the study period was divided into a former (1990 to 1997) and a recent (1997 to 2004) period, operation time, blood loss, and percentage of patients receiving blood transfusion of the elderly patients significantly improved from the former period to the recent period. The hospital mortality rate of the elderly patients dropped from the former period (5.9%) to the recent period (2.3%), but it was not statistically significant.
CONCLUSION: Preoperative medical risk factors and postoperative cardiopulmonary complications after esophagectomy are more common in the elderly, but operative mortality is comparable to that of younger patients. These encouraging results and improvements in postoperative mortality and morbidity of the elderly patients in recent period are attributed to better surgical techniques and more intensive perioperative care in the elderly.
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Affiliation(s)
- Jian-Yang Ma
- Department of Thoracic and Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China.
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Abstract
The dramatic increase in digestive surgery among patients of advanced age is the logical consequence of the aging population demographics in developed countries. Surgery in the aged is not fundamentally different, but it demands precise and tailored assessment and management of surgical indications and surgical and anesthetic techniques. Advanced age is not a contraindication to even major digestive surgery, but every effort must be made to avoid urgent operations by attention to pre-existing symptoms which are all-too-often neglected in the aged. Intensive care may help to shorten the hospital stay which should ideally occupy only a minor portion of the numbered days of the patient (whose life expectancy may be significantly longer than one may intuitively foresee).
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Affiliation(s)
- J J Duron
- Service de Chirurgie Générale, Hôpital de la Pitié Salpetrière, Paris.
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