Epidemiology of HPB malignancy in the elderly

British Society of Gastroenterology guidelines for the diagnosis and management of cholangiocarcinoma

These guidelines for the diagnosis and management of cholangiocarcinoma (CCA) were commissioned by the British Society of Gastroenterology liver section. The guideline writing committee included a multidisciplinary team of experts from various specialties involved in the management of CCA, as well as patient/public representatives from AMMF (the Cholangiocarcinoma Charity) and PSC Support. Quality of evidence is presented using the Appraisal of Guidelines for Research and Evaluation (AGREE II) format. The recommendations arising are to be used as guidance rather than as a strict protocol-based reference, as the management of patients with CCA is often complex and always requires individual patient-centred considerations.

The prognostic nutritional index and tumor pathological characteristics predict the prognosis of elderly patients with early-stage hepatocellular carcinoma after surgery

The elderly comprises over one-third of hepatocellular carcinoma (HCC) patients, however, they are not adequately represented in prognostic studies. The study aims to determine the prognostic significance of the preoperative prognostic nutritional index (PNI) and develop nomograms for predicting their recurrence-free and overall survival (RFS and OS). The study consisted of 282 elderly patients (aged ≥ 65 years) with early-stage HCC (China Liver Cancer Staging System: I-IIA) after curative resection (R0). They were randomly divided into a training (n = 197) and a test cohort (n = 85). The patients were stratified into two groups: PNI-low (PNI ≤ 49.05) and PNI-high (PNI > 49.05) based on a cut-off value. Most patients' demographics and perioperative outcomes were comparable, while patients in the PNI-high group were younger (P = 0.002), heavier (P < 0.001), and had lower comorbidity rates (P = 0.003). Although the tumor stages were earlier in the PNI-low group (P < 0.001), patients' OS (5-year OS: 48.9% vs. 93.1%) and RFS (5-year RFS: 27.3% vs. 75.7%) were significantly worse compared to the PNI-high group (both P < 0.0001). Patients' OS and RFS nomograms were developed by incorporating independent survival predictors including chronic obstructive pulmonary disease (COPD), age ≥ 75 years, PNI-low, tumor presence of satellite nodules, capsule, and microvascular invasion. The nomograms showed good calibration and discrimination, with all C-indexes ≥ 0.75 and calibration plots essentially coinciding with the diagonal. In conclusion, for elderly HCC patients, COPD, age ≥ 75 years, PNI-low, and tumor presence of satellite nodules, capsule, and microvascular invasion were independent prognostic factors. The nomogram could accurately predict the prognosis of these patients.

Persistent poverty impacts access to minimally invasive surgery among patients with hepatopancreatobiliary cancer

BACKGROUND AND OBJECTIVES

Minimally invasive surgery (MIS) has been successfully adopted in hepatopancreatobiliary (HPB) cancer, and has been associated with improved perioperative and comparable oncological outcomes. We sought to define the impact of county-level duration of poverty on access to MIS and clinical outcomes among patients with HPB cancer undergoing surgical treatment.

MATERIALS AND METHODS

Data on patients diagnosed with HPB cancer were obtained from the Surveillance, Epidemiology, and End Results (SEER)-Medicare data (2010-2016). County-level poverty data were obtained from the American Community Survey and the U.S. Department of Agriculture, and categorized into three groups: never high poverty (NHP), intermittent high poverty (IHP), and persistent poverty (PP). Multivariable regression was used to assess the relationship between PP and MIS.

RESULTS

Among 8098 patients, 82% (n = 664) resided in regions with NHP, 13.6% (n = 1104) resided in regions with IHP, and 4.4% (n = 350) resided in regions with PP. Median age at the diagnosis was 71 years (interquartile range [IQR]: 67-77). Patients from IHP and PP counties had lower odds of undergoing MIS (IHP/PP vs. NHP, odds ratio [OR]: 0.59, 95% confidence interval [CI]: 0.36-0.96, p = 0.034) and being discharged home (IHP/PP vs. NHP, OR: 0.64, 95% CI: 0.43-0.99, p = 0.043), as well as a higher risk of 1-year mortality (IHP/PP vs. NHP, HR: 1.51, 95% CI: 1.036-2.209, p = 0.032) compared with patients residing in NHP counties.

CONCLUSIONS

Duration of county-level poverty was associated with lower receipt of MIS and unfavorable clinical and survival outcomes among patients with HPB cancer. There is a need to improve access to modern surgical treatment options among vulnerable, PP populations.

Impact of Food Insecurity on Outcomes Following Resection of Hepatopancreaticobiliary Cancer

INTRODUCTION

Food insecurity (FI) may predispose individuals to suboptimal nutrition, leading to chronic disease and poor health outcomes. We sought to assess the impact of county-level FI on postoperative outcomes among patients undergoing resection of hepatopancreaticobiliary (HPB) cancer.

METHODS

Patients who were diagnosed with HPB cancer between 2010 and 2015 were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Data on annual county-level FI were obtained from the Feeding America: Mapping the Meal Gap report and were categorized into tertiles. Textbook outcome was defined as no extended length of stay, perioperative complications, 90-day readmission, and 90-day mortality. Multiple logistic regression and Cox regression models were used to assess outcomes and survival relative to FI.

RESULTS

Among 49,882 patients (hepatocellular: n = 11,937, 23.9%; intrahepatic cholangiocarcinoma: n = 2111, 4.2%; extrahepatic cholangiocarcinoma: n = 4047, 8.1%; gallbladder: n = 2853, 5.7%; pancreatic: n = 28,934, 58.0%), 6702 (13.4%) patients underwent a surgical resection. Median age was 75 years (interquartile range 69-82), and most patients were male (n = 25,767, 51.7%) and self-identified as White (n = 36,381, 72.9%). Overall, 5291 (10.6%) and 39,664 (79.5%) individuals resided in low or moderate FI counties, respectively, while 4927 (9.8%) patients resided in high FI counties. Achievement of textbook outcome (TO) was 56.3% (n = 6702). After adjusting for competing risk factors, patients residing in high FI counties had lower odds to achieve a TO versus individuals living in low FI counties (odds ratio 0.69, 95% confidence interval [CI] 0.54-0.88, p = 0.003). In addition, patients residing in moderate and high FI counties had a greater risk of mortality at 1- (referent, low, moderate: hazard ratio [HR] 1.09, 95% CI 1.05-1.14; high: HR 1.14, 95% CI 1.08-1.21), 3- (referent, low, moderate: HR 1.09, 95% CI 1.05-1.14; high: HR 1.14, 95% CI 1.08-1.21), and 5- (referent, low, moderate: HR 1.05, 95% CI 1.01-1.09; high: HR 1.07, 95% CI 1.02-1.13) years versus individuals from low FI counties.

CONCLUSIONS

FI was associated with adverse perioperative outcomes and long-term survival following resection of an HPB malignancy. Interventions directed towards mitigating nutritional inequities are needed to improve outcomes among vulnerable HPB populations.

Disparities in Socioeconomic Factors Mediate the Impact of Racial Segregation Among Patients With Hepatopancreaticobiliary Cancer

BACKGROUND

Structural racism within the U.S. health care system contributes to disparities in oncologic care. This study sought to examine the socioeconomic factors that underlie the impact of racial segregation on hepatopancreaticobiliary (HPB) cancer inequities.

METHODS

Both Black and White patients who presented with HPB cancer were identified from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2005-2015) and 2010 Census data. The Index of Dissimilarity (IoD), a validated measure of segregation, was examined relative to cancer stage at diagnosis, surgical resection, and overall mortality. Principal component analysis and structural equation modeling were used to determine the mediating effect of socioeconomic factors.

RESULTS

Among 39,063 patients, 86.4 % (n = 33,749) were White and 13.6 % (n = 5314) were Black. Black patients were more likely to reside in segregated areas than White patients (IoD, 0.62 vs. 0.52; p < 0.05). Black patients in highly segregated areas were less likely to present with early-stage disease (relative risk [RR], 0.89; 95 % confidence interval [CI] 0.82-0.95) or undergo surgery for localized disease (RR, 0.81; 95% CI 0.70-0.91), and had greater mortality hazards (hazard ratio 1.12, 95% CI 1.06-1.17) than White patients in low segregation areas (all p < 0.05). Mediation analysis identified poverty, lack of insurance, education level, crowded living conditions, commute time, and supportive income as contributing to 25 % of the disparities in early-stage presentation. Average income, house price, and income mobility explained 17 % of the disparities in surgical resection. Notably, average income, house price, and income mobility mediated 59 % of the effect that racial segregation had on long-term survival.

CONCLUSION

Racial segregation, mediated through underlying socioeconomic factors, accounted for marked disparities in access to surgical care and outcomes for patients with HPB cancer.

Safety and Effectiveness of Chemotherapy in Elderly Biliary Tract Cancer Patients

The safety and effectiveness of chemotherapy in elderly patients with biliary tract cancer (BTC) remain unclear. Therefore, we retrospectively reviewed patients who underwent chemotherapy for locally advanced, metastatic, or recurrent BTC at our institution from January 2016 to December 2021. Of the 283 included patients, 91 (32.5%) were aged 75 years or older when initiating chemotherapy. Elderly patients were more likely than non-elderly patients to receive monotherapy with gemcitabine or S-1 (58.7% vs. 9.4%, p < 0.001) and were less likely to experience grade 3-4 toxicities (55.4% vs. 70.2%, p = 0.015). The rates of termination due to intolerance (6.5% vs. 5.8%, p = 0.800) and transition to second-line chemotherapy (39.1% vs. 40.3%, p = 0.849) were similar between groups. In the overall cohort, age was not an independent predictor of overall survival (OS). Within the elderly cohort, there were no differences in severe adverse events between patients receiving monotherapy and combination therapy (50.0% vs. 63.2%, p = 0.211). Median OS was longer in the combination therapy group (10.4 vs. 14.1 months; p = 0.010); however, choice of monotherapy was not an independent predictor of overall survival. Monotherapy appears to be a viable alternative in selected elderly BTC patients.

Oncological liver resection in elderly - A retrospective comparative study

BACKGROUND

Due to demographic changes and higher life expectancy especially in industrial nations, the number of liver resections in patients ≥70 years is rising. It is known that older age is associated with higher postoperative morbidity and mortality after surgery under general anesthesia. The aim of this analysis is to compare the postoperative outcome after liver resections for malignancies in patients aged below and above 70 years.

MATERIALS AND METHODS

A prospectively collected electronic database of 1034 liver resections between 01/2013 and 12/2019 was retrospectively analyzed. Comparative analysis of patients <70 and ≥ 70 years receiving liver resections for malignancies included 889 operations in 703 patients. Analysis of postoperative outcome and uni- and multivariate analyses of associated risk factors were performed.

RESULTS

Median age of the whole cohort was 65 years (range 18-87 years). N = 582 liver resections (65.7%) were performed in patients <70 years with 42.8% major hepatectomies and n = 307 (34.3%) liver resections in patients ≥70 years with 50.5% major hepatectomies (p = 0.034). Relevant postoperative morbidity of the whole cohort was 27.9%. The 30-day mortality was 3.9% and re-operation rate 14.8%. Patients ≥70 years had significantly higher postoperative morbidity and mortality rates than patients <70 years. Major resections, longer operating time, need of intraoperative transfusions of blood products as well as biliodigestive anastomosis (BDA) and inferior vena cava (IVC) resection were independent risk factors for worse postoperative outcome.

CONCLUSION

Liver resections in patients ≥70 years are associated with a worse postoperative course after. Parenchyma sparing resections should be preferred in those patients.

The Prevalence and the Impact of Frailty in Hepato-Biliary Pancreatic Cancers: A Systematic Review and Meta-Analysis

Background: Frailty has been associated with increased mortality among hepatobiliary pancreatic (HBP) cancer patients. Nevertheless, estimates of frailty prevalence in HBP cancers and the precise average effect regarding mortality remains uncertain. The present systematic review and meta-analysis aimed to quantify: (1) the prevalence of frailty in patients with liver and pancreatic cancers and (2) the impact of frailty on mortality in patients affected by liver and pancreatic cancers. Methods: MEDLINE/PubMed database search was conducted from inception until 1 November 2021, the pooled prevalence and relative risk (RR) estimate were calculated. Results: A total of 34,276 patients were identified and the weighted prevalence of frailty was 39%; (95% [C.I.] 23–56; I2 = 99.9%, p < 0.0001). Frailty was significantly associated with increased mortality RR 1.98 (95% [C.I.] 1.49–2.63; I2 = 75.9%, p = 0.006). Conclusions: Frailty prevalence is common among HBP cancer patients and exerts a significant negative impact on survival. These findings are characterized by significant heterogeneity and caution is warranted on their interpretation. However, stratification of patients with HBP cancer by frailty status may provide prognostic information and may inform priorities for decision-making strategy.

Robotic-assisted pancreatic surgery in the elderly patient: experiences from a high-volume centre

BACKGROUND

Robotic-assisted pancreatic surgery (RPS) has fundamentally developed over the past few years. For subgroups, e.g. elderly patients, applicability and safety of RPS still needs to be defined. Given prognosticated demographic developments, we aim to assess the role of RPS based on preoperative, operative and postoperative parameters.

METHODS

We included 129 patients undergoing RPS at our institution between 2017 and 2020. Eleven patients required conversion to open surgery and were excluded from further analysis. We divided patients into two groups; ≥ 70 years old (Group 1; n = 32) and < 70 years old (Group 2; n = 86) at time of resection.

RESULTS

Most preoperative characteristics were similar in both groups. However, number of patients with previous abdominal surgery was significantly higher in patients ≥ 70 years old (78% vs 37%, p < 0.0001). Operative characteristics did not significantly differ between both groups. Although patients ≥ 70 years old stayed significantly longer at ICU (1.8 vs 0.9 days; p = 0.037), length of hospital stay and postoperative morbidity were equivalent between the groups.

CONCLUSION

RPS is safe and feasible in elderly patients and shows non-inferiority when compared with younger patients. However, prospectively collected data is needed to define the role of RPS in elderly patients accurately. Trial registration Clinical Trial Register: Deutschen Register Klinischer Studien (DRKS; German Clinical Trials Register). Clinical Registration Number: DRKS00017229 (retrospectively registered, Date of Registration: 2019/07/19, Date of First Enrollment: 2017/10/18).

Short-term postoperative outcomes after liver resection in the elderly patient: a nationwide population-based study

BACKGROUND

Liver resection is high-risk surgery in particular in elderly patients. The aim of this study was to explore postoperative outcomes after liver resection in elderly patients.

METHODS

In this nationwide study, all patients who underwent liver resection for primary and secondary liver tumours in the Netherlands between 2014 and 2019 were included. Age groups were composed as younger than 70 (70-), between 70 and 80 (septuagenarians), and 80 years or older (octogenarians). Proportion of liver resections per age group and 30-day major morbidity and 30-day mortality were assessed.

RESULTS

In total, 6587 patients were included of whom 4023 (58.9%) were younger than 70, 2135 (32.4%) were septuagenarians and 429 (6.5%) were octogenarians. The proportion of septuagenarians increased during the study period (aOR:1.06, CI:1.02-1.09, p < 0.001). Thirty-day major morbidity was higher in septuagenarians (11%) and octogenarians (12%) compared to younger patients (9%, p = 0.049). Thirty-day mortality was higher in septuagenarians (4%) and octogenarians (4%) compared to younger patients (2%, p < 0.001). Cardiopulmonary complications occurred more frequently with higher age, liver-specific complications did not. Higher age was associated with higher 30-day morbidity and 30-day mortality in multivariable logistic regression.

CONCLUSION

Thirty-day major morbidity and 30-day mortality are higher after liver resection in elderly patients, attributed mainly to non-surgical cardiopulmonary complications.

Outcome of neoadjuvant treatment for pancreatic cancer in elderly patients: comparative, observational cohort study

BACKGROUND

Use of neoadjuvant therapy for elderly patients with pancreatic cancer has been debatable. With FOLFIRINOX (folinic acid, 5-fluorouracil, irinotecan, oxaliplatin) or gemcitabine plus nab-paclitaxel (GnP) showing tremendous effects in improving the overall survival of patients with borderline resectable and locally advanced pancreatic cancer, there is no definitive consensus regarding the use of this regimen in the elderly.

METHODS

This study evaluated the eligibility of elderly patients with borderline resectable or locally advanced pancreatic cancer for neoadjuvant therapy. Patients registered in the database of pancreatic cancer at the University of Colorado Cancer Center, who underwent neoadjuvant treatment between January 2011 and March 2019, were separated into three age groups (less than 70, 70-74, 75 or more years) and respective treatment outcomes were compared.

RESULTS

The study included 246 patients with pancreatic cancer who underwent neoadjuvant treatment, of whom 154 and 71 received chemotherapy with FOLFIRINOX and GnP respectively. Among these 225 patients, 155 were younger than 70 years, 36 were aged 70-74 years, and 34 were aged 75 years or older. Patients under 70 years old received FOLFIRINOX most frequently (124 of 155 versus 18 of 36 aged 70-74 years, and 12 of 34 aged 75 years or more; P < 0.001). Resectability was similar among the three groups (60.0, 58.3, and 55.9 per cent respectively; P = 0.919). Trends towards shorter survival were observed in the elderly (median overall survival time 23.6, 18.0, and 17.6 months for patients aged less than 70, 70-74, and 75 or more years respectively; P = 0.090). After adjusting for co-variables, age was not a significant predictive factor.

CONCLUSION

The safety and efficacy of multiagent chemotherapy in patients aged 75 years or over were similar to those in younger patients. Modern multiagent regimens could be a safe and viable treatment option for clinically fit patients aged at least 75 years.

Synergistic Impact of Alpha-Fetoprotein and Tumor Burden on Long-Term Outcomes Following Curative-Intent Resection of Hepatocellular Carcinoma

INTRODUCTION

The prognostic role of tumor burden score (TBS) relative to pre-operative α -fetoprotein (AFP) levels among patients undergoing curative-intent resection of HCC has not been examined.

METHODS

Patients who underwent curative-intent resection of HCC between 2000 and 2017 were identified from a multi-institutional database. The impact of TBS on overall survival (OS) and cumulative recurrence relative to serum AFP levels was assessed.

RESULTS

Among 898 patients, 233 (25.9%) patients had low TBS, 572 (63.7%) had medium TBS and 93 (10.4%) had high TBS. Both TBS (5-year OS; low TBS: 76.9%, medium TBS: 60.9%, high TBS: 39.1%) and AFP (>400 ng/mL vs. <400 ng/mL: 48.5% vs. 66.1%) were strong predictors of outcomes (both p < 0.001). Lower TBS was associated with better OS among patients with both low (5-year OS, low-medium TBS: 68.0% vs. high TBS: 47.7%, p < 0.001) and high AFP levels (5-year OS, low-medium TBS: 53.7% vs. high TBS: not reached, p < 0.001). Patients with low-medium TBS/high AFP had worse OS compared with individuals with low-medium TBS/low AFP (5-year OS, 53.7% vs. 68.0%, p = 0.003). Similarly, patients with high TBS/high AFP had worse outcomes compared with patients with high TBS/low AFP (5-year OS, not reached vs. 47.7%, p = 0.015). Patients with high TBS/low AFP and low TBS/high AFP had comparable outcomes (5-year OS, 47.7% vs. 53.7%, p = 0.24). The positive predictive value of certain TBS groups relative to the risk of early recurrence and 5-year mortality after HCC resection increased with higher AFP levels.

CONCLUSION

Both TBS and serum AFP were important predictors of prognosis among patients with resectable HCC. Serum AFP and TBS had a synergistic impact on prognosis following HCC resection with higher serum AFP predicting worse outcomes among patients with HCC of a certain TBS class.

Development and Validation of Nomograms for Predicting Cancer-Specific Survival in Elderly Patients with Intrahepatic Cholangiocarcinoma After Liver Resection: A Competing Risk Analysis

Background

There are few studies on the prognosis of elderly intrahepatic cholangiocarcinoma (iCCA) patients after liver resection. The aims of this study were to assess the cumulative incidences of cancer-specific mortality in elderly iCCA patients and to construct a corresponding competing risk nomogram for elderly iCCA patients.

Methods

We performed a retrospective analysis of elderly patients with iCCA who underwent liver resection between January 2006 and December 2019. Eligible elderly iCCA patients were randomly divided into training and validation sets at a ratio of 7:3. Based on the results of multivariate analysis using the Fine-Gray competing risk model, we developed a competing risk nomogram using data from the training set to predict the cumulative probabilities of iCCA-specific mortality. The performance of the nomogram was measured by the concordance index (C-index) and calibration curves. To evaluate the clinical usefulness of the nomogram, the clinical benefit was measured by using decision curve analysis (DCA). Furthermore, the patients were categorized into two groups according to the dichotomy values of the nomogram-based scores, and their survival differences were assessed using Kaplan–Meier and cumulative incidence function (CIF) curves.

Results

The 1-year, 3-year and 5-year cumulative iCCA-specific mortalities were 19.7%, 48.3% and 56.1%, respectively, for elderly iCCA patients. The multivariate Fine-Gray analysis indicated that microvascular invasion, macroscopic vascular invasion and lymph node metastasis were related to a significantly higher likelihood of iCCA specific mortality. The established nomogram was well calibrated and had a good discriminative ability, with a concordance index (C-index) of 0.742 (95% CI, 0.708–0.748). Furthermore, the DCA indicated that the nomogram had positive net benefits compared with the conventional staging systems. In the training set and validation sets, the high-risk group had the higher probabilities of iCCA cancer-specific mortality than the low-risk group; meanwhile, the patients in the high-risk the group had significantly poorer overall survival (OS) than those in the low-risk group.

Conclusion

Elderly iCCA patients had comparable long-term outcomes with non-elderly iCCA patients. In addition, we constructed a prognostic nomogram for predicting survival in elderly iCCA patients based on the competing risk analysis. The competing risk nomogram displayed excellent discrimination and calibration.