Outcome of hepatectomy in super-elderly patients with hepatocellular carcinoma

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.

Comparison of Surgical Resection and Radiofrequency Ablation in Elderly Patients with Hepatocellular Carcinoma

BACKGROUND/AIMS

The aim of this study was to examine whether the efficacy of radiofrequency ablation (RFA) and surgical resection (SR) are comparable for hepatocellular carcinoma (HCC) less than 3 cm in elderly individuals aged 65 years or older.

METHODS

We used the National Health Insurance Service claims data in Korea, which was linked with liver cancer stage data from the Central Cancer Registry of the National Cancer Center, as well as death data from the National Statistical Office. Out of the 9213 registrants, we focused on 141 patients who underwent SR and 225 patients who underwent RFA when they were 65 years or older. To ensure comparability, a 1:1 propensity score (PS) matching was conducted.

RESULTS

The SR group had lower performance status and better liver function compared to the RFA group. Tumor diameter was larger in the SR group than in the RFA group (2.1 cm vs. 1.7 cm), and the proportion of stage II cases was higher (62.4% vs. 33.8%). After PS matching, the mortality rate in the RFA group did not significantly differ from the SR group (HR 1.33, 95% CI 0.86-2.06, P = 0.19). Also, liver related mortality was similar between the SR and RFA group after matching (log rank P = 0.13). However, recurrence free survival was significantly longer in the SR group than RFA group before and after matching (log rank P = 0.03).

CONCLUSION

In patients aged 65 years or older with resectable HCC, RFA demonstrates a therapeutic effect comparable to SR.

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.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Safety and benefits of major hepatectomy with extrahepatic bile duct resection in older perihilar cholangiocarcinoma patients

PURPOSE

To evaluate the safety and benefits of major hepatectomy with extrahepatic bile duct resection in older perihilar cholangiocarcinoma patients and to identify possible predictors of surgical mortality.

METHODS

We retrospectively analyzed the data of 102 consecutive patients who underwent major hepatectomy with extrahepatic bile duct resection for perihilar cholangiocarcinoma in our institution between 2004 and 2021. The patients were included and divided into two groups: older patients ≥ 75 years and non-older patients < 75 years. Patient characteristics, preoperative nutritional and operative risk scores, intraoperative details, postoperative outcomes, and long-term prognosis were compared between the groups. Univariate and multivariate analyses were used to identify the predictors of 90-day mortality after major hepatectomy with extrahepatic bile duct resection.

RESULTS

Significant differences were identified for some preoperative surgical risk scores, but not for nutritional scores. Older patients had a higher morbidity rate of respiratory complications (p = 0.016), but there were no significant differences in overall (p = 0.735) or disease-specific survival (p = 0.858). A high Dasari's score was identified as an independent predictive factor of 90-day mortality.

CONCLUSIONS

Major hepatectomy with extrahepatic bile duct resection can be performed for optimally selected older and younger patients with perihilar cholangiocarcinoma, resulting in a good prognosis. However, indications for extended surgery should be recognized. Dasari's preoperative risk score may be a good predictor of 90-day mortality.

Safety and Feasibility of Microwave Ablation for Hepatocellular Carcinomas in the Elderly: A Systematic Review

Background

Microwave ablation (MWA) for hepatocellular carcinomas (HCCs) in the elderly has been the subject of new research in recent years. However, there are currently no strong lines of evidence for the prognosis following MWA treatment for HCC in the elderly. Therefore, we conducted a systematic review to assess the safety and feasibility of MWA for HCC in elderly patients.

Methods

Up until August 15, 2021, a comprehensive literature search was undertaken in PubMed, Scopus, CENTRAL (Cochrane Central Register of Controlled Trials), and Google Scholar databases for all published articles. Observational studies reporting the safety and feasibility of MWA for HCC in elderly patients were included. The Newcastle–Ottawa Scale (NOS) was used to measure the quality assessment.

Results

Our review, composed of 7 observational studies, including a total of 7,683 HCC patients, looked at the safety and feasibility of MWA for HCC in the elderly. Current lines of evidence on the risks and outcomes of MWA of HCC treatments in elderly patients are discussed.

Conclusions

According to our findings, elderly patients, even those with a high comorbidity index, benefited from MWA of HCC similar to younger patients. More clinical data are needed to determine selection criteria for elderly HCC patients to increase the possibility of receiving MWA as a potential lifesaving option. As such, further studies evaluating the outcomes of MWA for HCC treatment modalities in elderly patients are warranted.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42021273091.

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

BACKGROUND

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

METHODOLOGY

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background

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

Methods

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

Results

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

Conclusion

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

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.

Multicenter analysis of long-term oncologic outcomes of hepatectomy for elderly patients with hepatocellular carcinoma

BACKGROUND

Aging of the population and prolonged life expectancy have significantly increased the number of elderly patients undergoing hepatectomy for hepatocellular carcinoma (HCC). However, potential benefits, especially long-term oncologic outcomes of hepatectomy for elderly patients with HCC remain unclear.

METHOD

Patients treated with curative-intent hepatectomy for HCC in 8 Chinese hospitals were enrolled. Patients were divided into the elderly (≥70 years old) and younger (<70 years old) groups. Overall survival (OS), cancer-specific survival (CSS), and time-to-recurrence (TTR) were compared. Risk factors of CSS and TTR were evaluated by univariable and multivariable competing-risk regression analyses.

RESULTS

Of 2134 patients, 259 (12.1%) and 1875 (87.9%) were elderly and younger aged, respectively. Postoperative 30-day and 90-day mortality was comparable among elderly and younger patients. Compared with younger patients, the elderly had a worse 5-year OS (49.4% vs. 55.3%, P = 0.032), yet a better 5-year CCS (74.5% vs. 61.0%, P = 0.005) and a lower 5-year TTR (33.7% vs. 44.9%, P < 0.001), respectively. Multivariable analyses identified that elder age was independently associated with more favorable CSS (HR 0.74, 95%CI 0.58-0.90, P = 0.011) and TTR (0.69, 0.53-0.88, P < 0.001) but was not associated with OS (P = 0.136).

CONCLUSIONS

Age by itself is not a contraindication to surgery, and selected elderly patients with HCC can benefit from hepatectomy. Compared with younger patients, elderly patients have noninferior oncologic outcomes following hepatectomy for HCC.

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.

Significance of Frailty in Prognosis After Hepatectomy for Elderly Patients with Hepatocellular Carcinoma

BACKGROUND

The concept of frailty becomes important for patients who undergo surgery in this recent aging society. The aim of this study is to investigate the frailty as a prognostic factor in elderly patients with hepatocellular carcinoma (HCC) who underwent hepatectomy.

PATIENTS AND METHODS

A total of 92 patients over 75 years old who underwent hepatectomy were enrolled in this study. Frailty was defined as clinical frailty scale (CFS) ≥ 4. Patients were divided into two groups, i.e., frailty group (n = 21) and no-frailty group (n = 71), and clinicopathological features were compared between them.

RESULTS

The frailty group showed significant higher PIVKA-II level and larger tumor diameter (p < 0.05). CRP level and modified Glasgow prognostic score were significantly higher in the frailty group (p < 0.05). The frailty group showed higher rate of postoperative complications of Clavien-Dindo III (p = 0.06) and longer postoperative stay (p = 0.08). Cancer-specific, overall, and disease-free survival rates were significantly worse in the frailty group (p < 0.05). Frailty was detected as an independent prognostic factor on multivariate analysis of cancer-specific survival.

CONCLUSION

Frailty can estimate the prognosis of HCC patients who underwent hepatectomy.

New landscapes and horizons in hepatocellular carcinoma therapy

Hepatocellular carcinoma (HCC), is the sixth most frequent form of cancer and leads to the fourth highest number of deaths each year. HCC results from a combination of environmental factors and aging as there are driver mutations at oncogenes which occur during aging. Most of HCCs are diagnosed at advanced stage preventing curative therapies. Treatment in advanced stage is a challenging and pressing problem, and novel and well-tolerated therapies are urgently needed. We will discuss further advances beyond sorafenib that target additional signaling pathways and immune checkpoint proteins. The scenario of possible systemic therapies for patients with advanced HCC has changed dramatically in recent years. Personalized genomics and various other omics approaches may identify actionable biochemical targets, which are activated in individual patients, which may enhance therapeutic outcomes. Further studies are needed to identify predictive biomarkers and aberrantly activated signaling pathways capable of guiding the clinician in choosing the most appropriate therapy for the individual patient.

A Review of Hepatocellular Carcinoma in Elderly Patients Focused on Management and Outcomes

Recent studies report a significant age-specific increase in hepatocellular carcinoma (HCC) development among persons over 75 years old. Therefore, there is an urgent need to determine the optimal treatment strategy in elderly patients with HCC. This systemic review examines the clinical characteristics, efficacy, and safety of first-line treatment modalities. The literature was searched regarding epidemiology and clinical outcomes in elderly patients (age ≥75 years) undergoing first-line treatment for HCC. Causative or comorbid conditions of HCC in elderly patients differed from those in younger patients. Radiofrequency ablation may be effective and safe in early stages. Surgical resection may also be feasible in the early stages for selected patients. Transarterial chemoembolization may be safe and effective for intermediate HCC, and sorafenib may be feasible in elderly patients with advanced HCC. Prospective randomized trials are needed to establish the treatment strategy for elderly patients with HCC.

Short-term autonomy and survival after hepatectomy in the elderly

AIM

To study morbi-mortality, survival after hepatectomy in elderly patients, and influence on their short-term autonomy.

PATIENTS AND METHODS

This is a retrospective study conducted between 2002 and 2017 comparing patients less than 65 years old (controls) to those more than 65 years old (cases) from a prospective database, with retrospective collection of geriatric data. Cases were divided into three sub-groups (65-70 years, 70-80 years and>80 years).

RESULTS

Four hundred and eighty-two patients were included. There was no age difference in number of major hepatectomies (P=0.5506), length of stay (P=0.3215), mortality at 90 days (P=0.3915), and surgical complications (P=0.1467). There were more Grade 1 Clavien medical complications among the patients aged over 65 years (P=0.1737). There was no difference in overall survival (P=0.460) or disease-free survival (P=0.108) according to age after adjustment for type of disease and hepatectomy. One-third of patients had geriatric complications. The "home discharge" rate decreased significantly with age from 92% to 68% (P=0.0001). Early loss of autonomy after hospitalization increased with age, 16% between 65 and 70 years, 23% between 70 and 80 years and 36% after 80 years (P=0.10). We identified four independent predictors of loss of autonomy: age>70 years, cholangiocarcinoma, length of stay>10 days, and metachronous colorectal cancer.

CONCLUSIONS

Elderly patients had the same management as young patients, with no difference in surgery or survival, but with an increase in early loss of autonomy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Liver resection for hepatocellular carcinoma in oldest old patients

Background

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

Patients and methods

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

Result

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

Conclusion

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

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.

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.

Short-Term Outcomes following Hepatectomy in Elderly Patients with Hepatocellular Carcinoma: An Analysis of 10,805 Septuagenarians and 2,381 Octo- and Nonagenarians in Japan

BACKGROUND

As the population is aging, the indication for hepatocellular carcinoma (HCC) resection in patients aged over 80 years will increase. Japan is facing the most aging society worldwide. We examined the safety of hepatectomy in octogenarians and nonagenarians using large-scale data from the Diagnosis Procedure Combination database, a national administrative database in Japan.

METHOD

We conducted a survey to collect data for all inpatients from 2007 and 2012. We identified 27,094 patients who underwent hepatectomy for HCC. Patients' age was divided into the following five categories: ≤59, 60-69, 70-79, 80-84, and ≥85 years (n = 5,099, 8,809, 10,805, 2,011, and 370, respectively). The primary outcomes of hepatectomy were in-hospital death within 90 days and complications. Logistic regression analyses were performed to analyze the impact of age on the outcomes with the adjustment of other individual-level factors.

RESULTS

The mortality and morbidity rates were 2.6 and 23.4%, respectively. Compared with patients in their 70s, the mortality rate was significantly lower in patients aged ≤59 years (odds ratio [OR], 0.34; 95% confidence interval [CI], 0.26-0.45; p < 0.01) and in those in their 60s (OR, 0.63; 95% CI, 0.53-0.74; p < 0.01). However, no significant difference was observed in patients aged 80-84 years (OR, 1.03; 95% CI, 0.78-1.385; p = 0.844) and those aged ≥85 years (OR, 0.95; 95% CI, 0.50-1.79; p = 0.870). Based on the multivariate logistic regression analysis, age ≥70 years, male gender, low hospital volume, and surgical procedure were identified as independent predictors of mortality.

CONCLUSIONS

The operative risk for hepatectomy gradually increases with age until patients are in their 70s, and it appears to reach a plateau among septuagenarian. Indeed, age over 70 years can also be a risk factor for HCC. By considering the aging risk, surgeons can attain good outcome after hepatectomy even in octo- and nonagenarian patients.

Mechanism of impairment on liver regeneration in elderly patients: Role of hepatic stellate cell function

Japan, along with most other countries in the world, is facing an increasingly aging population with a prolonged life expectancy. Concurrently, the need for medical intervention, including hepatectomy, has also increased for the elderly. Although surgical outcomes for older patients are reported to be comparable with those for younger patients, additional care in the selection of older patients for hepatectomy is considered necessary. Although the effect of aging on human liver regeneration is not fully understood, the regeneration of liver tissue after hepatectomy in elderly patients is shown to be generally worse than in younger patients and, to date, the mechanisms involved in the impairment of liver regeneration have not been fully clarified. Hepatic stellate cells (HSCs) are liver-specific mesenchymal cells that play critical roles in liver physiology and fibrogenesis. Recent studies in liver regeneration have increasingly focused on HSCs rather than on hepatocytes, Kupffer cells, endothelial cells, or infiltrating immune cells and suggest that HSCs might play a critical role in liver regeneration. In this review, we summarize the mechanisms involved in the impairment of liver regeneration in elderly patients, especially focusing on HSCs. We also discuss how HSCs contribute to the impairment of liver regeneration.

Effect of Age on Liver Function in Patients Undergoing Partial Hepatectomy

BACKGROUND

Postresectional liver failure is the most frequent cause of fatal outcome following liver surgery. Diminished preoperative liver function in the elderly might contribute to this. Therefore, the aim of the present study was to evaluate preoperative liver function in patients <60 or >70 years of age scheduled for liver resection.

METHODS

All consecutive patients aged <60 or >70 years who are about to undergo elective liver surgery between 2011 and 2013 and underwent the methacetin breath liver function test (LiMAx) preoperatively were included. Histologic assessment of the resected liver gave insight into background liver disease. Correlation between age and liver function was calculated with Pearson's test.

RESULTS

Fifty-nine patients were included, 31 were aged <60 and 28 were aged >70 years. General patient characteristics and liver function LiMAx values (340 (137-594) vs. 349 (191-530) μg/kg/h, p = 0.699) were not significantly different between patients aged <60 and >70 years. Moreover, no correlation between age and preoperative liver function LiMAx values was found (R = 0.04, p = 0.810).

CONCLUSION

Liver function did not seem to differ between younger and older patients.

Assessing the feasibility of clinicopathological features of hepatic resection for hepatocellular carcinoma in patients over 80 years of age

The aim of the present study was to evaluate the clinicopathological features, benefits and problems associated with hepatic resection of hepatocellular carcinoma in patients aged ≥80 years. Between 2006 and 2013, hepatic resection was performed in 395 hepatocellular carcinoma patients, including 351 patients aged <80 years and 44 patients aged ≥80 years. Clinicopathological examination revealed that the tumor size was significantly larger among patients of ≥80 years of age. However, recurrence-free and cumulative survival rates were similar between the two age groups. The occurrence of post-operative complications was an independent risk factor for survival among patients ≥80 years of age. In addition, the albumin level was identified as a risk factor for post-operative complications. The post-operative transition towards an improvement in the albumin level in the ≥80 years group was significantly lower compared with the <80 years group. It was revealed that hepatic resection was feasible for elderly patients. However, the post-operative improvement in the albumin levels was less marked among patients ≥80 years of age, and lower albumin levels were associated with post-operative complications and prognosis. Therefore, elderly patients undergoing hepatic resection should receive peri-operative management including special nutrition.

Hepatocellular carcinoma in elderly patients: challenges and solutions

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

Clinical characteristics and survival outcomes of super-elderly hepatocellular carcinoma patients not indicated for surgical resection

AIM

Considering the dramatic increase in average life expectancy during the 20th century throughout the world, the management of elderly patients with cancer has become a global issue. We herein investigated the clinical characteristics and outcomes of super-elderly hepatocellular carcinoma (HCC) patients over 80 years old not indicated for surgical resection.

METHODS

We retrospectively evaluated 206 newly diagnosed HCC patients. The patients were divided into two groups according to their age at inclusion; a super-elderly group (n = 37, ≥80 years) and a younger group (n = 169, <80 years). We compared the clinical characteristics, overall survival (OS) and disease-specific survival (DSS) rates among the two groups. Both univariate and multivariate analyses were performed to identify the factors associated with the OS and DSS.

RESULTS

The proportion of women was higher in the super-elderly group than in the younger group (P = 0.017). There were no significant differences in the OS (P = 0.171) or DSS (P = 0.176) between the two groups. The multivariate analysis revealed that only the Cancer Liver Italian Program score (hazard ratio [HR], 2.972; P < 0.0001; HR, 3.694; P < 0.0001) was independently associated with the OS and DSS. Age was not found to be associated with the OS or DSS according to either the univariate or multivariate analysis.

CONCLUSION

There were no significant differences in the OS and DSS rates among the super-elderly HCC patients and younger HCC patients not indicated for surgical resection. An advanced age itself does not restrict the therapeutic approach, even in super-elderly HCC patients not indicated for surgical resection.

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

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

Hepatocellular carcinoma in the elderly: Meta-analysis and systematic literature review

AIM: To conduct a meta-analysis to investigate the clinical outcomes of surgical resection and locoregional treatments for hepatocellular carcinoma (HCC) in elderly patients defined as aged 70 years or more.

METHODS: Literature documenting a comparison of clinical outcomes for elderly and non elderly patients with hepatocellular carcinoma was identified by searching PubMed, Ovid, Cochrane Library, and Web of Science databases, for those from inception to March 2015 with no limits. Dichotomous outcomes and standard meta-analysis techniques were used. Heterogeneity was tested by the Cochrane Q statistic. Pooled estimates were measured using the fixed or random effect model.

RESULTS: Twenty three studies were included with a total of 12482 patients. Of these patients, 6341 were treated with surgical resection, 3138 were treated with radiofrequency ablation (RFA), and 3003 were treated with transarterial chemoembolization (TACE). Of the patients who underwent surgical resection, the elderly had significantly more respiratory co-morbidities than the younger group, with both groups having a similar proportion of cardiovascular co-morbidities and diabetes. After 1 year, the elderly group had significantly increased survival rates after surgical resection compared to the younger group (OR = 0.762, 95%CI: 0.583-0.994, P = 0.045). However, the 3-year and 5-year survival outcomes with surgical resection between the two groups were similar (OR = 0.947, 95%CI: 0.777-1.154, P = 0.67 for the third year; and OR = 1.131, 95%CI: 0.895-1.430, P = 0.304 for the fifth year). Postoperative treatment complications were similar between the elderly and younger group. The elderly group and younger group had similar survival outcomes for the first and third year after RFA (OR = 1.5, 95%CI: 0.788-2.885, P = 0.217 and OR = 1.352, 95%CI: 0.940-1.944, P = 0.104). For the fifth year, the elderly group had significantly worse survival rates compared to the younger group after RFA (OR = 1.379, 95%CI: 1.079-1.763, P = 0.01). For patients who underwent TACE, the elderly group had significantly increased survival compared to the younger group for the first and third year (OR = 0.664, 95%CI: 0.548-0.805, P = 0.00 and OR = 0.795, 95%CI: 0.663-0.953, P = 0.013). At the fifth year, there were no significant differences in overall survival between the elderly group and younger group (OR = 1.256, 95%CI: 0.806-1.957, P = 0.313).

CONCLUSION: The optimal management strategy for elderly patients with HCC is dependent on patient and tumor characteristics. Compared to patients less than 70, elderly patients have similar three year survival after resection and ablation and an improved three year survival after TACE. At five years, elderly patients had a lower survival after ablation but similar survival with resection and TACE as compared to younger patients. Heterogeneity of patient populations and selection bias can explain some of these findings. Overall, elderly patients have similar success, if not better, with these treatments and should be considered for all treatments after assessment of their clinical status and cancer burden.

Outcome of hepatectomy for hepatocellular carcinoma in elderly patients with portal hypertension

The outcome of liver resection (LR) for elderly hepatocellular carcinoma (HCC) patients with portal hypertension (PHT) who may be excluded as liver transplantation candidates has not been fully evaluated. One hundred ninety-five patients who underwent initial curative LR for HCC with PHT were divided into 2 groups: age <70 years (n = 131) and age ≥70 years (n = 64). Clinicopathologic data and postoperative complications were compared. Preoperative characteristics and postoperative complications were similar in both groups. However, in-hospital mortality was significantly more frequent in elderly than in younger patients (11% versus 1%, P = 0.002). No significant intergroup differences were observed in the 5-year disease-free survival rate or recurrence rate (19.7% versus 17.2%; P = 0.338, 63% versus 56%; P = 0.339). Although LR for elderly HCC patients with PHT can be performed with curative intent and gives results comparable with those in younger patients, it is associated with higher in-hospital mortality.

Hepatectomy is a reasonable option for older patients with hepatocellular carcinoma

BACKGROUND

Hepatic resection is the main treatment for patients with hepatocellular carcinoma. However, surgery is generally stressful for older patients.

METHODS

Clinicopathologic data and outcomes after hepatic resection were retrospectively investigated for older patients with hepatocellular carcinoma. The younger group (n = 219) included patients aged 60 to 69 years, and the older group (n = 60) included patients >70 years of age.

RESULTS

Hepatitis B virus was more common in the younger group than in the older group (64.5% vs 28.8%, P < .001). The occurrence of pneumonia was higher in older group than in the younger group (10.0% vs 2.3%, P = .015), but postoperative complications and mortality were not significantly different between the 2 groups. There was no statistically significant difference in disease-free survival rates between the 2 groups.

CONCLUSIONS

Although the incidence of postoperative pneumonia was higher in the older group than in the younger group, hepatic resection was justified for hepatocellular carcinoma in selected patients >70 years of age.

Validation of hepatectomy for elderly patients with hepatocellular carcinoma

BACKGROUND

The safety and feasibility of hepatectomy for hepatocellular carcinoma (HCC) in the elderly population have not been defined to date.

METHODS

A single-center, retrospective cohort study was conducted with 104 patients who underwent hepatectomy for HCC from 2005 to 2010. The patients were divided into two groups, the elderly group (age, ≥75 years; n = 22) and the nonelderly group (age, <75 years; n = 82), for comparison of short- and long-term outcomes.

RESULTS

More patients were categorized as preoperative Eastern Cooperative Oncology Group (ECOG) performance status 1 in the elderly group (32 %) than in the nonelderly group (6 %) (P = 0.003). Complications with a Clavien-Dindo classification of grade 3a or higher were more frequently observed in the elderly group (41 %) than in the nonelderly group (17 %) (P = 0.006). Multivariate logistic regression showed ECOG performance status 1 as the only independent predictor of complications classified as Clavien-Dindo grade 3a or higher. The in-hospital mortality rates were similar between the two groups (P = 0.20). During a median follow-up period of 47 months, the unadjusted 5-year recurrence-free survival rates were similar in the elderly (25 %) and nonelderly (33 %) groups (P = 0.80). Multiple tumors and high alpha-fetoprotein levels emerged as independent negative indicators of recurrence-free survival using multivariate Cox analyses. The adjusted risk for recurrence was not elevated in the elderly group (hazard ratio [HR], 0.92; 95 % confidence interval [CI] 0.50-1.68; P = 0.78).

CONCLUSIONS

Despite the more frequent occurrence of complications with a Clavien-Dindo grade of 3a or higher among the elderly patients undergoing hepatectomy for HCC, their mortality and recurrence rates were comparable with those of the nonelderly patients. Therefore, age alone is not a determinant of surgical candidacy for HCC.

Age is no longer a limit: two cases of hepatectomy in patients over 90 years old

Hepatocellular carcinoma (HCC) is a common malignant tumor with poor prognosis. The age of patients affected by HCC is considered to be increasing, and several studies have reported significantly higher rates of morbidity and mortality after hepatectomy for HCC in elderly patients. However, other studies have reported that the short- and long-term outcomes of surgery for HCC in elderly patients are similar to those in younger patients. Whether the indications for hepatic resection in elderly patients resemble those in younger patients has thus been questioned. We describe two cases of patients over 90 years old who underwent major hepatectomy for HCC, representing the oldest patients in the world to have done so.

Advanced age remains an achilles heel for liver resections

BACKGROUND

As the general population is aging, surgery in elderly patients has become a major public health issue. This basic question is especially true for liver resection (LR). The aim of this study was to evaluate the operative risks of LR in the elderly.

METHODS

Retrospective analysis of a large recent and monocentric database of LR was performed between January 1, 2005 and May 31, 2011. Patients were categorized into three groups (<60, 60-74, and ≥75 years old) to analyze postoperative outcomes and 1-year mortality. Clinicopathologic factors likely to influence outcomes were assessed by univariate and multivariate analysis.

RESULTS

Altogether, 1,001 consecutive LRs were performed in 912 patients (mean age 62 ± 13 years). The distribution of the LR by age was 372 (37.2 %), 477 (47.6 %), and 152 (15.2 %) in patients <60, 60-74, and ≥75 years, respectively. The overall morbidity and mortality rates were 33.3 and 2.5 %, respectively. Age ≥75 years was independently associated with postoperative mortality [odds ratio (OR) 4.75, 95 % confidence interval (CI) 1.5-15.1; p = 0.008] and 1-year mortality (OR 2.8, 95 % CI 1.2-6.6; p = 0.015). The postoperative complication rate (p = 0.216) was not increased, even for major complications (p = 0.09). The other independent risk factors for mortality were a cirrhotic liver (p = 0.017), preoperative arterial chemoembolization (p = 0.001), caval vein clamping (p = 0.001), and intraoperative blood transfusion (p = 0.044).

CONCLUSIONS

Age beyond 75 years represent a risk factor of death after LR and should be avoided after chemoembolization or in cirrhotic patients. A specific assessment using geriatric indexes might be the key to success in this population.

Safety of hepatectomy for elderly patients with hepatocellular carcinoma

The number of elderly patients with hepatocellular carcinoma (HCC) has been increasing. Characteristics of elderly HCC patients are a higher proportion of females, a lower rate of positive hepatitis B surface antigen, and a higher rate of positive hepatitis C antibodies. Careful patient selection is vital for performing hepatectomy safely in elderly HCC patients. Treatment strategy should be decided by not only considering tumor stage and hepatic functional reserve, but also physiological status, including comorbid disease. Various assessment tools have been applied to predict the risk of hepatectomy. The reported mortality and morbidity rates after hepatectomy in elderly HCC patients ranged from 0% to 42.9% and from 9% to 51%, respectively. Overall survival rate after hepatectomy in elderly HCC patients at 5 years ranged from 26% to 75.9%. Both short-term and long-term results after hepatectomy for strictly selected elderly HCC patients are almost the same as those for younger patients. However, considering physiological characteristics and the high prevalence of comorbid disease in elderly patients, it is important to assess patients more meticulously and to select them strictly if scheduled to undergo major hepatectomy.

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

PURPOSE

We evaluated the preoperative and postoperative characteristics and prognosis of super-elderly patients with hepatocellular carcinoma (HCC).

METHODS

Four hundred and thirty-one patients who underwent hepatic resection for HCC were classified into three groups according to their age at the time of surgery: super-elderly (≥80 years; n = 20), elderly (70-80 years; n = 172) and younger (<70 years; n = 239). We compared the clinical characteristics, preoperative and postoperative factors and prognosis among the groups to evaluate whether liver resection is appropriate for super-elderly patients.

RESULTS

The liver function was not significantly different among the groups. The proportion of patients with preoperative cardiovascular and respiratory disease and hypertension was higher in the super-elderly group compared to the other groups. The super-elderly group had shorter operations and reduced hemorrhage rates compared to the other groups. Postoperative cardiovascular complications and delirium were more frequently observed in the super-elderly group. The overall and tumor-free survival rates were not significantly different among the groups. Super-elderly patients had a lower rate of liver or HCC-related death and a higher rate of death due to other causes than the other groups.

CONCLUSIONS

Super-elderly HCC patients who are appropriately evaluated and selected might have a favorable prognosis after undergoing hepatic resection.

Prediction of postoperative complications in elderly patients with hepatocellular carcinoma

BACKGROUND

The aim of the present study was to investigate whether advanced age was associated with a higher rate of postoperative complications and identify the predictive factors for postoperative complications in elderly patients with hepatocellular carcinoma (HCC).

METHODS

Between January 2000 and December 2010, 256 patients who underwent hepatectomy for HCC were investigated. Elderly patients were defined as those aged ≥75 y. The clinicopathologic data and outcomes after hepatectomy for 64 elderly and 192 younger patients were retrospectively collected and compared.

RESULTS

There were no significant differences in the incidence of postoperative complications (P = 0.936) or the long-term survival after hepatectomy (P = 0.641) between the elderly and younger patients. In multivariate analysis, the estimation of physiological ability and surgical stress-preoperative risk score (PRS) was an independent risk factor for postoperative morbidity in the elderly patients (P < 0.01). Moreover, the patients were analyzed according to the PRS for the assessment of their general preoperative condition and liver damage grade based on the hepatic reserve. The rate of postoperative complications in the patients with a PRS ≥0.5 and liver damage B was significantly higher in the elderly patients (P < 0.01), whereas a PRS and liver damage grade did not affect the incidence of postoperative morbidity in the younger patients (P = 0.516).

CONCLUSIONS

Hepatectomy for elderly patients with HCC is feasible as well as safe, and the preoperative assessment using the estimation of physiological ability and surgical stress scoring system, combined with the liver damage grade, can help to improve the safety of this procedure for elderly HCC patients.

Totally laparoscopic liver resections for primary and metastatic cancer in the elderly: safety, feasibility and short-term outcomes

BACKGROUND

Standard oncologic liver resections performed on elderly patients (≥70 years old) have been shown to be safe and effective. The aim of this study was to analyze operative and oncologic short-term outcomes of totally laparoscopic liver resections (TLLR) performed on elderly patients for malignancies.

METHODS

We performed a retrospective statistical analysis of prospectively recorded data of TLLR performed from October 2008 to February 2012 by a single hepato-pancreato-biliary (HPB) surgeon. Patients were divided into two groups according to age (<70 vs. ≥ 70 years old) and perioperative outcomes were compared.

RESULT

A total of 60 TLLR for malignancies were identified of which 25 patients (42 %) were aged ≥ 70 years (Group A) and 35 (58 %) were aged <70 years (Group B). There was no difference in operative time (170 vs. 180 min, p = 0.267), median blood loss (200 vs. 250 ml, p = 0.183), number and time of Pringle maneuver (p = 0.563 and p = 0.180), blood transfusion rate (4 vs. 17 %, p = 0.222), conversion rate (4 vs. 9 %, p = 0.443), morbidity rate (12 vs. 20 %, p = 0.797), and perioperative mortality rate (0 vs. 3 %, p = 0.688). An R0 resection was achieved in 92 (Group A) versus 83 % (Group B) (p = 0.265). At a median follow-up of 18 months, 12 % of patients in Group A experienced a disease recurrence with a related mortality rate similar to that of Group B (8 vs. 12 %, p = 0.375).

CONCLUSION

This retrospective comparative study shows that TLLR performed on elderly for liver neoplasm are feasible and safe and lead to short-term outcomes similar to those of younger patients.

Liver resection for hepatocellular carcinoma in patients without cirrhosis

BACKGROUND

Data on liver resection for hepatocellular carcinoma (HCC) without cirrhosis are sparse. The present study was conducted to evaluate the indications and results of liver resection for HCC with regard to safety and efficacy.

METHODS

Data for patients who had liver resection for HCC without cirrhosis between January 1996 and March 2011 were retrieved retrospectively using a prospective database containing information on all patients who underwent hepatectomy for HCC. Patient and tumour characteristics were analysed for influence on overall and disease-free survival to identify prognostic factors by univariable and multivariable analysis.

RESULTS

The 1-, 3- and 5-year overall survival rates after resection with curative intent for HCC without cirrhosis were 84, 66 and 50 per cent respectively. Disease-free survival rates were 69, 53 and 42 per cent respectively. The 90-day mortality rate was 4·5 per cent (5 of 110 patients). Surgical radicality and growth pattern of the tumour were independent prognostic factors for overall survival. Disease-free survival after resection with curative intent was independently affected by growth pattern and by the number and size of tumour nodules.

CONCLUSION

Liver resection for HCC without cirrhosis carries a low perioperative risk and excellent long-term outcome if radical resection is achieved.

Relationship between hospital volume and operative mortality for liver resection: Data from the Japanese Diagnosis Procedure Combination database

AIM

  The present study aimed to conduct a nationwide investigation on the relationship between hospital volume and outcomes following liver resection in Japan. We also discuss health policy implications of the results.

METHODS

  Using the Japanese Diagnosis Procedure Combination database, we identified 18 046 patients who underwent hepatic resection between July and December 2007-2009. Patients were subdivided into hospital-volume quartiles: very low- (<18/year), low- (18-35), high- (36-70) and very high-volume groups (>70). Multivariate logistic regression analysis for in-hospital mortality within 30 days of surgery was performed to analyze adjusted effects of various factors.

RESULTS

  Patients in the very high-volume group had a higher Charlson Comorbidity Index (P < 0.001) than those in the very low-volume group. Very low-volume hospitals were significantly less likely to perform extended lobectomy than very high-volume hospitals (5.4% vs 17.6%, P < 0.001). Crude in-hospital mortality within 30 days of surgery was 1.1% (0.6%, 0.8%, 1.9% and 3.0% for limited resection, segmentectomy, lobectomy and extended lobectomy, respectively). With reference to the very low-volume group, risk-adjusted odds ratios (95% confidence intervals) of low-, high- and very high-volume groups for overall mortality were 0.70 (0.48-1.02; P = 0.060), 0.52 (0.34-0.81; P = 0.004) and 0.16 (0.09-0.30; P < 0.001), respectively.

CONCLUSION

  There is a linear trend between higher hospital volume and lower in-hospital mortality of liver resection in Japan, particularly for lobectomy and extended lobectomy. Based on these results, regionalization of lobectomy and extended lobectomy in high-volume centers could be effective for reducing postoperative mortality.

Effects of progesterone and its antagonist mifepristone on progesterone receptor a expression in human umbilical vein endothelial cells

Effects of female steroid hormones on endothelial cells are gaining increased importance due to several studies on the effects of hormonal treatment on cardiovascular risk. Recent data argue for an improvement of endothelium-derived relaxation and impaired vascular contraction by estradiol, whereas progesterone and testosterone might entail contrary effects. So far, gestagenic influence on endothelial cell physiology is poorly understood. Human umbilical vein endothelial cells (HUVECs) exposed to the female sex hormones estradiol and progesterone show expression of estrogen receptor-beta (ERbeta) and progesterone receptor A (PR-A), and are negative for ERalpha and PR-B. The aim of this study was to analyze the expression and stimulation of PR-A and -B in HUVECs after stimulation with progesterone and PR antagonists that are commercially available. PR-B expression or upregulation was abrogated after application of progesterone or antagonists to HUVECs. Expression of PR-A could be significantly upregulated with progesterone and mifepristone. Unexpectedly, stimulation with the progesterone antagonist RU486 (mifepristone) was accomplished by an upregulation of PR-A expression in our study. We conclude that gestagenic effects on HUVECs independent of modulators are mediated via the PR-A.