**1. Introduction**

Hepatocellular carcinoma (HCC) is characterized by high clinical and biological variability [1]. Diagnosis and treatment of HCC always require multidisciplinary approaches.

**2. Patient management**

**2.1. Epidemiology and risk factors**

ing from cryptogenic cirrhosis (0.5 vs. 9%) [5].

**2.2. Elderly management and evaluation**

both risk of treatment toxicity and survival [9].

outcome from their condition.

is expectable.

evaluated.

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the third most common cause of cancer mortality. In almost all populations, males have higher liver cancer rates than females, with male/female ratios usually averaging between 2:1 and 4:1 [1, 2]. HCC global distribution varies by region, incidence rate, sex, and also, by etiology. Normally, HCC incidence in female peaks 5 years later than males. Age-specific onset patterns are likely related to differences in the dominant hepatitis virus in population, age at viral infection, and the existence of other risk factors. As for average age at infection, normally, HCV carriers became infected in adulthood, while HBV carriers tend to become infected in childhood [2]. Recently, a significant increase in HCC incidence in hepatitis-free patients was noted; this index had a boost and went from 22% in 2000–2004 to 31% in 2010–2014 (database ITALICA) [5]. Among nonvirus-related hepatopathy, incidence of HCC in Alcoholic fatty liver disease patients (AFLD-patients) remains stable (17 vs. 19%), while a significant incidence increase was seen in Non Alcoholic fatty liver disease Patients (NAFLD-Patients) or in patients suffer-

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

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

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Often NAFLD-patients are demanding to treat; patients in this group have commonly several comorbidities such as metabolic syndrome; therefore, they need a more accurate and multidimensional clinical evaluation in order to choose the best treatment and achieve the best

HCV interferon-mediated clearance, associated with mild to severe fibrosis reduces hepatopathy progression and cirrhosis incidence, thus HCC's incidence reduction in SVR patients

HCC hazard in HBV replication-controlled infection is reduced but not abolished, although effective antiviral therapy reduces HCC incidence in HBV- or HCV-positive patients [6].

Sudden HCC recurrence was reported by several papers after Direct Acting Antiretrovirals (DAA) mediated HCV clearance [7]. Other papers have found similar incidence of HCC after DAA-mediated HCV clearance when compared to IFN-mediated SVR but considering an overall 24-month follow-up [7]. HCC incidence after HCV clearance is still not sufficiently

More than two-third of patients newly diagnosed with HCC are aged >65 years [8], and this number is expected to increase as the world population ages. Furthermore, there is heterogeneity in the aging process, which further contributes to the complexity of treatment decisions. These factors contribute to age-related variations in treatment patterns and outcomes, potentially resulting in increased likelihood of under- or overtreatment, which can influence

Treatment requires commonly to make a decision between several specific interventions and to choose the one that allows the best risk-benefit ratio for a chosen patient.

Therapeutical approach shall take into account acute cirrhotic impairment risk and patient management experience, thus to avoid iatrogenic prognosis worsening.

Nowadays, patients older than 75 years account for 22% of HCC patients [2]. That is due to treatment and technological advancements which allow to reach an overall survival of decades, if therapy is well pondered; patients are kept in lifelong follow-up and intervention is timed well.

Therapeutical approaches to treat HCC can be divided into surgical approaches, such as major hepatic resection, minor hepatic resection, and wedge resection. Nonsurgical approaches are interventional radiology, chemotherapy, and most recently hadrontherapy. Since people older in age frequently have several comorbidities, often a specific less invasive therapeutical approach is needed.

Age is not a good outcome predictor: fit elderly patients may tolerate radical and invasive approaches, while unfit patients may not [3]. Treatment of older adults must take into account multiple issues related to the condition of aging itself. First of all, patient's frailty, thus invasive approaches are commonly excluded in patients advanced in age; on the other hand, noninvasive treatments are often palliative and do not achieve a satisfactory disease-free survival (DFS) or long-term survival (LTS) [3, 4]. Into this complex scenario, treatment strategies should also consider obstacles to cure the patients either physical or psychological, illness awareness, linguistic or cultural barriers, poverty, depression, and family environment.

Giving indication for or against invasive treatments is arduous in elderly. A decision for intervention shall consider either oncological principles and radical excision on one side or performance status, tolerability of treatment, and actual life expectancy on the other. HCC patients are not only in need for specific treatments, they must also be guided through routine activities in order to ameliorate their own hepatopathic condition, such as lifestyle correction (diet, water and salt assumption, physical activity, and smoking); instructions to the patient himself and to his family for therapeutical adhesion and instruction for early recognition of cirrhotic impairment or therapeutical side effects.

Physiological age is a new fundamental concept which is crucial in evaluating an advance in aged patient's performance status beyond his chronological age, which is still today too often used as a threshold to exclude or include a patient into specific treatment protocols [4].

The aim of this chapter is to give guidelines about management of elderly patients suffering from HCC and to give indications to treat those suffering from HCC as primary malignancy, recurrent illness, or metastatic disease either.
