Outcomes in Elderly Patients Undergoing Liver Transplantation Compared with Liver-Directed Ablative Therapy in Early-Stage Hepatocellular Carcinoma

Abstract

BACKGROUND: Orthotopic liver transplantation (OLT) is the accepted treatment in patients with unresectable, early-stage hepatocellular carcinoma (HCC) in the setting of cirrhosis. Due to increasing waitlist demand for OLT, determining optimal groups for transplant is critical. Elderly patients are known to have poorer postoperative outcomes. Considering the effectiveness of liver-directed therapies for HCC, we sought to determine whether elderly patients received survival benefit from OLT over liver-directed therapy alone. STUDY DESIGN: The National Cancer Database participant use file was used to analyze data between 2004 and 2017. Only patients ≥70 years of age who received OLT or liver-directed therapy alone were included. Patients with alpha-fetoprotein >500 ng/mL or missing alpha-fetoprotein values were excluded. Baseline demographic variables, model for end-stage liver disease score, and overall survival from time of diagnosis were collected. Descriptive statistics, Kaplan-Meier survival, Cox proportional hazards model, and propensity score matching were used. RESULTS: A total of 2,377 patients received ablative therapy alone, and 214 patients received OLT. Multivariable analysis and Kaplan-Meier showed that OLT conferred a significant survival benefit compared to liver-directed therapy alone. Age was also associated with a yearly 3% increase in risk of mortality. Propensity-matched analysis adjusting also demonstrated a significant survival benefit for elderly patients receiving OLT compared to liver-directed therapy alone. CONCLUSION: Despite increased age and associated comorbidities being factors associated with poor outcomes, OLT confers a survival advantage compared to liver-directed ablative therapies alone in selected elderly patients with HCC. OLT should be offered in medically appropriate elderly patients with HCC.

Outcomes in elderly patients undergoing hepatic resection compared to ablative therapy for hepatocellular carcinoma

“…The NCDB does not have information related to specific comorbid conditions and uses the Charlson-Deyo score as the only available measure of comorbid conditions. 23 Further complicating the assessment of comorbid conditions is that the NCDB categorizes the score as 0, 1, 2, and 3+. This categorizing does not allow for a comprehensive analysis of illness severity because portal hypertension results in three points.…”

“…Even if specific data do not exist in the literature to date, the evidence summarized in this review suggests the use of geriatric scales in everyday clinical practice. Fit patients could receive the best standard treatment for HCC according to the Barcelona Clinic Liver Cancer (BCLC) stage, regardless the chronological age 23 …”

“…Several limitations exist in this study. The NCDB does not have information related to specific comorbid conditions and uses the Charlson‐Deyo score as the only available measure of comorbid conditions 23 . Further complicating the assessment of comorbid conditions is that the NCDB categorizes the score as 0, 1, 2, and 3+.…”

“…The NCDB also does not delineate specific comorbid conditions, thus preventing assessment of specific disease processes contributing to a worsening severity of illness. The reference group undergoing locoregional ablative therapy may include patients without cirrhosis 23 . Considering that most HCC cases arise in the setting of cirrhosis allowed us to assume that the reference group would largely comprise cirrhotic patients.…”

“…F I G U R E 3 Overall survival among patients with negative surgical margins after 1:1 propensity score matching. AHMED ET AL.| 809 cirrhosis 23. Considering that most HCC cases arise in the setting of cirrhosis allowed us to assume that the reference group would largely comprise cirrhotic patients.…”