Hepatic resection for hepatocellular carcinoma in super-elderly patients aged 80 years and older in the first decade of the 21st century

Clinical Report of the Immediate Placement Implants in Patients Aged 80 and Over: Five Cases and a Short Review

With the population aging, the proportion of elderly individuals is expected to increase, and the proportion of individuals over 80 is also likely to increase. Given that the population is aging and life expectancy is increasing, elderly patients who have lost their teeth will also increase. Impaired masticatory function caused by tooth loss is a risk factor for cognitive decline and frailty, and neglecting to treat tooth loss is a critical issue. In this report, 5 patients over 80 requested dental implants for new missing teeth and underwent immediate implant placement. All patients were treated by the same surgeon using the same technique, materials, and dental implants. Five elements were measured for the peri-implant bone from the cone-beam computed tomography images. All patients were followed for 3 or more years and exhibited good progress without any abnormal findings in their oral cavities or notable radiographic abnormalities such as bone absorption or peri-implantitis. Compared with conventional treatment with delayed placement, combining immediate implant placement and regenerative medicine for fixed superstructures may be the better option for missing tooth replacement if the conditions are suitable. Thus, this treatment modality may improve the quality of life in elderly patients, especially super elderly patients.

Textbook outcome and nomogram-guided approaches for enhancing surgical success in elderly HCC patients: Deciphering the influence of sarcopenia

Sarcopenia, serving as a surrogate for frailty, is clinically significant in liver resection (LR) for elderly hepatocellular carcinoma (HCC) patients. Our study aims to assess sarcopenia's impact, measured by Psoas Muscle Index (PMI), on postoperative outcomes. We retrospectively studied patients aged ≥ 60 years who underwent LR for HCC between 2014 and 2018. PMI, derived from preoperative CT scans, and Textbook Outcome (TO) for LR were assessed. A nomogram predicting overall survival (OS) was developed via multivariable analysis. Of the 149 eligible HCC patients, the median PMI was 7.225 cm2/m2 in males and 4.882 cm2/m2 in females, with 37 (24.8%) patients identified as sarcopenic. Mortality was significantly associated with sarcopenia (HR 2.15; p = 0.032), MELD ≥ 10 (HR 3.13; p = 0.001), > 3 HCC nodules (HR 4.97; p = 0.001), and Clavien-Dindo ≥ 3 complications (HR 3.38; p < 0.001). Sarcopenic patients had a 5-year OS of 38.8% compared to 61% for non-sarcopenic individuals (p = 0.085). Achieving TO correlated with higher OS (p = 0.01). In sarcopenic cases, the absence of postoperative complications emerged as a limiting factor. Sarcopenic patients failing to achieve TO had worse OS compared to non-sarcopenic and TO-achieving counterparts (5-year OS 18.5%; p = 0.00039). Sarcopenia emerges as a prognostic factor for LR outcomes in elderly HCC patients. Postoperative complications in sarcopenic patients may compromise oncological outcomes.

Perihilar cholangiocarcinoma resection: Is it beneficial for survival in elderly patients?

INTRODUCTION

As the population ages, surgeons are growing frequently faced with hard choices among a vast array of treatment options for the elderly. This study was to investigate safety and efficacy of resection in elderly patients with perihilar cholangiocarcinoma (PHCC).

PATIENTS AND METHODS

Literature reading and meta-analysis unveiled that elderly PHCC patients held a higher risk of death within 90 days after hepatectomy relative to younger patients, but their 5-year overall survival and disease-free survival were comparable. Among PHCC patients who underwent hepatectomy, the proportion of elderly patients with tumor classification Bismuth I-II and tumor stage pStage 1-3 was significantly higher than that of younger patients.

RESULTS

Curative resection R0 was more common in elderly patients than younger patients, but the difference was not statistically significant. Because of more comorbidities and less physiological reserve of elderly patients, they seemed to suffer more postoperative complications.

CONCLUSION

Considering improved life expectancy, it is crucial to treat elderly PHCC patients appropriately and attempts should be made to radical surgery based on comorbidities and functional status.

Efficacy and Safety of Surgical Resection in Elderly Patients with Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

Background/Aims

: With increased life expectancy, the management of elderly hepatocellular carcinoma (HCC) patients became a crucial issue, yet it is still challenging due to comorbidities and high surgical risks. While surgical resection is considered as primary treatment for eligible HCC patients, systematic evidence on its outcomes in elderly patients remains scarce. In this review, we aimed to analyze the efficacy and safety outcomes of surgical resection in elderly HCC patients.

Methods

: The studies included in this meta-analysis were selected from Ovid-MEDLINE, Ovid-Embase, CENTRAL, KoreaMed, KMbase, and KISS databases following a predefined protocol. Efficacy outcomes included overall survival and disease-free survival, while the safety outcomes included postoperative mortality and complications.

Results

: Patients in the elderly group (≥65 years) who underwent surgery exhibited non-inferior overall survival (hazard ratio [HR], 1.26; 95% confidence interval [CI], 0.92 to 1.74) and disease-free survival (HR, 1.03; 95% CI, 0.99 to 1.08) compared to the non-elderly group. Overall postoperative mortality exhibited no statistical difference (odds ratio [OR], 1.07; 95% CI, 0.87 to 1.31), but 30-day, 90-day, and in-hospital mortality were higher in the elderly group. The incidence of overall complications was higher in the elderly group (OR, 1.44; 95% CI, 1.22 to 1.69). Sensitivity analysis for the super elderly group (≥80 years) showed significantly higher in-hospital mortality compared to the non-super elderly group (OR, 2.51; 95% CI, 1.16 to 5.45).

Conclusions

: The efficacy outcome of surgical resection in the elderly HCC patients was not worse than that in the non-elderly HCC patients, while in-hospital mortality and complications rates were higher. Therefore, surgical resection should be purposefully considered in the elderly population, with careful candidate selection.

A Novel Nomogram to Predict Prognosis in Elderly Early-Stage Hepatocellular Carcinoma Patients After Ablation Therapy

Purpose

Hepatocellular carcinoma (HCC) is the predominant form of primary liver cancer. Early diagnosis is crucial for improving prognosis. Elderly HCC patients often have underlying liver diseases such as chronic hepatitis and cirrhosis, leading to impaired liver function and suboptimal liver reserve. Radiofrequency ablation (RFA) has rapidly become one of the most important methods for treating early-stage hepatocellular carcinoma (EHCC) due to its advantages, including minimal trauma, short operation time, less intraoperative bleeding, quick postoperative recovery, cost-effectiveness, and few postoperative-complications. However, the prognostic model for early recurrence after local ablation in elderly EHCC patients has not been widely evaluated. We have developed a prognostic model for the recurrence of local RFA in elderly EHCC patients. This is expected to provide a new early warning system for preventing early recurrence in elderly EHCC patients, prolonging patient's life, and improving overall quality of life.

Methods

In this study, we included 661 EHCC patients who underwent local ablation, dividing them into a Primary cohort and a Validation cohort in a 7:3 ratio. We characterized the cohorts and utilized the primary cohort to develop a prognostic nomogram model for recurrence after local ablation in elderly EHCC patients. Additionally, the validation cohort was used to assess the potential of the nomogram as a non-invasive biomarker for post-ablation recurrence in EHCC.

Results

The user-friendly nomogram incorporates common clinical variables including gender, BCLC stage, tumor number, tumor size, red blood cell (RBC), gamma-glutamyl transferase (GGT), and prothrombin time activity (PTA). The nomogram constructed using the identified seven variables exhibits robust discriminatory capabilities, favorable predictive performance, and noteworthy clinical utility.

Conclusion

We developed a user-friendly nomogram based on the BCLC stage classification, which may provide prognostic assessments for elderly EHCC patients at 1, 3, and 5 years post-RFA.

Effect of laparoscopic liver resection on postoperative delirium in elderly patients with hepatocellular carcinoma

BACKGROUND

Delirium is a multifactorial and heterogeneous syndrome that is defined as acutely altered consciousness. This retrospective multicenter study evaluated the impact of postoperative delirium after liver resection for hepatocellular carcinoma (HCC) in elderly patients.

METHODS

Patients aged ≥75 years, who underwent curative liver resection for HCC at nine university hospitals from April 2010 to December 2017, were evaluated to compare short- and long-term outcomes between patients with and without delirium. Risk factors for delirium were determined using multivariate regression analysis.

RESULTS

The rate of postoperative delirium was 14.2% (n = 80) in the study cohort of 562 patients. Multivariate analysis revealed smoking history, hypertension, sleeping pill consumption, and open liver resection as risk factors for postoperative delirium. The rate of other causes of death was significantly higher in the delirium group than in the no-delirium group although the rate of death at 1 year due to HCC or liver failure was similar between the two groups (p = .015). The 1-year mortality rates due to vascular diseases were 71.4% and 15.4% in the delirium and no-delirium groups, respectively (p = .022). The 1-, 3-, and 5-year survival rates after liver resection were 86.6%, 64.1%, and 36.5% in the delirium group and 91.3%, 71.2%, and 56.9% in the no-delirium group, respectively (p = .046).

CONCLUSION

The multivariate analysis revealed the possible benefits of laparoscopic liver resection in reducing the rate of postoperative delirium after liver resection for HCC in elderly patients.

Liver resection versus radiofrequency ablation in octogenarian patients for hepatocellular carcinoma: a propensity score multicenter analysis

BACKGROUND

Liver resection (LR) and radiofrequency ablation (RFA) are considered curative options for hepatocellular carcinoma (HCC). The aim of this study was to compare outcomes after LR and RFA in octogenarian patients with HCC.

MATERIALS AND METHODS

This multicenter retrospective study included 102 elderly patients (> 80 years old) treated between January 2009 and January 2019, who underwent LR or RFA for HCC (65 and 37 with, respectively).

RESULTS

After Propensity Score Matching, the postoperative course of LR was burdened by a higher rate of complications than RFA group (64% vs 14%, respectively, p: 0.001). The LR group had also significantly longer operative time (207 ± 85 min vs 33 ± 49 min, p < 0.001) and postoperative hospital stays than the RFA group (7 d vs 2 d, p = 0.019). Overall survival at 1-, 2-, and 3-year were 86%, 86%, and 70% for the LR group and 82%, 64%, and 52% for the RFA group (p = 0.380). Disease-free survival at 1-, 2-, and 3-year were 89%, 74%, and 56% for the LR group, and 51%, 40%, and 40% for the RFA group (p = 0.037).

CONCLUSION

Despite a higher rate of Dindo-Clavien I-II post-operative complications, a longer operative time and length of hospital stay, LR in octogenarian patients can provide comparable 90d mortality than RFA and better long-term outcomes.

Positioning of Minimally Invasive Liver Surgery for Hepatocellular Carcinoma: From Laparoscopic to Robot-Assisted Liver Resection

Laparoscopic liver resection (LLR) is widely accepted in the surgical treatment of hepatocellular carcinoma (HCC) through international consensus conferences and the development of difficulty classifications. LLR has been reported to result in earlier postoperative recovery and fewer postoperative complications than open liver resection (OLR) for HCC. However, the prevalence of liver cirrhosis, obesity, the elderly, HCC recurrence (repeat liver resection), and major resection must be considered for LLR for HCC. Some systematic reviews, meta-analysis studies, and large cohort studies indicated that LLR is technically feasible for selected patients with HCC with these factors that led to less intraoperative blood loss, fewer transfusions and postoperative complication incidences, and shorter hospital stays than OLR. Furthermore, some reported LLR prevents postoperative loss of independence. No difference was reported in long-term outcomes among patients with HCC who underwent LLR and OLR; however, some recent reports indicated better long-term outcomes with LLR. In recent years, robot-assisted liver resection (RALR) has gradually become popular, and its short- and long-term results for HCC are not different from those of LLR. Additionally, RALR is expected to become the mainstay of minimally invasive surgery in the future.

Safety and oncological benefits of hepatectomy for hepatocellular carcinoma in octogenarians

BACKGROUND

The number of octogenarians requiring surgery for hepatocellular carcinoma (HCC) is increasing. However, the safety of hepatectomy in octogenarians remains controversial. The aim of this retrospective study was to determine the effect of age on the short- and long-term outcomes of hepatectomy for HCC to evaluate the safety of hepatectomy for octogenarians.

METHODS

Data from a total of 845 patients who underwent initial hepatectomy for HCC between April 1990 and March 2021 were retrospectively reviewed. Patients were categorized based on the age at the time of surgery (<80 years, n = 790; ≥80 years, n = 55), and the short- and long-term postoperative outcomes of the two groups were compared to evaluate whether hepatectomy is appropriate for octogenarian patients.

RESULTS

The proportion of octogenarian patients undergoing hepatectomy increased from 2.6% in 1990-1995 to 16.8% in 2016-2020 (P < 0.001), and the overall incidences of anatomical and major hepatectomy have increased. There was no significant difference in the morbidity rate between the octogenarians and the group of patients <80 years old (60.0% vs. 54.4%, P = 0.420), and the 90-day mortality rate was 0% in the octogenarian group. Furthermore, the two groups had similar overall survival and recurrence-free survival rates (P = 0.173 and 0.671, respectively).

CONCLUSION

Favorable postoperative outcomes following initial hepatectomy for HCC are achieved in appropriately selected octogenarians.

Effect of age on the short- and long-term outcomes of patients undergoing curative liver resection for HCC

BACKGROUND

Few studies have evaluated the outcomes of curative liver resection (LR) in octogenarian patients, analysed cancer-specific survival (CSS) with HCC-related death or explored the age-varying effect of HCC-related death in elderly patients undergoing LR. We aim to determine the effect of age on the short and long-term outcomes of LR for HCC.

METHODOLOGY

Between 2000 and 2018, 1,092 patients with primary HCC who underwent LR with curative intent were retrospectively reviewed. The log-rank test and Gray's test were used to assess the equality of survivor functions and competing risk-adjusted cumulative incidence functions between patients in the three age categories respectively. Regression adjustment was used to control for confounding bias via a Principal Component Analysis. Quantile, Firth logistic, Cox, and Fine-Gray competing risk regression were used to analyse continuous, binary, time-to-event, and cause-specific survival respectively. Restricted cubic splines were used to illustrate the dose-effect relationship between age and patient outcomes.

RESULTS

The study comprised of 764 young patients (<70 years), 278 septuagenarians (70-79 years old) and 50 octogenarians (≥80 years). Compared to young patients, octogenarians had significantly lower 5-year OS(62.1% vs 37.7%, p < 0.001). However, there was no significant difference in 1-year RFS(73.1% vs 67.0%, p = 0.774) or 5-year CSS (5.4% vs 15.2%, p = 0.674). Every 10-year increase in age was significantly associated with an increase length of stay (p < 0.001), postoperative complications (p = 0.004) and poorer OS(p = 0.018) but not significantly associated with major complications (p = 0.279), CSS(p = 0.338) or RFS(p = 0.941).

CONCLUSION

Age by itself was associated with OS after LR for HCC but was not a significant risk factor for HCC-related death.

Is laparoscopic liver resection safe for super-elderly patients (aged ≥80)? A propensity score-matched analysis

BACKGROUND/PURPOSE

The safety of laparoscopic liver resection in super-elderly patients with comorbidities is unknown. We used propensity score matching to evaluate the utility and safety of laparoscopic liver resection in super-elderly patients.

METHODS

Two-hundred and five patients who underwent laparoscopic liver resection were retrospectively reviewed. They were classified into two groups based on age: ≥80 years (elderly group, n = 49) and <80 years (control group, n = 156). Propensity score matching (PSM) was performed based on preoperative clinical parameters. The intraoperative and postoperative outcomes were compared.

RESULTS

After matching, 45 patients were included in each group. The intraoperative blood loss was identical between the control and elderly groups (60 vs 60 mL, respectively, P = .588); the frequency of serious postoperative complications (Clavien-Dindo class ≥3, 1/45 vs 1/45, P = 1.00) was also similar. There was no significant difference in terms of the exacerbation of malignancy (22.2% vs 11.1%, P = .258) or other diseases (8.9% vs 22.2%, P = .144). There was no difference in overall survival before and after PSM. However, 5-year overall survival excluding primary cancer-related death showed a difference after PSM (90.7% vs 70.4%; P = .048).

CONCLUSIONS

Laparoscopic liver resection is feasible and safe in super-elderly patients. The long-term prognosis was poor in patients affected by other illnesses compared to the younger population with similar risk profiles, but there was no difference in overall survival.

Overdiagnosis of hepatocellular carcinoma: Prevented by guidelines?

Overdiagnosis refers to detection of disease that would not otherwise become clinically apparent during a patient's lifetime. Overdiagnosis is common and has been reported for several cancer types, although there are few studies describing its prevalence in HCC surveillance programs. Overdiagnosis can have serious negative consequences including overtreatment and associated complications, financial toxicity, and psychological harms related to being labeled with a cancer diagnosis. Overdiagnosis can occur for several different reasons including inaccurate diagnostic criteria, detection of premalignant or very early malignant lesions, detection of indolent tumors, and competing risks of mortality. The risk of overdiagnosis is partly mitigated, albeit not eliminated, by several guideline recommendations, including definitions for the at-risk population in whom surveillance should be performed, surveillance modalities, surveillance interval, recall procedures, and HCC diagnostic criteria. Continued research is needed to further characterize the burden and trends of overdiagnosis as well as identify strategies to reduce overdiagnosis in the future.

Major hepatectomy for perihilar cholangiocarcinoma in elderly patients: is it reasonable?

INTRODUCTION

We sought to evaluate the effect of age on postoperative outcomes among patients undergoing major liver surgery for perihilar cholangiocarcinoma (PHCC).

METHODS

77 patients were included. Patients were categorized into two groups: the "< 70-year-olds" group (n = 54) and the "≥ 70-year-olds" group (n = 23).

RESULTS

Median LOS was 19 both for < 70-year-old group and ≥ 70-year-old group (P = 0.72). No differences in terms of severe complication were detected (44.4% Clavien-Dindo 3-4-5 in < 70-year-old group vs 47.8% in ≥ 70-year-old group, P = 0.60). Within 90 postoperative days, 11 patients died, 6 in < 70-year-old group (11.3%) and 5 in ≥ 70-year-old group (21.7%), P = 0.29. The median follow-up was 20 months. The death rate was 72.2% and 78.3% among patients < 70 years old and ≥ 70 years old. The OS at 2 and 5 years was significantly higher among the < 70 years old (57.0% and 27.7%) compared to the ≥ 70 years old (27.1% and 13.6%), P = 0.043. Adjusting for hypertension and Charlson comorbidity index in a multivariate analysis, the HR for age was 1.93 (95% CI 0.84-4.44), P = 0.12. Relapse occurred in 43 (81.1%) patients in the < 70-year-old group and in 19 (82.6%) patients in the ≥ 70-year-old group. DFS at 12, 24, and 36 months was, respectively, 59.6, 34.2, and 23.2 for the < 70 -year-old group and 32.5, 20.3, and 13.5 for the ≥ 70-year-old group (P = 0.26). Adjusting for hypertension and Charlson comorbidity index in a Cox model, the HR for age was 1.52 (95% CI 0.67-3.46), with P = 0.32.

CONCLUSIONS

 ≥ 70-year-old patients with PHCC can still be eligible for major liver resection with acceptable complication rates and should not be precluded a priori from a radical treatment.

The Age-Specific Features and Clinical Significance of NRF2 and MAPK10 Expression in HCC Patients

BACKGROUND

Nuclear factor (erythroid-derived 2)-like 2 (NRF2) functions decline with age; however, cancer cells can hijack its pathways to ensure survival and aggressiveness. Yet, the role of NRF2 in hepatocellular carcinoma (HCC) is rarely investigated in an age-specific manner. This study investigates the expression of NRF2 and its activator (MAPK10) in different age groups of HCC patients, in addition to the age-specific features of NRF2 and MAPK10 interaction and their clinical significance.

METHODS

Tumor and near-tumor tissue samples of 181 HCC patients were used to complete a protein expression analysis of NRF2 and MAPK10. Patients' survival and clinical data were collected for clinical analysis. Global databases (TCGA, ICGC) were used to collect MAPK10 genetic mutation and mRNA expression data in patients with HCC, colorectal, stomach, and pancreatic cancers.

RESULTS

Our findings revealed an increase in NRF2 protein expression but only in younger HCC patients, along with a decline in MAPK10 ability to activate NRF2 in older patients. We also found an increased MAPK10 genetic mutation rate and decreased mRNA expression in older patients. Low MAPK10 and NRF2 expression levels were associated with shorter survival and poorer prognosis due to positive correlation with microvascular invasion, tumor thrombus, elevated AFP levels, and larger tumor size.

CONCLUSION

NRF2 expression and oxidative stress mechanism in HCC patients are influenced by age. This magnifies the need to consider patients' age in treatment strategies and guidelines and re-evaluates the application of studies' age-standardized findings in older patients who are usually excluded from relevant research.

Usefulness of measuring temporal changes in physical activity levels using an accelerometer for prediction and early detection of postoperative complications after hepatectomy

BACKGROUND

This research aimed to determine whether patterns of temporal changes in activity levels can indicate postoperative complications following hepatectomy.

METHODS

Between December 2016 and December 2019, 147 patients wore an accelerometer to measure their physical activity levels after hepatectomy until postoperative day 7. Patterns of changes in activity levels were categorized as follows: upward slope type (n = 88), wherein activity levels gradually increased; bell curve type (n = 13), wherein activity levels initially increased but subsequently decreased; and flat type (n = 46), wherein there was no apparent increase in activity levels. Patient characteristics and postoperative complications were compared for each group.

RESULTS

Postoperative complications occurred in 4.5% of patients in the upward slope group, in 76.9% in the bell curve group, and in 65.2% in the flat group (p < 0.001). Surgical site infections (SSI), refractory pleural effusion, and ascites were more common in the bell curve group, while pneumonia was only observed in the flat group.

CONCLUSION

SSI, pleural effusion, and ascites should be considered when previously increasing activity levels decline during the postoperative period. In addition, there is a high risk of SSI and pneumonia when activity levels do not increase at all after surgery.

Identification of Aging-Related Genes Associated With Clinical and Prognostic Features of Hepatocellular Carcinoma

Background: Aging is a well-studied concept, but no studies have comprehensively analyzed the association between aging-related genes (AGs) and hepatocellular carcinoma (HCC) prognosis. Methods: Gene candidates were selected from differentially expressed genes and prognostic genes in The Cancer Genome Atlas (TCGA) database. A gene risk score for overall survival prediction was established using the least absolute shrinkage and selection operator (LASSO) regression analysis, and this was validated using data from the International Cancer Genome Consortium (ICGC) database. Functional analysis was conducted using gene ontology enrichment, Kyoto Encyclopedia of Genes and Genomes analysis, gene set enrichment analysis, and immune microenvironment and tumor stemness analyses. Results: Initially, 72 AGs from the TCGA database were screened as differentially expressed between normal and tumor tissues and as genes associated with HCC prognosis. Then, seven AGs (POLA1, CDK1, SOCS2, HDAC1, MAPT, RAE1, and EEF1E1) were identified using the LASSO regression analysis. The seven AGs were used to develop a risk score in the training set, and the risk was validated to have a significant prognostic value in the ICGC set (p < 0.05). Patients with high risk scores had lower tumor differentiation, higher stage, and worse prognosis (all p < 0.05). Multivariate Cox regression analyses also confirmed that the risk score was an independent prognostic factor for HCC in both the TCGA and ICGC sets (all p < 0.05). Further analysis showed that a high risk score was correlated with the downregulation of metabolism and tumor immunity. Conclusion: The risk score predicts HCC prognosis and could thus be used as a biomarker not only for predicting HCC prognosis but also for deciding on treatment.

Liver resection for octogenarians in a French center: prolonged hepatic pedicle occlusion and male sex increase major complications

PURPOSE

The prolonged life expectancy and increase in aging of the population have led surgeons to propose hepatectomy in the elderly population. In this study, we evaluate the surgical outcome of octogenarians in a single French center.

METHODS

Between 2000 and 2020, 78 patients over 80 years old were retrospectively analyzed. The risk factors of major complications (Clavien-Dindo ≥ grade IIIa) and patient performance after surgery by using textbook outcome (TO) (no surgical complications, no prolonged hospital stay (≤ 15 days), no readmission ≤90 days after discharge, and no mortality ≤90 days after surgery) were studied.

RESULTS

The main surgical indication was for malignancy (96%), including mainly colorectal liver metastases (n = 41; 53%) and hepatocellular carcinoma (n = 22; 28%), and major hepatectomy was performed in 28 patients (36%). There were 6 (8%) postoperative mortalities. The most frequent complications were pulmonary (n = 22; 32%), followed by renal insufficiency (n = 22; 28%) and delirium (n = 16; 21%). Major complications occurred in 19 (24%) patients. On multivariate analysis, the main risk factors for major complications were the median vascular clamping time (0 vs 35; P = 0.04) and male sex (P = 0.046). TO was ultimately achieved in 30 patients (38%), and there was no prognostic factor for achievement of TO.

CONCLUSIONS

Hepatectomy in octogenarians is associated with acceptable morbidity and mortality. Meanwhile, prolonged hepatic pedicle clamping should be avoided especially if hepatectomy is planned in a male patient.

Current Status of Therapeutic Choice and Feasibility for Patients with Hepatocellular Carcinoma Aged ≥ 70 Years: A Nationwide Cancer Registry Analysis

Background

The opportunities for examining elderly patients with hepatocellular carcinoma (HCC) have increased. We investigated the treatment of HCC for elderly patients and the overall survival associated with each treatment modality.

Methods

From January 2003 to December 2005 (n=578, period I) and January 2008 to December 2014 (n=2428, period II), the National Cancer Center and Korean Liver Cancer Association collected clinical data of 3006 patients with HCC aged ≥70 years old at 54 medical centers in Korea. We analyzed the treatment modalities and overall survival for patients with HCC aged ≥70 years.

Results

The mean age, Child-Pugh score, and model for end-stage liver disease score and proportion of male patients were not different between period I and period II (74 years, 6.6, 10.4 and 70.1% vs 76 years, 6.2, 9.9 and 67.3%). TNM stage II and BCLC stage A were most commonly noted in periods I and II (44.3% and 49.1% vs 40.4% and 40.2%). Transarterial therapy was the most commonly used treatment modality according to age in both periods. Surgical resection was associated with significant superior overall survival compared to local ablation and transarterial therapy (p<0.001). After propensity score matching between surgical resection and transarterial therapy in period II, surgical resection was associated with more favorable overall survival outcomes (median: 39 months vs 86 months, p<0.001).

Conclusion

Transarterial therapy was the most commonly used treatment modality for patients with HCC aged ≥70 years. However, surgical resection led to significantly higher overall survival rates compared to other treatment modalities.

Open hepatic resection in the elderly at two tertiary referral centers

BACKGROUND

Surgeons are being increasingly called upon to operate on the very elderly. This study aimed to evaluate outcomes following hepatectomy in patients ≥80 years of age at two tertiary care centers.

METHODS

All adult patients who underwent liver resection from 2001 to 2017 were included. Primary outcome was 90-day postoperative mortality. Secondary outcomes included 30-day postoperative mortality and postoperative complications.

RESULTS

Between 2001 and 2017, 2397 patients underwent liver resection. On unadjusted analysis, patients ≥80 years of age had higher rates of 90-day mortality (13.3% vs. 3.6%, p < 0.001), 30-day mortality (5.6% vs. 1.8%, p = 0.01), MI (7.9% vs. 3.5%, p = 0.04), and UTI (10.0% vs. 4.5%, p = 0.02). On multivariable analysis, age ≥80 years was significantly associated with 90-day postoperative mortality (OR 4.51, 95%CI 2.11-9.67, p < 0.001).

CONCLUSIONS

Across these two major referral tertiary care centers, very elderly patients had higher rates of 90-day and 30-day postoperative mortality on both unadjusted and adjusted analyses.

Preoperative Risk Assessment for Delirium After Hepatic Resection in the Elderly: a Prospective Multicenter Study

BACKGROUND

Hepatic resection often results in delirium in preoperatively self-sufficient elderly people. The association of frailty with postoperative delirium remains unclear, and preoperative risk assessment, including frailty, of postoperative delirium has not been established.

METHODS

This prospective multicenter study included 295 independently living patients aged ≥ 65 years scheduled for initial hepatic resection. All patients answered the phenotypic frailty index Kihon Checklist, which is a self-reporting list of 25 questions, within a week before surgery. The risk factors for postoperative delirium were investigated. Patients who scored ≥ 4 in the Intensive Care Delirium Screening Checklist were designated as having postoperative delirium.

RESULTS

Delirium developed after liver resection in 22 of 295 patients (7.5%). Total Kihon Checklist score (≥ 6 points), age (≥ 75 years), and serum albumin concentration (≤ 3.7 g/dL) were the independent risk factors for postoperative delirium. The proportion of patients with postoperative delirium was 0% in those with no applicable risk factors, 3.2% in those with one applicable risk factor, 12.0% in those with two applicable risk factors, and 40.9% in those with all three factors (p < 0.001). The area under the receiver operating characteristic curve for this risk assessment for predicting postoperative delirium was 0.842.

CONCLUSION

The use of these three factors for preoperative risk assessment may be effective in predicting and preparing for delirium after hepatic resection in elderly patients.

A Comparison of Short-Term Outcomes between Laparoscopic and Open Liver Resection in Elderly Patients

Purpose

The aim of this study was to compare the short-term outcomes between laparoscopic liver resection (LLR) and open liver resection (OLR) in elderly patients with hepatic tumors.

Methods

From January 2013 to December 2019, a retrospective study was conducted for a total of 143 patients with over 70 years of age, who underwent liver resection for hepatic tumors. Forty-five patients who received biliary reconstruction at the same time were excluded. According to surgical approaches, 98 patients were classified into LLR and OLR groups. All postoperative complications were classified according to the Clavien-Dindo grading system and the Comprehensive Complication Index (CCI).

Results

Incidence of the postoperative complications was not statistically different between LLR and OLR groups. The CCI was significantly lower in the LLR group, with a median of 8.556, and a median of 19.698 in the OLR group (p=0.042). The length of hospital stay in the LLR group was significantly shorter than in the OLR group (p=0.008).

Conclusion

LLR is safe and feasible as a treatment for hepatic tumor in elderly patients with potentially less postoperative complications compared to OLR.

Outcomes of liver resection for hepatocellular carcinoma in octogenarians

BACKGROUND

There is a dearth of information about operative outcomes in patients ≥80 years for hepatocellular carcinoma (HCC) from Western institutions. We compare the result of HCC resections in patients <80 years vs. patients ≥80 years from our institution in the UK.

METHODS

We conducted a retrospective review of all patients undergoing liver resections for HCC between 2005 and 2015. Demographics, comorbidities, morbidity, mortality and survival were compared between the two age groups.

RESULTS

200 patients underwent resection for HCC in this time period. Nineteen patients were ≥80 years and 181 were <80 years. Comorbidities measured by the Charlson Comorbidity Index were significantly higher in the ≥80 group (p < 0.0001). There was no significant difference in the extent of resection in the two groups. Morbidity and mortality between the <80 years and the ≥80 years group were not significantly different (morbidity 27% vs.16%; p = 0.29) (mortality 7% vs. 0%; p = 0.11). The one-year (83.4% vs. 88.2%; p = 0.83), five-year (56.3% vs. 55.8%; p = 0.83) and the overall survival rate rates (887 days vs. 1035 days; p = 0.66) were not significantly different between the groups.

DISCUSSION

Liver resection should not be precluded based on age alone; with good outcomes in patients ≥80 years justifying surgery.

Predictive Value of the Age-Adjusted Charlson Comorbidity Index for Outcomes After Hepatic Resection of Hepatocellular Carcinoma

BACKGROUND

This study aimed to evaluate the impact of the age-adjusted Charlson comorbidity index (ACCI) on outcomes after hepatic resection for hepatocellular carcinoma (HCC).

METHODS

We assessed 763 patients who underwent hepatic resection for HCC. The ACCI scores were categorized as follows: ACCI ≤ 5, ACCI = 6, and ACCI ≥ 7.

RESULTS

A multivariate analysis showed that the odds ratios for postoperative complications in ACCI = 6 and ACCI ≥ 7 groups, with reference to ACCI ≤ 5 group, were 0.71 (p = 0.41) and 4.15 (p < 0.001), respectively. The hazard ratios for overall survival of ACCI = 6 and ACCI ≥ 7 groups, with reference to ACCI ≤ 5 group, were 1.52 (p = 0.023) and 2.45 (p < 0.001), respectively. The distribution of deaths due to HCC-related, liver-related, and other causes was 68.2%, 11.8%, and 20% in ACCI ≤ 5 group, 47.2%, 13.9%, and 38.9% in ACCI = 6 group, and 27.3%, 9.1%, and 63.6% in ACCI ≥ 7 group (p = 0.053; ACCI ≤ 5 vs. = 6, p = 0.19; ACCI = 6 vs. ≥ 7, p < 0.001; ACCI ≤ 5 vs. ≥ 7). In terms of the treatment for HCC recurrence in ACCI ≤ 5, ACCI = 6, and ACCI ≥ 7 groups, adaptation rate of surgical resection was 20.1%, 7.3%, and 11.1% and the rate of palliative therapy was 4.3%, 12.2%, and 22.2%, respectively.

CONCLUSIONS

The ACCI predicted the short-term and long-term outcomes after hepatic resection of HCC. These findings will help physicians establish a treatment strategy for HCC patients with comorbidities.

Data driven decision-making for older patients with hepatocellular carcinoma

Older age is a risk factor for the development of HCC. However, the treatment options available for older patients with HCC, their safety, efficacy and utility, are poorly understood resulting in challenging decision-making. In this review, we aim to report the best available evidence to facilitate optimal decision making for older patients with HCC. We report that surgical resection for HCC is equally safe (90-day mortality ~3%) and effective (five-year disease free survival ~40%) for older patients as it is for younger patients. Five-year survival after ablation therapy for HCC is in excess of 50% in older patients, whilst morbidity rates are in the region of 3%. Survival rates of 30% after chemoembolisation reflects its role as a non-curative treatment. Transplantation is an option that may be helpful for a minority of patients, but the high risks of in-hospital mortality and lower likelihood of receiving a transplant should be duly considered before committing to this approach. We therefore advocate an individualised assessment for older patients based on these risk profiles and probabilities of optimal outcomes. In patients with a projected life-span ≥ 3 years, and who have sufficient physiological and functional reserve, surgical resection should be the treatment of choice. Patients with a projected life-span < 3 years are better served with loco-regional therapies, and tumour size, at a threshold of 3 cm, should guide the choice between ablation and chemoembolisation therapies.

Surgical oncology in patients aged 80 years and older is associated with increased postoperative morbidity and mortality: A systematic review and meta-analysis of literature over 25 years

BACKGROUND

The study aim is to analyze the evolution over the last 25 years of the results reported after abdominal oncological surgery in patients aged 80 years of age and older. The primary endpoint was morbidity and mortality in this group of patients; the secondary endpoint was overall survival.

METHODS

A systematic search strategy was used to browse through Medline/PubMed, EMBASE, Scopus, ClinicalTrials.gov, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials using a combination of standardized index terms. Studies published between 1997 and 2017 were selected. Only those studies that showed morbidity and mortality after digestive and hepatobiliary tract oncological surgery in individuals aged 80 years and older were included. The PROSPERO registration number is CRD42018087921. PRISMA and MOOSE guidelines were applied.

RESULTS

A total of 79 studies were included, categorized by origin of malignancy: esophageal (7), stomach (26), liver (4), pancreas (19), and colorectal (23). Compared with the non-elderly group, the elderly group had similar esophageal morbidity with higher mortality (RR 2.51, 1.50 to 4.21; P = 0.0005); higher gastric morbidity (RR 1.25, 1.09 to 1.43; P = 0.001), and mortality (RR 2.51, 1.81 to 3.49; P = 0.0001); similar liver morbidity and mortality; higher pancreatic morbidity (RR 1.17, 1.03 to 1.33; P = 0.02) and mortality (RR 2.37, 1.86 to 3.03; P < 0.00001); and similar colorectal morbidity with higher mortality (RR 4.44, 1.91 to 10.32; P = 0.005).

CONCLUSION

Oncological surgery of most abdominal visceral tumors is associated with increased morbidity and mortality in patients older than 80 years.

Risk factors for postoperative delirium after colorectal surgery: a systematic review and meta-analysis

PURPOSE

Postoperative delirium is common after any type of surgery and can lead to serious outcomes; thus, its prevention is important. Early assessment can help identify patients at higher risk of postoperative delirium. However, the risk factors for postoperative delirium in patients who underwent colorectal surgery are unclear. This meta-analysis aimed to identify the risk factors for postoperative delirium after colorectal cancer surgery.

METHODS

We selected all articles related to postoperative delirium after colorectal surgery published up to March 2019. Studies using any method for diagnosing delirium were eligible. Ovid-Embase, Ovid-Medline, and the Cochrane library were searched. Two reviewers independently conducted quality assessment and data collection. The risk factors identified in the studies were recorded, and a meta-analysis was conducted.

RESULTS

Of the 1216 studies initially screened, 1197 were reviewed by two independent reviewers. Finally, 14 articles were identified to be relevant for this review. In total, 11 of the 14 studies reported the risk factors for postoperative delirium. The incidence of postoperative delirium ranged from 8% to 54%. A total of 19 risk factors were identified, and we classified them into two categories as patient-related and treatment-related risk factors.

CONCLUSION

Postoperative delirium is highly common in those undergoing colorectal surgery including cancer, with advanced old age, history of preoperative delirium and preoperative serum albumin level which are risk factors for POD. Larger multi-institutional randomized studies to address this issue are warranted in the future.

Cirrhotic patients and older people

The global population is aging, and so the number of older cirrhotic patients is increasing. Older patients are characterised by a risk of frailty and comorbidities, and age is a risk factor for mortality in cirrhotic patients. The incidence of non-alcoholic fatty liver disease as an aetiology of cirrhosis is increasing, while that of chronic viral hepatitis is decreasing. Also, cirrhosis is frequently idiopathic. The management of portal hypertension in older cirrhotic patients is similar to that in younger patients, despite the greater risk of treatment-related adverse events of the former. The prevalence of hepatocellular carcinoma increases with age, but its treatment is unaffected. Liver transplantation is generally recommended for patients < 70 years of age. Despite the increasing prevalence of cirrhosis in older people, little data are available and few recommendations have been proposed. This review suggests that comorbidities have a considerable impact on older cirrhotic patients.

Expanding the Surgical Pool for Hepatic Resection to Treat Biliary and Primary Liver Tumors

Surgical management of primary liver and biliary tract tumors has evolved over the past several decades, resulting in improved outcomes in these malignancies with historically poor prognoses. Expansion of patient selection criteria, progress in neoadjuvant and adjuvant therapies, development of techniques to increase future liver remnant, and the select utilization of liver transplantation have all contributed to increasing the patient pool for surgical intervention. Ongoing and future studies need to focus on improving multimodality treatment regimens and further refining the selection criteria for transplantation in order to optimize utilization of limited organ resources.

Preoperative Risk Assessment for Loss of Independence Following Hepatic Resection in Elderly Patients: A Prospective Multicenter Study

OBJECTIVE

To establish a preoperative risk assessment method for loss of independence after hepatic resection.

SUMMARY BACKGROUND DATA

Hepatic resection often results in loss of independence in preoperatively self-sufficient elderly people. Elderly patients should therefore be carefully selected for surgery.

METHODS

In this prospective, multicenter study, 347 independently-living patients aged ≥65 years, scheduled for hepatic resection, were divided into study (n = 232) and validation (n = 115) cohorts. We investigated the risk factors for postoperative loss of independence in the study cohort and verified our findings with the validation cohort. Loss of independence was defined as transfer to a rehabilitation facility, discharge to residence with home-based healthcare, 30-day readmission for poor functionality, and 90-day mortality (except for cancer-related deaths).

RESULTS

In the study cohort, univariate and multivariate analyses indicated that frailty, age ≥ 76 years, and open surgery were independent risk factors for postoperative loss of independence. Proportions of patients with postoperative loss of independence in the study and validation cohorts were respectively 3.0% and 0% among those with no applicable risk factors, 8.1% and 12.5% among those with 1 applicable risk factor, 25.5% and 25.0% among those with 2 applicable risk factors, and 56.3% and 50.0% among those with all 3 factors applicable (P < 0.001 for both cohorts). Areas under the receiver operating characteristic curves for the study and validation groups were 0.777 and 0.783, respectively.

CONCLUSIONS

Preoperative risk assessments using these 3 factors may be effective in predicting and planning for postoperative loss of independence after hepatic resection in elderly patients.

Laparoscopic versus open liver resection for hepatocellular carcinoma in elderly patients: a multi-centre propensity score-based analysis

BACKGROUND

The frequency of liver resection in elderly patients has been increasing. However, data are limited regarding the safety of laparoscopic liver resection (LLR) compared with that of open liver resection (OLR) for hepatocellular carcinoma (HCC) in elderly patients. The present study aimed to compare short-term outcomes between LLR and OLR in elderly patients with HCC using propensity score matching.

METHODS

The study included 630 patients (age, ≥ 75 years) who underwent liver resection for HCC at nine liver centres between April 2010 and December 2017. Patients were divided into LLR and OLR groups, and perioperative outcomes were compared between the groups. In addition, subgroup analysis was performed according to age (75-79 and ≥ 80 years).

RESULTS

Of the 630 patients, 221 and 409 were included in the LLR and OLR groups, respectively. After propensity score matching, 155 patients were included in each group. Intraoperative blood loss and the transfusion, post-operative overall complication and major complication rates were lower in the matched LLR than the matched OLR group (P < 0.001, P = 0.004, P < 0.001 and P < 0.001, respectively). Moreover, post-operative pulmonary and cardiovascular complications were less frequent in the matched LLR group (P = 0.008 and P = 0.014, respectively). In subgroup analysis, among octogenarians, the post-operative major complication rate was lower and hospital stay was shorter in the matched LLR than the matched OLR group (P < 0.001 and P < 0.001, respectively).

CONCLUSION

LLR for HCC is associated with good short-term outcomes in patients aged ≥ 75 years compared with OLR. LLR is safe and feasible in selected octogenarians with HCC.

The impact of age and ageing on hepatocarcinoma surgery: Short- and long-term outcomes in a multicentre propensity-matched cohort

BACKGROUND

Management of malignancy in elderly patients is challenging. We aimed to assess the impact of age and ageing on overall survival (OS), recurrence-free survival (RFS), tumour-specific survival (TSS) and potential years of life lost (PYLL) after surgery for hepatocarcinoma (HCC).

METHODS

Consecutive patients treated for HCC between 2005 and 2015 were evaluated. Patients were divided according to age-decade. Afterwards, elderly patients (≥75 years) were compared with patients < 75 years. A 1:1 propensity matching was used to reduce the risk of bias. Survival was estimated by Kaplan-Meier method and Cox regression analysis.

RESULTS

Four hundred and thirty-nine patients were stratified: group 1 (age ≤ 55, n = 72), group 2 (age: 56-65, n = 133), group 3 (age: 66-74, n = 141) and group 4 (age ≥ 75, n = 93). Group 1 had the highest median PYLL (27.6, IQR 24.6-32.5) while group 4 the lowest (2.0, IQR 0-9.6; P < 0.001). Comparing elderly vs younger, there were no significant differences in terms of OS (P = 0.054), TSS (P = 0.321) and RFS (P = 0.240). Ageing was the only variable associated with post-operative complications (OR: 2.51; 95% CI: 1.23-5.13; P = 0.025) and liver-related morbidity was an independent predictor of OS. (HR 2.49, 95% CI: 1.34-4.64, P = 0.004).

CONCLUSION

Ageing per se is not an absolute contraindication for liver resection, given the acceptable oncologic long-term prognosis, but the worse short-term outcomes in the elderly should induce an accurate patient selection.

Hepatic resection of solitary HCC in the elderly: A unique disease in a growing population

BACKGROUND

Management of elderly patients with solitary hepatocellular carcinoma (sHCC) is challenging with perceived clinicopathologic differences driving treatment options. We sought to determine factors predictive of disease control and survival after hepatic resection of sHCC in elderly patients.

METHODS

We identified n = 45 elderly patients (³≥65 yo) with sHCC treated with hepatic resection alone from our prospective database from 2003-16. Clinicopathologic data were analyzed and survival was assessed from the time of hepatic resection.

RESULTS

The median age was 75-years-old. Less than half of patients (47%) had viral hepatitis. At resection, the median Child-Pugh score was A6, median tumor size 5 cm, and mean AFP of 1050 (ng/mL). Major hepatectomy was performed in 23 patients (51%) with R0 resection achieved in 96%. Two patients (4%) had Grade III complications with no mortalities at 30 days and one death (2%) at 90-days. After R0 resection 44% (n = 20) had intrahepatic recurrence at a median of 32 months (95% CI: 15-46) with 20% (n = 9) developing extrahepatic recurrence at a median of 78 months (95% CI: 78-.). The median survival was 72 months (95% CI: 30-108 months). For patients with at least 3 years of follow-up, the 1-, 3-, and 5-year overall survival was 74%, 59%, and 50%, respectively. Mortality was associated with higher AFP and lower Prognostic Nutritional Index (PNI).

CONCLUSION

Carefully selected elderly patients with sHCC appear to have unique disease that is amenable to hepatic resection with low morbidity and mortality with excellent overall and recurrence-free survival.

Liver resection for hepatocellular carcinoma in oldest old patients

Background

For hepatocellular carcinoma (HCC), liver resection is a classical curative modality, despite its technical complexity. The incidence of HCC in the oldest old people (aged ≥ 85 years) is rising along with the global increase in life expectancy. Currently, no report has addressed liver resection for HCC in this aged population.

Patients and methods

We conducted a retrospective review of 1889 patients receiving curative liver resection for newly diagnosed HCC from 1992 to 2016. At the time of operation, 1858 of them were aged < 85 years (group A), and 31 were aged ≥ 85 years (group B). Another 18 oldest old patients, whose HCC was considered resectable but were not operated on due to the patient’s refusal, served as the control group (group C). The clinicopathological characteristics and early and long-term outcomes were compared between groups A and B. All associated co-morbidities of the patients were well-treated before liver resection. The overall survival (OS) rates were also compared between groups B and C.

Result

Group B had a significantly higher incidence of associated co-morbidities and hepatitis C infection. Postoperative complication rates and 90-day mortality rates after liver resection did not differ between groups A and B (p = 0.834 and p = 1.000, respectively), though group B had a longer postoperative stay (p = 0.001). In groups A and B, the 5-year disease-free survival rates were 29.7% and 22.6% (p = 0.163), respectively, and their overall survival rates were 43.5% and 35.5% (p = 0.086). The overall survival rate of group B was significantly different from group C (35.5% vs. 0%, p = 0.001).

Conclusion

Despite a longer postoperative recovery period, liver resection for HCC in the oldest old patients may be justified if co-morbidities are well controlled.

The Short- and Long-Term Outcomes in Elderly Patients with Hepatocellular Carcinoma after Curative Surgery: A Case-Controlled Study with Propensity Score Matching

BACKGROUND

With aging populations increasing in developed countries, the prevalence of elderly patients with hepatocellular carcinoma (HCC) is expected to rise. The aim of this study was to determine the short- and long-term outcomes of HCC surgery in elderly patients (≥75 years) using propensity score matching.

METHODS

The study group included 421 patients who underwent hepatectomy as their initial treatment with curative intent. The patients were divided into elderly (n = 111) and non-elderly (n = 310) groups. We applied propensity score matching - taking into consideration patient background, blood examination, and tumor factors - to minimize the effect of potential confounders. We then compared the results before and after the propensity matching.

RESULTS

Before propensity matching, the elderly group included significantly more patients with a high American Society of Anesthesiologists physical status (p < 0.001). In addition, they were taking antihypertensive drugs or an anticoagulant (both p < 0.001). The severe postoperative complications and the overall survival rates for these elderly patients were significantly poorer than for the non-elderly patients (p = 0.015 and p = 0.030, respectively). We then chose 70 patients from each group for whom the preoperative confounding factors were balanced and compared the two groups. The factors identified before matching (severe complications and overall survival rates) were no longer relevant, i.e. there were no significant differences between the two groups.

CONCLUSION

Hepatectomy for HCC in elderly patients is justified.

Hepatic resection for elderly patients with hepatocellular carcinoma: a systematic review of more than 17,000 patients

BACKGROUND

With the aging population and increasing incidence of hepatic malignancies in elderly patients, establishing the safety and efficacy of hepatic resection for elderly patients with hepatocellular carcinoma (HCC) is crucial. The present systematic review investigates postoperative morbidity, hospital mortality, median survival time, overall and disease-free survival in elderly patients with undergoing hepatic resection.

METHODS

Some databases were systematically searched for prospective or retrospective studies to reveal the safety and efficacy of hepatic resection for elderly patients with primary HCC.

RESULTS

Fifty studies involving 4,169 elderly patients and 13,158 young patients with HCC were included into analyses. Elderly group patients had similar rate of median postoperative morbidity (28.2% vs. 29.6%) but higher mortality (3.0% vs. 1.2%) with young group patients. Moreover, elderly group patients had slightly lower median survival time (55 vs. 58 months), 5-years overall survival (51% vs. 56%) and 5-years disease-free survival (27% vs. 28%) than young group patients. There was an upward trend in 5-years overall and disease-free survival in either elderly or young group.

CONCLUSION

Though old age may increase the risk of hospital mortality for patients with HCC after hepatic resection, elderly patients can obtain acceptable long-term prognoses from hepatic resection.

A pilot study: The association between physical activity level using by accelerometer and postoperative complications after hepatic resection

Recently, accelerometers measuring physical activity level have been available to the public. In the present study, it was examined whether the accelerometer could evaluate postoperative outcomes for 12 patients subjected to hepatic resection from August-November 2016. The association was evaluated between the changing pattern of activity level until the postoperative day (POD) 7 and the occurrence of postoperative complications. The median age of patients was 79 years (range, 58-85). Postoperative complications were identified in 6 patients. The activity level in patients with complications was low from POD 1 and was significantly lower than patients without complications following POD 6. The changing pattern of activity level with all included patients could be divided into the following 3 types: Increase type, bell curve type and flat type. Patients without complications exhibited an accelerated increase of postoperative activity level, categorized as increase type. Bell curve type and flat type demonstrated delay of recovery in postoperative activity levels, and were suggested to be associated with the occurrence of postoperative complications. These findings may provide rationale for larger sample studies to evaluate whether physical activity level measured via accelerometer may be a surrogate marker for postoperative complications.

Revisiting Partial Hepatectomy of Large Hepatocellular Carcinoma in Older Patients

Hepatectomy of large hepatocellular carcinomas (>10 cm) in over 70 year-old patients is presumed futile. We retrospectively reviewed 5970 patients with liver tumors Jan 2010 through Dec 2016 in our institute, of them, 37 older patients with large hepatocellular carcinomas staged I-III and Child-Pugh A liver functions receiving conservative treatments (conservative group, n = 37) and 16 older patients with large hepatocellular carcinomas staged I- III who underwent partial hepatectomy (resection group, n = 16) were included, the risk factors for poor survival were analyzed by univariate and multivariate analyses. Compared with the conservative treatments, Partial hepatectomy achieved better median survival time (25.5 months versus 11 months, log-rank = 0.0001) and better median performance status (1 versus 3, p = 0.023), there was different in Charlson comorbidity index (p = 0.019). For the conservative group, the 3-month, 1, 2, 3-year survival rate was 78.4%, 43.2%, 5.4%, 0%; for the resection group, The 3-month, 1, 2, 3-year survival rate was 100%, 93.7.2%, 56.3%, 12.5%; Multivariate Cox regression analysis showed the Charlson comorbidity index and the performance status associated with poor outcomes of those patients (p = 0.001, 0.018, respectively). Resections of large hepatocellular carcinomas in older patients can be performed safely to prolong life expectancy and improve life quality with or without cancer recurrence.

Integrated analysis of the impact of age on genetic and clinical aspects of hepatocellular carcinoma

Despite the rapid growing and aging of populations worldwide, our knowledge on hepatocellular carcinoma (HCC) is still age-standardized rather than age-specific, with only few studies exploring the topic from a genetic point of view. Here, we analyze clinical and genetic aspects of HCC in patients of different age groups with the major attention directed to children (≤20 y) and elderly groups (≥80 y). A number of significant differences were found in elderly patients compared to children group, including smaller tumor size (P=0.001) and improved survival rates (P=0.002). Differences in gene mutations, copy number variants, and mRNA expressions were identified between the groups, with alteration rates for some genes like AKR1B10 increasing significantly with the age of patients. Immunohistochemistry testing of AKR1B10 showed a significant difference in expression levels at the age of 40 (30.77% high expression rate in patients younger than 40 compared to 51.57% in older patients) (P=0.043). Expression levels also differed between HCC tissues (49.64%) and near-tumor tissues (6.58%) (P<0.001). These findings contribute to the limited data available regarding the age-specific aspects of HCC patients, and support the need to address potential differences in the diagnosis, treatment, and prevention strategies of HCC.

Does an extreme age (≥80 years) affect outcomes in patients after liver cancer surgery? A meta-analysis

BACKGROUND

Increasing global life expectancy has resulted in a greater demand for cancer surgery in aged patients. However, whether extreme age causes poorer clinical outcomes remains unclear. This meta-analysis aimed to evaluate the impact of extreme age (≥80 years) on outcomes in patients after liver cancer surgery.

METHODS

A systematic search was performed to enrol relevant studies. Data were analysed using fixed-effects or random-effects models. Eight retrospective studies involving 253 participants older than 80 years were included.

RESULTS

Compared with younger patients, patients of extreme age (≥80 years) who had undergone curative liver cancer surgery experienced less operating time and blood loss (both P < 0.0001); a larger size (weighted mean difference = 0.48 cm, 95% confidence interval (CI) 0.08-0.87 cm; P = 0.02) and more advanced stage of hepatocellular carcinoma (risk ratio (RR) = 1.20, 95% CI 1.04-1.39; P = 0.01); a higher overall morbidity (RR = 1.24, 95% CI 1.05-1.47; P = 0.01); and more post-operative ileus (POI) (RR = 3.45, 95% CI 1.03-11.56; P = 0.04), delirium (RR = 3.04, 95% CI 1.36-6.78; P = 0.007) and cardiovascular events (RR = 6.17, 95% CI 2.79-13.60; P < 0.00001). No significant difference was noted in overall (hazard ratio (HR) = 1.15, 95% CI 0.87-1.53; P = 0.32) or disease-free (HR = 0.96, 95% CI 0.75-1.24; P = 0.77) survival.

CONCLUSION

Although an extreme age may not be a contraindication for undertaking liver cancer surgery, it may cause more morbidity. Perioperative intervention should be considered for prevention and early treatment of POI, delirium and cardiovascular events.

Clinical outcomes of stereotactic body radiotherapy for elderly patients with hepatocellular carcinoma

AIM

To evaluate the safety and efficacy of stereotactic body radiotherapy (SBRT) for the treatment of hepatocellular carcinoma (HCC) in elderly patients.

METHODS

From 2008 to 2015, 117 patients with HCC (≤3 nodules, ≤30 mm in diameter, Child-Pugh score ≤7, and no vascular or extracellular metastasis) were treated with SBRT at our hospital. We evaluated overall survival (OS), disease-free survival (DFS), local control, and adverse events. Patients were stratified according to age 75 years and older (elderly group, n = 54) and age younger than 75 years (young group, n = 63).

RESULTS

The median OS in the elderly group was not significantly different from that in the young group (52 months vs. not reached, P = 0.27). The 1-, 2-, and 3-year OS rates were 96.2%, 77.6%, and 63.9%, respectively, in the elderly group, and 96.8%, 84.8%, and 67.7%, respectively, in the young group. The median DFS in the elderly group was significantly shorter than that in the young group (13 vs. 25 months, respectively; P = 0.03). The 1-, 2-, and 3-year DFS rates were 50.6%, 30.4%, and 26.6%, respectively, in the elderly group and 66.5%, 50.7%, and 45.3%, respectively, in the young group. The 3-year local tumor control rate in the elderly group was 98.1%, and that in the young group was 98.4% (P = 0.83). There was no difference between groups in the incidence of any adverse events.

CONCLUSIONS

Stereotactic body radiotherapy can be effective and safe for the treatment of HCC in elderly patients.

Perioperative outcome of elderly versus younger patients undergoing major hepatic or pancreatic surgery

Objective

The aim of this study was to determine the safety of elderly cancer patients (≥70 years) undergoing hepatic resection (HR) or pancreaticoduodenectomy (PD) in comparison with younger adults (<70 years).

Methods

A total of 1,012 consecutive patients undergoing HR or PD were included. The incidence and severity of morbidity were documented within 30 days postoperatively and compared between elderly and younger groups. Risk factors associated with postoperative morbidity were investigated by multivariate logistic regression analysis.

Results

Elderly patients (n=111, 11.0%) had more comorbidities and worse preoperative general condition and liver function versus younger patients (n=901, 89.0%), and thus were more likely to develop infectious (eg, systemic sepsis and urinary tract infection, both p<0.01) and technical-associated complications (intraperitoneal bleeding and biliary/pancreatic fistula, p=0.029 and p=0.074, respectively). However, the incidence and severity of complications were comparable between elderly and younger patients in the whole cohort, and also in HR and PD surgery groups separately. Preoperative hemoglobin (odds ratio [OR] 1.4, p=0.007) and intraoperative blood transfusion (OR 1.9, p=0.002), rather than age, were independently associated with postoperative morbidity. Hepatitis (OR 2.9, p=0.001), preoperative hemoglobin (OR 1.6, p=0.036), and pancreatic versus hepatic surgery (OR 2.3, p=0.005) were independently associated with postoperative infectious. For elderly patients only, American Society of Anesthesiologists (ASA) score III (OR 2.1, p=0.033) and intraoperative blood transfusion (OR 3.2, p=0.030) were independently associated with postoperative morbidity.

Conclusion

HR and PD can be safely performed in selected elderly patients versus younger patients. Elderly patients with ASA score III or above should be cautiously selected for major surgeries.

Carbon ion radiotherapy for 80 years or older patients with hepatocellular carcinoma

BACKGROUND

To evaluate the safety and efficacy of carbon ion radiotherapy (C-ion RT) for 80 years or older patients with hepatocellular carcinoma (HCC).

METHODS

Eligibility criteria of this retrospective study were: 1) HCC confirmed by histology or typical hallmarks of HCC by imaging techniques of four-phase multidetector-row computed tomography or dynamic contrast-enhanced magnetic resonance imaging; 2) no intrahepatic metastasis or distant metastasis; 3) no findings suggesting direct infiltration of the gastrointestinal tract; 4) performance status ≤2 by Eastern Cooperative Oncology Group classification; and 5) Child-Pugh classification A or B. Patients received C-ion RT with 52.8 Gy (RBE) or 60.0 Gy (RBE) in four fractions for usual cases and 60.0 Gy (RBE) in 12 fractions for close-to-gastrointestinal tract cases. Toxicities were classified using the National Cancer Institute's Common Terminology Criteria for Adverse Events (Version 4.0).

RESULTS

Between March 2011 and November 2015, 31 patients were treated. The median follow-up period of all patients was 23.2 months (range: 8.4-55.3 months). Median age at the time of registration of C-ion RT was 83 years (range: 80-95 years). Child-Pugh grade A and B were 27 patients and 4 patients, respectively. The 2-year estimated overall survival, local control, and progression-free survival rates were 82.3%, 89.2%, and 51.3%, respectively. No patients had Grade 2 or higher acute toxicities (within 3 months after C-ion RT). One patient experienced progression in Child-Pugh classification from A to B within 3 months after C-ion RT. In late toxicities, Grade 3 encephalopathy was observed in 3 patients, and 2 improved with medication.

CONCLUSIONS

C-ion RT was effective with minimal toxicities for 80 years or older patients with hepatocellular carcinoma.

TRIAL REGISTRATION

UMIN000020571 : date of registration, 14 January 2016, retrospectively registered.

Nomograms for prediction of long-term survival in elderly patients after partial hepatectomy for hepatocellular carcinoma

BACKGROUND

Partial hepatectomy is an important treatment for elderly patients with hepatocellular carcinoma. However, prediction of long-term outcomes of an individual elderly patient after partial hepatectomy still is lacking. This study aimed to develop 2 nomograms to pre- or postoperatively predict overall survival for these patients.

METHODS

Of the 528 elderly patients (aged ≥65 years) who underwent partial hepatectomy for hepatocellular carcinoma at the Eastern Hepatobiliary Surgery Hospital between 2008 and 2011, 425 patients served as a training cohort to develop pre- and postoperative nomograms, and the remaining 103 patients comprised a validation cohort. The Cox proportional hazards model was used for univariate and multivariable analyses of tumor recurrence and overall survival. Discrimination and calibration of the models were measured using the concordance index, calibration plots, and Kaplan-Meier curves.

RESULTS

Based on preoperative data, the independent risk factors of overall survival were age ≥75 years, Charlson score, α-fetoprotein ≥20 μg/L, hepatitis B virus-deoxyribonucleic acid ≥10⁴ IU/mL, and tumor diameter. Based on postoperative data, nonanatomic hepatectomy, absence of tumor encapsulation, and presence of microvascular invasion were additional independent risk factors. These independent predictors were incorporated into the pre- and postoperative nomograms, respectively. The concordance indexes of the 2 nomograms for overall survival prediction were 0.70 (95% confidence interval, 0.67-0.74) and 0.72 (0.69-0.78), respectively. Both nomograms accurately predicted 1-, 3-, and 5-year overall survival probability, and their predictive performances were optimally validated.

CONCLUSION

The proposed 2 nomograms showed good individualized predictive performance in elderly patients with hepatocellular carcinoma before and after partial hepatectomy.

Hepatocellular carcinoma in elderly patients: challenges and solutions

Hepatocellular carcinoma (HCC) is the second most common cause of death by cancer in the world. Due to the delayed HCC development in hepatitis C carriers and nonalcoholic fatty liver disease, the incidence of HCC in the elderly is increasing and is becoming a global health issue. Elderly patients with HCC should be assessed through proper oncologic approach, namely, screening tools for frailty (Geriatric-8 or Vulnerable Elders Survey-13) and comprehensive geriatric assessment. This review of the literature supports the same treatment options for elderly patients as for younger patients, in elderly patients selected as fit following proper oncogeriatric assessment. Unfit patients should be managed through a multidisciplinary team involving both oncological and geriatrician professionals. Specific studies and recommendations for HCC in the elderly should be encouraged.

Clinical features and prognosis of elderly patients with hepatocellular carcinoma not indicated for surgical resection

Hepatocellular carcinoma (HCC) is a major health problem worldwide. The average life expectancy during the 20th century has increased in many parts of the world, and therefore the opportunities to examine elderly HCC patients have significantly increased worldwide. Many elderly patients develop HCC with intermediate to advanced stages of disease at the initial diagnosis, and have more comorbidities and compromised liver regeneration compared with younger patients. These circumstances show that elderly patients with HCC are poorer candidates for surgical resection or transplantation. The aim of the present review was to focus on the clinical features and prognosis of elderly HCC patients not indicated for surgical resection including multimodal treatment. Although the chronological age of 60 or 65 years as the definition of an elderly person is accepted in most countries, many studies in our review article define elderly as those aged 75 years or older. Geriatr Gerontol Int 2017; 17: 189-201.

Preliminary study on liver function changes after trisectionectomy with versus without prior portal vein embolization

PURPOSE

Post-hepatectomy liver failure (PHLF) is the major risk factor for mortality after hepatectomy. Preoperative planning of the future liver remnant volume reduces PHLF rates; however, future liver remnant function (FLR-F) might have an even stronger predictive value. In this preliminary study, we used a new method to calculate FLR-F by the LiMAx test and computer tomography-assisted volumetric-analysis to visualize liver function changes after portal vein embolization (PVE) before extended hepatectomy.

METHODS

The subjects included patients undergoing extended right hepatectomy either directly (NO-PVE group) or after PVE (PVE group). Computed tomography (CT) scan and liver function tests (LiMAx) were done before PVE and preoperatively. FLR-F was calculated and correlated with the postoperative liver function.

RESULTS

There were 12 patients in the NO-PVE group and 19 patients in the PVE group. FLR-F and postoperative liver function correlated significantly in both groups (p = 0.036, p = 0.011), although postoperative liver function was slightly overestimated, at 32 and 45 µg/kg/min, in the NO-PVE and PVE groups, respectively. LiMAx value did not change after PVE.

CONCLUSIONS

Volume-function analysis using LiMAx and CT scan enables us to reliably predict early postoperative liver function. Global enzymatic liver function measured by the LiMAx test did not change after PVE, confirming that liver function distribution in the liver stays constant after PVE. An overestimation of FLR-F is needed to compensate for the intraoperative liver injury that occurs in patients undergoing extended hepatectomy.