The prognostic nutritional index and tumor pathological characteristics predict the prognosis of elderly patients with early-stage hepatocellular carcinoma after surgery.

The elderly comprises over one-third of hepatocellular carcinoma (HCC) patients, however, they are not adequately represented in prognostic studies. The study aims to determine the prognostic significance of the preoperative prognostic nutritional index (PNI) and develop nomograms for predicting their recurrence-free and overall survival (RFS and OS). The study consisted of 282 elderly patients (aged ≥ 65 years) with early-stage HCC (China Liver Cancer Staging System: I-IIA) after curative resection (R0). They were randomly divided into a training (n = 197) and a test cohort (n = 85). The patients were stratified into two groups: PNI-low (PNI ≤ 49.05) and PNI-high (PNI > 49.05) based on a cut-off value. Most patients' demographics and perioperative outcomes were comparable, while patients in the PNI-high group were younger (P = 0.002), heavier (P < 0.001), and had lower comorbidity rates (P = 0.003). Although the tumor stages were earlier in the PNI-low group (P < 0.001), patients' OS (5-year OS: 48.9% vs. 93.1%) and RFS (5-year RFS: 27.3% vs. 75.7%) were significantly worse compared to the PNI-high group (both P < 0.0001). Patients' OS and RFS nomograms were developed by incorporating independent survival predictors including chronic obstructive pulmonary disease (COPD), age ≥ 75 years, PNI-low, tumor presence of satellite nodules, capsule, and microvascular invasion. The nomograms showed good calibration and discrimination, with all C-indexes ≥ 0.75 and calibration plots essentially coinciding with the diagonal. In conclusion, for elderly HCC patients, COPD, age ≥ 75 years, PNI-low, and tumor presence of satellite nodules, capsule, and microvascular invasion were independent prognostic factors. The nomogram could accurately predict the prognosis of these patients.