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

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.

Survival benefit of second line therapies for recurrent hepatocellular carcinoma: repeated hepatectomy, thermoablation and second-line transplant referral in a real life national scenario

BACKGROUND

Despite second-line transplant(SLT) for recurrent hepatocellular carcinoma(rHCC) leads to the longest survival after recurrence(SAR), its real applicability has never been reported. The aim was to compare the SAR of SLT versus repeated hepatectomy and thermoablation(CUR group).

METHODS

Patients were enrolled from the Italian register HE.RC.O.LE.S. between 2008 and 2021. Two groups were created: CUR versus SLT. A propensity score matching (PSM) was run to balance the groups.

RESULTS

743 patients were enrolled, CUR = 611 and SLT = 132. Median age at recurrence was 71(IQR 6575) years old and 60(IQR 53-64, p < 0.001) for CUR and SLT respectively. After PSM, median SAR for CUR was 43 months(95%CI = 37 - 93) and not reached for SLT(p < 0.001). SLT patients gained a survival benefit of 9.4 months if compared with CUR. MilanCriteria(MC)-In patients were 82.7% of the CUR group. SLT(HR 0.386, 95%CI = 0.23 - 0.63, p < 0.001) and the MELD score(HR 1.169, 95%CI = 1.07 - 1.27, p < 0.001) were the only predictors of mortality. In case of MC-Out, the only predictor of mortality was the number of nodules at recurrence(HR 1.45, 95%CI= 1.09 - 1.93, p = 0.011).

CONCLUSION

It emerged an important transplant under referral in favour of repeated hepatectomy or thermoablation. In patients with MC-Out relapse, the benefit of SLT over CUR was not observed.

Should Laparoscopic Complete Mesocolic Excision Be Offered to Elderly Patients to Treat Right-Sided Colon Cancer?

BACKGROUND

Despite its potential oncologic benefit, complete mesocolic excision (CME) has rarely been offered to elderly patients. The present study evaluated the effect of age on postoperative outcomes among patients undergoing laparoscopic right colectomies with CME for right-sided colon cancer (RCC).

METHODS

Data of patients undergoing laparoscopic right colectomies with CME for RCC between 2015 and 2018 were retrospectively analyzed. Selected patients were divided into two groups: the under-80 group and the over-80 group. Surgical, pathological, and oncological outcomes among the groups were compared.

RESULTS

A total of 130 patients were selected (95 in the under-80 group and 35 in the over-80 group). No difference was found between the groups in terms of postoperative outcomes, except for median length of stay and adjuvant chemotherapy received, which were in favor of the under-80 group (5 vs. 8 days, p < 0.001 and 26.3% vs. 2.9%, p = 0.003, respectively). No difference between the groups was found regarding overall survival and disease free survival. Using multivariate analysis, only the ASA score > 2 (p = 0.01) was an independent predictor of overall complications.

CONCLUSIONS

laparoscopic right colectomy with CME for RCC was safely performed in elderly patients ensuring similar oncological outcomes compared to younger patients.

Machine Learning Predictive Model to Guide Treatment Allocation for Recurrent Hepatocellular Carcinoma After Surgery

Importance

Clear indications on how to select retreatments for recurrent hepatocellular carcinoma (HCC) are still lacking.

Objective

To create a machine learning predictive model of survival after HCC recurrence to allocate patients to their best potential treatment.

Design, Setting, and Participants

Real-life data were obtained from an Italian registry of hepatocellular carcinoma between January 2008 and December 2019 after a median (IQR) follow-up of 27 (12-51) months. External validation was made on data derived by another Italian cohort and a Japanese cohort. Patients who experienced a recurrent HCC after a first surgical approach were included. Patients were profiled, and factors predicting survival after recurrence under different treatments that acted also as treatment effect modifiers were assessed. The model was then fitted individually to identify the best potential treatment. Analysis took place between January and April 2021.

Exposures

Patients were enrolled if treated by reoperative hepatectomy or thermoablation, chemoembolization, or sorafenib.

Main Outcomes and Measures

Survival after recurrence was the end point.

Results

A total of 701 patients with recurrent HCC were enrolled (mean [SD] age, 71 [9] years; 151 [21.5%] female). Of those, 293 patients (41.8%) received reoperative hepatectomy or thermoablation, 188 (26.8%) received sorafenib, and 220 (31.4%) received chemoembolization. Treatment, age, cirrhosis, number, size, and lobar localization of the recurrent nodules, extrahepatic spread, and time to recurrence were all treatment effect modifiers and survival after recurrence predictors. The area under the receiver operating characteristic curve of the predictive model was 78.5% (95% CI, 71.7%-85.3%) at 5 years after recurrence. According to the model, 611 patients (87.2%) would have benefited from reoperative hepatectomy or thermoablation, 37 (5.2%) from sorafenib, and 53 (7.6%) from chemoembolization in terms of potential survival after recurrence. Compared with patients for which the best potential treatment was reoperative hepatectomy or thermoablation, sorafenib and chemoembolization would be the best potential treatment for older patients (median [IQR] age, 78.5 [75.2-83.4] years, 77.02 [73.89-80.46] years, and 71.59 [64.76-76.06] years for sorafenib, chemoembolization, and reoperative hepatectomy or thermoablation, respectively), with a lower median (IQR) number of multiple recurrent nodules (1.00 [1.00-2.00] for sorafenib, 1.00 [1.00-2.00] for chemoembolization, and 2.00 [1.00-3.00] for reoperative hepatectomy or thermoablation). Extrahepatic recurrence was observed in 43.2% (n = 16) for sorafenib as the best potential treatment vs 14.6% (n = 89) for reoperative hepatectomy or thermoablation as the best potential treatment and 0% for chemoembolization as the best potential treatment. Those profiles were used to constitute a patient-tailored algorithm for the best potential treatment allocation.

Conclusions and Relevance

The herein presented algorithm should help in allocating patients with recurrent HCC to the best potential treatment according to their specific characteristics in a treatment hierarchy fashion.

Outcomes of Geriatric Patients with Hepatocellular Carcinoma

Background: The treatment modalities and outcomes of geriatric patients with hepatocellular carcinoma (HCC) remain controversial. This retrospective observational cohort study compared the outcomes of HCC between geriatric and younger patients. Methods: The medical records of patients with HCC managed between January 2001 and December 2017 were retrieved from the Chang Gung Memorial Hospital Research Database. Patients were stratified by age into two groups: a geriatric group (65−75 years) and a younger group (<65 years). The two groups were matched through 1:2 propensity score matching (PSM) according to sex, cardiovascular disease, cerebrovascular attack, diabetes mellitus, cirrhosis, hepatitis, and hypertension. Results: Of the 11,033 patients with HCC, 2147 patients aged 65−75 years and 4294 patients aged <65 years were identified after 1:2 PSM. The Kaplan−Meier model revealed that the HCC outcomes in patients older than 65 years were not significantly different after 3 years (p = 0.060). Consistent results were also obtained when the laboratory data associated with HCC incidence were included in the Fine−Gray competing risk model after 1:2 PSM (p = 0.1695). The major risk factors for HCC survival were systemic immune-inflammation index (SII) ≥ 610 × 109 cells/L, advanced tumor stage, and model for end-stage liver disease (MELD) score, etc. Conclusion: Age was not an independent factor for mortality in patients with HCC in the first 3 years. Geriatric patients with HCC should be as aggressively managed as younger patients.

Hepatectomy Versus Sorafenib in Advanced Non-Metastatic Hepatocellular Carcinoma: A Real-Life Multicentric Weighted Comparison

OBJECTIVE

The aim of the study was to compare surgery (SURG) vs sorafenib (SOR) regarding the overall survival (OS) and progression-free survival (PFS) in a real-world clinical scenario.

BACKGROUND DATA

The treatment for advanced non-metastatic hepatocellular carcinoma (HCC) belonging to the Barcelona Clinic Liver Cancer stage C (BCLC C) is still controversial.

METHODS

BCLC C patients without extra-hepatic spread and tumoral invasion of the main portal trunk were considered. Surgical patients were obtained from the HE.RC.O.LE.S. Register, while sorafenib patients were obtained from the ITA.LI.CA register The inverse probability weighting (IPW) method was adopted to balance the confounders between the two groups.

RESULTS

Between 2008 and 2019, 478 patients were enrolled: 303 in SURG and 175 in SOR group. ECOG-PS, presence of cirrhosis, steatosis, Child-Pugh grade, HBV and HCV, alcohol intake, collateral veins, bilobar disease, localization of the tumor thrombus, number of nodules, alpha-fetoprotein, age, and Charlson Comorbidity index were weighted by IPW to create two balanced pseudo-populations: SURG=374 and SOR=263. After IPW, 1-3-5 years OS was 83.6%, 68.1%, 55.9% for SURG, and 42.3%, 17.8%, 12.8% for SOR (p < 0.001). Similar trends were observed after subgrouping patients by ECOG-PS =0 and ECOG-PS >0, and by the intra-hepatic location of portal vein invasion. At Cox regression, sorafenib treatment (HR 4.436; 95%CI 3.19-6.15; p < 0.001) and Charlson Index (HR 1.162; 95%CI 1.06-1.27; p = 0.010) were the only independent predictors of mortality. PFS at 1-3-5 years were 65.9%, 40.3%, 24.3% for SURG and 21.6%, 3.5%, 2.9% for SOR (p = 0.007).

CONCLUSIONS

In BCLC C patients without extra-hepatic spread but with intra-hepatic portal invasion, liver resection, if feasible, was followed by better OS and PFS compared with sorafenib.

OUP accepted manuscript

Background

Methods

Results

Conclusion

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.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

Introduction

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

Methods

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

Results

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

Conclusions

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

Liver resection in elderly patients with hepatocellular carcinoma: age does matter

Increasing proportions of elderly patients with hepatocellular carcinoma (HCC) requiring oncological treatment have been noted. We aim to evaluate the impact of elderly age on outcomes of liver resection (LR) for HCC. This retrospective study enrolled 1004 patients with HCC who underwent curative LR in our institution from 2007 to 2017, dividing them into three groups according to age (18-59 years, n = 461; 60-74 years, n = 447; ≥ 75 years, n = 96). Elderly patients were defined as those ≥ 75 years old. Outcomes were then compared among the three groups, with a multivariate competing risk model used to estimate cause-specific subdistribution hazard ratios (SHRs) for HCC- and non-HCC-related deaths. The OS was significantly lower in the elderly than younger patients. However, recurrence-free survival was similar among the three groups. The cumulative incidence of HCC-related death was similar among the three groups; however, the cumulative incidence of non-HCC-related death was significantly higher in the elderly than younger patients. Moreover, the multivariate analysis showed that elderly age was not an independent variable associated with HCC-related death. However, elderly age was an independent variable associated with non-HCC-related death. The 60-year SHR for non-HCC-related death increased with increasing age. The elderly patients had significantly worse OS after LR than the younger patients, possibly due to the cumulative incidence of non-HCC-related death being significantly higher among the elderly than among the younger patients. Elderly patients should be more stringently selected for LR.

How to Treat Hepatocellular Carcinoma in Elderly Patients

Hepatocellular carcinoma (HCC) is the primary tumour of the liver with the greatest incidence, particularly in the elderly. Additionally, improvements in the treatments for chronic liver diseases have increased the number of elderly patients who might be affected by HCC. Little evidence exists regarding HCC in old patients, and the elderly are still underrepresented and undertreated in clinical trials. In fact, this population represents a complex subgroup of patients who are hard to manage, especially due to the presence of multiple comorbidities. Therefore, the choice of treatment is mainly decided by the physician in the clinical practice, who often tend not to treat elderly patients in order to avoid the possibility of adverse events, which may alter their unstable equilibrium. In this context, the clarification of the optimal treatment strategy for elderly patients affected by HCC has become an urgent necessity. The aim of this review is to provide an overview of the available data regarding the treatment of HCC in elderly patients, starting from the definition of "elderly" and the geriatric assessment and scales. We explain the possible treatment choices according to the Barcelona Clinic Liver Cancer (BCLC) scale and their feasibility in the elderly population.

Performance of Comprehensive Complication Index and Clavien-Dindo Complication Scoring System in Liver Surgery for Hepatocellular Carcinoma

Simple Summary

The comprehensive complication index (CCI) and the Clavien-Dindo Complication (CDC) scoring system are two metrics designed to quantify the burden of postoperative morbidity. We performed a retrospective study retrieving data from a multi-institutional Italian register. The aim was to compare the performance of the two metrics in predicting excessive length of hospital stay (e-LOS) of patients who underwent liver resections for hepatocellular carcinoma. A total of 2669 patients were analyzed. A derivation (n = 1345) and validation sets (n = 1324) were created to test the strength of results. In both cohorts, the analysis showed that CCI was slightly superior in predicting e-LOS in complicated patients. The accuracy of CCI was even better when considering a subgroup of patients who experienced at least two complications. The results of this population-specific analysis suggest that CCI is preferable in weighting postoperative morbidity burden.

Abstract

Background: We aimed to assess the ability of comprehensive complication index (CCI) and Clavien-Dindo complication (CDC) scale to predict excessive length of hospital stay (e-LOS) in patients undergoing liver resection for hepatocellular carcinoma. Methods: Patients were identified from an Italian multi-institutional database and randomly selected to be included in either a derivation or validation set. Multivariate logistic regression models and ROC curve analysis including either CCI or CDC as predictors of e-LOS were fitted to compare predictive performance. E-LOS was defined as a LOS longer than the 75th percentile among patients with at least one complication. Results: A total of 2669 patients were analyzed (1345 for derivation and 1324 for validation). The odds ratio (OR) was 5.590 (95%CI 4.201; 7.438) for CCI and 5.507 (4.152; 7.304) for CDC. The AUC was 0.964 for CCI and 0.893 for CDC in the derivation set and 0.962 vs. 0.890 in the validation set, respectively. In patients with at least two complications, the OR was 2.793 (1.896; 4.115) for CCI and 2.439 (1.666; 3.570) for CDC with an AUC of 0.850 and 0.673, respectively in the derivation cohort. The AUC was 0.806 for CCI and 0.658 for CDC in the validation set. Conclusions: When reporting postoperative morbidity in liver surgery, CCI is a preferable scale.

Treatment of hepatocellular carcinoma beyond the Milan criteria. A weighted comparative study of surgical resection versus chemoembolization

BACKGROUND

Optimal treatment of hepatocellular carcinoma (HCC) beyond the Milan criteria (MC) is debated. The aim of the study was to assess overall-survival (OS) and disease-free-survival (DFS) for HCC beyond MC when treated by trans-arterial-chemoembolization (TACE) or surgical resection (SR).

METHOD

between 2005 and 2015, all patients with a first diagnosis of HCC beyond MC(1 nodule>5 cm, or 3 nodules>3 cm without macrovascular invasion) were evaluated. Analyses were carried out through Kaplan-Meier, Cox models and the inverse probability weighting (IPW) method to reduce allocation bias. Sub-analyses have been performed for multinodular and single large tumors compared with a MC-IN cohort.

RESULTS

226 consecutive patients were evaluated: 118 in SR group and 108 in TACE group. After IPW, the two pseudo-populations were comparable for tumor burden and liver function. In the SR group, 1-5 years OS rates were 72.3% and 35% respectively and 92.7% and 39.3% for TACE (p = 0.500). The median DFS was 8 months (95%CI:8-9) for TACE, and 11 months (95%CI:9-12) for SR (p < 0.001). TACE was an independent predictor for recurrence (HR 1.5; 95%CI: 1.1-2.1; p = 0.015). Solitary tumors > 5 cm and multinodular disease had comparable OS and DFS as Milan-IN group (p > 0.05).

CONCLUSION

Surgery allowed a better control than TACE in patient bearing HCC beyond MC. This translated into a significant benefit in terms of DFS but not OS.

Prognosis of microwave ablation for hepatocellular carcinoma: does age make a difference?

Objective: Hepatocellular carcinoma (HCC) is a notable threat to the longevity of elderly people. However, there is no trial to study the prognosis of these elderly patients after microwave ablation (MWA) treatment. This study investigated whether elderly patients with HCC benefit from MWA similar to younger patients.Materials and methods: Patients who underwent ultrasound-guided percutaneous MWA were included and divided into four age groups and the prognosis was compared. The senior group (Group S, ≥75 years) was then compared with the younger group (Group Y, <75 years) after a 1:1 propensity score matching was applied. The prognostic outcomes were evaluated and Cox analysis was performed to determine the factors associated with survival.Results: The four age groups showed a statistically different distribution in terms of sex, size of liver nodules, and the Charlson comorbidity index. Although Group S had a higher Charlson comorbidity index, no significant differences were found between Group S and Group Y in the rates of complete ablation and major complications as well as overall survival and progression-free survival after matching. Cox analysis demonstrated that the size of tumors and Child Pugh grade rather than age or Charlson comorbidity index were significant prognostic factors for overall survival.Conclusion: The elderly patients with HCC, even though associated with more comorbidities, may achieve acceptable prognostic outcomes following MWA, which are not worse than their younger counterparts.

Should radical surgery for rectal cancer be offered to elderly population? A propensity-matching analysis on short- and long-term outcomes

Elderly patients with rectal tumor are often undertreated if compared to younger ones. The reasons for this attitude are not fully clear.The aim of this study was to determine the feasibility of radical treatments for rectal cancer in subjects with an age ≥ 75 years (group 1) and to compare short- and long-term outcomes of these patients with patients with an age of less that 75 years (group 2). 311 consecutive patients who underwent radical surgery for rectal cancer were evaluated. A propensity-matching analysis on short- and long-term outcomes was conducted to compare older and younger patients. Overall postoperative complication rate was 23.8% (19/80) in the group 2 and 33.8% (27/80) in group 1 (p = 0.162). OS at 1, 3 and 5 years was 96.2%, 88.4% and 75.9% in under 75 and 92.5%, 64.3% and 50.6% in over 75 group, respectively (p = 0.001). However, TSS was considered, no significant difference was found. Major complications were comparable within groups: 10 (12.5%) versus 11 (13.8%) in groups 2 and 1, respectively (p = 0.633). This study suggests that major rectal cancer surgery with curative intent should not be denied to an elderly population on the basis of age alone. Specific oncologic features and comorbidities are better long-term mortality predictors than aging.