Trans-arterial Chemo-embolization Is Safe and Effective for Elderly Advanced Hepatocellular Carcinoma Patients

Results From an International Database

Matan J. Cohen; Izhar Levy; Orly Barak; Allan I. Bloom; Mario Fernández-Ruiz; Massimo Di Maio; Francesco Perrone; Ronnie T. Poon; Daniel Shouval; Thomas Yau; Oren Shibolet


Liver International. 2014;34(7):1109-1117. 

In This Article

Abstract and Introduction


Objective: Hepatocellular carcinoma (HCC) incidence among elderly patients is increasing. Trans-arterial chemo-embolization (TACE) prolongs survival in selected HCC patients. The safety and efficacy of TACE in elderly patients has not been extensively studied. The objective of this study was to assess the safety and efficacy of TACE in elderly patients (older than 75) with HCC.

Design: Combined HCC registries (Spain, Italy, China and Israel) and cohort design analysis of patients who underwent TACE for HCC.

Results: Five hundred and forty-eight patients diagnosed and treated between 1988 and 2010 were included in the analysis (China 197, Italy 155, Israel 102 and Spain 94,). There were 120 patients (22%) older than 75 years and 47 patients (8.6%) older than 80. Median (95% CI) survival estimates were 23 (17–28), 21 (17–26) and 19 (15–23) months (P = 0.14) among patients aged younger than 65, 65–75 and older than 75 respectively. An age above 75 years at diagnosis was not associated with worse prognosis, hazard ratio of 1.05 (95% CI 0.75–1.5), controlling for disease stage, sex, diagnosis year, HBV status and stratifying per database. No differences in complication rates were found between the age groups.

Conclusions: TACE is safe for patients older than 75 years. Results were similar over different eras and geographical locations. Though selection bias is inherent, the results suggest overall adequate selection of patients, given the similar outcomes among the different age groups.


The proportion of elderly patients newly diagnosed with hepatocellular carcinoma (HCC) is increasing, and age-specific incidence rates are estimated to peak above the age of 70 years.[1,2]

Few HCC patients are eligible for curative treatments such as liver resection, liver transplantation or radiofrequency ablation for small tumours. Most patients, therefore, receive palliative treatments including, trans-arterial chemo-embolization (TACE), selective internal radiation therapy, sorafenib or supportive care.

The European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD) guidelines for the treatment of HCC, as well as guidelines published by other professional societies, highlight the importance of patient risk assessment prior to treatment selection including both disease stage and comorbidities. Age per se is not considered to be a contraindication for HCC treatment in any of the guidelines except for eligibility for liver transplantation.[3–7] However, elderly patients may still be expected to experience more adverse effects and enjoy less favourable prognosis compared to younger patients. Indeed, it has been shown that elderly HCC patients are poorer transplantation candidates.[8] Similarly, elderly patients are reported to receive less aggressive treatment plans compared to younger patients with similar disease stages.[9] Still, there is data to suggest that the outcome and prognosis of hepatic resection is similar among elderly and younger patients.[10–13]

To date, there have been only a few publications describing the results of TACE among elderly patients; these data come from diverse geographical regions, including East Asia,[14–17] the Middle East, Europe and the USA.[18–22] The data from these publications suggested that TACE is safe and effective in selected elderly patients with HCC. Nevertheless, the studies were relatively small and heterogeneous.

We sought to provide robust outcome estimates of elderly HCC patients treated with TACE and identify factors effecting prognosis. This information would be relevant for decision makers, physicians and patients. To that end, we collaborated together to form a large data set, combining our repositories. We hypothesized that, controlling for disease stage, the natural history of HCC would be similar and that there would be negligible heterogeneity between our data sets. The collaborative effort would provide the sample size and power enabling confident results and conclusions.