title: Trans-arterial chemo-embolization is safe and effective for very elderly patients with hepatocellular carcinoma.
abstract: OBJECTIVE
  To assess the safety and efficacy of trans-arterial chemo-embolization (TACE) in very elderly patients.
  
  
  METHODS
  A prospective cohort study, from 2001 to 2010, compared clinical outcomes following TACE between patients ≥ 75 years old and younger patients (aged between 65 and 75 years and younger than 65 years) with hepatocellular carcinoma (HCC), diagnosed according to the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases criteria. The decision that patients were not candidates for curative therapy was made by a multidisciplinary HCC team. Data collected included demographics, co-morbidities, liver disease etiology, liver disease severity and the number of procedures. The primary outcome was mortality; secondary outcomes included post-embolization syndrome (nausea, fever, abdominal right upper quadrant pain, increase in liver enzymes with no evidence of sepsis and with a clinical course limited to 3-4 d post procedure) and 30-d complications. Additionally, changes in liver enzyme measurements were assessed [alanine and aspartate aminotransferase (ALT and AST), gamma-glutamyl transpeptidase and alkaline phosphatase] in the week following TACE. Analysis employed both univariate and multivariate methods (Cox regression models).
  
  
  RESULTS
  Of 102 patients who underwent TACE as sole treatment, 10 patients (9.8%) were > 80 years old at diagnosis; 13 (12.7%) were between 75 and 80 years, 45 (44.1%) were between 65 and 75 years and 34 (33.3%) were younger than 65 years. Survival analysis demonstrated similar survival patterns between the elderly patients and younger patients. Age was also not associated with the adverse event rate. Survival rates at 1, 2 and 3 years from diagnosis were 74%, 37% and 31% among patients < 65 years; 83%, 66% and 48% among patients aged 65 to 75 years; and 86%, 41% and 23% among patients ≥ 75 years. There were no differences between the age groups in the pre-procedural care, including preventive treatment for contrast nephropathy and prophylactic antibiotics. Multivariate survival analysis, controlling for disease stage at diagnosis with the Barcelona Clinic Liver Cancer score, number of TACE procedures, sex and alpha-fetoprotein level at the time of diagnosis, found no significant difference in the mortality hazard for elderly vs younger patients, and there were no differences in post-procedural complications. Serum creatinine levels did not change after 55% of the procedures, in all age groups. In 42% of all procedures, serum creatinine levels increased by no more than 25% above the baseline levels prior to TACE. Overall, there were 69 post-embolization events (23%). Hepatocellular enzymes often increased following TACE, with no association with prognosis. In 40% of the procedures, ALT and AST levels rose by at least 100%. The increases in hepatocellular enzymes occurred similarly in all age groups.
  
  
  CONCLUSIONS
  TACE is safe and effective in very elderly patients with HCC, and is not associated with decreased survival or increased complication rates.
authors.affiliation: Division of Internal Medicine, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel.
authors.forename: Matan J
authors.initials: MJ
authors.lastname: Cohen
authors.forename: Allan I
authors.initials: AI
authors.lastname: Bloom
authors.forename: Orly
authors.initials: O
authors.lastname: Barak
authors.forename: Alexander
authors.initials: A
authors.lastname: Klimov
authors.forename: Tova
authors.initials: T
authors.lastname: Nesher
authors.forename: Daniel
authors.initials: D
authors.lastname: Shouval
authors.forename: Izhar
authors.initials: I
authors.lastname: Levi
authors.forename: Oren
authors.initials: O
authors.lastname: Shibolet
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D006528:Carcinoma, Hepatocellular / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D016461:Chemoembolization, Therapeutic / Q000009:adverse effects / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008113:Liver Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D008875:Middle Aged; D015999:Multivariate Analysis; D018579:Patient Selection; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: Chemoembolization; Complications; Elderly; Hepatocellular carcinoma; Prognosis; Therapeutic