Abstract
PURPOSE: As the global population ages, precise prognostic tools are needed to optimize postoperative care for elderly hepatocellular carcinoma (HCC) patients. This study established a machine learning-driven predictive model to identify key prognostic determinants and evaluate age/surgical approach impacts, overcoming limitations of traditional statistical methods. METHODS: This retrospective study included 252 postoperative HCC patients aged ≥65 years (mean age 69.0±4.3; 68.25% male). Patients were randomly divided into training (70%, n=177) and validation sets (30%, n=75). We evaluated 147 machine learning models to establish the optimal predictive model. Patients were grouped by age (>75 vs ≤75 years) and surgical approach (laparoscopic vs open). RESULTS: The LASSO+RSF model showed strong predictive performance with AUC values of 0.869 and 0.818 in the training and validation sets, respectively. Time-dependent AUCs for 1-, 2- and 3-year survival were 0.874, 0.903, and 0.883 in the training set, and 0.878, 0.882, and 0.915 in the validation set. Key predictors included age-adjusted Charlson index (ACCI, LASSO+RSF synergistic weight (LRSW) =0.160), microvascular invasion (0.111), tumor capsule integrity (0.034), and lymphatic invasion (0.023), while three variables (intraoperative blood loss, tumor margin, WBC) were excluded (LRSW<0.01). A web-based dynamic nomogram (https://cliniometrics.shinyapps.io/LRSF-GeroHCC/) enabled real-time risk stratification. Patients >75 years had longer length of stay (16 vs 14 days, P=0.033), higher Clavien-Dindo scores (P=0.014), higher ACCI scores (5.5 vs 4.0, P=0.002), and lower PFS (16.5 vs 24 months, P=0.041). Laparoscopic surgery was associated with longer operative time (202.5 vs 159.0min, P<0.001), shorter length of stay (14 vs 17days, P<0.001), and lower Clavien-Dindo scores (P=0.038). CONCLUSION: The LASSO+RSF model provides validated tools for personalized prognosis management in elderly HCC patients, emphasizing age-adapted surgical strategies and comorbidity-focused perioperative care.