Douglas Thorburn, MD, MRCP and Paul J. Marotta, MD, FRCPC, Multi-Organ Transplant Unit, London Health Sciences Centre, University of Western Ontario, London, ON.

Liver transplantation improves survival for selected patients with chronic liver disease, fulminant hepatic failure and hepatocellular carcinoma. There is no absolute upper age limit for liver transplantation and the proportion of patients undergoing liver transplantation who are older than 60 years is increasing. Although the indications for liver transplantation in elderly patients do not differ from those in younger patients, the prevalence of comorbidities that are contraindications to liver transplantation are higher among the elderly. Outcomes after transplantation for selected patients over 60 years of age with Child-Pugh class B cirrhosis who are well nourished and at home are comparable to those for younger patients.
Key words: liver transplantation, fulminant hepatic failure, hepatocellular carcinoma, indications.

Morris Sherman, MB BCh, PhD, FRCP(C)
University of Toronto and,
University Health Network,
Toronto, ON.

Introduction
Although hepatocellular carcinoma (HCC) is not a common cancer in North America, it is the fifth most common cancer in the world.¹ Age standardized incidence rates vary from three per 100,000 in North American men to 80 per 100,000 in China.^1,2 HCC affects people of all ages. However, as with many cancers, the incidence of this disease increases with age, so that the peak incidence is at about age 67-70, (M Sherman, submitted) regardless of the underlying etiology. In Canada, the incidence of HCC is largely driven by three chronic liver diseases: chronic hepatitis B, chronic hepatitis C and alcoholic cirrhosis. In Toronto, hepatitis B is the single most common cause of HCC, accounting for nearly half of all cases, while elsewhere in Ontario hepatitis C and alcohol are the major causes. (M Sherman, submitted)

Prognosis
HCC causes substantial morbidity and mortality. In the absence of early detection programs, most HCC present late, with advanced incurable disease. The reported survival rates for untreated symptomatic HCC varies from 0% at four months to 1% at two years.^3-5 The prognosis for small, untreated HCC--lesions that are the target of surveillance--is not well described. However, two-year survival in excess of 50% is not unusual.