Surgical treatment of liver metastases from colorectal cancer in elderly patients

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.

Safety of anastomoses in colorectal cancer surgery in octogenarians: a prospective cohort study with propensity score matching

Background

Up to 20 per cent of all operations for patients with colorectal cancer (CRC) are performed in octogenarians. Anastomotic leakage is a leading cause of morbidity and death after resection for CRC. The aim of this study was to assess the rate of anastomosis creation, the risk of anastomotic leakage and death in surgery for left-sided CRC in elderly patients.

Methods

This prospective cohort study compared patients less than 80 and 80 or more years with left-sided CRC resection performed between 2013 and 2019. Data were provided from a risk-adjusted surgical quality-assessment system with 219 participating centres in Germany. Outcome measures were the rate of anastomoses, anastomotic leakages, death at 30 days and 2-year overall survival (OS). Propensity score matching was used to control for selection bias and compare subgroups of patients of less than 80 and 80 or more years.

Results

Out of 18 959 patients, some 3169 (16.7 per cent) were octogenarians. Octogenarians were less likely to receive anastomoses (82.0 versus 92.9 per cent, P < 0.001; odds ratio 0.50 (95 per cent c.i. 0.44 to 0.58), P < 0.001). The rate of anastomotic leakages did not differ between age groups (8.6 versus 9.7 per cent, P = 0.084), but 30-day mortality rate after leakage was significantly higher in octogenarians (15.8 versus 3.5 per cent, P < 0.001). Overall, anastomotic leakage was the strongest predictor for death (odds ratio 4.95 (95 per cent c.i. 3.66 to 6.66), P < 0.001). In the subgroup with no leakage, octogenarians had a lower 2-year OS rate than younger patients (71 versus 87 per cent, P < 0.001), and in the population with anastomotic leakage, the 2-year OS was 80 per cent in younger and 43 per cent in elderly patients (P < 0.001). After propensity score matching, older age remained predictive for not receiving an anastomosis (odds ratio 0.54 (95 per cent c.i. 0.46 to 0.63), P < 0.001) and for death (odds ratio 2.60 (95 per cent c.i. 1.78 to 3.84), P < 0.001), but not for the occurrence of leakages (odds ratio 0.94 (95 per cent c.i. 0.76 to 1.15), P = 0.524).

Conclusion

Anastomotic leakage is not more common in octogenarians, but an age of 80 years or older is an independent factor for not receiving an anastomosis in surgery for left-sided CRC. The mortality rate in the case of leakage in octogenarians was reported to exceed 15 per cent.

The survival benefit of surgery for perihilar cholangiocarcinoma in octogenarians: Shinshu University experience

BACKGROUND AND OBJECTIVES

In today's aging society, surgery is increasingly performed for older patients with perihilar cholangiocarcinoma (PHCC). This study aimed to examine survival and oncological outcomes in octogenarians with PHCC who underwent surgery.

METHODS

We retrospectively examined 480 consecutive PHCC patients treated for PHCC between 1991 and 2020. Two hundred forty-seven underwent resection. Patient and clinical characteristics, including postoperative complications, overall survival (OS), and disease-free survival (DFS) were analyzed.

RESULTS

The proportion of octogenarians with PHCC undergoing surgery increased from 5.2% in 1991-2000 to 13.4% in 2016-2020. R0 resection and postoperative complication rates were comparable between octogenarians and younger patients. Five-year OS (30.0% vs. 31.7%) and DFS (20.0% vs. 29.5%) did not significantly differ. One-year OS was significantly better in octogenarians who underwent resection than those who did not (95.0% vs. 17.6%; p < .001). Two octogenarians who developed Clavien-Dindo grade III complications had undergone right hemihepatectomy (RH). Posthepatectomy liver failure and biliary leakage (Grade B) were also observed in octogenarians who underwent RH.

CONCLUSION

In well-selected octogenarians with PHCC, surgery offers short- and long-term outcomes comparable with those of their younger counterparts. RH may be considered in octogenarians on an individual basis.

Surgical and oncologic outcomes following repeat hepatic resection of colorectal liver metastasis: Who benefits?

BACKGROUND

Resected colorectal liver metastases (CRLM) frequently recur intrahepatically. Selection criteria for repeat hepatectomy of recurrent CRLM are ill-defined.

METHODS

We performed an institutional review of patients with recurrent CRLM undergoing repeat hepatectomy from 2003 to 19. Post-recurrence overall (rOS) and recurrence-free survival (RFS) were analyzed with Cox proportional hazards modeling.

RESULTS

n = 147 experienced recurrent CRLM; 11% (n = 38) received repeat hepatectomy of which there was one Clavien-Dindo IIIa complication. Median rOS was 41 months; median RFS was 9 months. Improved rOS and RFS were independently associated with additional post-operative chemotherapy after repeat hepatectomy (HR 0.35 and 0.34, respectively); poor rOS with recurrent CRLM >3 cm (HR 4.4) and <12 months from first hepatectomy to recurrence (HR 4.8); poor RFS with ≥3 recurrence liver metastases (HR 2.8) (All P < 0.05).

DISCUSSION

Repeat hepatectomy for recurrent CRLM can be performed safely. Worse survival following repeat hepatectomy is independently associated with >3 cm and ≥3 liver lesions at recurrence, and <12 months to recurrence. Additional post-operative chemotherapy after repeat hepatectomy is associated with improved outcomes.

Surgical and regional treatments for colorectal cancer metastases in older patients: A systematic review and meta-analysis

Objective

The present study explored the existing literature to describe the outcomes of surgical and regional treatments for colorectal cancer metastases (mCRC) in older patients.

Methods

A literature search was conducted in PubMed, EMBASE, Cochrane and ClinicalTrials.gov for studies published since 2000 that investigated the short- and long-term outcomes of regional treatments (surgical or non-surgical) for mCRC in patients aged ≥65 years. Pooled data analyses were conducted by calculating the risk ratio (RR), mean differences (MD) and hazard ratio (HR) between older and younger patients or between two different approaches in older patients.

Results

After screening 266 articles, 29 were included in this review. These studies reported the outcomes of surgery (n = 19) and non-surgical local ablation treatments (n = 3) for CRC metastases in older vs. younger patients or compared the outcomes of different interventions in older patients (n = 7). When comparing older vs. younger patients undergoing liver surgery for mCRC, pooled data analysis showed higher postoperative mortality [RR = 2.53 (95%CI: 2.00–3.21)] and shorter overall survival [HR = 1.17 (95%CI: 1.07–1.18)] in older patients, whereas no differences in operative outcomes, postoperative complications and disease-free survival were found. When comparing laparoscopy vs. open surgery for liver resection in older mCRC patients, laparoscopy was associated with fewer postoperative complications [RR = 0.27 (95%CI: 0.10–0.73)].

Conclusion

Liver resection for mCRC should not be disregarded a priori in older patients, who show similar operative and postoperative outcomes as younger patients. However, clinicians should consider that they are at increased risk of postoperative mortality and have a worse overall survival, which may reflect comorbidities and frailty.

Is the treatment outcome of hepatocellular carcinoma inferior in elderly patients?

In view of the increasing life expectancy in different parts of the world, a larger proportion of elderly patients with hepatocellular carcinoma (HCC) requiring oncological treatment is expected. The clinicopathological characteristics of HCC in elderly patients and in younger patients are different. Elderly patients, in general, also have more comorbidities. Evaluation of the efficacy of different HCC treatment options in elderly patients is necessary to optimize treatment outcomes for them. Treatment modalities for HCC include hepatectomy, liver transplantation, radiofrequency ablation, transarterial chemoembolization, and molecular-targeted therapy with sorafenib. In this review, current evidence on the risks and outcomes of the different HCC treatments for elderly patients are discussed. According to data in the literature, elderly patients and younger patients benefited similarly from HCC treatments. More clinical data are needed for the determination of selecting criteria on elderly HCC patients to maximize their chance of getting the most appropriate and effective treatments. As such, further studies evaluating the outcomes of different HCC treatment modalities in elderly patients are warranted.

Surgery for perihilar cholangiocarcinoma from a viewpoint of age: Is it beneficial to octogenarians in an aging society?

BACKGROUND

Whether operative treatment provides benefits for elderly patients with perihilar cholangiocarcinoma is unknown. The aim of this study was to review resection of perihilar cholangiocarcinoma according to age and to clarify its value for octogenarians.

METHODS

Between April 1977 and December 2015, we reviewed consecutive patients who underwent resection for perihilar cholangiocarcinoma with a special focus on patient age.

RESULTS

During the study interval, 831 patients underwent resection for perihilar cholangiocarcinoma. The median age of the resected patients increased by 11 years over approximately 40 years. Before 2001, no octogenarians underwent operative intervention; however, the proportion of operations for octogenarians increased to 9% after 2010. Further analyses were performed on 643 resected patients between 2001 and 2015. The resectability rate was not different between the octogenarians and the other age groups (71% vs 72.4%). The Charlson Comorbidity Index and preoperative laboratory data were similar between the 2 groups. A less advanced tumor was a predominant feature in the octogenarians compared to the other age groups. Consequently, the procedure used in the octogenarians were less extensive, but the proportion of R₀ resection was greater in the octogenarians than in the other age groups (95.% vs 78.3%, P = .008). The ratio of patients who died of other diseases was also greater among octogenarians (29% vs 6.0%, P < .001). Overall survival was similar between the 2 groups (41% vs 38.9% at 5 years).

CONCLUSION

Resection of perihilar cholangiocarcinoma can be performed with low mortality irrespective of age with careful patient selection and offers long-term survival even in octogenarians.

Systematic Review and Meta-Analysis of Liver Resection for Colorectal Metastases in Elderly Patients

BACKGROUND

This systematic review and meta-analysis evaluated the short- and long-term outcomes of liver resection for colorectal liver metastases (CRLM) in elderly patients.

METHODS

A PubMed, EMBASE, and Cochrane Library search was performed from January 1995 to April 2017, for studies comparing both short- and long-term outcomes in younger and elderly patients undergoing liver resection for CRLM.

RESULTS

Eleven studies comparing patients aged <70 years with patients aged >70 years and 4 studies comparing patients aged <75 years with patients aged >75 years were included. Postoperative morbidity was similar in patients aged >70 years (27 vs. 30%; p = 0.35) but higher in patients aged >75 years (21 vs. 32%; p = 0.001). Postoperative mortality was higher in both patients aged >70 years (2 vs. 4%; p = 0.01) and in patients aged >75 years (1 vs. 6%; p = 0.02). Mean 5-year overall survival was lower in patients aged >70 years (40 vs. 32%; p < 0.001) but equal in patients aged >75 years (42 vs. 32%; p = 0.06).

CONCLUSION

Although postoperative morbidity and mortality were increased with higher age, liver resection for CRLM seems justified in selected elderly patients.

Minimally invasive liver resection for primary and metastatic liver tumors: influence of age on perioperative complications and mortality

BACKGROUND

As minimally invasive technique becomes more popular, an increasing number of elderly patients were considered for minimally invasive liver resection (MILR). Limited physiologic reserve remains a major concern, which frequently leads surgeons to recommend nonresectional alternatives. We sought to evaluate complications and outcomes of elderly patients undergoing MILR.

METHODS

Eight hundred and thirty-one patients who underwent MILR were classified into groups A, B, and C based on age [(< 70, n = 629), (70-79, n = 148), (≥ 80, n = 54) years old, respectively].

RESULTS

Gender distribution, BMI, and cirrhotic status were comparable among all groups. Groups B and C had higher MELD (p = 0.047) and ASA (p = 0.001) scores. Operative time (170, 157, 152 min; p = 0.64) and estimated blood loss (145, 130, 145 ml; p = 0.95) were statistically equal. Overall postoperative complications were greater in groups B and C (12.9 and 9.3 vs. 6.5%, respectively). Complications in group C were all minor. Clavien-Dindo grade III-IV complications were higher in group B when compared to group A (6.8 vs. 2.7%, p = 0.43). There was no significant difference in cardiopulmonary complications, thromboembolic events, ICU admissions, and transfusion rates seen in groups B and C when compared to group A. Duration of hospital stay was statistically longer in groups B and C (3.6, 3.5 vs. 2.5 days, p = 0.0012). 30- and 90-day mortality rates were comparable among the groups, irrespective of age.

CONCLUSIONS

In spite of greater preoperative comorbidities and ASA score, there was no significant increase in postoperative morbidity after minimally invasive liver resection in patients ≥ 70 years of age.

Colorectal cancer care in elderly patients: Unsolved issues

Colorectal cancers are common in elderly patients. However, cancer screening is poorly used after 75. Elderly patients form a heterogeneous population with specific characteristics. Standards of care cannot therefore be transposed from young to elderly patients. Tumour resection is frequently performed but adjuvant chemotherapy is rarely prescribed as there are no clearly established standards of care. In a metastatic setting, recent phase III studies have demonstrated that doublet front-line chemotherapy provided no survival benefit. Moreover, several studies have established the benefit of bevacizumab in association with chemotherapy. There is a lack of evidence for the efficacy of anti-epidermal growth factor antibodies in elderly patients. Geriatric assessments could help to select the adequate treatment strategy for individual patients. Geriatric oncology is now the challenge we have to face, and more specific trials are needed.

Liver Metastasis from Colorectal Cancer in the Elderly: Is Surgery Justified?

BACKGROUND

The elderly population with liver metastasis from colorectal cancer has been increasing. As the potentially curative treatment, the role of liver resection in the elderly remains undetermined.

AIMS

This study provides a meta-analysis on the outcome of liver resection of colorectal liver metastasis in patients aged over 70.

METHODS

PubMed, Embase, Ovid, Web of Science, and Cochrane databases from the years 2000 to 2015 were searched for eligible studies. Data on perioperative mortality, postoperative complications, and survival were collected.

RESULTS

Twelve retrospective studies with a total of 11,285 patients (2498 elderly patients and 8787 younger patients) were identified. The elderly (>70 years old) were associated with a similar overall complication rate (30.5 vs. 28.0%; OR 1.08; 95% CI 0.91-1.28; p = 0.39) and a higher 30-day mortality (OR 1.92; 95% CI 1.12-3.31; p = 0.02) after liver resection of colorectal liver metastasis (CRLM). The overall survival showed a significant difference in favor of the younger patients (HR 0.76; 95% CI 0.65-0.89; p = 0.0007). However, with regard to disease-free survival, there was no significant difference between elderly and younger patients (HR 0.93; 95% CI 0.82-1.06; p = 0.30).

CONCLUSION

Liver resection of CRLM is relatively safe in carefully selected elderly patients. Liver resection should be offered to selected elderly patients with CRLM.

Hepatectomy in elderly patients: does age matter?

BACKGROUND

With the increase in average life expectancy in recent decades, the proportion of elderly patients requiring liver surgery is rising. The aim of the meta-analysis reported here was to evaluate the safety and efficacy of hepatectomy in elderly patients.

METHODS

An extensive electronic search was performed for relevant articles that compare the outcomes of hepatectomy in patients ≥70 years of age with those in younger patients prior to October 2012. Analysis of pooled data was performed with RevMan 5.0.

RESULTS

Twenty-eight observational studies involving 15,480 patients were included in the analysis. Compared with the younger patients, elderly patients experienced more complications (31.8 vs 28.7 %; P = 0.002), mainly as a result of increased cardiac complications (7.5 vs 1.9 %; P < 0.001) and delirium (11.7 vs 4.5 %; P < 0.001). Postoperative major surgical complications (12.6 vs 11.3 %; P = 0.55) and mortality (3.6 vs 3.3 %; P = 0.68) were comparable between elderly and younger patients. For patients with malignancies, both the 5-year disease-free survival (26.5 vs 26.3 %; P = 0.60) and overall survival (39.5 vs 40.7 %; P = 0.29) did not differ significantly between the two groups.

CONCLUSIONS

Postoperative major surgical complications, mortality, and long-term results in elderly patients seem to be comparable with those in younger patients, suggesting that age alone should not be considered a contraindication for hepatectomy.

Functional hepatocellular regeneration in elderly patients undergoing hepatectomy

BACKGROUND & AIMS

More than 50% of liver tumours occur in patients aged 65 years or more. Assessment of functional liver regeneration capacity is crucial to minimize postoperative liver failure. We aimed to study functional hepatocellular regeneration, through scintigraphic quantification of Mebrofenin hepatic extraction fraction (HEF), after partial hepatectomy, comparing elderly patients with younger ones.

METHODS

One hundred and two patients undergoing partial hepatectomy for primary or secondary hepatic lesions were prospectively included and divided in two groups: Group A - 58 patients aged <65 years (33 men, 53.9 ± 8.7 years), Group B - 44 patients aged ≥65 years (32 men, 71 ± 5 years). Groups were comparable in several aspects except for the presence of cirrhosis (more common in Group B, all patients Child-Pugh score A) and the initial diagnosis (Group B - primary lesions, Group A - metastases). The scintigraphic evaluation of Mebrofenin-HEF was performed before surgery, on the 5th and 30th day post-hepatectomy.

RESULTS

Mortality and morbidity were 3.4 and 12.1%, respectively, in Group A and 2.3 and 11.4% in Group B (n.s.). HEF values (%), T1/2 (min) and Tmax (min) showed no significant differences between the two groups: Group A (preoperative: HEF = 99.2 ± 1.5%, T1/2 = 36.7 ± 21.3, Tmax = 15 ± 6. Day 5: HEF = 96.3 ± 10.8%, T1/2 = 76.4 ± 75.9; Tmax = 13.3 ± 4.9. Day 30: HEF = 98.4 ± 5.5%, T1/2 = 38.6 ± 7.7, Tmax = 12.8 ± 3.6) and Group B (preoperative: HEF = 95.3 ± 13%, T1/2 = 38.1 ± 24.1; Tmax = 15.9 ± 9.4. Day 5: HEF = 98.4 ± 2.6%, T1/2 = 106.6 ± 131.7; Tmax = 15.1 ± 6.2. Day 30: HEF = 99 ± 2.1%, T1/2 = 40.5 ± 27; Tmax = 15.5 ± 6.7).

CONCLUSION

Our results suggest that functional hepatocellular regeneration is early, fast and similar between elderly and younger patients. Thus, age alone, does not appear to represent an absolute contraindication to hepatectomy.

Optimal management of colorectal liver metastases in older patients: a decision analysis

BACKGROUND

Comparative trials evaluating management strategies for colorectal cancer liver metastases (CLM) are lacking, especially for older patients. This study developed a decision-analytic model to quantify outcomes associated with treatment strategies for CLM in older patients.

METHODS

A Markov-decision model was built to examine the effect on life expectancy (LE) and quality-adjusted life expectancy (QALE) for best supportive care (BSC), systemic chemotherapy (SC), radiofrequency ablation (RFA) and hepatic resection (HR). The baseline patient cohort assumptions included healthy 70-year-old CLM patients after a primary cancer resection. Event and transition probabilities and utilities were derived from a literature review. Deterministic and probabilistic sensitivity analyses were performed on all study parameters.

RESULTS

In base case analysis, BSC, SC, RFA and HR yielded LEs of 11.9, 23.1, 34.8 and 37.0 months, and QALEs of 7.8, 13.2, 22.0 and 25.0 months, respectively. Model results were sensitive to age, comorbidity, length of model simulation and utility after HR. Probabilistic sensitivity analysis showed increasing preference for RFA over HR with increasing patient age.

CONCLUSIONS

HR may be optimal for healthy 70-year-old patients with CLM. In older patients with comorbidities, RFA may provide better LE and QALE. Treatment decisions in older cancer patients should account for patient age, comorbidities, local expertise and individual values.

Impact of liver-directed therapy in colorectal cancer liver metastases

BACKGROUND

There is a paucity of data on the current management and outcomes of liver-directed therapy (LDT) in older patients presenting with stage IV colorectal cancer (CRC). The aim of the study was to evaluate treatment patterns and outcomes in use of LDT in the setting of improved chemotherapy.

METHODS

We used Cancer Registry and linked Medicare claims to identify patients aged ≥66 y undergoing surgical resection of the primary tumor and chemotherapy after presenting with stage IV CRC (2001-2007). LDT was defined as liver resection and/or ablation-embolization.

RESULTS

We identified 5500 patients. LDT was used in 34.9% of patients; liver resection was performed in 1686 patients (30.7%), and ablation-embolization in 554 patients (10.1%), with 322 patients having both resection and ablation-embolization. Use of LDT was negatively associated with increasing year of diagnosis (odds ratio [OR] = 0.96, 95% confidence interval [CI] 0.93-0.99), age >85 y (OR = 0.61, 95% CI 0.45-0.82), and poor tumor differentiation (OR = 0.73, 95% CI 0.64-0.83). LDT was associated with improved survival (median 28.4 versus 21.1 mo, P < 0.0001); however, survival improved for all patients over time. We found a significant interaction between LDT and period of diagnosis and noted a greater survival improvement with LDT for those diagnosed in the late (2005-2007) period.

CONCLUSIONS

Older patients with stage IV CRC are experiencing improved survival over time, independent of age, comorbidity, and use of LDT. However, many older patients deemed to be appropriate candidates for resection of the primary tumor and receipt of systemic chemotherapy did not receive LDT. Our data suggest that improved patient selection may be positively impacting outcomes. Early referral and optimal selection of patients for LDT has the potential to further improve survival in older patients presenting with advanced colorectal cancer.

Laparoscopic major hepatectomy for colorectal liver metastases in elderly patients: a single-center, case-matched study

BACKGROUND

The incidence of colorectal cancer liver metastases (CRLM) among elderly patients has increased; therefore, older patients are increasingly being considered for hepatic resection. However, data regarding the outcome of laparoscopic major hepatectomy (LMH) in elderly patients are limited. The aim of this study was to evaluate the safety and feasibility of LMH in elderly patients with CRLM.

METHODS

From January 1998 to September 2013, a total of 31 patients aged ≥ 70 years (elderly group) were matched with 62 patients < 70 years (young group) by demographics, tumor characteristics, and details of surgical procedures.

RESULTS

The elderly group was characterized by a higher incidence of hypertension (41.9 vs. 17.7 %, P = 0.022), ≥ 2 comorbidities (32.3 vs. 11.3 %, P = 0.021), and lower prevalence of metastatic rectal cancer (12.9 vs. 38.7 %, P = 0.015). Intraoperative variables, such as surgical duration (300 vs. 240 min, P = 0.920), blood loss (400 vs. 300 mL, P = 0.361), and transfusion rate (9.7 vs. 12.9 %, P = 0.726), were not notably different between the groups. Postoperative mortality (0 vs. 0 %), complications (54.8 vs. 41.9 %, P = 0.276), and major complications (27.4 vs. 16.1 %, P = 0.303, respectively) were comparable between the groups. The 3-year overall survival rates were 61.7 % in the young group (median 40 months) and 57.9 % in the elderly group (median 39 months), respectively (P = 0.842).

CONCLUSIONS

Our results clearly demonstrated that LMH for CRLM could be safely performed in elderly patients; thus, advanced age itself should not be regarded as a contraindication for LMH.

Impact of aging on morbidity and mortality after liver resection: a systematic review and meta-analysis

Surgery involving elderly patients is becoming increasingly common due to the rapid aging of societies all over the world. The objective of this study was to elucidate the prognostic differences between elderly and young patients who undergo liver resection. A systematic review based on the PRISMA flow diagram was conducted. Ovid Medline and PubMed were used to search for relevant literature published between January 2000 and March 2013, and the modified MINORS score was used to assess the methodological quality. In cases of hepatocellular carcinoma and miscellaneous liver tumors, the morbidity and mortality rate did not differ significantly between the elderly and young patients. For patients with colorectal metastatic liver cancer, the mortality of the young patients was 2.7 times lower than that of elderly patients. Our review of high-quality retrospective studies was able to elucidate the clinical risks of age on the outcomes after liver surgery in specific patient populations.

Postoperative mortality and need for transitional care following liver resection for metastatic disease in elderly patients: a population-level analysis of 4026 patients

OBJECTIVES

The goal of this study was to characterize the association of age with postoperative mortality and need for transitional care following hepatectomy for liver metastases.

METHODS

A retrospective cohort study using the Nationwide Inpatient Sample (2005-2008) was performed. Patients undergoing hepatectomy for liver metastases were categorized by age as: Young (aged <65 years); Old (aged 65-74 years), and Oldest (aged ≥75 years). Multivariate logistic regression analyses were performed to identify predictors of in-hospital mortality and need for transitional care (non-home discharge).

RESULTS

A total of 4026 patients were identified; 36.6% (n = 1475) were elderly (aged ≥65 years). Rates of in-hospital mortality and non-home discharge increased with advancing age group [1.3% vs. 2.2% vs. 3.3% (P = 0.005) and 2.1% vs. 6.1% vs. 18.3% (P < 0.001), respectively]. Independent predictors of in-hospital mortality were age within the Oldest category [odds ratio (OR) 2.21, 95% confidence interval (CI) 1.19-4.12] and a Deyo Comorbidity Index score of ≥3 (OR 6.95, 95% CI 3.55-13.60). Independent predictors for need for transitional care were age within the Old group (OR 2.44, 95% CI 1.66-3.58), age within the Oldest group (OR 8.48, 95% CI 5.87-12.24), a Deyo score of 1 (OR 2.00, 95% CI 1.40-2.85), a Deyo score of 2 (OR 4.70, 95% CI 2.93-7.56), a Deyo score of ≥3 (OR 6.41, 95% CI 3.67-11.20), and female gender (OR 1.56, 95% CI 1.15-2.11).

CONCLUSIONS

Although increasing age was associated with higher risk for in-hospital mortality, the absolute risk was low and within accepted ranges, and comorbidity was the primary driver of mortality. Conversely, need for transitional care was significantly more common in elderly patients. Therefore, liver resection for metastases is safe in well-selected elderly patients, although consideration should be made for potential transitional care needs.

Resection of colorectal liver metastases in the elderly: does age matter?

AIM

Despite the incidence of colorectal cancer increasing with age the proportion of patients undergoing surgery for colorectal liver metastases decreases dramatically in the elderly. Is this referral or selection bias justified?

METHOD

A prospective database of resection for colorectal liver metastases at a single centre was retrospectively analysed to compare the outcome in patients aged ≥75 years (group E) with those aged <75 years (group Y). Data were analysed using the Kaplan-Meier method with Cox regression modelling.

RESULTS

Of 1443 resections, 151 (10.5%) in group E were compared with 1292 (89.5%) in group Y. The two groups were matched apart from higher American Society of Anesthesiology scores (P=0.001) and less use of chemotherapy (P=0.01) in the elderly. Perioperative morbidity and 90-day mortality were higher in the elderly compared with the younger group (32.5%vs 21.2%, P=0.02, and 7.3%vs 1.3%, P=0.001). In the last 5 years, mortality in the elderly improved and was no longer significantly different from that of the younger patients [n=2/76 (2.6%) vs n=9/559 (1.6%); P=0.063]. The 5-year survival was similar in groups E and Y for cancer-specific (41.4%vs 41.6%, P=0.917), overall (37.0%vs 38.2%) and median (44.1 months vs 43.6 months, P=0.697) survival respectively.

CONCLUSION

In the elderly liver resection for metastatic disease can be performed with acceptable mortality and morbidity with as good a prospect of survival as for younger patients.

Liver resection of colorectal liver metastases in elderly patients

BACKGROUND

The percentage of elderly patients with colorectal liver metastases (CLM) has increased. Liver resection remains the only curative therapy; data evaluating the outcome in this age group is limited. Aim of the present study was to determine if postoperative morbidity, mortality, and other independent predictors influence survival in patients ≥ 70 years undergoing liver resection for CLM.

METHODS

Clinical data on primary tumor and metastases of 939 patients after liver resection for CLM between 1994 and 2008 were retrospectively collected and subdivided in three age-groups (≥ 70, 40-69, <40). Independent predictors of survival were evaluated with overall and age-specific univariate and multivariate Cox regression models.

RESULTS

A total of 939 patients underwent liver resection for CLM, 20.3% aged ≥ 70 years. Overall postoperative mortality and morbidity were 1.08 and 14.82%, revealing no age-related differences. With 5-year survival of 31.8% in the elderly and 37.5% in the mid-age population, age ≥ 70 years was linked with decreased survival (Hazard Ratio [HR] = 1.305; P = 0.0186). Multivariate overall analyses showed size of CLM > 50 mm (HR = 1.376; P = 0.0060), a high amount of transfusion during surgery (HR = 1.676; P = 0.0110), duration of surgery >210 min (HR = 1.241; P = 0.0322), primary UICC (International Union Against Cancer) stage IV (HR = 2.297; P < 0.0001), and performance of repeat resections (HR = 0.652; P = 0.0107) as independent predictors of survival. In the elderly group, effects of UICC IV (HR = 3.260; P = 0.0148) and high numbers of transfusions (HR = 3.647; P = 0.0129) were confirmed; the others did not show statistical significance.

CONCLUSIONS

Resection of CLM at older age is feasible with morbidity and mortality rates similar to those in younger patients. Although age ≥ 70 was shown to be associated with poorer overall outcome, reasonable 5-year survival was observed.

Safety and efficacy of hepatectomy for colorectal metastases in the elderly

BACKGROUND AND OBJECTIVES

The aim of this study was to determine the safety and efficacy of hepatic metastasectomy in elderly patients with colorectal liver metastases (CLM).

METHODS

A retrospective review of a hepatobiliary database was performed on consecutive patients treated with metastasectomy for CLM. Patients were stratified by age (<70 years old vs. ≥70). Patient and tumor characteristics as well as operative factors were compared, as were morbidity, mortality, and length of stay. Logistic regression and Cox proportional hazards were used to evaluate the association of age and postoperative outcomes.

RESULTS

There were 59 elderly (median age 75) and 220 non-elderly (median age 58) patients analyzed over a 13 year period. The Charlson comorbidity index was higher in the elderly group (mean 4.7 vs. 4.4 P = 0.005). Postoperative morbidity and mortality were 52.5 and 0% vs. 48.2 and 4.1% in the elderly and non-elderly groups, respectively (P = 0.56 and P = 0.21). There were no differences in median DFS (21.8 months vs. 28.9 months; P = 0.157) or OS (36 months vs. 47.7 months; P = 0.070) between the elderly and non-elderly groups, respectively.

CONCLUSIONS

Age itself does not appear to be a significant contraindication to liver resection, including major hepatectomy, when patients are appropriately selected.

Safety of liver resection in the elderly: how important is age?

BACKGROUND

With the aging population, more elderly patients are being considered for hepatic resection. We investigated whether advanced age was associated with higher rate and severity of postoperative complications.

METHODS

A total of 75 patients aged ≥70 years (group E) were matched with 75 patients aged <70 years (group Y) by the extent of liver resection and by operative indications. Primary outcome measures were rates and severity of complications. Secondary outcome measures were length of hospital stay and discharge destination. Univariate analysis was also performed to identify variables associated with higher surgical risk.

RESULTS

Male-to-female ratio was 43:32 in both groups. Overall complication rates were 44 and 33.3% in group E and Y, respectively (P = 0.241; odds ratio = 1.57; 95% confidence interval [95% CI], 0.81-3.05). There was no mortality in both groups. The only postoperative age-related morbidity was confusion in the elderly. There was no difference in the rates of severe complications (grade ≥3) between group E and group Y (16 vs. 14.7%; P = 0.744; odds ratio = 1.11; 95% CI, 0.46-2.70). Median length of hospital stay were 7 and 6 days, respectively (P = 0.01). Nineteen percent and 1% of patients in group E and group Y were discharge to rehabilitation facilities, respectively (P = 0.001). Univariate analysis showed that preoperative systemic chemotherapy and longer operative time were associated with higher morbidity in the elderly.

CONCLUSIONS

Liver resection can be performed in patients aged ≥70 years as safely as in younger patients. Duration and timing of systemic chemotherapy before liver resection should be optimized to minimize postoperative morbidity.

EORTC Elderly Task Force experts' opinion for the treatment of colon cancer in older patients

As a result of an increasing life expectancy, the incidence of colon cancer in the older population is rising. As a consequence oncologists and their older patients commonly face the dilemma of whether or not to give/receive treatment for colon cancer. However, the paucity of large, well conducted prospective trials makes it difficult to provide evidence-based clinical recommendations for these patients. The current evidence supports the safety and efficacy of treatment for colon cancer in fit older patients and demonstrates that treatment outcome can be similar to that of their younger counterparts. However, it should be noted that these data are derived from retrospective studies which are likely to suffer from selection bias. Despite a growing body of data, further work is still needed to establish optimal strategies to care for this special population and prospective specific trials for older colon cancer patients are clearly needed.

Disparities in the treatment of colon cancer in octogenarians

BACKGROUND

Disparities in healthcare for the elderly are understudied, despite the increasing proportion of patients over 80 years of age. Advanced age is a principal risk factor for colorectal adenocarcinoma, but there are few data to guide treatment in the elderly patient population.

METHODS

We performed a retrospective review of prospectively gathered data on 10,433 patients diagnosed with primary colon tumors between 1998 and 2004. We compared demographics, stage at diagnosis, and initial treatment between patients younger than 80 years and those age 80 years or older.

RESULTS

Patients who were >or=80 years old made up 30% of the database. Older patients were less likely to have colectomy for advanced or metastatic disease than younger patients. Patients who were >or=80 years of age had fewer lymph nodes removed than younger patients (11 vs 10, P <.01). Older patients were significantly less likely to receive chemotherapy for every stage of colon cancer than younger patients. When older patients did get chemotherapy, it was more likely to be with a single agent. Multivariate analysis revealed that predictors of receiving chemotherapy for patients >or=80 years of age include living in an urban county, younger age, and worse stage at diagnosis.

CONCLUSIONS

Older patients make up a large portion of the patients treated for colon cancer and are treated less aggressively. While some of the treatment difference may be explained by medical factors, demographic factors affect treatment decisions as well.

Colorectal cancer treatment in elderly patients: an update on recent clinical studies

Colorectal cancer (CRC) is one of the most common cancers in the Western world, with > 500,000 new cases diagnosed each year. One of the strongest risk factors for colon cancer is age. Physicians and their older patients commonly face the dilemma of whether to give/receive systemic chemotherapy for CRC. Evidence supports similar survival benefits with adjuvant and palliative chemotherapy in elderly patients compared with younger age groups. Data on treatment- related side effects did not reveal a different toxicity profile for elderly patients. The safety and efficacy of systemic chemotherapy in fit older patients were proven, and this group of patients could be enrolled in clinical trials. Conversely, frail older patients are more likely to suffer adverse outcomes when faced with stressors and might not benefit from chemotherapy. Despite a growing body of data, a great deal of work is still needed to establish optimal strategies to care for patients diagnosed with cancer later in life. There is a paucity of reports published in the literature because of the difficulty in routinely collecting such data. We report an overview of recent studies (clinical trials, pooled analysis, and population studies) to provide more information and to identify new and better treatment options.

Colon cancer and the elderly: from screening to treatment in management of GI disease in the elderly

Colorectal cancer is one of the commonest tumours in the Westernized world affecting mainly the elderly. This neoplasm in older individuals occurs more often in the right colon and grows more rapidly than in the young, often shows a mucinous histology and mismatch repair gene changes. Effective screening permits discovery of colorectal cancer at an early highly treatable stage and allows for detection and removal of premalignant colorectal adenomas. Screening methods that focus on cancer detection use fecal assays for the presence of blood or altered DNA, those for detection of adenomas (and early cancer) use endoscopic or computerised radiologic techniques. Broad use of screening methods has lowered colorectal cancer development by about 50%. In addition, prevention of the earliest stage of colon carcinogenesis has been shown to be effective in small prospective studies and epidemiologic surveys but have not been employed in the general population. Since 1996 the chemotherapeutic armamentarium for metastatic colorectal cancer has grown beyond 5-fluorouracil to include an oral 5-fluorouracil prodrug, capecitabine as well as irinotecan and oxaliplatin. Three targeted monoclonal antibodies (Moabs), bevacizumab (an anti-vascular endothelial growth factor Moab) and cetuximab/panitumumab, both anti-epidermal growth factor receptor inhibitors, have also earned regulatory approval. Most stage IV patients are treated with all of these drugs over 2 or 3 sequential lines of palliative chemotherapy and attain median survivals approaching 24 months. Lastly, adjuvant oxaliplatin plus 5-fluorouracil for high risk resected stage II and stage III colon cancer patient has led to substantial improvement in cure rates. With appropriate care of age associated comorbidities these treatment modalities are feasible and effective in the geriatric population.

The survival paradox of elderly patients after major liver resections

OBJECTIVE

The objective of this study is to assess the outcome of liver resections in the elderly in a matched control analysis.

PATIENTS AND METHODS

From a prospective single center database of 628 patients, 132 patients were aged 60 years or over and underwent a primary major liver resection. Of these patients, 93 could be matched one-to-one with a control patient, aged less than 60 years, with the same diagnosis and the same type of liver resection. The mean age difference was 16.7 years.

RESULTS

Patients over 60 years of age had a significantly higher American Society of Anaesthesiologists (ASA) grade. All other demographics and operative characteristics were not different. In-hospital mortality and morbidity were higher in the patients over 60 years of age (11% versus 2%, p = 0.017 and 47% versus 31%, p = 0.024). One-, 3-, and 5-year survival rates in the patients over 60 years of age were 81%, 58%, and 42%, respectively, compared to 90%, 59%, and 42% in the control patients (p = 0.558). Unified model Cox regression analysis showed that resection margin status (hazard ratio 2.51) and ASA grade (hazard ratio 2.26), and not age, were determining factors for survival.

CONCLUSION

This finding underlines the important fact that in patient selection for major liver resections, ASA grade is more important than patient age.

Treatment of the elderly colorectal cancer patient: SIOG expert recommendations

Colorectal cancer (CRC) is one of the commonest malignancies of Western countries, with approximately half the incidence occurring in patients >70 years of age. Elderly CRC patients, however, are understaged, undertreated and underrepresented in clinical trials. The International Society of Geriatric Oncology created a task force with a view to assessing the potential for developing guidelines for the treatment of elderly (geriatric) CRC patients. A review of the evidence presented by the task force members confirmed the paucity of clinical trial data in elderly people and the lack of evidence-based guidelines. However, recommendations have been proposed on the basis of the available data and on the emerging evidence that treatment outcomes for fit, elderly CRC patients can be similar to those of younger patients. It is hoped that these will pave the way for formal treatment guidelines based upon solid scientific evidence in the future.

Liver resection for colorectal liver metastases in older patients

INTRODUCTION

Seventy-six percentages of patients with a newly diagnosed colorectal carcinoma are between 65 and 85 years old. A substantial proportion will develop liver metastases, for which resection is the only potential curative treatment. This study was conducted to investigate both the feasibility, and short- and long-term outcomes of liver resection for colorectal liver metastases in elderly patients.

METHODS

Between August 1990 and April 2007 data were prospectively collected on patients over 70 years of age who underwent a liver resection for colorectal liver metastases in a single centre.

RESULTS

One hundred and eighty-one liver resections were performed in 178 consecutive patients (median age 74 years). Thirty-four patients (18.8%) received neoadjuvant chemotherapy (all FOLFOX) prior to liver surgery and the majority (57.5%) of liver resections involved more than two Couinaud's segments. Median hospital stay was 13 days, 70 (38.5%) patients had postoperative complications, and overall in hospital mortality was 4.9% (9 patients). Overall- and disease-free survival rates at 1, 3 and 5 years were 86.1%, 43.2% and 31.5% and 65.8%, 26% and 16%, respectively. In multivariate analysis: T3 primary staging; major liver resections; more than three liver lesions; and the occurrence of postoperative complications were associated with inferior overall survival.

CONCLUSIONS

Liver resection for colorectal liver metastases in elderly patients is safe and may offer long-time survival to a substantial percentage of patients. We strongly recommend considering senior patients for surgical treatment whenever possible.