Evaluation of the risk factors and prognostic factors of hepatectomy for hepatocellular carcinoma in patients aged 80 years or more

EASL Clinical Practice Guidelines on the management of hepatocellular carcinoma

Liver cancer is the third leading cause of cancer-related deaths worldwide, with hepatocellular carcinoma (HCC) accounting for approximately 90% of primary liver cancers. Advances in diagnostic and therapeutic tools, along with improved understanding of their application, are transforming patient treatment. Integrating these innovations into clinical practice presents challenges and necessitates guidance. These clinical practice guidelines offer updated advice for managing patients with HCC and provide a comprehensive review of pertinent data. Key updates from the 2018 EASL guidelines include personalised surveillance based on individual risk assessment and the use of new tools, standardisation of liver imaging procedures and diagnostic criteria, use of minimally invasive surgery in complex cases together with updates on the integrated role of liver transplantation, transitions between surgical, locoregional, and systemic therapies, the role of radiation therapies, and the use of combination immunotherapies at various stages of disease. Above all, there is an absolute need for a multiparametric assessment of individual risks and benefits, considering the patient's perspective, by a multidisciplinary team encompassing various specialties.

Effect of abdominal aortic calcification on long-term outcomes after the first liver resection in very old patients with hepatocellular carcinoma

Aim

We previously reported that abdominal aortic calcification is associated with poor overall and recurrence-free survival after hepatectomy for hepatocellular carcinoma (HCC). However, the effect of abdominal aortic calcification on cancer-specific prognosis in very old patients with several comorbidities remains unknown. This multicenter study aimed to evaluate the impact of abdominal aortic calcification on the cumulative recurrence rate and recurrence-free survival in patients with HCC aged >80 years.

Methods

We retrospectively analyzed the data of 128 patients (aged ≥80 years) who underwent liver resection for hepatocellular carcinoma at seven hospitals belonging to Hiroshima Surgical Study Group of Clinical Oncology between January 2014 and December 2018. Patients were divided into two groups: high and low abdominal aortic calcification groups. The primary endpoints were cumulative recurrence rate and recurrence-free survival.

Results

Kaplan-Meier survival curve analysis demonstrated that the cumulative recurrence rate in the high abdominal aortic calcification group was significantly higher than that in the low abdominal aortic calcification group, and the high abdominal aortic calcification group had a significantly lower recurrence-free survival rate. In the multivariate analysis, high abdominal aortic calcification (p = 0.03), high des-gamma-carboxyprothrombin score (p = 0.04), and multiple tumors (p < 0.01) were independent predictive factors for recurrent HCC, and high abdominal aortic calcification (p = 0.01) and high des-gamma-carboxyprothrombin (p = 0.01) were independent predictive factors for poor cancer-specific survival.

Conclusions

Our results indicate that the abdominal aortic calcification score is associated with cumulative recurrence rate and recurrence-free survival in very old patients with HCC.

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 new risk calculation model for complications of hepatectomy in adults over 75

BACKGROUND

Owing to poor organ function reserve, older adults have a high risk of postoperative complications. However, there is no well-established system for assessing the risk of complications after hepatectomy in older adults.

METHODS

This study aimed to design a risk assessment tool to predict the risk of complications after hepatectomy in adults older than 75 years. A total of 326 patients were identified. A logistic regression equation was used to create the Risk Assessment System of Hepatectomy in Adults (RASHA) for the prediction of complications (Clavien‒Dindo classification ≥ II).

RESULTS

Multivariate correlation analysis revealed that comorbidity (≥ 5 kinds of disease or < 5 kinds of disease, odds ratio [OR] = 5.552, P < 0.001), fatigue (yes or no, OR = 4.630, P = 0.009), Child‒Pugh (B or A, OR = 4.211, P = 0.004), number of liver segments to be removed (≥ 3 or ≤ 2, OR = 4.101, P = 0.001), and adjacent organ resection (yes or no, OR = 1.523, P = 0.010) were independent risk factors for postoperative complications after hepatectomy in older persons (aged ≥ 75 years). A binomial logistic regression model was established to evaluate the RASHA score (including the RASHA scale and RASHA formula). The area under the curve (AUC) for the RASHA scale was 0.916, and the cut-off value was 12.5. The AUC for the RASHA formula was 0.801, and the cut-off value was 0.2106.

CONCLUSION

RASHA can be used to effectively predict the postoperative complications of hepatectomy through perioperative variables in adults older than 75 years.

TRIAL REGISTRATION

The Research Registry: researchregistry8531. https://www.researchregistry.com/browse-the-registry#home/registrationdetails/63901824ae49230021a5a0cf/ .

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.

Impact of abdominal aortic calcification on clinical outcomes following initial hepatectomy for hepatocellular carcinoma: A retrospective cohort study

AIM

The clinical impact of abdominal aortic calcification (AAC) in patients who undergo hepatectomy for hepatocellular carcinoma (HCC) is unknown.

METHODS

To evaluate the impact of AAC on clinical outcomes, we analyzed 203 patients who underwent hepatectomy for HCC between 2010 and 2013.

RESULTS

Kaplan-Meier survival curve analysis showed significantly worse overall survival (OS) in the high AAC group than in the low AAC group. The recurrence-free survival (RFS) was also significantly worse in the high AAC group. In the multivariate analysis, high AAC (hazard ratio [HR], 2.51; 95% confidence interval [CI], 1.24-5.09; P = .01) was an independent risk factor for poor OS after hepatectomy for HCC. High AAC was also an independent risk factor for poor RFS (HR, 1.69; 95% CI, 1.04-2.76; P = .04).

CONCLUSIONS

Abdominal aortic calcification had a strong relationship with poor OS and RFS after hepatectomy for HCC. We suggest that AAC had a relationship with smoking and diabetes; therefore, AAC could reflect a surrogate for older age, worse health status, and inflammatory score.

Impact of Postoperative Complications on Long-Term Survival After Resection of Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

BACKGROUND

Controversy exists over the relationship between postoperative complications (POCs) and long-term survival for hepatocellular carcinoma (HCC) after hepatectomy. This study aimed to evaluate the impact of POCs on overall survival (OS) and disease-free survival (DFS) for HCC after liver resection.

PATIENTS AND METHODS

The PubMed, EMBASE, and Cochrane Library databases were used to search for eligible studies published through 18 April 2020, and studies comparing the long-term outcomes between HCC patients with and without POCs after hepatectomy were included. A random-effects model was used to calculate the pooled hazard ratio (HR) with a 95% confidence interval (CI). Subgroup analysis and meta-regression were performed to assess the potential influence of study-, patient-, and tumor-related factors on the relationship between POCs and oncologic outcomes and to adjust their effect. This study was registered at the International Prospective Register of Systematic Reviews (CRD42019136109).

RESULTS

Thirty-seven studies, including 14,096 patients, were deemed eligible and included in this study. Compared with those without POCs, patients who developed POCs had a significant reduction in OS (HR 1.39, 95% CI 1.28-1.50, P < 0.001; prediction interval 1.04-1.85) and tended to have worse DFS (HR 1.25, 95% CI 1.16-1.35, P < 0.001; prediction interval 0.98-1.60). Contour-enhanced funnel plots suggested a risk of publication bias. Subgroup analysis and meta-regression showed that POCs remained a threat to OS and DFS regardless of the influence of clinicopathological factors.

CONCLUSION

This study demonstrated that POCs had an adverse impact on OS and DFS in HCC patients after liver resection.

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.

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.

Development and Validation of a Clinicopathological-Based Nomogram to Predict the Survival Outcome of Patients with Recurrent Hepatocellular Carcinoma After Hepatectomy Who Underwent Microwave Ablation

Aim

To develop and validate a nomogram for predicting the overall survival (OS) in patients with recurrent hepatocellular carcinoma (HCC) after hepatectomy who underwent microwave ablation (MWA).

Methods

The training cohort included 299 patients with recurrent HCCs after hepatectomy who met the Milan criteria and received MWA from April 2007 to December 2017. Baseline characteristics were collected to identify risk factors for the determination of death after MWA. A multivariate Cox proportional hazards model based on significant risk factors was used to develop the nomogram, which was then assessed for its predictive accuracy using Harrell’s C-index and the area under the curve (AUC). The nomogram was validated by internal (n = 240) and external cohorts (n = 205) from another hospital.

Results

After a median follow-up of 32.3 months, 38.8% (116/299) of patients had died. Multivariate Cox proportional hazards analyses showed that comorbid disease, early recurrence, and albumin-bilirubin (ALBI) grades 2–3 were independent prognostic factors for poor OS. This nomogram accurately stratified patients into subgroups with low or high risk. The 1-, 3- and 5-year OS rates in the low-risk subgroup were 99.4%, 97.2%, and 86.1%, respectively, and they were 92.8%, 70.3%, and 45.8% in the high-risk subgroup (P < 0.001). The nomogram predicted OS in the training cohort with a C-index score of 0.801 (95% CI 0.761–0.841). The nomogram was validated by internal and external cohorts, with C-index scores of 0.792 (95% CI 0.738–0.846) and 0.744 (95% CI 0.703–0.785), respectively.

Conclusion

The nomogram provides individualized risk estimates for long-term OS for patients with recurrent HCC after hepatectomy who underwent MWA.

Hepatocellular carcinoma in old age: are there any benefits of liver resection in old age?

Purpose

Elderly individuals have comorbidities that can adversely affect surgical outcomes. Some studies reported that elderly patients with hepatocellular carcinoma (HCC) have higher liver- and non-liver-related deaths. Therefore, palliative treatments are preferred in these patients. We compared surgical treatment outcomes between young and old age groups.

Methods

In total, 233 liver resections were performed in patients with HCC from March 2012 to December 2018. We retrospectively reviewed medical records. The old age group was defined as patients aged more than 70 years. We compared perioperative characteristics and surgical outcomes and analyzed the prognostic factors for disease-free survival (DFS) and overall survival (OS) rates.

Results

The young and old age group included 184 and 49 patients, respectively. Preoperative characteristics were similar. Major liver resection rate was similar (young age group, 26.1% vs. old age group, 20.4%), but the operation time was a little bit shorter in old age group. Major postoperative complications were 23 (12.5%) and 9 (18.4%) in the young and old age group (P = 0.351). Median non-liver-related overall survival were 80 and 76 months (P = 0.889) and liver-related OS were 76 and 76 months (P = 0.514) in the young and old age groups, respectively. Age was not an independent risk factor for DFS and OS.

Conclusion

Elderly patients showed similar non-liver- and liver-related OS rates as young patients after liver resection. Postoperative complications were also similar. If elderly patients are well selected, they can receive curative treatment and show good surgical outcomes.

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.

Prognoses, outcomes, and clinicopathological characteristics of very elderly patients with hepatocellular carcinoma who underwent hepatectomy

Objectives

The aim was to evaluate the prognostic factors, clinicopathological characteristics, and surgical outcomes after hepatectomy in very elderly patients with hepatocellular carcinoma (HCC).

Methods

We analyzed 796 patients with HCC from 2000 to 2017. Patients aged 80 years or older were classified into the very elderly group (group VE; n = 49); patients younger than 80 years old and aged 65 years or older were classified into the elderly group (group E; n = 363), and patients younger than 65 years old were classified into the young group (group Y; n = 384). We investigated the prognoses, clinicopathological characteristics, and surgical outcomes after hepatectomy.

Results

The number of surgical procedures and outcomes, including morbidities, was not significantly different. Groups VE, E, and Y showed similar prognoses in terms of both survival and recurrence. In group VE, prothrombin activity (PA) < 80% and PIVKA-II ≥ 400 mAU/ml were unfavorable factors for survival, and PIVKA-II ≥ 400 mAU/ml and the presence of portal venous invasion (PVI), hepatic venous invasion, and fibrosis were unfavorable factors for recurrence. In group E, ChE < 180 IU/l, AFP ≥ 20 ng/ml, tumor size ≥ 10 cm, and the presence of multiple tumors, PVI, and hepatic venous invasion (HVI) were unfavorable factors for survival, and ChE < 180 IU/l, tumor size ≥ 10 cm, and the presence of multiple tumors, PVI, and HVI were unfavorable factors for recurrence. In group Y, AFP ≥ 20 ng/ml, the presence of multiple tumors, poor differentiation, PVI, HVI, and blood loss ≥ 400 ml were unfavorable factors for survival, and PA < 80%, albumin < 3.5 g/dl, AFP ≥ 20 ng/ml, tumor size ≥ 10 cm, and the presence of multiple tumors, poor differentiation, and PVI were unfavorable factors for recurrence.

Conclusions

Tumor factors might have limited influence on the prognosis of very elderly patients, and liver function reserve might be important for the long-term survival of very elderly patients. Hepatectomy can be performed safely, even in very elderly patients. Hepatectomy should not be avoided in very elderly patients with HCC if patients have a good general status because these patients have the same prognoses as nonelderly individuals.

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.

Polymorphisms in TRAIL predict long-term survival and extrahepatic recurrence following initial hepatectomy for hepatocellular carcinoma

BACKGROUND

Liver natural killer (NK) cells are the first cells to respond to infections and malignancies, such as intraoperative tumor spill. Liver NK cells express tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), a marker for hepatocellular carcinoma (HCC). However, the influence of TRAIL single-nucleotide polymorphisms (SNPs) on hepatectomy patients with HCC remains unclear.

METHODS

Here, we investigated TRAIL SNPs (rs1131568, rs1131579, and rs1131580) located at positions 1525, 1588, and 1595 of exon 5 of the TNFSF10 gene. A total of 104 HCC patients who underwent initial hepatectomy were analyzed. Kaplan-Meier survival analysis and Cox proportional hazard regression were conducted to evaluate the associations between TRAIL genotypes and clinical HCC outcomes.

RESULTS

Patients harboring the homozygous AA genotype of TRAIL SNPs rs1131568 and rs1131579 and the TT genotype of the TRAIL SNP rs1131580 had lower overall survival and higher rates of extrahepatic recurrence (EHR) than patients harboring the wild type or heterozygous genotypes. Moreover, univariate and multivariate Cox regression analysis revealed that the homozygous genotypes of the target TRAIL SNPs were independent predictive factors for EHR after initial hepatectomy for HCC.

CONCLUSION

Our findings revealed that the homozygous genotypes of TRAIL SNPs are independent predictors of EHR in initial hepatectomy patients with HCC.

Independent risk factors that predict bile leakage after hepatectomy for hepatocellular carcinoma: Cohort study

BACKGROUND

Bile leakage is a major cause of morbidity after hepatectomy. This study aimed to identify the predictive factors for bile leakage after hepatectomy.

MATERIALS AND METHODS

Between January 2011 and December 2016, 556 patients underwent a liver resection for hepatocellular carcinoma with curative intent, and were enrolled to participate in this study. The incidence of postoperative bile leakage (POBL) was determined and the predictive factors for POBL were identified using univariate and multivariate analysis.

RESULTS

POBLs occurred in 28 patients (5.0%). The multivariate analysis identified a history of stereotactic body radiotherapy, a body mass index <20 kg/m², Child-Pugh class B cirrhosis, a central hepatectomy, and an operation time ≥375 min as risk factors that were associated with POBL. When the study cohort was grouped according to the number of the predictive factors present, the incidence of POBL increased as the number of the extant independent predictive factors increased. The POBL rate was 45.0% in patients with ≥3 predictive factors.

CONCLUSION

We determined that POBL was associated with operative mortality and identified five independent predictive factors associated with POBL. Risk stratification using these predictive factors may be useful for identifying patients at a high risk of POBL.

Long-term outcomes in elderly patients with resectable large hepatocellular carcinoma undergoing hepatectomy

BACKGROUND

In contrast to the feasibility of hepatectomy for resectable large hepatocellular carcinoma (HCC, >5 cm) in the younger patients, the concerns of benefits for the elderly patients remain in practice. This study aimed to evaluate the long-term outcomes and safety after hepatectomy in elderly patients with resectable large HCC compared with younger patients.

METHODS

Between 2003 and 2014, a total of 2211 HCC patients were reviewed using a prospective database and 257 patients with resectable large HCC undergoing hepatectomy were included: 79 elderly patients with age ≥70 years and 178 younger patients with age <70 years. The last follow-up was assessed in December 2017. The complications, long-term outcomes and risk factors of disease-free and overall survival were analysed.

RESULTS

The 1-, 3-, 5- and 7-year overall survival rates in the elderly and younger groups were 76%, 55%, 48%, and 42% and 79%, 57%, 51%, and 49%, respectively (P = 0.319). The 1-, 3-, 5-, and 7-year disease-free survival rates in the elderly and younger groups were 60%, 40%, 38%, and 27% and 54%, 36%, 32%, and 32%, respectively (P = 0.633). The analysis of post-operative outcomes of interest, including hospital stay and hospital death and hepatectomy-related complications in both groups revealed no significant difference. Serum albumin and AJCC TNM stage were independent risk factors for survival. Serum alpha-fetoprotein, tumour number and AJCC TNM stage predicted HCC recurrence.

CONCLUSIONS

Our results suggested that hepatectomy can achieve comparable long-term outcomes in the selected younger and elderly patients with resectable large 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.

Hepatectomy versus stereotactic body radiotherapy for primary early hepatocellular carcinoma: A propensity-matched analysis in a single institution

OBJECTIVE

To evaluate the efficacy of both surgical resection and stereotactic body radiotherapy for small hepatocellular carcinoma.

BACKGROUND

Although the number of stereotactic body radiotherapies being performed for hepatocellular carcinoma has gradually increased, data comparing surgical resection and stereotactic body radiotherapy are limited.

METHODS

Between 2008 and 2015, a total of 281 patients with 1 to 3 small hepatocellular carcinoma tumors (≤3 cm in diameter), treated initially with curative intent (surgical resection, 254; stereotactic body radiotherapy, 27), were retrospectively analyzed. Overall survival and disease-free survival were compared in a propensity score matching analysis.

RESULTS

Patients in the surgical resection group tended to be younger, had more tumors, and had better hepatic function than those in the stereotactic body radiotherapy group (P < .05). The percent recurrence of the same sub-segment in the stereotactic body radiotherapy group was significantly higher than that in the surgical resection group (P = .0034). Propensity score analysis revealed that 54 patients with surgical resection and 27 with stereotactic body radiotherapy had the same baseline characteristics. The 5-year overall survival and disease-free survival rates for the surgical resection and stereotactic body radiotherapy groups were 75.2% vs 47.8% (P = .0149) and 33.8% vs 16.4% (P = .0512), respectively. Multivariate analysis showed that surgical resection was a significant favorable factor for overall survival and disease-free survival of patients with one to three small hepatocellular carcinomas.

CONCLUSION

Surgical resection provided better long-term overall survival and disease-free survival in patients with small hepatocellular carcinoma tumors. However, stereotactic body radiotherapy may be an effective alternative treatment for inoperable patients with early hepatocellular carcinoma.