Age is no longer a limit: two cases of hepatectomy in patients over 90 years old.

Hepatocellular carcinoma (HCC) is a common malignant tumor with poor prognosis. The age of patients affected by HCC is considered to be increasing, and several studies have reported significantly higher rates of morbidity and mortality after hepatectomy for HCC in elderly patients. However, other studies have reported that the short- and long-term outcomes of surgery for HCC in elderly patients are similar to those in younger patients. Whether the indications for hepatic resection in elderly patients resemble those in younger patients has thus been questioned. We describe two cases of patients over 90 years old who underwent major hepatectomy for HCC, representing the oldest patients in the world to have done so.

Introduction

Mean life expectancy has been increasing in many countries, and the management of malignancies in the elderly has thus become a global issue [1, 2, 3]. Hepatocellular carcinoma (HCC) is a common malignant tumor with poor prognosis, and the numbers of elderly patients with HCC are expected to increase around the world [4].

Several studies in the 1990s and early 2000s reported significantly higher rates of morbidity and mortality after hepatectomy in elderly patients [5, 6, 7, 8]. On the other hand, recent studies have found that the short- and long-term outcomes of hepatectomy in elderly patients are similar to those in younger patients [4, 9, 10, 11, 12]. The indications for hepatic resection in elderly patients have been questioned, and given the increasing number of affected elderly patients, this issue requires serious consideration. We report herein two cases of successful hepatectomy in patients over 90 years old.

Case Reports

Case 1

The patient was a 91-year-old man. He underwent a medical examination for hypertension and chronic atrial fibrillation, during which a mass was palpated through the abdominal wall. He was then referred to our hospital. Laboratory data were as follows: aspartate aminotransferase (AST) 61 IU/l (normal 5–35), alanine aminotransferase (ALT) 37 IU/l (normal 5–30), alkaline phosphatase (ALP) 334 U/l (normal 115–359), gamma-glutamyl transferase (γ-GTP) 230 IU/l (normal 0–50), lactate dehydrogenase (LDH) 177 IU/l (normal 106–211), albumin (Alb) 3.6 g/dl (normal 3.7–5.5), total bilirubin (TB) 0.71 mg/dl (normal 0.2–1.0), and prothrombin time-international normalized ratio (PT-INR) 1.03. Child-Turcotte-Pugh grade was A. The indocyanine green retention rate at 15 min (ICG-R15) was 8%. The concentration of serum alpha-fetoprotein (AFP) was 3,600 ng/ml (normal <20) and plasma des-γ-carboxy prothrombin (DCP), also known as protein induced by vitamin K deficiency or antagonist-II, was 93,300 mAU/ml (normal <40). No serological evidence of hepatitis B or C was seen. Contrast-enhanced computed tomography (CECT) revealed a tumor measuring 78 mm in diameter in the left lateral sector of the liver (fig. 1). HCC was suspected. The patient requested radical surgery, so left lateral sectorectomy was performed (fig. 2). The operation time was 370 min, and the amount of blood loss was 978 ml. Pathological findings revealed well to moderately differentiated HCC (fig. 3).

Fig. 1

CECT. The arrow shows a tumor measuring 78 mm in diameter in the left lateral sector of the liver.

Fig. 2

Postoperative view. The arrow shows the left hepatic vein exposed at the cut surface of the liver.

Fig. 3

The resected specimen. Pathological examination showed well to moderately differentiated HCC.

Case 2

The patient was a 91-year-old woman. Laboratory data were as follows: AST 35 IU/l (normal 5–35), ALT 21 IU/l (normal 5–30), ALP 198 U/l (normal 115–359), γ-GTP 67 IU/l (normal 0–50), LDH 162 IU/l (normal 106–211), Alb 2.9 g/dl (normal 3.7–5.5), TB 0.7 mg/dl (normal 0.2–1.0), and PT-INR 1.18. Child-Turcotte-Pugh grade was A. The ICG-R15 was 19%. The concentration of serum AFP was 1,210 ng/ml (normal <20) and plasma DCP was 209 mAU/ml (normal <40). No serological evidence of hepatitis B or C was seen. CECT revealed a tumor measuring 20 mm in diameter in segment 2 of the liver, accompanied by tumor thrombi toward the main left portal vein (fig. 4). We diagnosed HCC with tumor thrombi. The patient requested radical surgery, so left hemi-hepatectomy was performed (fig. 5). The operation time was 304 min, and the amount of blood loss was 379 ml. Pathological findings revealed poorly differentiated HCC (fig. 6).

Fig. 4

CECT. The arrows show a tumor measuring 20 mm in diameter in segment 2 of the liver, accompanied by tumor thrombi toward the main left portal vein.

Fig. 5

Postoperative view. The arrow shows the middle hepatic vein exposed at the cut surface of the liver.

Fig. 6

The resected specimen. Pathological examination showed poorly differentiated HCC.

Discussion

HCC is a common malignant tumor with poor prognosis. Mean life expectancy has been increasing in many countries, and the management of malignancy in the elderly has become a global issue [1, 2, 3]. Aging is associated with gradual decreases in liver volume and blood flow [13]. General markers of liver function, such as levels of AST, ALT, serum TB and ALP, are largely unaffected by aging [14]. In contrast, decreases are seen in serum levels of Alb, some amino acids and some coagulation factors, including fibrinogen, prothrombin and thromboplastin [15]. Several studies in old rodents have suggested that aging compromises the regenerative capacity of the liver after hepatectomy or ligation of the portal vein [16, 17]. Advanced age is already a high risk factor for staying alive [18], and the risks associated with surgical treatment are thus considered to be further magnified. Furthermore, advanced age increases complications such as high blood pressure and diabetes mellitus.

In recent years, hepatectomy for much more elderly patients has been attracting increasing attention. Several studies in the 1990s and early 2000s reported significantly higher rates of morbidity and mortality in elderly patients [5, 6, 7, 8]. On the other hand, recent studies have reported the safety of surgery in elderly patients [4, 9, 10, 11, 12]. The age standards for hepatectomy are rising because hepatectomy is being performed with increasing safety. After stringent criteria for hepatectomy were proposed, the mortality rate decreased markedly [19]. With the development of surgical energy devices, such as vessel-sealing instruments and ultrasonic surgical devices, surgical procedures have become easier than ever before [20]. Furthermore, in recent years, the laparoscope for hepatectomy has been attracting attention as a means to reduce surgical stress [21]. Such developments are contributing to the increasing use of hepatectomy and the increasing standard age of recipients. However, the optimal age limits remain unclear. In our department, we place emphasis on anesthetic procedures to reduce surgical stress. We perform hepatectomy solely under epidural anesthesia, avoiding general anesthesia (fig. 7) [22]. By avoiding overly stressful surgery in this manner, we have been able to perform major hepatectomy in patients over 90 years old with no postoperative complications.

Fig. 7

Hepatectomy without endotracheal general anesthesia.

Here, we reported two cases of successful treatment for patients over 90 years old, and our cases represent the oldest cases yet described to have undergone major hepatectomy. We think hepatectomy offers survival benefits for carefully selected elderly patients. Case 2 remarked that elderly patients who were afraid of undergoing surgery at her age could be encouraged by her results. We want to emphasize that age is no longer a limit for hepatectomy.