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

Abstract

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

How to Treat Hepatocellular Carcinoma in Elderly Patients

“…The studies had a retrospective design with questionable validity, and the cut-off used for old age also varied, making direct comparison difficult. Nevertheless, the eligibility for LT should not be based only on age, but other factors must be considered in patients selection, such as the evaluation of liver function (through the model for end-stage liver disease—MELD), functional reserve (with the indocyanine green kinetics (ICG) test) and the assessment of liver stiffness (with transient elastography—LSM) [ 35 , 36 , 37 , 38 ]. In addition, recent studies showed that elderly HCC patients have different clinical and pathological characteristics compared to younger patients.…”

“…The morbidity and mortality rates after hepatectomy in elderly HCC patients range from 9% to 51% and from 0% to 42.9%, respectively [ 46 ]. Due to recent advances in surgical procedures and perioperative management, most recent studies and meta-analyses have shown comparable short-term outcomes, such as hospital stay, post-operative morbidity and mortality, between younger and elderly patients undergoing hepatectomy for HCC [ 6 , 35 , 46 , 50 , 51 , 52 , 53 ]. This could probably be explained by the more careful selection criteria of elderly patients.…”

“…Tools that allow better selection of candidates for hepatectomy play a central role. There are different scoring systems for assessing elderly patients, including the American Society of Anesthesiologists (ASA), POSSUM/P-POSSUM, E-PASS and APACHE II score [ 35 ]. In addition, in a recent study, the use of cardiopulmonary exercise testing (CPET), enhanced recovery (ERAS) and parenchymal sparing liver surgery in the selection, management and treatment of octogenarian patients with liver tumours allowed to achieve similar post-operative outcomes to younger patients [ 44 ].…”

“…In order to reduce surgical stress and improve outcomes, in the last ten years, laparoscopic and robotic techniques have been applied in liver surgery, which have been shown to be safe and effective approaches, with morbidity and mortality in major laparoscopic-robotic series in very early and early HCC of 10–15% and 1%, respectively [ 35 , 56 , 57 , 58 ]. Laparoscopic-robotic resection of HCC, in particular when the tumours are mainly located in superficial peripheral positions of the liver, provides optimal survival outcomes and minimizes complications and hospital stay [ 57 , 59 ].…”

“…Regarding long-term outcomes of liver resection, most studies showed that 5-year OS rates of elderly HCC patients after hepatectomy ranged between 26% and 75.9%, whereas those in younger HCC patients ranged from 31.4 to 68% [ 35 , 46 , 53 ]. Recent reports demonstrated comparable results between young and elderly patients for 1, 3 and 5 year OS and DFS rates [ 6 , 35 , 46 , 53 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 ]. In the study of Hirokawa et al, the DFS was worse in elderly patients than in the younger ones [ 66 ].…”