Geriatric colon cancer

Early onset colorectal cancer: Cancer promotion in young tissue

The incidence of colorectal cancer (CRC) in patients under 50 has been increasing over the past several decades. The factors underlying the increase in early onset colorectal cancer (EOCRC) are not entirely clear, although several genetic and clinical differences with late onset colorectal cancer (LOCRC) have been noted. EOCRC cases are often diagnosed at a more advanced stage, raising the possibility that these cancers progress more rapidly than LOCRC cases. The impact of age on cancer progression is an intriguing topic and numerous lines of research have found that a young tissue environment is often more promotional. In fact, a less hospitable promotional tissue environment in older individuals may offset the increased cancer risk associated with the increased mutational load associated with age. Here we address how youthful aspects of angiogenesis, the tumor immune response, and the oxidative stress response may contribute to the rapid progression of EOCRC. Understanding the factors promoting EOCRC may provide insight into why EOCRC cases are increasing.

Immunosenescence: a key player in cancer development

Immunosenescence is a process of immune dysfunction that occurs with age and includes remodeling of lymphoid organs, leading to changes in the immune function of the elderly, which is closely related to the development of infections, autoimmune diseases, and malignant tumors. T cell-output decline is an important feature of immunosenescence as well as the production of senescence-associated secretory phenotype, increased glycolysis, and reactive oxygen species. Senescent T cells exhibit abnormal phenotypes, including downregulation of CD27, CD28, and upregulation of CD57, killer cell lectin-like receptor subfamily G, Tim-3, Tight, and cytotoxic T-lymphocyte-associated protein 4, which are tightly related to malignant tumors. The role of immunosenescence in tumors is sophisticated: the many factors involved include cAMP, glucose competition, and oncogenic stress in the tumor microenvironment, which can induce the senescence of T cells, macrophages, natural killer cells, and dendritic cells. Accordingly, these senescent immune cells could also affect tumor progression. In addition, the effect of immunosenescence on the response to immune checkpoint blocking antibody therapy so far is ambiguous due to the low participation of elderly cancer patients in clinical trials. Furthermore, many other senescence-related interventions could be possible with genetic and pharmacological methods, including mTOR inhibition, interleukin-7 recombination, and NAD⁺ activation. Overall, this review aims to highlight the characteristics of immunosenescence and its impact on malignant tumors and immunotherapy, especially the future directions of tumor treatment through senescence-focused strategies.

Alterations in composition of immune cells and impairment of anti-tumor immune response in aged oral cancer-bearing mice

OBJECTIVES

Aging has been suggested to be associated with immune dysregulation. An understanding of alterations in the host immunity with advancing age is, therefore, important for designing immune therapy for elderly cancer patients. In this context, not much is known about age-associated alterations in the immune system in oral cancer.

METHODS

To evaluate age-associated alterations in the immune system, which might affect anti-tumor immune responses in oral cancer, we performed a comparative analysis of the proportion of different immune cells, the proliferative capacity of T cell compartment, and the response against immune therapies targeting immune check point molecules between young and aged oral cancer-bearing mice.

RESULTS

The proportion of immune regulatory cells, such as regulatory T cells and myeloid derived suppressor cells, was significantly increased in aged mice compared to that in young mice. Moreover, the expression of PD-1 and CTLA-4 on both CD4⁺ and CD8⁺ T cells was elevated in aged mice compared to that in young mice, and the proliferative abilities of CD4⁺ and CD8⁺ T cells derived from aged mice were significantly reduced following stimulation of T-cell receptors. Moreover, tumor growth was significantly enhanced in aged mice compared to that in young mice. However, immunotherapies targeting PD-1, CTLA-4, and PD-L1 resulted in faster tumor regression in aged mice than in young mice.

CONCLUSIONS

Together, our results indicate that age-associated alterations in the immune system are directly associated with the impairment of anti-tumor immunity in aged mice bearing oral cancer, and might facilitate the progression of the tumor.

Age-related tumor growth in mice is related to integrin α 4 in CD8+ T cells

Cancer incidence increases with age, but paradoxically, cancers have been found to grow more quickly in young mice compared with aged ones. The cause of differential tumor growth has been debated and, over time, attributed to faster tumor cell proliferation, decreased tumor cell apoptosis, and/or increased angiogenesis in young animals. Despite major advances in our understanding of tumor immunity over the past 2 decades, little attention has been paid to comparing immune cell populations in young and aged mice. Using mouse colon adenocarcinoma model MC38 implanted in young and mature mice, we show that age substantially influences the number of tumor-infiltrating cytotoxic CD8+ T cells, which control cancer progression. The different tumor growth pace in young and mature mice was abrogated in RAG1null mice, which lack mature T and B lymphocytes, and upon selective depletion of endogenous CD8+ cells. Transcriptome analysis further indicated that young mice have decreased levels of the Itga4 gene (CD49d, VLA-4) in tumor-infiltrating lymphocytes when compared with mature mice. Hypothesizing that VLA-4 can have a tumor-protective effect, we depleted the protein, which resulted in accelerated tumor growth in mature mice. These observations may explain the paradoxical growth rates observed in murine cancers, point to the central role of VLA-4 in controlling tumor growth, and open new venues to therapeutic manipulation.

Prognostic significance of c-Met, β-catenin and FAK in patients with hepatocellular carcinoma following surgery

The present study aimed to investigate the prognostic value of specific molecular markers in patients with hepatocellular carcinoma (HCC) who had received surgery. Immunohistochemical analysis was used to measure the expression of hepatocyte growth factor receptor (c-Met), β-catenin and focal adhesion kinase (FAK) in patients with HCC. c-Met expression was identified to be high in patients with larger tumors, higher α-fetoprotein (AFP) levels, higher Edmondson grades, portal vein invasion and higher tumor-node-metastasis (TNM) stages. FAK expression was high in patients with portal vein invasion, higher Edmondson grades and higher TNM stages. β-catenin expression was high in patients with larger tumors, hepatitis B virus (HBV) infection, portal vein invasion, higher Edmondson grades and higher TNM stages. Following multivariate analysis, FAK (P=0.002) and β-catenin (P=0.006) expression levels were demonstrated to be significantly associated with Edmondson grade. Additionally, the tumor size (P=0.009) and HBV infection status (P=0.002) were revealed to be associated with β-catenin expression. Kaplan-Meier survival curve analysis demonstrated that patients with HCC with higher FAK expression, higher β-catenin expression, portal vein invasion, higher Edmondson grades, higher TNM stages, younger ages and higher AFP levels had significantly poorer prognoses. Cox's regression analysis revealed that the survival period was correlated with the Edmondson grade, age, AFP level, and FAK and β-catenin expression. Univariate analysis of c-Met, β-catenin and FAK identified a significant correlation between FAK and β-catenin (P=0.015). Correlation analysis revealed no significant correlation between the three molecular markers, but β-catenin and c-Met were markedly correlated (P=0.052). No significant correlation between FAK, c-Met or β-catenin expression was identified. FAK and β-catenin expression demonstrated a correlation with a range of clinicopathological factors, and high FAK and β-catenin expression levels were identified to be correlated with a poor survival rate of patients with HCC. Thus, patients with higher FAK and β-catenin expression may require more aggressive therapy. The results of the present study suggest that FAK and β-catenin expression possess more prognostic value than c-Met expression in patients with HCC.

Gompertz' survivorship law as an intrinsic principle of aging

We defend the hypothesis that life-spanning population survivorship curves, as described by Gompertz' law and composed from cross-sectional data (here mortality), reflect an intrinsic aging principle active in each subject of that population. In other words Gompertz' law reflects aging of a prototypical subject, provided minimal (or no) external causes of death (i.e. fatal infections, starvation, accidents). Our approach deviates from the traditional (exponential) Gompertz' hazard function. For instance, the here formulated Gompertz' law accurately describes old-age deceleration of both all-cause mortality and the incidence of some ageing-associated cancers, as illustrated for the Dutch population. We consider the possibility that the old-age expression and progression of cancer and other pathologies becomes suppressed, because of random (and exponential) accumulation of damage during life. Gompertz' law may trigger new concepts and models describing life-spanning physiological and pathological processes of aging. We discuss (and reject) various aging models (e.g. a predominant role of individual variations at birth; reliability theory) and point to the explanatory potential of network models and systemic regulatory models.

Emergent and Elective Colon Surgery in the Extreme Elderly: Do the Results Warrant the Operation?

With the elderly population rising continuously, surgeons are increasingly confronted by the dilemma of operative management in these patients, which frequently encompasses end-of-life issues. Increasing age and emergent surgery are known risk factors for poor outcomes in colon surgery. The purpose of this study is to delineate differences in outcomes between emergent and elective colon surgery and identify risk factors that can guide the surgeon in caring for the extreme elderly (age 80 years or older). From 2001 to 2006, a retrospective review of the resident database at Greenville Hospital System identified 104 extreme elderly patients who underwent colon surgery (65 elective, 39 emergent). Comparing elective and emergent operations, results showed substantial differences in morbidity (20% vs 51.2%, P < 0.001), 30-day mortality rate (7.7% vs 30.7%, P < 0.005), and length of stay (13.6 days vs 21.6 days, P < 0.004). Percentage of patients discharged to home was significantly less in the emergent group (13% vs 59%, P < 0.001). Evaluation of the emergent surgery group revealed male gender, history of smoking, and ischemic changes on pathologic examination were statistically significant risk factors for failure of surgery. As a result of the high-risk nature of emergent colon operations in the extreme elderly, it is important that surgeons carefully assess the benefits in relation to the risks and functional outcomes of surgery when planning patient care and providing informed consent.

Designing ageing conditions in tumour microenvironment-a new possible modality for cancer treatment

While tumour incidence is known to augment with age, paradoxically tumour growth and metastasis were often found to proceed at a slower rate at late ages. This age-related biological behaviour of tumours actually imposes a differential therapeutic approach to the old cancer patient. Several mechanisms of the age-related reduced tumour progression have been demonstrated: decreased tumour cell proliferation, increased apoptotic cell death, decreased angiogenesis and anti-tumoural immune response changes. We postulated that it might be possible to design age-adjusted treatment modalities based on the mechanisms responsible for the reduced tumour progression rate in the aged. Based on these mechanisms, we compared the effect of different treatments (apoptosis-inducing agents, Hydrocortisone and Adriamycin, anti-angiogenic agent, TNP-470, and immunomodulators-Levamisole and BCG) on two experimental tumours (B16 melanoma and AKR lymphoma) growing in young and old mice. Most treatments showed, in both tumours, a higher inhibitory effect on tumours growing in old mice than on those developing in young ones, to our knowledge, a feature not described before for anti-tumoural agents. We suggest that designing ageing conditions in tumours of young patients might possibly alleviate neoplastic aggressiveness in these patients as well.

The effects of aging on tumor growth and angiogenesis are tumor-cell dependent

It is generally accepted that histologically similar tumors grow more slowly, with less angiogenesis, in aged mice relative to young mice. We subcutaneously implanted TRAMP-C2 tumor cells, a prostate cancer cell line not previously examined in aging, into syngeneic C57/Bl6 young (4 month) and aged (20 month) mice and compared tumor growth and angiogenesis. Unexpectedly, the prostate tumors grew as fast in aged as in young mice. Angiogenesis in TRAMP-C2 tumors was robust, with no differences between the young and aged mice in the number of vessels, distribution of vessel sizes or features of vessel maturation. Aged mice had lower levels of serum testosterone than the young mice. VEGF levels were similar in the tumors and sera of the young and aged mice. Comparison with B16/F10 melanoma, a cancer cell line that is representative of previous studies in aged mice, showed that B16/F10 tumors grew minimally in the aged mice. In contrast to the B16/F10, TRAMP-C2 tumors had an extracellular matrix with significantly higher levels of MMP2 and MMP9 expression and activity. These unique results demonstrate that tumor progression can be as robust in aged tissues as young tissues. The ability of aged mice to grow large, vascularized prostate tumors is associated with high levels of MMP2/9 activity that may produce a permissive environment for tumor growth and angiogenesis. These data demonstrate that tumor-cell specific features determine the effect of aging on tumor growth and angiogenesis.

Efficacy of anti-angiogenic treatment of tumors in old versus young mice

Cancer treatment in the older population, the most afflicted by the disease, is as yet, inefficient. A reduced aggressiveness of tumors is often observed in the elderly, implying the necessity for therapeutic modalities adjusted to age. A rational design of age-related cancer therapy could be based on the mechanisms of this phenomenon. It is suggested that, in addition to the patient's old age-specific health problems (which prohibit the use of the aggressive cancer treatments now in use), the age-related differential tumor biology (apparently beneficial to the old) should also be considered for the design of treatment modalities suitable for the aged. Based on one mechanism of the reduced aggressiveness of tumors in the old (age-dependent decreased angiogenesis), we compared the effect of an anti-angiogenic treatment in young and old mice. TNP-470 treatment resulted in an inhibitory effect on B16 melanoma in both young and old mice but the effect was more pronounced in old animals. Moreover, a high percentage of long-term surviving animals was observed only in the old-treated mice. Treatment with TNP-470 of the AKR lymphoma produced similar results. We thus found a differential age-dependent therapeutic efficiency of an anti-angiogenic agent on two tumors. Importantly, the anti-angiogenic drug was more efficient against tumors of old animals.

The management of rectal cancer in the elderly

INTRODUCTION

The majority of patients with rectal cancer are elderly. Due to the increasingly aging population the number of people with colorectal cancer is increasing. As medical advances in the areas of local therapy, radiation therapy, and surgical technique, such as, laparoscopy are made more elderly patients are offered various types of treatment for rectal cancer. As the number of treatment options increase, the debate on how to treat elderly patients' with rectal cancer intensifies.

METHODS

A Medline search using "rectal cancer," "elderly," "local therapy," "radical surgery," and "radiation therapy" as key words was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each work.

DISCUSSION

Numerous treatment options exists for elderly patients with rectal cancer. These range from transanal local excision to radical surgery. The best treatment option for a certain elderly patient is multifactorial and includes tumor stage, operative curability, preoperative functioning of the patient, patient comorbidities, quality of life goals, and patient preference.

CONCLUSION

Age, taken as an independent variable, is not a contraindication to any specific type of therapy, including radical surgery with primary anastomsis. Patients' who meet the criteria for local resection should undergo this procedure. However, for tumors which are not amenable to local resection, these patients should be considered for radical surgery if this provides the best chance for cure. Elderly patients who can tolerate a major operation, and have good preoperative sphincter function should undergo a resection with primary anastomosis.

Age-dependent differences in the efficacy of cancer immunotherapy in C57BL and AKR mouse strains

While tumor incidence increases with age, tumor growth and metastasis often proceed at a slower rate in aged organisms. The mechanisms underlying this age-related reduced tumor development may suggest therapeutic modalities appropriate for the aged. Decreased tumor aggressiveness in the old was shown to be related to altered immune response. Consequently, the aim of the present study was to assess whether cancer immunotherapy has an age-dependent effect. Only a few studies have compared cancer immunotherapy efficiency as a function of age, most showing lower inhibition in older animals. In the present study, we tested the effect of two immunomodulators, levamisole and BCG, on two tumors, B16 melanoma and AKR lymphoma, in mice of different ages. We demonstrated a higher efficiency of immunotherapy in aged as compared to young mice, particularly at low immunomodulator doses. While decreased T cell function during aging is apparently established, nonspecific immunity is more preserved or even enhanced in later life. We found an increased number of macrophages in tumors of old compared to young mice and an increase in MAC-1+ cells in old levamisole-treated compared to non-treated mice. The stronger therapeutic effect of this immunomodulator in old mice might thus be due to an increased macrophage-mediated anti-tumoral effect.

Age-adjusted antitumoral therapy based on the demonstration of increased apoptosis as a mechanism underlying the reduced malignancy of tumors in the aged

In view of the constant increase in the aged population, age-adjusted cancer therapy becomes an urgent target. Although cancer incidence rises with age, paradoxically, growth rate and metastasis often proceed at a slower rate in the aged. Determining the mechanism(s) underlying this reduced tumor progression in the old might have implications for a rational design of age-adjusted therapy. Thus far, decreased cell proliferation or immune response modifications were suggested as possible mechanisms. We show here that an increased tendency to apoptotic tumor cell death in the aged could constitute an additional mechanism. Based on this mechanism, we compared the therapeutic efficacy of two apoptosis inducers, hydrocortisone and adriamycin, on AKR lymphoma and B16 melanoma growth in young and old mice. Treatment with hydrocortisone acetate inhibited tumor growth practically only in old mice in the two tumor systems. Similar effects were obtained with adriamycin treatment of AKR lymphoma but opposite results were seen with B16 melanoma. We thus demonstrated, in three of the four tumor-therapeutic modality systems examined, an age-related antitumoral efficacy of two apoptosis-inducing agents, with tendency for a remarkably more pronounced effect in aged mice.

Gastrointestinal malignancies

Gastrointestinal cancers are collectively the most common malignancies in the world. In the United States, colorectal cancer accounts for most of these malignancies. This is unfortunate, because colorectal cancer is highly preventable. Moreover, screening for colorectal cancer is cost effective and becomes increasingly important in an aging population. Individuals who are more at risk require earlier screening and intervention. For all gastrointestinal cancer, surgery remains the most important curative option. For patients who cannot be cured, quality of life is the yardstick by which palliative options should be evaluated.

Could age be an indication for laparoscopic colectomy in colorectal cancer?

BACKGROUND

The incidence of colorectal carcinoma increases in the elderly. Regardless of age as an isolated factor, postoperative complications represent the main factor in increasing hospital mortality.

METHODS

The aim of this study was to compare the short-term results (first 30 postoperative days) after laparoscopically assisted colectomy (LAC) and open segmental colectomy (OC) in colorectal carcinoma between two groups of patients, older than 70 and younger than 70 years of age. In the study from November 1993 to June 1998, 255 patients were evaluated to participate.

RESULTS

Peristalsis, oral intake, and discharge from the hospital occurred earlier in LAC than in OC treated patients, in the two age groups. The mean operative time was significantly longer in the LAC than in the OC patients in the two age groups. No differences were observed in morbidity between LAC and OC in the group younger than 70 years of age. However, the overall morbidity was significantly lower in the LAC group in patients older than 70 years. One patient in the LAC group older than 70 years died.

CONCLUSION

These results suggest that laparoscopically assisted colectomy may be particularly indicated in elderly patients.

Comparison of growth rate of two B16 melanomas differing in metastatic potential in young versus middle-aged mice

The rise of cancer frequency as a function of age is a well-established fact. The aspect of the host age-tumor progression relationship, namely the slower metastatic spread in aged patients, has been investigated to a lesser extent. In the present study, we examined whether host-age-dependent growth rate varies with metastatic capacity of the tumor. The parental B16 and the B16/Col/R, a highly metastatic variant, were employed. A more pronounced growth of both tumors in young as compared to middle-aged mice was found. However, the differential growth in middle-aged versus young mice was more evident in the highly metastatic variant. According to the tumor size data, a sixfold growth reduction in middle-aged mice was observed with B16/Col/R and an only twofold growth reduction was seen with the B16 melanoma. The data might eventually contribute to the finding of more appropriate treatment modalities for the middle-aged cancer patient.

Which kind of surgery in elderly people for colorectal cancer?

Colo-rectal cancers are of high incidence in elderly patients. Different clinical features and the peculiar behavior of the tumor may influence surgical results and should be considered in the decision making, when the surgeon has to decide whether to perform radical gut resection or less straining palliative procedures. In a retrospective study, 102 large bowel cancer patients are analyzed submitted to surgery in the period 1989-1994. Patients were divided in two age classes: Group A: above 70 years of age, 45 cases (44.2%); Group B: under 70 years of age, 57 cases (55.8%). Emergency surgery procedures were necessary in 35 patients (34.4%), 20 cases (57%) in Group A and 15 cases (43%) in Group B. Radical resections could be performed in 25 (37%) old patients, 67% of the cases underwent a curative resection. Perioperative mortality and surgical complication rates were significantly higher in Group A than in Group B. The technical and biological difficulties in performing radical curative resections, the high complication rates and the occurrence of negative results of treatments provide a reason for careful evaluation of the risk/benefit ratio in older patients, where less straining palliative therapies may sometimes offer similar results.

Role of immune response as determinant of tumor progression in function of host age in the B16 melanoma

Aging constitutes the major cause for the development of most neoplastic diseases. However, tumors in aged people present with a lower degree of aggressiveness than in young patients. The reasons for this paradoxical behavior are not clear. We attempted to verify whether the immune system has a role in the relation between host age, immune response and tumor progression. We compared the growth rate of B16 melanoma and a highly malignant variant, the B16/Col/R, in young and aged mice that have or have not undergone splenectomy. The following results were obtained: (1) Splenectomy stimulated growth in the parental melanoma in both young and aged mice, indicating a protective role of the spleen against this tumor at all ages; (2) Spleen ablation provoked inhibition of the highly-metastatic variant growth in young mice, suggesting a stimulatory role of the spleen in this case; (3) By contrast, in aged mice inoculated with the B16/Col/R variant, splenectomy enhanced tumor growth, indicating a defensive role of the spleen. Age favors a positive host response against the aggressive clone of the melanoma. Differential host response in young versus aged mice can explain, in this tumor system, the difference in tumor progression rate as a function of age.

Surgical treatment of colon and rectum adenocarcinoma in elderly patients

The results are presented of disease-free interval and overall survival in 53 elderly patients with colon or rectum adenocarcinoma treated with curative surgery. The average age was 75.3 years (median = 75.0); 21 patients were male and 32 were female. Tumor location was as follows: rectum 18 (34%), sigmoid 17 (32.1%), right colon 14 (26.4%), and transverse colon 4 (7.5%) All patients were surgically treated following the classical patterns for tumor resection. After pathological examination, which included the histological grade differentiation, the disease stage was reevaluated following the pTNM system. Overall and disease-free survival at 5 years, for all patients, independent of histological grade differentiation and disease stage, were 75.3% and 55.5%, respectively. Overall survival at 5 years for patients with grades I and II histological differentiation was 74.1% and 85.0%, respectively. None of the grade III patients (2 cases) survived more than 1 year. The 5 years disease-free survival for patients with histological grade differentiation I and II was 56.8% and 60%, respectively. There was no statistically significant difference in overall survival for patients with stages SI, SII, and SIII, but the disease-free survival at 5 years by stages was found to be significant with rates of 100%, 67.6%, and 22.6%. Postoperative mortality was 4 (7.5%). The postoperative mortality and survival rates obtained in this group of patients encourage us not to consider age as a limiting factor for curative surgical treatment.

Explanations for reduced tumor proliferative capacity with age

Tumors in general occur more frequently in older people, but many of the common tumors appear to be less malignant in older hosts. In this article mechanisms of tumor enhancement are reviewed, and those that are age-sensitive are emphasized. In this regard, our earlier experimental work suggested that age-associated immune change (immune senescence) is most important in explaining reduced tumor growth. We have found that unstimulated spleen cells in culture produce a tumor-enhancing factor (TEF) that enhances B16 murine melanoma cell proliferation. TEF, and others, such as lymphocyte-induced angiogenesis factor (LIA) and various other autocrine growth factors, may stimulate malignant cells in cancer-bearing hosts. An age-associated reduction in those factors could account for the observed reduced tumor growth and spread in hosts of advanced age.

Results of colectomy in elderly patients with colon cancer, based on Medicare claims data

Currently available estimates of outcomes following colon resection in elderly patients with colon cancer are based on series collected at academic medical centers. We used Medicare Part A claims and enrollment records of a 5% nationally random sample of elderly Medicare beneficiaries from 1983 to 1985 to estimate how patient age and sex affected perioperative mortality and 1- and 2-year survival rates among elderly patients undergoing a colon resection procedure for colon cancer. Among the 5,586 individuals in our data set, the overall perioperative mortality rate was 5.0%, ranging from 3.3% in beneficiaries 66 to 69 years of age to 9.3% in those 85 years of age and older. Men had a 31% higher perioperative mortality rate than women (5.8% versus 4.4%, p less than 0.05). The overall postoperative survival rates at 1 and 2 years were 72% and 63%, respectively, decreasing with increasing age, but were similar in men and women. This analysis provides age- and sex-specific estimates of outcomes following surgery for elderly patients with colon cancer that are more precise and have more potential for generalization than those that were available previously.

Colorectal cancer in patients over 80 years of age

Between January 1, 1973, and December 31, 1986, 1,734 patients underwent colorectal resections for carcinoma. Patients were divided into two groups: Group I included 163 patients aged greater than or equal to 80 years on first presentation; Group II comprised 1,571 patients aged less than 80 years. The total perioperative mortality rates for the elderly and young group were 15.3 percent and 5 percent, respectively (P less than 0.001). The surgical mortality rates after elective operations in Groups I and II were 7.4 and 4.5 percent, respectively, and were not statistically different. Emergency surgery was associated with a significantly higher incidence of perioperative deaths at any age (P less than 0.001). In the elderly group, most deaths (88 percent) resulted from complications of coexisting medical disorders or thromboembolic complications. The 5-year survival for the young and elderly group were 46.2 percent and 35 percent, respectively (P less than 0.05). However, excluding patients dying from nonmalignant disease, the 5-year survival rate did not differ significantly between the two groups of patients (49.5 percent vs. 41.2 percent).

Surgery for carcinoma of the colon in people aged 75 years and older

From January 1976 to June 1986, 154 patients (75 men and 79 women) who were 75 years of age or older were admitted for the surgical treatment of a colonic cancer. The mean age was 80.7 years. Patients were divided into two groups: 66 patients, between 75 and 80 years of age, were in Group I; 88 patients, 80 years of age and older, were in Group II. One hundred and forty-three patients (93%) were operated on and a resection was carried out in 125 patients (87%). The overall post-operative mortality rate was 12% (Group I: 5%; Group II: 17%; p less than 0.02). The actuarial survival rate of patients operated on was 32 +/- 8% at 3 years and 26 +/- 8% at 5 years (Group I: 37%; Group II: 17%). In both groups the survival rate was closely related to the extent of the disease according to Dukes classification. These results suggest that in the 75-80 year group age alone should no longer be considered a major risk factor for immediate surgical outcome. In patients aged 80 and older, the results are worse but it is not advanced age per se which influences mortality, rather the physiologic status of the patient.

Surgery for colorectal cancer in elderly patients--a comparison with younger adult patients

Between 1972 and 1986, 668 patients without familial polyposis coli underwent surgery for colorectal cancer at the National Kyushu Cancer Center. Among these, there were 85 patients aged 75 years and older, and 39 patients aged 39 years and younger. The older patients tended to have a higher frequency of less advanced disease (stage I-III) and the progression of cancer in the older patients appeared to be relatively mild. The operative mortality rate of the older patients was as low as 1.2 per cent, which was almost identical to that of the younger adults (0 per cent), being 16.7 per cent for emergency operations, whereas it was 0 per cent for elective operations. The five-year survival curve of the older patients with curative resections was significantly better than that of those with noncurative resections. There was no significant difference in the cancer-related five-year survival curves between the older and younger patients with curative resections. Surgery for colorectal cancer in elderly patients should therefore not be restricted on the basis of chronological age alone.

Immunologic enhancement of B16 melanoma growth

In certain experimental tumor models, tumor growth is less pronounced in immune deficient animals. Characteristically, tumors such as the murine B16 melanoma and Lewis lung carcinoma (3LL) are weakly antigenic. We proposed that with such tumors that are weakly antigenic, growth is enhanced by T-cell factors. Young mice were inoculated with irradiated B16 cells in complete Freunds adjuvant (CFA) on three occasions, each separated by 2 weeks. Specific antibody (IgG) to B16 membrane antigens was detected by an enzyme-linked immunosorbent assay (ELISA) after the first injection, and it continued to rise for 6 weeks. B16 growth was compared in 20 mice that had received irradiated B16 in CFA or CFA alone by the same schedule previously. Despite the previous sensitization, the rates of tumor appearance and growth were similar. In an additional experiment involving 23 mice that had received B16 immunization, the period of time in which a palpable tumor developed after the injection of viable B16 cells did not correlate with anti-B16 antibody level. It appeared that detectable antibody to B16 antigens was of little consequence. To explain why B16 primary growth and metastases were reduced in immune deficient hosts, we proposed that lymphocytes might enhance tumor growth. To demonstrate this, splenic lymphocytes from tumor-bearing (B16 or 3LL) or control mice were injected with B16 cells into young, immune competent hosts. Tumors (B16) developed earlier and growth was more rapid in mice that received spleen cells from tumor-bearing (B16) mice. Subsequent cell depletion experiments to determine the mediator of tumor enhancement implicated a T-cell fraction that was neither of T-helper nor T-suppressor cell type phenotypically. Immune deficiency states that are associated with dysfunction of those cells that account for tumor enhancement might explain the reduced tumor aggressiveness that is observed frequently in these conditions.

Colorectal cancer in patients older than 75 years of age

Two hundred and seven hospital records of patients with colon or rectal cancer from 1982 to 1985 were reviewed retrospectively. Ninety-six patients were 75 years of age or older and 111 were younger than 75 years. Comparison of the two groups showed that the elderly group presented with lower hematocrits and serum albumin values despite comparable pathologic stages and tumor location. A higher preanesthetic stage was seen in the elderly group. The total perioperative mortality rates for the young and elderly groups were 3.6 percent and 7.1 percent, respectively, and were not statistically different. Emergency perioperative mortality rates were 5.2 percent and 10 percent, respectively, and also were not statistically different. All nine patients aged 90 and older underwent a major abdominal operation without the occurrence of any perioperative mortality. This study suggests that age need no longer be considered a major risk factor for immediate surgical outcome in colorectal cancer.

Surgery for large bowel cancer in people aged 75 years and older

Three hundred ten predominantly male patients who were 75 years of age or older and had surgery for colorectal carcinoma had a hospital mortality rate of 9 percent and a cancer-related five-year survival of 50 percent. These results and a detailed analysis of the causes of complications and mortality were compared with the outcome of 710 patients who were treated concurrently and who were younger than 75 years. Tumors in older patients had a tendency to occur on the right side and were more locally advanced. Increased mortality was particularly attributable to sepsis and cardiovascular causes. Increased morbidity was due principally to respiratory and urinary problems. There were no significant differences, however, in wound or anastomotic complications, nor was therapy for the older patients more costly. The indications for surgical resection for colorectal cancer in patients aged 75 years and older should be the same as those for any younger group.

Tube cecostomy and staged resection for obstructing carcinoma of the left colon

Over a 17-year period, all patients presenting with acute obstruction of the left colon due to carcinoma were treated by emergency tube cecostomy. There were 57 patients aged between 35 and 93 years. After the decompressive procedure, eight died, 34 had complications, and eight were left with permanent cecostomies. Forty-one underwent secondary procedures of which 35 had resections. Seven patients died postoperatively and 15 had complications. Of the 34 survivors, in 23 the cecostomy closed spontaneously, and 11 had operative cecostomy closure. Of the latter, four died postoperatively, and nine had complications. Thus, 30 survived the entire treatment program. Reasons for the high morbidity and mortality are discussed. Comparison is made with other forms of treatment in the literature. A treatment program is suggested, using tube cecostomy for poor-risk patients and primary resection without anastomosis for patients in better condition.

Abdominoperineal resection in the octogenarian

Traditionally, abdominoperineal resection has been the accepted surgical therapy for anorectal carcinoma. A review is presented of the experience with this procedure at the University of Iowa Hospitals, involving 52 patients (33 men, 19 women) over the age of 80 (median, 81 years). The most common symptoms were: rectal bleeding in 35 patients, change in character of stool in 35, weight loss in 13, and abdominal pain in 7. A rectal mass was palpable in 45 patients and visible by sigmoidoscopy in 3 others. Of the 52 patients, 23 percent (12/52) died before postoperative discharge from the hospital, and 32 percent of the survivors had significant postoperative complications. The most lethal complications were related to problems of surgical technique. The median survival time for patients discharged from the hospital was 22 months, with causes of death being equally distributed between recurrent carcinoma and other disorders. Abdominoperineal resection remains an acceptable method for treatment of anorectal carcinoma in the aged (80 or older) provided it is carried out with meticulous technique and careful selection of the patients.

Carcinoma of the large bowel in patients aged 70 years and older

In a prospective series of 443 cases of large-bowel cancer there were 192 cases occurring in patients aged 70 years and over. The resectability rate in this group was 84.9% and was almost identical with that of the whole series (84.6%). There was an overall operative mortality rate of 7.3% in the older age group, compared with 6.4% in the whole series. However, when octogenarians were considered, the resectability rate fell to 74.6% and the overall operative mortality rate increased to 19%. In the treatment of large-bowel cancer it would seem that special consideration should be given to octogenarians.

Review of abdominoperineal resections for cancer

One hundred eighty-six consecutive abdominoperineal resections for primary carcinoma of the anus, rectum, or sigmoid colon performed at Charity Hospital of Louisiana at New Orleans between January 1, 1963 and December 31, 1974 were reviewed. The operative mortality was 16 per cent. Complications during the same hospitalization occurred in 70 percent of the patients. Although most of the complications were minor, 22 percent did require some form of surgical intervention. Twenty-nine percent of the patients who were discharged developed late mechanical or cancer-caused complications which required surgical correction. A history of congestive heart failure or a significant weight loss were the most consistent preoperative findings in the operative mortality group. The overall five year survival rate was 25 percent. White females with no history of weight loss had the best long-term prognosis. Better survival in white patients can be accounted for by the less advanced lesions in these patients. No such difference between male and female patients could be demonstrated. Better selection of surgical candidates with alternate forms of therapy for poor risk patients have probably been the most significant factors in decreasing the operative mortality from 21 percent in the first six years of the study to 9 percent in the last six years. Primary closure of the perineal wound would appear to be of value in decreasing operative morbidity.