Combined-Modality Therapy With Radiation and Chemotherapy for Elderly Patients With Glioblastoma in the Temozolomide Era: A National Cancer Database Analysis

Glioblastoma in the oldest old: Clinical characteristics, therapy, and outcome in patients aged 80 years and older

Background

Incidence rates of glioblastoma in very old patients are rising. The standard of care for this cohort is only partially defined and survival remains poor. The aims of this study were to reveal current practice of tumor-specific therapy and supportive care, and to identify predictors for survival in this cohort.

Methods

Patients aged 80 years or older at the time of glioblastoma diagnosis were retrospectively identified in 6 clinical centers in Switzerland and France. Demographics, clinical parameters, and survival outcomes were annotated from patient charts. Cox proportional hazards modeling was performed to identify parameters associated with survival.

Results

Of 107 patients, 45 were diagnosed by biopsy, 30 underwent subtotal resection, and 25 had gross total resection. In 7 patients, the extent of resection was not specified. Postoperatively, 34 patients did not receive further tumor-specific treatment. Twelve patients received radiotherapy with concomitant temozolomide, but only 2 patients had maintenance temozolomide therapy. Fourteen patients received temozolomide alone, 35 patients received radiotherapy alone, 1 patient received bevacizumab, and 1 took part in a clinical trial. Median progression-free survival (PFS) was 3.3 months and median overall survival (OS) was 4.2 months. Among patients who received any postoperative treatment, median PFS was 3.9 months and median OS was 7.2 months. Karnofsky performance status (KPS) ≥70%, gross total resection, and combination therapy were associated with better outcomes. The median time spent hospitalized was 30 days, accounting for 23% of the median OS. End-of-life care was mostly provided by nursing homes (n = 20; 32%) and palliative care wards (n = 16; 26%).

Conclusions

In this cohort of very old patients diagnosed with glioblastoma, a large proportion was treated with best supportive care. Treatment beyond surgery and, in particular, combined modality treatment were associated with longer OS and may be considered for selected patients even at higher ages.

Effect of palliative care decisions making on hospital service use at end-of-life in patients with malignant brain tumors: a retrospective study

BACKGROUND

Palliative care (PC) improves Quality of life and reduces the symptom burden. Aggressive treatments at end of life (EOL) postpone PC. The aim of this single-center retrospective study was to evaluate the timing of the PC decision i.e., termination of cancer-specific treatments and focusing on symptom-centered PC, and its impact on the use of tertiary hospital services at the EOL.

METHODS

A retrospective cohort study on brain tumor patients, who were treated at the Comprehensive Cancer Center of the Helsinki University Hospital from November 1993 to December 2014 and died between January 2013 and December 2014, were retrospectively reviewed. The analysis comprised 121 patients (76 glioblastoma multiforme, 74 males; mean age 62 years; range 26-89). The decision for PC, emergency department (ED) visits and hospitalizations were collected from hospital records.

RESULTS

The PC decision was made for 78% of the patients. The median survival after diagnosis was 16 months (13 months patients with glioblastoma), and after the PC decision, it was 44 days (range 1-293). 31% of the patients received anticancer treatments within 30 days and 17% within the last 14 day before death. 22% of the patients visited an ED, and 17% were hospitalized during the last 30 days of life. Of the patients who had a PC decision made more than 30 days prior to death, only 4% visited an ED or were hospitalized in a tertiary hospital in the last 30 days of life compared to patients with a late (< 30 days prior to death) or no PC decision (25 patients, 36%).

CONCLUSIONS

Every third patient with malignant brain tumors had anticancer treatments during the last month of life with a significant number of ED visits and hospitalizations. Postponing the PC decision to the last month of life increases the risk of tertiary hospital resource use at EOL.

Mortality trends in primary malignant brain and central nervous system tumors vary by histopathology, age, race, and sex

PURPOSE

Primary malignant brain and other central nervous system tumors are rare cancers that have shown rising mortality rates in recent years. To elucidate potential factors involved in this rising death rate, we examined mortality trends for primary malignant BT in the United States stratified by histopathology groupings, age, race, and sex.

METHODS

Mortality rates for demographic factors within primary malignant BT were generated using the National Center for Health Statistics' National Vital Statistics Systems data from 2004 to 2018. Additionally, histopathology-specific incidence-based mortality rates were calculated using the National Cancer Institute's Surveillance, Epidemiology, and End-Results (SEER) 18 data from 2004 to 2018. Joinpoint modeling was used to estimate mortality trends and annual percent changes with corresponding 95% confidence intervals.

RESULTS

Overall, there was a very small increase in mortality from 2004 to 2018. Individuals > 65 years saw a small increase in mortality, while changes in individuals of other ages were non-significant. Asian/Pacific Islander or American Indian/Alaskan Native had the largest increase in mortality. Among histopathology groupings, there was a small mortality increase in adults ages > 65 years with glioblastoma, while the mortality rate of other malignant gliomas declined in the same age group. CNS lymphoma mortality rates in patients ages 15-39 and 40-64 years declined significantly while rising significantly in the > 65 age group. In pediatric patients, embryonal tumor mortality had a non-significant increase between 2004 and 2007 but declined significantly between 2007 and 2018.

CONCLUSION

Examining age, race, sex, and histopathology-specific mortality trends at the population level can provide important information for clinicians, researchers, and aid in public health planning.

Population-level and individual-level explainers for propensity score matching in observational studies

Precis

The exclusion of unmatched observations in propensity score matching has implications for the generalizability of causal effects. Machine learning methods can help to identify how the study population differs from the unmatched subpopulation.

Background

There has been widespread use of propensity scores in evaluating the effect of cancer treatments on survival, particularly in administrative databases and cancer registries. A byproduct of certain matching schemes is the exclusion of observations. Borrowing an analogy from clinical trials, one can view these exclusions as subjects that do not satisfy eligibility criteria.

Methods

Developing identification rules for these “data-driven eligibility criteria” in observational studies on both population and individual levels helps to ascertain the population on which causal effects are being made. This article presents a machine learning method to determine the representativeness of causal effects in two different datasets from the National Cancer Database.

Results

Decision trees reveal that groups with certain features have a higher probability of inclusion in the study population than older patients. In the first dataset, younger age categories had an inclusion probability of at least 0.90 in all models, while the probability for the older category ranged from 0.47 to 0.65. Most trees split once more on an even higher age at a lower node, suggesting that the oldest patients are the least likely to be matched. In the second set of data, both age and surgery status were associated with inclusion.

Conclusion

The methodology presented in this paper underscores the need to consider exclusions in propensity score matching procedures as well as complementing matching with other propensity score adjustments.

Bisdemethoxycurcumin suppresses human brain glioblastoma multiforme GBM 8401 cell migration and invasion via affecting NF-κB and MMP-2 and MMP-9 signaling pathway in vitro

Human glioblastoma (GBM) is one of the common cancer death in adults worldwide, and its metastasis will lead to difficult treatment. Finding compounds for future to develop treatment is urgent. Bisdemethoxycurcumin (BDMC), a natural product, was isolated from the rhizome of turmeric (Curcuma longa), which has been shown to against many human cancer cells. In the present study, we evaluated the antimetastasis activity of BDMC in human GBM cells. Cell proliferation, cell viability, cellular uptake, wound healing, migration and invasion, and western blotting were analyzed. Results indicated that BDMC at 1.5-3 μM significantly decreased the cell proliferation by MTT assay. BDMC showed the highest uptake by cells at 3 h. After treatment of BDMC at 12-48 h significantly inhibited cell motility in GBM 8401 cells by wound healing assay. BDMC suppressed cell migration and invasion at 24 and 48 h treatment by transwell chamber assay. BDMC significantly decreased the levels of proteins associated with PI3K/Akt, Ras/MEK/ERK pathways and resulted in the decrease in the expressions of NF-κB, MMP-2, MMP-9, and N-cadherin, leading to the inhibition of cell migration and invasion. These findings suggest that BDMC may be a potential candidate for the antimetastasis of human GBM cells in the future.

Optimizing Postoperative Adjuvant Therapy in Elderly Patients with Newly Diagnosed Glioblastoma: Single-Institution Audit of Clinical Outcomes from a Tertiary-Care Comprehensive Cancer Center in India

BACKGROUND

There is lack of consensus regarding optimal adjuvant therapy in elderly glioblastoma (GBM). We have been treating elderly (≥60 years) GBM patients with normofractionated or hypofractionated radiotherapy (RT) plus temozolomide (TMZ) based on Karnofsky performance status (KPS). Herein we report clinical outcomes in this cohort treated at our institute using this approach.

METHODS

Medical records of elderly GBM patients (≥60 years) treated between 2013 and 2017 with either normofractionated RT (59.4-60 Gy/30-33 fractions/6-6.5 weeks) or hypofractionated RT (35 Gy/10 fractions/2 weeks) plus TMZ were reviewed retrospectively. Outcomes of interest included progression-free survival (PFS), overall survival (OS), and ≥grade 3 myelotoxicity. Time-to-event outcomes were analyzed with Kaplan-Meier methods, compared using log-rank test, and reported as point estimates with 95% confidence interval (CI).

RESULTS

The normofractionated cohort (n = 126) was characterized by a higher proportion of patients younger than age 65 years, KPS ≥70, methylated O⁶-methylguanine DNA methyltransferase (MGMT), and receiving adjuvant TMZ including extended adjuvant TMZ (>6 cycles) compared with the hypofractionated cohort (n = 20), confirming selection bias. At a median follow-up of 13 months, 1-year Kaplan-Meier estimates of PFS and OS were 43% (95% CI: 36%-52%) and 56% (95% CI: 48%-64%), yielding median PFS and OS of 11.0 months and 13.1 months, respectively. Higher KPS, methylated MGMT, normofractionated RT, and extended adjuvant TMZ emerged as favorable prognostic factors. TMZ was well tolerated with a low risk of ≥grade 3 myelotoxicity.

CONCLUSIONS

Our single-institution clinical audit confirms poor survival in elderly GBM with suboptimal performance status but demonstrates acceptably fair outcomes in patients with preserved KPS comparable with the nonelderly cohort.

Butterfly glioblastoma: Clinical characteristics, treatment strategies and outcomes in a population-based cohort

Background

Butterfly glioblastoma is a rare subgroup of glioblastoma with a bihemispheric tumor crossing the corpus callosum, and is associated with a dismal prognosis. Prognostic factors are previously sparsely described and optimal treatment remains uncertain. We aimed to analyze clinical characteristics, treatment strategies, and outcomes from butterfly glioblastoma in a real-world setting.

Methods

This retrospective population-based cohort study included patients diagnosed with butterfly glioblastoma in Western Norway between 01/01/2007 and 31/12/2014. We enrolled patients with histologically confirmed glioblastoma and patients with a diagnosis based on a typical MRI pattern. Clinical data were extracted from electronic medical records. Molecular and MRI volumetric analyses were retrospectively performed. Survival analyses were performed using the Kaplan–Meier method and Cox proportional hazards regression models.

Results

Among 381 patients diagnosed with glioblastoma, 33 patients (8.7%) met the butterfly glioblastoma criteria. Median overall survival was 5.5 months (95% CI 3.1–7.9) and 3-year survival was 9.1%. Hypofractionated radiation therapy with or without temozolomide was the most frequently used treatment strategy, given to 16 of the 27 (59.3%) patients receiving radiation therapy. Best supportive care was associated with poorer survival compared with multimodal treatment [adjusted hazard ratio 5.11 (95% CI 1.09–23.89)].

Conclusion

Outcome from butterfly glioblastoma was dismal, with a median overall survival of less than 6 months. However, long-term survival was comparable to that observed in non-butterfly glioblastoma, and multimodal treatment was associated with longer survival. This suggests that patients with butterfly glioblastoma may benefit from a more aggressive treatment approach despite the overall poor prognosis.

Real-world evaluation of the impact of radiotherapy and chemotherapy in elderly patients with glioblastoma based on age and performance status

Background

This retrospective study investigated the impact of, in addition to age, the management and outcomes of elderly patients with glioblastoma (GBM).

Methods

The National Cancer Database was queried between 2004 and 2015 for GBM patients age 60 years and older. Three age groups were created: 60 to 69, 70 to 79, and 80 years and older, and 4 age/KPS groups: "age ≥ 60/ KPS < 70" (group 1), "age 60 to 69/KPS ≥ 70" (group 2), "age 70 to 79/KPS ≥ 70" (group 3), and "age ≥ 80/KPS ≥ 70" (group 4). Multivariable (MVA) modeling with Cox regression determined predictors of survival (OS), and estimated average treatment effects analysis was performed.

Results

A total of 48 540 patients with a median age of 70 years (range, 60-90 years) at diagnosis, and a median follow-up of 6.8 months (range, 0-151 months) were included. Median survival was 5.0, 15.2, 9.6, and 6.8 months in groups 1, 2, 3, and 4, respectively (P < .001). On treatment effects analysis, all groups survived longer with combined chemotherapy (ChT) and radiation therapy (RT), except group 1, which survived longer with ChT alone (P < .001). RT alone was associated with the worst OS in all groups (P < .01). Across all groups, predictors of worse OS on MVA were older age, lower KPS, White, higher comorbidity score, worse socioeconomic status, community treatment, tumor multifocality, subtotal resection, and no adjuvant treatment (all P < .01).

Conclusions

In elderly patients with newly diagnosed GBM, those with good KPS fared best with combined ChT and RT across all age groups. Performance status is a key prognostic factor that should be considered for management decisions in these patients.

Treatment approach and survival from glioblastoma: results from a population-based retrospective cohort study from Western Norway

OBJECTIVES

To evaluate treatment and survival from glioblastoma in a real-world setting.

DESIGN AND SETTINGS

A population-based retrospective cohort study from Western Norway.

PARTICIPANTS

363 patients aged 18 years or older diagnosed with glioblastoma between 1 January 2007 and 31 December 2014.

PRIMARY AND SECONDARY OUTCOME MEASURES

Overall survival and survival rates determined by Kaplan-Meier method, groups compared by log-rank test. Associations between clinical characteristics and treatment approach assessed by logistic regression. Associations between treatment approach and outcome analysed by Cox regression.

RESULTS

Median overall survival was 10.2 months (95% CI 9.1 to 11.3). Resection was performed in 221 patients (60.9%), and was inversely associated with age over 70 years, higher comorbidity burden, deep-seated tumour localisation and multifocality. Median survival was 13.7 months (95% CI 12.1 to 15.4) in patients undergoing tumour resection, 8.3 months (95% CI 6.6 to 9.9) in patients undergoing biopsy and 4.5 months (95% CI 4.0 to 5.1) in patients where no surgical intervention was performed. Chemoradiotherapy according to the Stupp protocol was given to 157 patients (43%). Age over 70 years, higher comorbidity burden and cognitive impairment were associated with less intensive chemoradiotherapy. Median survival was 16.3 months (95% CI 14.1 to 18.5), 7.9 months (95% CI 6.7 to 9.0) and 2.0 months (95% CI 0.9 to 3.2) in patients treated according to the Stupp protocol, with less intensive chemoradiotherapy and with best supportive care, respectively. Surgical resection (HR 0.61 (95% CI 0.47 to 0.79)) and chemoradiotherapy according to the Stupp protocol (HR 0.09 (95% CI 0.06 to 0.15)) were strongly associated with favourable overall survival, when adjusted for clinical variables.

CONCLUSIONS

In a real-world setting, less than half of the patients received full-course chemoradiotherapy, with a median survival comparable to results from clinical trials. Survival was considerably worse in patients receiving less intensive treatment. Our results point out a substantial risk of undertreating glioblastoma, especially in elderly patients.

Comparative Effectiveness of Proton vs Photon Therapy as Part of Concurrent Chemoradiotherapy for Locally Advanced Cancer

Importance

Concurrent chemoradiotherapy is the standard-of-care curative treatment for many cancers but is associated with substantial morbidity. Concurrent chemoradiotherapy administered with proton therapy might reduce toxicity and achieve comparable cancer control outcomes compared with conventional photon radiotherapy by reducing the radiation dose to normal tissues.

Objective

To assess whether proton therapy in the setting of concurrent chemoradiotherapy is associated with fewer 90-day unplanned hospitalizations (Common Terminology Criteria for Adverse Events, version 4 [CTCAEv4], grade ≥3) or other adverse events and similar disease-free and overall survival compared with concurrent photon therapy and chemoradiotherapy.

Design, Setting, and Participants

This retrospective, nonrandomized comparative effectiveness study included 1483 adult patients with nonmetastatic, locally advanced cancer treated with concurrent chemoradiotherapy with curative intent from January 1, 2011, through December 31, 2016, at a large academic health system. Three hundred ninety-one patients received proton therapy and 1092, photon therapy. Data were analyzed from October 15, 2018, through February 1, 2019.

Interventions

Proton vs photon chemoradiotherapy.

Main Outcomes and Measures

The primary end point was 90-day adverse events associated with unplanned hospitalizations (CTCAEv4 grade ≥3). Secondary end points included Eastern Cooperative Oncology Group (ECOG) performance status decline during treatment, 90-day adverse events of at least CTCAEv4 grade 2 that limit instrumental activities of daily living, and disease-free and overall survival. Data on adverse events and survival were gathered prospectively. Modified Poisson regression models with inverse propensity score weighting were used to model adverse event outcomes, and Cox proportional hazards regression models with weighting were used for survival outcomes. Propensity scores were estimated using an ensemble machine-learning approach.

Results

Among the 1483 patients included in the analysis (935 men [63.0%]; median age, 62 [range, 18-93] years), those receiving proton therapy were significantly older (median age, 66 [range, 18-93] vs 61 [range, 19-91] years; P < .01), had less favorable Charlson-Deyo comorbidity scores (median, 3.0 vs 2.0; P < .01), and had lower integral radiation dose to tissues outside the target (mean [SD] volume, 14.1 [6.4] vs 19.1 [10.6] cGy/cc × 107; P < .01). Baseline grade ≥2 toxicity (22% vs 24%; P = .37) and ECOG performance status (mean [SD], 0.62 [0.74] vs 0.68 [0.80]; P = .16) were similar between the 2 cohorts. In propensity score weighted-analyses, proton chemoradiotherapy was associated with a significantly lower relative risk of 90-day adverse events of at least grade 3 (0.31; 95% CI, 0.15-0.66; P = .002), 90-day adverse events of at least grade 2 (0.78; 95% CI, 0.65-0.93; P = .006), and decline in performance status during treatment (0.51; 95% CI, 0.37-0.71; P < .001). There was no difference in disease-free or overall survival.

Conclusions and Relevance

In this analysis, proton chemoradiotherapy was associated with significantly reduced acute adverse events that caused unplanned hospitalizations, with similar disease-free and overall survival. Prospective trials are warranted to validate these results.

Sex-specific aspects of epidemiology, molecular genetics and outcome: primary brain tumours

Recent years have seen a great interest in sex-specific aspects of many diseases, including cancer, in part because of the assumption that females have often not been adequately represented in early drug development and determination of safety, tolerability and efficacy in clinical trials. Brain tumours represent a highly heterogeneous group of neoplastic diseases with strong variation of incidence by age, but partly also by sex. Most gliomas are more common in men whereas meningiomas, the most common primary intracranial tumours, are more common in females. Potential sex-specific genetic risk factors and specific sex biology have been reported in a tumour-specific manner. Several small studies have indicated differences in tolerability and safety of, as well as benefit from, treatment by sex, but no conclusive data have been generated. Exploring sex-specific aspects of neuro-oncology should be studied more systematically and in more depth in order to uncover the biological reasons for known sex differences in this disease.

Pineal Region Glioblastomas: Clinical Characteristics, Treatment, and Survival Outcome

OBJECTIVE

Given the rarity of patients with pineal glioblastoma (GBM), clinical characteristics, treatment, and prognostic factors are not well characterized. This study aimed to investigate these characteristics and identify the prognostic factors of overall survival (OS).

METHODS

A retrospective analysis of newly diagnosed patients with pineal GBM, including our 3 cases and an additional 44 cases from published articles, was conducted. Survival analysis was performed by Kaplan-Meier analysis and Cox regression analysis was used to determine the prognostic factors.

RESULTS

A total of 47 patients (28 males and 19 females) were enrolled, with a median age of 46 years (range, 5-74 years). Forty-four patients (90.9%) had preoperative obstructive hydrocephalus. Among 38 patients, 21 (55.3%) had distal leptomeningeal dissemination. Forty-five patients (95.7%) had resection/biopsy, 6 of whom had gross total resection, 22 had subtotal resection, 7 had partial resection, and 10 had biopsy. Adjuvant therapy included radiotherapy in 36 patients and chemotherapy in 27 patients. The median OS was 10.0 months. The 6-month, 1-year, and 2-year survival was 68.0%, 42.6%, and 17.0%, respectively. Cox regression analysis showed that patients receiving biopsy (P = 0.042) or chemotherapy (P = 0.029) had the better OS and these were regarded as independent prognostic factors. Further survival analysis showed that chemoradiotherapy had better survival benefit than other regimens.

CONCLUSIONS

In this study, we summarized the characteristics of patients with pineal GBM and showed the correlation between clinical characteristics and prognosis. This study may give readers a deep understanding of these rare GBMs and provide some references for future management.

Longer-term (≥ 2 years) survival in patients with glioblastoma in population-based studies pre- and post-2005: a systematic review and meta-analysis

Translation of survival benefits observed in glioblastoma clinical trials to populations and to longer-term survival remains uncertain. We aimed to assess if ≥ 2-year survival has changed in relation to the trial of radiotherapy plus concomitant and adjuvant temozolomide published in 2005. We searched MEDLINE and Embase for population-based studies with ≥ 50 patients published after 2002 reporting survival at ≥ 2 years following glioblastoma diagnosis. Primary endpoints were survival at 2-, 3- and 5-years stratified by recruitment period. We meta-analysed survival estimates using a random effects model stratified according to whether recruitment ended before 2005 (earlier) or started during or after 2005 (later). PROSPERO registration number CRD42019130035. Twenty-three populations from 63 potentially eligible studies contributed to the meta-analyses. Pooled 2-year overall survival estimates for the earlier and later study periods were 9% (95% confidence interval [CI] 6-12%; n/N = 1,488/17,507) and 18% (95% CI 14-22%; n/N = 5,670/32,390), respectively. Similarly, pooled 3-year survival estimates increased from 4% (95% CI 2-6%; n/N = 325/10,556) to 11% (95% CI 9-14%; n/N = 1900/16,397). One study with a within-population comparison showed similar improvement in survival among the older population. Pooled 5-year survival estimates were 3% (95% CI 1-5%; n/N = 401/14,919) and 4% (95% CI 2-5%; n/N = 1,291/28,748) for the earlier and later periods, respectively. Meta-analyses of real-world data suggested a doubling of 2- and 3-year survival in glioblastoma patients since 2005. However, 5-year survival remains poor with no apparent improvement. Detailed clinically annotated population-based data and further molecular characterization of longer-term survivors may explain the unchanged survival beyond 5 years.

Surgical treatment and survival outcome of patients with adult thalamic glioma: a single institution experience of 8 years

PURPOSE

Given the rarity in the population with adult thalamic gliomas (ATGs), comprehensive characteristics, treatments and survival outcome are not well characterized. This study was conducted to investigate the comprehensive characteristic and treatment of ATGs and identify the prognostic factors associated with overall survival (OS).

METHODS

A retrospective analysis of newly diagnosed ATGs who underwent surgical resection consecutively was conducted. Survival analysis of OS was performed by Kaplan-Meier analysis. Cox proportional hazard model was used to investigate the possible prognostic factors associated with OS.

RESULTS

A total of 102 patients with ATG were enrolled in this study. The median age was 41 years (range 18-68 years). There were 56 (54.9%) males. Sixty-two patients (60.8%) had glioblastoma (GBM). Among these patients, 46 patients (45.1%) had GTR/NTR, 50 patients (49.0%) had STR and 6 patients (5.9%) had PR. Postoperatively, 71.6% of these patients received adjuvant therapy. The median OS was 13.6 months (range 1 week-75 months). COX regression analysis revealed that ATG patients with longer duration of symptoms (p = 0.024), better pre-KPS (p = 0.045), maximal resection (p = 0.013), or lower tumor grade (p = 0.002) had longer OS, and these predictors are considered as independent prognostic factors. Survival analysis showed that ATGs with GTR/NTR plus chemoradiotherapy had significant OS advantage compared with other treatment regimens.

CONCLUSIONS

This study comprehensively summarized the characteristics, treatments and survival outcomes of ATGs in the largest sample size. Maximal surgical resection can bring survival benefit. Combined-modality therapy regimen of GTR/NTR plus chemoradiotherapy may be better beneficial for OS than other regimens.

Optimal adjuvant therapy in elderly glioblastoma: results from a systematic review and network meta-analysis

BACKGROUND

There exists lack of consensus worldwide regarding the most optimal adjuvant therapy regimen in elderly patients with newly-diagnosed glioblastoma (GBM).

PURPOSE

To identify the most optimal adjuvant therapy regimen in elderly GBM patients through systematic review and network meta-analysis.

METHODS

Prospective trials randomly assigning elderly GBM patients post-operatively to any adjuvant therapy regimen were included. The primary outcome measure was overall survival. Numbers of events, patients at-risk, and censored patients for survival were estimated from Kaplan-Meier survival curves in the interval of 0-12 months. The total person-time at risk and the mortality × 100 person-months was also estimated. The relative ranking probability of each treatment and rankograms were used to estimate the hierarchy of each intervention in terms of overall survival. The mean rank values and the surface under the cumulative ranking (SUCRA) curves were also calculated.

RESULTS

A systematic literature search identified 1278 abstracts, that were screened to retrieve full-text manuscripts of potentially eligible articles. After detailed assessment, data from 1569 patients in 7 randomized controlled trials (RCTs) treated with one of following regimens was extracted and analyzed: normofractionated radiotherapy (RT) delivered over 5.5-6 weeks; moderately hypofractionated RT (2-3 weeks) either alone or in combination with temozolomide or bevacizumab; extremely hypofractionated RT (1-week); temozolomide monotherapy; and best supportive care alone. In terms of overall survival, moderately hypofractionated RT (3-weeks) with concurrent and adjuvant temozolomide emerged as the best and second-best adjuvant therapy option with 81% probability and 99.1% probability respectively. Using SUCRA, the surface area for moderately hypofractionated RT (3-weeks) with concurrent and adjuvant temozolomide reached almost 100%, confirming it as the best intervention. As expected, best supportive care alone was ranked as the worst treatment strategy.

CONCLUSION

Moderately hypofractionated RT (3-weeks) with concurrent and adjuvant temozolomide is the most optimal and preferred adjuvant therapeutic regimen in elderly GBM.

Interstitial high-dose-rate brachytherapy in the primary treatment of inoperable glioblastoma multiforme

Purpose

To report our results of image-guided interstitial (IRT) high-dose-rate (HDR) brachytherapy (BRT) in the primary treatment of patients with inoperable glioblastoma multiforme (GBM) in the pre-temozolomide period.

Material and methods

Between 1994 and 2004, 17 patients were treated with HDR BRT for inoperable GBM. Of those, only 11 patients were treated with IRT BRT, and the remaining six patients received combined IRT BRT and external beam radiotherapy (EBRT). Patient’s median age was 59.3 years (range, 29-83 years) and median tumor volume was 39.3 cm³ (range, 2-162 cm³). The prescribed HDR dose was median 40 Gy (range, 30-40 Gy), delivered twice daily in 5.0 Gy fractions over four consecutive days. Survival from BRT, toxicity as well as the impact of several prognostic factors was evaluated.

Results

At a median follow-up of 9.3 months, the median overall survival for the whole population, after BRT alone, and combined BRT with EBRT was 9.3, 7.3, and 10.1 months, respectively. Of the prognostic variables evaluated in univariate analysis, i.e., age, Karnofsky performance score, BRT dose, and tumor volume, only the latter one reached statistical significance. Two patients (11.7%) developed treatment-associated adverse events, with one (5.8%) symptomatic radionecrosis and one (5.8%) severe convulsion episode, respectively.

Conclusions

For patients with inoperable GBM, IRT HDR BRT alone or in combination with EBRT is a safe and effective irradiation method providing palliation without excessive toxicity.

Between-hospital variation in mortality and survival after glioblastoma surgery in the Dutch Quality Registry for Neuro Surgery

Purpose

Standards for surgical decisions are unavailable, hence treatment decisions can be personalized, but also introduce variation in treatment and outcome. National registrations seek to monitor healthcare quality. The goal of the study is to measure between-hospital variation in risk-standardized survival outcome after glioblastoma surgery and to explore the association between survival and hospital characteristics in conjunction with patient-related risk factors.

Methods

Data of 2,409 adults with first-time glioblastoma surgery at 14 hospitals were obtained from a comprehensive, prospective population-based Quality Registry Neuro Surgery in The Netherlands between 2011 and 2014. We compared the observed survival with patient-specific risk-standardized expected early (30-day) mortality and late (2-year) survival, based on age, performance, and treatment year. We analyzed funnel plots, logistic regression and proportional hazards models.

Results

Overall 30-day mortality was 5.2% and overall 2-year survival was 13.5%. Median survival varied between 4.8 and 14.9 months among hospitals, and biopsy percentages ranged between 16 and 73%. One hospital had lower than expected early mortality, and four hospitals had lower than expected late survival. Higher case volume was related with lower early mortality (P = 0.031). Patient-related risk factors (lower age; better performance; more recent years of treatment) were significantly associated with longer overall survival. Of the hospital characteristics, longer overall survival was associated with lower biopsy percentage (HR 2.09, 1.34–3.26, P = 0.001), and not with academic setting, nor with case volume.

Conclusions

Hospitals vary more in late survival than early mortality after glioblastoma surgery. Widely varying biopsy percentages indicate treatment variation. Patient-related factors have a stronger association with overall survival than hospital-related factors.

Electronic supplementary material

The online version of this article (10.1007/s11060-019-03229-5) contains supplementary material, which is available to authorized users.

PTEN expression by an oncolytic herpesvirus directs T-cell mediated tumor clearance

Engineered oncolytic viruses are used clinically to destroy cancer cells and have the ability to boost anticancer immunity. Phosphatase and tensin homolog deleted on chromosome 10 loss is common across a broad range of malignancies, and is implicated in immune escape. The N-terminally extended isoform, phosphatase and tensin homolog deleted on chromosome 10 alpha (PTENα), regulates cellular functions including protein kinase B signaling and mitochondrial adenosine triphosphate production. Here we constructed HSV-P10, a replicating, PTENα expressing oncolytic herpesvirus, and demonstrate that it inhibits PI3K/AKT signaling, increases cellular adenosine triphosphate secretion, and reduces programmed death-ligand 1 expression in infected tumor cells, thus priming an adaptive immune response and overcoming tumor immune escape. A single dose of HSV-P10 resulted in long term survivors in mice bearing intracranial tumors, priming anticancer T-cell immunity leading to tumor rejection. This implicates HSV-P10 as an oncolytic and immune stimulating therapeutic for anticancer therapy.

Oncolytic viruses are a promising therapeutic approach for cancer treatment. The authors demonstrate the efficacy of an engineered HSV-1 expressing PTENα as an oncolytic and immune stimulating therapy against brain cancer metastases.

Impact of gender on the survival of patients with glioblastoma

Background: Preclinical models have suggested a role for sex hormones in the development of glioblastoma multiforme (GBM). However, the impact of gender on the survival time of patients with GBM has not been fully understood. The objective of the present study was to clarify the association between gender and survival of patients with GBM by analyzing population-based data.Methods: We searched the Surveillance, Epidemiology, and End-Results database who were diagnosed with GBM between 2000 and 2008 and were treated with surgery. Five-year cancer specific survival data were obtained. Kaplan-Meier methods and multivariable Cox regression models were used to analyze long-term survival outcomes and risk factors.Results: A total of 6586 patients were identified; 61.5% were men and 38.5% were women. The 5-year cancer-specific survival (CSS) rates in the male and female groups were 6.8% and 8.3%, respectively (P=0.002 by univariate and P<0.001 by multivariate analysis). A stratified analysis showed that male patients always had the lowest CSS rate across localized cancer stage and different age subgroups.Conclusions: Gender has prognostic value for determining GBM risk. The role of sex hormones in the development of GBM warrants further investigation.

Survival in elderly glioblastoma patients treated with bevacizumab-based regimens in the United States

BACKGROUND

The efficacy of bevacizumab (BEV) in elderly patients with glioblastoma remains unclear. We evaluated the effect of BEV on survival in this patient population using the Survival, Epidemiology, and End Results (SEER)-Medicare database.

METHODS

This retrospective, cohort study analyzed SEER-Medicare data for patients (aged ≥66 years) diagnosed with glioblastoma from 2006 to 2011. Two cohorts were constructed: one comprised patients who had received BEV (BEV cohort); the other comprised patients who had received any anticancer treatment other than BEV (NBEV cohort). The primary analysis used a multivariate Cox proportional hazards model to compare overall survival in the BEV and NBEV cohorts with initiation of BEV as a time-dependent variable, adjusting for potential confounders (age, gender, Charlson comorbidity index, region, race, radiotherapy after initial surgery, and diagnosis of coronary artery disease). Sensitivity analyses were conducted using landmark survival, propensity score modeling, and the impact of poor Karnofsky Performance Status.

RESULTS

We identified 2603 patients (BEV, n = 597; NBEV, n = 2006). In the BEV cohort, most patients were Caucasian males and were younger with fewer comorbidities and more initial resections. In the primary analysis, the BEV cohort showed a lower risk of death compared with the NBEV cohort (hazard ratio, 0.80; 95% confidence interval, 0.72-0.89; P < .01). The survival benefit of BEV appeared independent of the number of temozolomide cycles or frontline treatment with radiotherapy and temozolomide.

CONCLUSION

BEV exposure was associated with a lower risk of death, providing evidence that there might be a potential benefit of BEV in elderly patients with glioblastoma.

Treatment and survival of glioblastoma patients in Denmark: The Danish Neuro-Oncology Registry 2009-2014

BACKGROUND

As many glioblastoma patients are in a poor condition they are unable to undergo the full treatment documented in clinical trials. We aimed to examine the survival and its relationship to clinical characteristics and treatment in a nationwide population of glioblastoma patients in Denmark.

METHODS

We included prospectively recorded clinical data from 1364 adult patients with histologically verified glioblastoma from the Danish Neuro-Oncology Registry, 2009-2014.

RESULTS

The age standardized incidence rate was 6.3/100,000 person-years for males and 3.9 for females and the median age was 66 years. The median overall survival was 11.2 months. There was an independently significant prognostic effect of age, performance status, cognitive symptoms, tumor diameter, multifocality, crossing midline, and contrast enhancement. For partial and total resection compared to biopsy only, the adjusted risk of dying was reduced by 43% (HR [CI] 0.57 [0.48-0.68]) and 51% (0.49 [0.40-0.60]), respectively. For patients receiving a partial and full radiochemotherapy regimen compared to no postsurgical treatment, the risk reduction was 56% (HR [CI] 0.44 [0.37-0.53]) and 70% (0.30 [0.25-0.35]), respectively. The full radiochemotherapy regimen was only allocated to 50% of the patients, 29% among the oldest (70+ years) and 60% among the younger (18-69 years).

CONCLUSIONS

Glioblastoma patients had a poor overall survival but with several specific independent prognostic factors. Extensive cancer treatment was associated with an increasing survival in all age groups, but only half of the patients were sufficiently fit for a full regimen of postoperative combined radiochemotherapy.

Human papilloma virus: global research architecture assessed by density-equalizing mapping

Human papilloma virus (HPV) infection is linked to cervical cancer, which represents the world's fourth most common cancer in women. So far, no detailed map of the worldwide HPV research architecture has been constructed. Hence, this study focuses on the chronological development and geographical distribution of the global HPV-specific publications and evaluates citation-based parameters as well as socioeconomic features of the publishing countries. In total, 29,330 HPV-related publications were identified. The US was the leading country with 12,270 publications. Only high-income-countries were found in the ranking of the fifteen most active countries with Germany, France, and Japan among the top five. Analysis of HPV research activity in relation to the economic strength demonstrated a lead position of Finland and Sweden with an average of 2248.78 and 1924.67 HPV-related publications per GDP in 1000 bn US-$, respectively. The most active upper-middle-income country was Mexico (416.78 HPV-related publications per GDP in 1000 bn US-$). India as lower-middle-income country reached a value of 279.78 HPV-related publications per GDP in 1000 bn US-$. Collaboration analysis pointed to the US as the center of the 4517 international HPV collaborations. The worldwide HPV-research landscape is dominated by North American and Western European countries. By contrast, a high prevalence of HPV-related cervical cancer is documented for low-income countries. Hence, HPV-related public health interventions and prevention research specifically tailored to these countries needs to be fostered by monetary support and international collaborations.

Glioblastoma in elderly patients: solid conclusions built on shifting sand?

Management of glioblastoma in the elderly population is challenging. In the near future, more than half of patients with this tumor will be over the age of 65. Clinicians have been historically reluctant to treat such patients with the same intensity as younger patients. Due to upper age limits or poor accrual of elderly patients in clinical trials, randomized data for this patient population have been relatively sparse until recently. In this review, we will discuss the concept of an elderly patient population, describe evidence for molecular differences in glioblastoma of elderly versus young patients, evaluate recent first-line trials studying glioblastoma in elderly patients, and discuss best therapeutic practices including the value of molecular testing.

Management and Outcomes in the Oldest-Old Population with Glioblastoma

OBJECTIVES

Glioblastoma is a lethal disease in the elderly population. We aimed to evaluate disease and treatment outcomes in the oldest-old patients.

METHODS

Patients >80 years old with histologically confirmed glioblastoma treated between 2004 and 2009 were identified. We included patients managed with best supportive care (BSC), temozolomide (TMZ) alone, radiotherapy (RT) alone, or concomitantly with TMZ (CRT). Survival outcomes were analyzed using the Kaplan-Meier method.

RESULTS

Ultimately, 48 patients were analyzed. Median age and Eastern Cooperative Oncology Group (ECOG) Performance Status were 82 years and 2, respectively. The median Age-Adjusted Charlson Index (AAC) was 6. Gross total and subtotal resections were performed in 16.7% and 18.8% of patients, respectively. Biopsy followed by RT alone was the treatment modality for 23/48 (47.9%), while 17/48 (35.4%) received surgery followed by RT alone or CRT. A total of 8 (16.7%) were managed with BSC after biopsy. Median overall survival (OS) and progression-free survival (PFS) were 4.1 (95% confidence interval [95% CI] 3.3-4.9) and 2.7 (95% CI 1.5-3.9) months, respectively. Improved median OS was observed in those treated with surgical resection followed by RT alone or CRT (7.1 months), compared to biopsy followed by RT alone (4.2 months) or BSC (2.0 months; p=0.002). Surgical resection, age≤85, and AAC<6 were associated with better OS (p=0.032, p=0.031, and p=0.02, respectively). Cause of death was neurological progression in 56% of cases. RT was well-tolerated.

CONCLUSIONS

PFS and OS outcomes remain poor in the oldest-old patients (>80 years old). Younger age, lower AAC, surgical resection, and adjuvant treatment were associated with improved OS.

Utilization of hypofractionated radiotherapy in treatment of glioblastoma multiforme in elderly patients not receiving adjuvant chemoradiotherapy: A National Cancer Database Analysis

To assess the utilization and outcomes of adjuvant monotherapy with hypofractionated radiation (RT) among elderly patients not receiving traditional adjuvant chemoradiotherapy (cRT) for glioblastoma multiforme (GBM). A retrospective analysis using the National Cancer Data Base with GBM patients aged 65 years or older treated between 2005 and 2012 was conducted. Patients who underwent hypofractionated RT (40 Gy), conventional RT (60 Gy), chemotherapy, or best supportive care alone were included. Statistical methods included logistic regression for utilization and Cox regression for survival analysis. A total of 9556 patients were analyzed. On multivariate analysis (compared to those receiving conventional RT), patients more likely to be treated with hypofractionated RT were older (75-84 years old OR 2.05; p < 0.01 and ≥ 85 years old OR 3.32; p < 0.01), with a Charlson/Deyo score of 2 or higher (OR 1.80; p = 0.05), from communities > 50 miles from their treatment facility (50-100 miles OR 8.03; p < 0.01 and > 100 miles OR 7.16; p < 0.01), treated at an Academic/Research facility (OR 2.85; p = 0.04), and diagnosed between 2011 and 2012 (OR 4.15; p < 0.01). On Cox regression, hypofractionated RT (HR 0.65; p < 0.01), conventional RT (HR 0.60; p < 0.01), and chemotherapy alone (HR 0.69; p < 0.01) were all associated with decreased risk of death compared to no adjuvant therapy. Among patients receiving adjuvant treatment, utilization of hypofractionated RT increased from 7 to 19% during the study period. Among elderly patients with GBM not receiving cRT, the utilization of adjuvant monotherapy with hypofractionated RT has increased over time. Retrospective evidence suggests it may be better than best supportive care alone and as good as conventionally fractionated RT alone.

Addition of chemotherapy to hypofractionated radiotherapy for glioblastoma: practice patterns, outcomes, and predictors of survival

This study evaluated practice patterns, outcomes, and predictors of survival with respect to the addition of chemotherapy to definitive hypofractionated radiation therapy (HFRT) for glioblastoma in a general patient population. The National Cancer Data Base was queried for patients diagnosed with glioblastoma between 2005 and 2012 that received definitive HFRT with or without chemotherapy. Patient, tumor, and treatment parameters were extracted. Statistics included Kaplan-Meier analysis to evaluate overall survival (OS) as well as Cox proportional hazards modeling to determine variables associated with receipt of chemotherapy and OS. Propensity score matching was performed in order to assess groups in a balanced manner while reducing indication biases. 693 patients met the inclusion criteria, of which 297 (42.9%) received HFRT alone, while 396 (57.1%) received chemotherapy and radiation therapy. Median follow-up was 5.2 months. Factors independently associated with chemotherapy delivery included age ≤ 65, methylated MGMT, and Asian race. Chemotherapy use was associated with improved median OS (6.8 vs. 4.3 months, p < 0.001). This persisted in both age groups of age ≤ 65 (8 vs. 4.4 months, p < 0.001) and > 65 years (6.1 vs. 4.3 months, p = 0.002) as well as on propensity-matched analysis (6.0 vs. 4.3 months, p < 0.001). In this patient population, novel independent predictors of OS were identified, which included the addition of chemotherapy (p < 0.001), receipt of surgery other than biopsy (both p < 0.05), and treatment at an academic institution (p = 0.002). Addition of chemotherapy to definitive HFRT was associated with improved OS in patients ≤ 65 and > 65 years of age. Chemotherapy was an independent predictor of OS, along with receipt of surgery and treatment at an academic institution.

Recurrent glioblastomas in the elderly after maximal first-line treatment: does preserved overall condition warrant a maximal second-line treatment?

A growing literature supports maximal safe resection followed by standard combined chemoradiotherapy (i.e. maximal first-line therapy) for selected elderly glioblastoma patients. To assess the prognostic factors from recurrence in elderly glioblastoma patients treated by maximal safe resection followed by standard combined chemoradiotherapy as first-line therapy. Multicentric retrospective analysis comparing the prognosis and optimal oncological management of recurrent glioblastomas between 660 adult patients aged of < 70 years (standard group) and 117 patients aged of ≥70 years (elderly group) harboring a supratentorial glioblastoma treated by maximal first-line therapy. From recurrence, both groups did not significantly differ regarding Karnofsky performance status (KPS) (p = 0.482). Oncological treatments from recurrence significantly differed: patients of the elderly group received less frequently oncological treatment from recurrence (p < 0.001), including surgical resection (p < 0.001), Bevacizumab therapy (p < 0.001), and second line chemotherapy other than Temozolomide (p < 0.001). In multivariate analysis, Age ≥70 years was not an independent predictor of overall survival from recurrence (p = 0.602), RTOG-RPA classes 5-6 (p = 0.050) and KPS at recurrence <70 (p < 0.001), available in all cases, were independent significant predictors of shorter overall survival from recurrence. Initial removal of ≥ 90% of enhancing tumor (p = 0.004), initial completion of the standard combined chemoradiotherapy (p = 0.007), oncological treatment from recurrence (p < 0.001), and particularly surgical resection (p < 0.001), Temozolomide (p = 0.046), and Bevacizumab therapy (p = 0.041) were all significant independent predictors of longer overall survival from recurrence. Elderly patients had substandard care from recurrence whereas age did not impact overall survival from recurrence contrary to KPS at recurrence <70. Treatment options from recurrence should include repeat surgery, second line chemotherapy and anti-angiogenic agents.

Hypofractionated short-course radiotherapy in elderly patients with glioblastoma multiforme: an analysis of the National Cancer Database

For elderly patients with glioblastoma multiforme (GBM), randomized trials have shown similar survival with hypofractionated short-course radiotherapy (SCRT) compared to conventionally fractionated long-course radiotherapy (LCRT). We evaluated the adoption of SCRT along with associated factors and survival in a national patient registry. Using the National Cancer Data Base (NCDB), we identified patients aged ≥70 years with GBM, diagnosed between 1998 and 2011, who received SCRT (34-42 Gy in 2.5-3.4 Gy fractions), or LCRT (58-63 Gy in 1.8-2.0 Gy fractions). Crude and adjusted hazard ratios (HR) were calculated using Cox regression modeling. 4598 patients were identified, 304 (6.6%) in the SCRT group and 4294 (93.4%) in the LCRT group. Median follow-up was 8.4 months. Median age was 78 versus 75 years, respectively (P < 0.0001). Patients who received SCRT had higher Charlson-Deyo comorbidity scores versus LCRT (score of ≥2: 16.9% vs. 10.8%, respectively; P = 0.006), and were more likely to be female (53.0% vs. 44.6%, P = 0.005). Patients who received SCRT were less likely to undergo chemotherapy (42.8% vs. 79.3%, P < 0.0001), more likely to undergo biopsy only (34.5% vs. 19.5%, P < 0.0001), and more likely to receive treatment at academic/research programs (49.2% vs. 37.2%, P = 0.0001). Median survival was 4.9 months versus 8.9 months, respectively (P < 0.0001). The survival detriment with SCRT persisted on multivariable analysis [HR 1.51 (95% CI: 1.33-1.73, P < 0.0001)], adjusting for age, gender, race, comorbidities, diagnosis year, facility type, surgery, and chemotherapy. In conclusion, hypofractionated SCRT was associated with worse survival compared to conventionally fractionated LCRT for elderly patients with GBM. Patients who received SCRT were older with worse comorbidities, and were less likely to undergo chemotherapy or resection.

Is mortality due to primary malignant brain and other central nervous system tumors decreasing?

Primary malignant brain and other central nervous system tumors (BT) are a rare cancer that causes morbidity and mortality disproportionate to their incidence. This study presents the most up-to-date mortality data for malignant BT in the United States (US) by histology groupings, age, race, and sex. Mortality rates for malignant BT were generated using the Center for Disease Control's National Vital Statistics Systems (NVSS, ~100% of US) data from 1975 to 2012. Histology-specific incidence-based mortality rates were calculated using the National Cancer Institute's Surveillance, Epidemiology, and End-Results 9 (SEER9, ~9.4% of US) data from 1975 to 2012. Joinpoint modeling was used to estimate trends. Mortality was similar in both the NVSS and SEER9 datasets. Overall, mortality from 1975 to 2012 was higher among men, higher in older individuals, and higher in Whites compared to other races. Persons age 65+ years had significant increases in mortality for all malignant tumors overall and for glioma histologies, while persons age <20 years had no significant changes in mortality. This study reports up-to-date mortality rates by histology groupings, age, race, and sex for malignant BT. There have been no significant changes in overall mortality due to these tumors from 1975 to 2012. There have been significant increases in mortality in the elderly (age 65+ years), especially those age 75-84 years, mirroring the effect of overall population aging. Examining age-, race-, sex-, and histology-specific morality at the population level can provide important information for clinicians, researchers, and public health planning.

Management of Glioblastoma Multiforme in Elderly Patients: A Review of the Literature

Glioblastoma multiforme (GBM) is the most common primary malignant brain tumor in adults, occurs most commonly in individuals older than 65 years of age, and is universally fatal. Increasing age compounds the poor prognosis of GBM, as elderly patients have markedly worse outcomes than younger patients. However, many of the studies previously investigating optimal treatment regimens exclude patients older than the age of 65 years and thus may not represent the best approaches to ensuring prolonged survival with preserved quality of life. This review aims to highlight the current literature on surgical and medical management, including our own experience, for GBM in the elderly patients, and to provide rational treatment approaches for a vulnerable, often-overlooked, patient population.

A comprehensive comparative analysis of treatment modalities for sinonasal malignancies

BACKGROUND

Sinonasal malignancies are a rare and heterogeneous group of tumors for which there is a paucity of robust data with which to guide management decisions. The authors used the National Cancer Data Base to better understand the presenting characteristics of these tumors and to compare outcomes by treatment modality.

METHODS

The National Cancer Data Base was queried for sinonasal malignancies diagnosed between 2004 and 2012. Overall survival was assessed using multivariate analyses and propensity score matching.

RESULTS

A total of 11,160 patients were identified for the initial analysis. The majority were male, aged 40 to 69 years, with tumors of the nasal cavity or maxillary sinus. Squamous cell histology was most common. The majority of patients presented with advanced tumor stage but without locoregional lymph node or distant metastases. Treatment modalities were compared for squamous cell carcinomas. In multivariate analysis, compared with surgery alone, patients who received adjuvant radiotherapy (hazard ratio [HR], 0.658 [P<.001]), adjuvant chemoradiotherapy (HR, 0.696 [P = .002]), or neoadjuvant therapy (HR, 0.656 [P = .007]) had improved overall survival. Patients who received radiotherapy alone (HR, 1.294 [P = .001]) or chemotherapy alone (HR, 1.834 [P<.001]) had worse outcomes. These findings were validated in propensity score matching. It is important to note that neoadjuvant chemoradiotherapy was associated with achieving a negative surgical margin (odds ratio, 2.641 [P = .045]).

CONCLUSIONS

Surgery is the mainstay of therapy for patients with sinonasal malignancies, but multimodality therapy is associated with improved overall survival. Cancer 2017;123:3040-49. © 2017 American Cancer Society.