**3.2. Liver transplantation**

multicentric study confirmed that HCC patients suffering from metabolic syndrome have

Nevertheless, hepatic resection on metabolic syndrome-liver has excellent oncologic effective-

In cirrhotic patients, hepatic resection is the first-line treatment for single HCC nodule and preserved hepatic function, strict indications for hepatic resection are serum-bilirubin <1.5 mg/ dl and Hepatic Portal-Venous Gradient (HPVG) ≤10 mmHg or platelets ≥100,000 [17].

Resection in patients with light portal hypertension and nonenrollable for liver transplant

Cirrhotic liver resection can be a safe practice in well-selected patients with low morbidity and mortality rates [18]. Selection shall be lead through a global, multiparametric evaluation

All guidelines agree that is needed to select cirrhotic patients for hepatic resection thus to achieve the best outcome, but selection criteria are not universally accepted, the ones suggested from several surgical groups are not based on strong evidence. Therefore, it is necessary to develop a multiparametric evidence-based prognostic score to allow to evaluate a

Tailored-risk evaluation is even more important in elderly patients since aging is a strictindividual process, multidimensional evaluation, and CGA score, in particular, are crucial to assess whether advanced in aged patients can be either enrolled or not for surgery with a deep

Child-Pugh class B patients are routinely excluded from surgery; however, in some cases, satisfying outcome was achieved by performing limited hepatic resections in strictly selected patients, with mild serum bilirubin raise (≤2 mg/dl) and without portal hypertension [19] (**Table 2**).

Laparoscopic or robotic approaches could widen indications to Child-Pugh class B patients

higher postoperative hepatic failure, mortality, and morbidity rates [15, 16].

ness and leads to long-time survival [16].

38 Liver Cancer

shall be well weighted against locoregional treatments [17].

"tailored" operative risk and expected survival.

gap in quality of life and overall survival [4].

**Table 2.** Indications to liver resection in HCC patient.

due to their little invasivity.

of the patient and shall pass beyond a dogmatic data interpretation.

In elderly patients, these approaches are extremely interesting.

Liver transplantation (LT) is considered the first-line treatment for cirrhotic patients. LT indications are given following the Milan criteria: single HCC nodules (diameter <5 cm) or less than 3 HCC nodules all <3 cm and in any case nonresectable [17].

A modest expansion to Milan criteria was given by "up to seven criteria," which had achieved satisfactory results in patients without extrahepatic metastases and/or macrovascular invasion. A prospective validation is needed [28].

An increasing number of older patients with end-stage liver disease (ESLD) are evaluated for liver transplantation (LT). In fact, patients aged ≥65 years represent one of the fastest-growing patient populations in LT [29]. The most extreme of these patients, those aged ≥70 years, are associated with several difficult clinical dilemmas. Firstly, advanced patient age is associated with higher risk and poorer outcomes after complex surgical procedures [30]. LT in advanced age patients is associated with increased risk for infection and cardiovascular impairment, increased resource utilization, and lower patient survival [31]. Since the number of adult candidates on the waiting list continues to rise and organ availability remains unable to fully meet this demand, proper organ allocation and utilization are critically important.

Several randomized studies have documented the superiority of surgical resection over percutaneous ablation techniques in terms of efficacy, while thermoablation has shown lower

HCC in Elderly Patients. Curative Intraoperative Strategies and Management in Recurrences

http://dx.doi.org/10.5772/intechopen.79748

41

MWA and RFTA have shown comparable safety and effective results, although MWA seems to have certain theoretical advantages compared to RFTA: shorter procedure, higher ablation temperature, larger area of necrosis, lower probability of biliary duct injury, and reduction in the heat-sink effect through a more uniform heating in the volume of ablation. However, these advantages have not been confirmed in clinical practice. Although EASL guidelines recommend the use of MWA for nodules up to 4 cm, a recent phase II trial, comparing the two techniques in patients with similar mean lesion volumes, showed no significant difference between them in terms of outcome and recurrence ratio [36].

RFTA and MWA can also be safely and effectively performed via a video laparoscopic (VL) approach [37]. VL allows the operator to treat nodules that would normally not be eligible for a percutaneous approach due to nonaccessible locations and allows for hybrid management of patients with multiple nodules (e.g., surgical resection and RFTA on additional nonresect-

Percutaneous ablation techniques are a precious tool in management of elderly patients with

HCC is often methacronous and new nodules are expected to develop during follow-up after the first tumor. Therefore, it is crucial to perform an appropriate follow-up in patients who have been treated for HCC, in order to detect new nodules at an early stage, so that the least invasive treatment available can be delivered. This is particularly relevant in elderly patients, or those who have already undergone extensive hepatic resection, who might not be eligible for surgery. Percutaneous ablation is a recommended treatment modality, when indicated, due to its mini-invasive nature, high effectiveness, low rates of adverse events, short hospitalization

Transarterial chemoembolization (TACE) is a palliative treatment that is routinely used in patients with HCC that are neither eligible for surgery nor for percutaneous ablation, and in

morbidity, mortality, hospitalization rates, and costs [35].

**Table 3.** Indications to Radio-Frequency Thermal Ablation.

able nodules).

multiple comorbidities.

times, and its relatively few contraindications.

*4.1.2. Transarterial chemoembolization*

Equivalent outcomes can be achieved in elderly recipients and age alone should not be used as a barrier to LT.

Recent data for waitlist registrants on the SRTR registry suggest that <12% of waitlisted patients are aged ≥65 years, but this proportion has steadily increased over the past decade. Continued improvements in care in pre- and posttransplant medicine and surgery suggest that this age group will continue to grow on the waiting list. With this demographic shift in the ESLD, more elderly patients will be considered for LT, and the use of scarce donor livers will need to be addressed because these recipients have a shorter life expectancy compared with younger patients. Despite the shortened lifespan, single-centered reports have shown equivalent posttransplant survival in super-selected patients [32, 33].

Due to physical and psychological impairment, elderly patients are often considered unfit for liver transplantation, since in super-selected groups only satisfying result in LT is achieved, surgical resection remains, for elderly, the first-line approach when performable.
