Are Extensive Open Lung Resections for Elderly Patients with Lung Cancer Justified?
and Dimitrios Dougenis 5
Round 1
Reviewer 1 Report
The authors investigated 510 patients who underwent anatomical lung resections for lung cancer and divided them into elderly group and control group. The authors identified there were no statistical differences in the complication and OS between the two groups. This is an interesting study. Although propensity score in matched pairs will make this conclusion more reliable, sufficient sample size in this study make this conclusion acceptable.
Minor revision
1. please cited the age in elderly group with IQR or range.
2. Charlson Risk Index (CCI) score will be more useful in comparing comorbidity between two groups which could be summarized in Table 2.
3. Would you please explain why surgery was conducted in patients of Stage â…¢ and â…£.
Author Response
Response Reviewer 1:
Thank you for your productive comments!
1 Age-range was added in the section of Results.
2 Unfortunately, due to the retrospective nature of our study and the anonymization of the patient’s data any further analysis is impossible. However, we included your comment in the section of limitations.
3 Surgery for Stadium III was conduct for clinical stadium: T1-2 N2, T3 N1 and T4N01-. Stadium IV was determined postoperatively after the detection of pleural carcinosis on parietal pleura. This information was added in the text in the Methods section.
Reviewer 2 Report
Nikolaos Panagopoulos are presented an article about patients who underwent lung resection for lung cancer and thier were categorized them into two groups: the elderly group (≥70 years old) and the control (<70).
The article looks interesting but unfortunatlly as the authors wrote that the included patient were those whi underwent anatomical lung resections in our institution from 2008 to 2013.
Unfortunately its very old results, its almost more than 10-15 years!
Author Response
Response Reviewer 2:
As mentioned in the text, the data of our study reflect on surgeries between 2008 and 2013. However, I believe that after investigating more than 500 patients that all underwent lung resection with an open thoracotomy, our study population represents the everyday clinical praxis.
Concerning the comment of the 10-15 years time-gap, I believe that for the correct planning of a single-center retrospective study a minimum of 10 years distance is required in order to investigate the overall survival from the disease.
In addition, as it is stated from the title of our study we exclusively investigated lung resections with an open thoracotomy. This was the initial aim of our study. As a result, no patients undergoing VATS or RATS were included. To my knowledge an open lung resection is performed today as it was 15 years ago.
Reviewer 3 Report
The results of this study did not preclude elderly patients aged 70 years or older from selecting open lung resections to prolong life. I found this manuscript was well written and designed. However, there are some points of concern.
The difference in sample size between the younger group and the older group is more than double. I think this should be mentioned about statistical significance.
The number and characteristics of patients should be indicated in the materials and methods section. Likewise, please also indicate the minimum and maximum ages for each group.
In the results of this study, there was no significant difference in overall survival between younger and elderly. The prognosis of the younger group is likely to be worse than that of the older group in terms of tumor attributes i.e., stage and N. Did you compare young and elderly for each tumor stage?
Author Response
Response Reviewer 3
Thank you for your productive comments.
1 Your remark was added in the section of limitations.
2 The number of patients and their characteristics were added in the section of materials and methods. Maximum and minimum ages of each group were also added.
3 Young and elderly for each tumor stage were compared and added in the text.
Reviewer 4 Report
This retrospective study included 510 patients with NSCLC who underwent open thoracic pneumonectomy from 2008 to 2013 to investigate the safety of open thoracic pneumonectomy in older patients.
1. Nowadays, minimally invasive surgery is widely covered, and older patients tolerate thoracoscopy better. Some patients with central lung cancer or pleural adhesions are more likely to choose open thoracotomy. This study did not present the proportion of central lung cancer and pleural adhesions among 510 patients. It would be more clinically meaningful to do a subgroup analysis of peripheral lung cancer with central lung cancer.
2. Baseline information was too little, only information on preoperative co-morbidities and a lack of information on BMI, smoking, and alcohol consumption.
3. The study concluded that there was no statistical difference in survival, but there was a lack of sample size calculation, and it is difficult to support this negative conclusion if the sample size is small.
The median age of the elderly group was 74 years, and the median age of the control group was 62 years, and the age difference between the two groups was not significant.
5. The one-way Cox regression analysis in Table 6 did not indicate which factors were included in the analysis, and only positive results were given, not negative results.
6. The legends of Figure 2 and Figure 3 are schematically unclear, and the horizontal coordinates lack units. There is no control comparison for Stage grouping.
7. There is a textual error in line 209, "P=0.5," which corresponds to "P=0.6" in Table 4.
8. Reference 48 is incomplete.
Author Response
Response Reviewer 4
Thank you for your comments and remarks.
1 Unfortunately, due to the retrospective nature of our study and the anonymization of the patient’s data any further analysis is impossible. However, we included your comment in the section of limitations.
2 Here, unfortunately, the evaluation of the morbidity in both groups with e.g. Charlson Risk Index score is not any more possible due to the anonymization of our data. We included your recommendation in the section of limitation. However, a series of significant comorbidities are already included and compared in the two groups.
3 Your remark is already added in our text. As mentioned in the limitation-section a minimal-invasive operation should be indicated in elderly patients. However, the main conclusion of our study is that elderly patients should not be excluded from a major lung resection only because of their age, but they should be preoperatively carefully evaluated.
5 Thank you for your remark. An additional mention was made in the text.
6 Thank you for your comment. The figures are produced with The legends were clearly described. (Blue: stage I, green: stage: II, gold: stage:III). The comparison of median survival between the two groups is described on the text above. + media survival for every group.
7 thank you for your mention. The textual error was corrected.
8 Reference 48 is completed
Round 2
Reviewer 2 Report
still think that these results are very old -between 2008 and 2013-, need to collect new updated data.
Author Response
Thank you for your comments.
As mentioned before the current study investigates open lung resections in elderly patients.
Possibly a future study involving patients operated with VATS could demonstrate more differences on the field.
Reviewer 4 Report
Dear Authors,
Thanks for your reply.
I do not have any other comments.
Author Response
Thank you very much for your comments!
