The influence of age in decision-making of patients with HCC

Background

Hepatocellular carcinoma (HCC) is usually associated with liver cirrhosis and is the principal cause of death among patients with cirrhosis [1]. Apart from liver transplantation that may cure both conditions, treatment of HCC and cirrhosis is complex because of the need to be oncologically radical but simultaneously conservative. Hepatectomy is considered an invasive approach and has a marginal role in the treatment of HCC [2, 3]. A retrospective analysis of 62 patients affected by HCC observed from 2000 to 2008 was performed. The treatment choice was compared with the treatment schedule proposed by BCLC. Among these patients, 27 (43.5%) were over 70 years old; of these 16 were men and 11 women. Regarding Child classification 18 patients (66.6%) were CHILD A, 8 (29.6 %) CHILD B and 1 (3.8%) CHILD C. We evaluated the influence of age in our clinical behaviour, exploiting the BCLC guidelines. In 9 (33.3 %) cases patients were treated according to BCLC algorithm but mainly with percutaneous ablation therapies, while in the remaining18 (66.7%) cases there was an undertreatment in 15 (83.3 %) patients and an overtreatment in 3 (16.7 %). About the undertreatment cases we didn’t perform hepatic resection or liver transplantation such as BCLC suggests mainly because of advanced age (> 70 years old). With regard to the overtreatment we performed 3 transarterial embolizations rather than sorafenib or symptomatic therapy because the general conditions of patients were fairly good.

Conclusions

BCLC algorithm is considered the most important staging system for patients with HCC. This classification uses variables related to tumour stage, liver functional status, physical status but not the age of patients. This concept is very important because decision-making of hepatic surgeons often depends on age of patient. Although there are many papers in scientific literature that confirm the safety of surgery in elderly patients, it is also true that the risk of local and general complications is very high. The presence of comorbidity and refusal of patients to undergo surgery or liver transplantation are often the main reason for our clinical behaviour. In the management of these patients we have to consider the age and risk-benefit ratio.