In the current retrospective study, we analyzed the surgical outcomes of 166 consecutive patients aged ≥ 80 years with gastric cancer who underwent gastrectomy with curative intent in two institutions. Most of the participants were in relatively good general condition, which may mean that only selected patients underwent surgery. The extents of gastrectomy and lymphadenectomy were often limited. The incidence of postoperative respiratory complications including pneumonia was high, and complications were likely to become serious. Pneumonia was the second leading cause of death following gastric cancer. Univariate analyses showed that extremely advanced age (≥ 90 years), worse general, physiological, nutritional, or physical condition (ECOG-PS 3, POSSUM physiological score ≥ 40, PNI < 40, ASA-PS 3,4), open surgery, total or proximal gastrectomy, D1 lymphadenectomy, advanced cancer stage (pStage II-IV), and R1 resection were prognostic factors for worse OS. A multivariate analysis revealed that ASA-PS 3,4, total or proximal gastrectomy, D0 lymphadenectomy, and pStage II-IV were independent risk factors for worse OS.
This result may mean that, among several parameters that may predict postoperative mortality, ASA-PS, while simple, is the keenest classification. A disadvantage of ASA-PS is that it can vary among evaluators even for the same patient. To address this, specific examples and explanations were added in 2014 as follows . The definition of ASA-PS 3 is “a patient with severe systemic disease”; for example, poorly controlled diabetes mellitus or hypertension, chronic obstructive pulmonary disease, morbid obesity (body mass index ≥ 40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, end-stage renal disease undergoing regularly scheduled dialysis, history (> 3 months) of myocardial infarction, cerebrovascular accident, transient ischemic attack, or coronary artery disease stents. Since this edition, ASA-PS has been evaluated relatively objectively.
The extent of gastrectomy was an independent risk factor for mortality. Patients who underwent gastrectomy including the cardia (total, proximal, and completion gastrectomy) had shorter survival than those who underwent distal gastrectomy or subtotal resection of the remnant stomach. The former patients were more likely to die of pneumonia and senility (six and four among 48 patients, respectively) than were the latter patients (six and three among 105 patients, respectively), although no significant differences were found. Preserving the cardia may contribute to preventing regurgitation and malnutrition after gastrectomy. A previous report with patients aged ≥ 85 years also mentioned that the prognosis of patients undergoing total gastrectomy was worse than that of patients after distal gastrectomy .
As well as the extent of gastrectomy, the extent of lymphadenectomy is also recommended to be limited in patients aged ≥ 80 years . A recent paper showed that D2 lymphadenectomy was an independent risk factor for postoperative pneumonia in patients aged ≥ 75 years . Our multivariate analysis showed that D0 lymphadenectomy was an independent risk factor for worse OS compared with D2 lymphadenectomy, which may mean that excessively limited lymphadenectomy for advanced cancer is best avoided, while local resection with D0 lymphadenectomy for early cancer is acceptable.
The pros and cons of adjuvant chemotherapy for gastric cancer in the elderly are also controversial. In the ACTS-GC trial , which showed the effectiveness of S-1 adjuvant treatment for stage II or III gastric cancer, the eligibility criteria excluded patients aged over 80 years. In the current series, the number of patients who received postoperative chemotherapy was only 10 (6%), which was too small for a statistical analysis. A questionnaire survey of JCOG also showed that only 99 (6.0%) of 1,660 gastrectomized patients aged > 80 years received S-1 adjuvant chemotherapy . A phase III trial to confirm modified S-1 adjuvant chemotherapy for pathological stage II/III vulnerable elderly gastric cancer patients after gastric resection (JCOG1507, BIRDIE) is ongoing , and the results are awaited.
The present study had several potential limitations. First, this study was limited by its retrospective nature. Second, it was conducted with a relatively small number of patients from two institutions. Third, some patients were not followed up for a sufficient period of time.