Gastrointestinal Cancer
Table 1: Reported Series on Hepatic Resection for Colorectal Liver Metastases in the Elderly First Author,
Number of Patients
Year of Publication Zieren, 199414 Fong, 199515 Fong, 199712
Brunken, 199813 Brand, 200034
Zacharias, 200411 Nagano, 200535 Figueras, 200716 Nojiri, 200937 Adam, 201018
18
128 83 25 41 61 62
160 64
1,624 Age Cut-off (Years)
>70 ≥70 >65 ≥70
Peri-operative Morbidity (%)
28 42 47 28
41
19.7 41
29.6 32.3
Peri-operative Mortality (%)
6 4 4 4
1.6 0 8 0
3.8
3- and 5-year Overall Survival (%)
25 (5-year) 35 (5-year) 50 (3-year) 44 (5-year)
≥70 29 7.3 – >70 ≥70 ≥70 ≥75 ≥70
chronological age of a cancer patient when taking an oncological decision and whether an age limit alone should be considered as a deterrent to surgical treatment.
Several physiological and functional changes that occur with ageing to a great extent reduce the ability of the elderly to sustain the stress of a surgical procedure. Over half a century ago, in his large series of abdominal operations in patients over 70 years of age Welch reported a peri-operative mortality rate of 20.7%. He concluded that surgery itself was safe but that the elderly require greater attention in the peri-operative period.19
However, current evidence suggests
that the health of the extreme elderly is improving and interventions can be successfully undertaken at later ages. Over the last two decades, the mortality and morbidity rates associated with hepatic resection have decreased in elderly patients (
In addition, in studies reporting resection of CRLM, age did not appear as a risk factor influencing short- and long-term outcomes.9,20–23 Moreover, the results of resection in the elderly were not very different from those in the younger population. Thus, it is not chronological age alone that determines post-operative mortality, morbidity and long-term survival after surgery.24–26
A true limit in terms
of chronological age should not exist for resection, which indeed continues to be the sole potentially curative treatment; instead functional status should be taken in account when planning an intention-to-treat onco-surgical strategy.
The Necessity and Feasibility of Liver Resection in the Elderly with Colorectal Liver Metastases
The liver is the most common organ for distant metastases from CRC.27
It has been documented that CRC in the elderly may be a biologically low-grade malignancy compared with that in the younger population.28
21 (5-year) 34.1 (5-year) 36 (5-year) 33.2 (5-year)
57 (3-year), 36 (5-year)
In studies investigating the role of surgery in CRLM in the elderly, differences in patient selection, limited numbers of patients and the arbitrary definition of elderly patients have made the interpretation of results difficult. Thus, we recently published a study that compared the outcomes of CRLM resection in patients at least 70 years of age compared with those in younger patients.18
This study was performed
in a large prospective multicentre cohort (the International LiverMetSurvey register). Twenty-one per cent of patients (out of 7,764 patients resected for CRLM) were at least 70 years of age. The trend in recent years of operating on elderly patients was shown by the fact that 29% of resected patients were at least 70 years of age in 2006 compared with only 5% in 1990. The post-operative mortality rate in the elderly was
When Fong et al.15
compared the results of CRLM resection in elderly and younger patients, they found no difference in peri-operative morbidity (younger group 40% versus older group 42%) or mortality (4% for both groups). Similarly, Zieren et al.14
reported that there was no
difference in peri-operative mortality (3 versus 6%) or major morbidity (10 versus 16%) among elderly and younger patients.
Unfortunately, little is known about the clinico- pathological characteristics of CRLM specifically in the elderly. The natural course of unresectable CRLM is limited to 4.5–6.5 months of survival; similarly, patients treated by chemotherapy alone have a median survival of 9.2–16.5 months.4,29–31
Chemotherapy is capable of
downstaging the disease and rendering CRLM resectable, and a combination of chemotherapy and curative surgery has been shown to achieve survival rates of up to 58%.10,22,32,33
Hence, it is
essential that complete surgical resection be the therapeutic goal in these patients.
38
showed that not only a first liver resection but also repeat liver resection for CRLM can be performed safely in elderly patients (>70 years of age). However, in their study the short-term results (mortality rate of 7% and morbidity rate of 38%) and long-term outcomes (three-year OS of 25% and no survivors at five
Zacharias et al.11 EUROPEAN ONCOLOGY
reported results in 160 elderly patients (≥70 years of age) undergoing liver resection for CRLM. Elderly patients had higher peri-operative mortality than younger patients, but in recent years that difference had markedly reduced. Excluding post-operative mortality, the overall survival (OS) and disease-free survival (DFS) were similar in both groups. The authors concluded that the criteria to indicate surgery must essentially be the same in both groups. Noting these results, one would be justified in saying that resection of CRLM in the elderly is indeed feasible and yields comparable peri-operative outcomes to those in younger patients.
Figueras et al.16
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92