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.Key words: Liver resection, Recurrence, Portal hypertension, Liver transplantation, Liver failureRecently, the number of elderly patients with hepatocellular carcinoma (HCC) has been increasing with the increased proportion of the geriatric population in Japan.^1,2 Thanks to recent advances in surgical techniques, perioperative management, and anesthesia, the indications for surgical treatment modalities such as liver resection (LR) or liver transplantation (LT) in elderly patients have expanded.^3,4 Thus, age itself is no longer a contraindication for liver surgery.When considering the treatment of HCC, most patients already have existing liver dysfunction due to chronic hepatitis or liver cirrhosis, and portal hypertension (PHT) may be present at the time of diagnosis.^5,6 The American Association for the Study of Liver Diseases (AASLD)/Barcelona Clinic for Liver Cancer (BCLC) Guidelines have been widely utilized for the management of HCC in Western countries.^7,8 They recommend that only LT can be regarded as curative treatment for early-stage HCC (single nodule or up to 3 nodules measuring ≤3 cm) with PHT. However, LT for all HCC patients with PHT is impossible because of donor organ shortage, especially in Asian counties.⁹ In addition, expanding the indications of LT for elderly patients is still controversial. A previous study suggested that patients with PHT who underwent LR showed the same incidence of postoperative complications and survival rate as patients without PHT.¹⁰ In other words, LR still plays an important role as the mainstay of curative treatment for HCC patients with PHT, even if they are elderly. There have been several reports on the safety and feasibility of LR for elderly HCC patients, but there is little information on the outcome of elderly patients with PHT, who are considered to be at extremely high risk.^11–16 Against this background, the aim of the present study was to examine the short- and long-term outcomes of LR in both elderly (age ≥70 years) and younger (age <70 years) HCC patients with PHT at a single center over a 12-year period.