To clarify the clinical features and to select optimal treatment of hepatocellular carcinoma (HCC) in the elderly, 163 patients were divided into the following three groups and retrospectively evaluated: Group O (> or = 70 years of age, 47 cases), Group IM (< 70 and > or = 60 years, 70 cases) and Group Y (< 60 years, 46 cases). There were fewer HBsAg-positive cases and those in clinical stage III in Group O than in Group Y (p < 0.05). Although the percentage of women and small HCCs in Group O were somewhat higher than those in other groups, there were no significant differences among the three groups with regard to sex, size of nodule and time after blood transfusion. Most of the alcohol-abuser were in Group Y (p < 0.05). Some active treatment was possible in 76.6% of the elderly individuals, in 87.1% of the patients of Group IM, and in 78.3% of the Group Y, while few underwent hepatic resections (Group O, 4.3% vs. Group IM, 8.5% vs. Group Y, 8.6%) or PMCT (4.3% vs. 11.4% vs. 8.6%). The allocation of other therapeutic modalities in the three groups were also statistically identical. The prevalence of concomitant diseases was significantly higher in the elderly patients (53%) than in their younger counterparts (Group IM; 30%, Group Y; 28.2%) (p < 0.05). Although the reasons for the paucity of treatment in Group IM and Y (9 and 10 cases) were liver-associated factors (i.e., advanced clinical stage or tumor size), attempts to apply therapeutic measures were abandoned in 11 cases in Group O because of their advanced age (2 cases) or heart failure (1 case). The 5-year survival rate was higher in Group O (55%) than those in Group IM (32%) and Y (26%) (p < 0.01). These results suggest that because of the higher incidence of concomitant diseases, less invasive therapeutic modalities, such as PEI/PMCT, should be recommended for elderly patients with HCC.