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Page 2 of 7 Freedman. Hepatoma Res 2020;6:10 I http://dx.doi.org/10.20517/2394-5079.2019.32

INTRODUCTION
Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide and the fourth most
[1]
common cause of cancer death according to the 2018 WHO report . During the last 30 years, life
expectancy, worldwide, has increased from 63 to 71.7 years with countries such as Japan and South Korea,
as well as those in Western European and Northern America having a life expectancy of 80-84 years in
[2]
2015 . At present, a 70-year-old person in Sweden is expected to live 16.3 more years and a person of 80
[3]
has on average 9.2 years left .
Curative treatment of HCC is foremost surgical. Postoperative complications increase with age. In a UK
study, patients over 75 had a 62% increase in risk of complications and a more than three-fold increased
risk of one-year overall mortality compared to patients younger than 65. For one-year overall mortality,
[5]
[4]
the risk was increased by 349% after surgery for colorectal cancer . Leal et al. investigated the impact
of liver resection for colorectal liver metastases on octogenarians compared to younger patients in a
matched cohort study and found twice the morbidity (19% vs. 9%) and a 90-day mortality of 7% vs. 0%.
[6]
In a recent review by Cho et al. , curative intended treatments for hepatocellular cancer with resection
[5]
or radiofrequency ablation (RFA) was found to be safe in selected patients over the age of 75 , namely
patients who generally had less severe underlying liver disease, were predominantly female and had more
well-differentiated tumours, indicating that there was a clear selection bias when comparing the elderly
with younger HCC patients. With careful selection, excellent results of resection can be achieved [7-9] .
However, with increasing age, comorbidities amass and resective surgery is often not deemed appropriate
and patients can be offered local ablative treatments with RFA instead without having age or comorbidities
affecting outcome [10,11] . In a recent publication, octogenarians undergoing stereotactic RFA for primary liver
tumours were compared to a younger control group using propensity score matching and no significant
[12]
differences in terms of local recurrence, major complications and overall survival were found .
With microwave technology (MWA) entering the scene, with quicker energy delivery and larger ablation
[13]
volumes compared to RFA , the present study aimed to evaluate the results of treating octogenarians with
HCC using MWA in comparison with septuagenarians in a highly specialised centre in northern Europe.

METHODS
We retrospectively analysed all patients undergoing microwave ablation for HCC who were seventy years
or older at first ablation in a single centre specialised in minimally invasive ablative treatments in Sweden,
from June 2010 to December 2018. The collection and publication of data was approved by the regional
ethics committee.

All patients were selected for ablative treatment for their HCC at the regional multidisciplinary team
conference. Patients without cirrhosis or with cirrhosis without portal hypertension were typically firstly
considered for resection, general condition permitting. For the others, with Child-Pugh grade below C and
performance status 0-2 as well as with the possibility of curative treatment and largest tumour diameter
below 30 mm, ablative treatment was the first choice. The diagnosis was based on radiological LIRADS
criteria and not primarily on histology. Microwaves was the energy source of choice for ablative treatment.
Tumour targeting was performed with computer-assisted technologies such as ultrasound fused with
computed tomography (CT) images or with the aid of computer assisted CT-guided navigation technology
(CAS-one, Cascination AG, Bern). Details on the set-up, ablation technique, energy devices and targeting
technologies applied were described previously .
[14]

Patients were followed-up with CT or MRI imaging every three months for one year and according to the
[15]
national surveillance guidelines . Ablation site recurrence was defined as viable tumour tissue detected