Glioblastoma multiforme in the very elderly

Risk factors for unintended discontinuation of tumor-specific treatment after tumor surgery in glioblastoma patients aged 70 or older

Purpose

The most beneficial treatment option for newly diagnosed glioblastoma is maximum safe resection and adjuvant therapy. Elderly patients carry a higher perioperative risk for complications, thus, predictors of unfavorable surgical outcome must be evaluated more intensively. Consequently, we sought to evaluate surgery-related paradigms leading to discontinuation of adjuvant treatment after initial neurosurgical resection.

Methods

Patients receiving microsurgical tumor resection for newly diagnosed glioblastoma CNS WHO grade 4 were evaluated. Further inclusion criteria was age >70 years. Comorbidities were summarized using the Charlson Comorbidity Index (CCI), the 5 and 11 item modified frailty index (mFI-5 and mFI-11) and the CHA2DS2-VASc Score. Primary endpoint was discontinuation of tumor-specific before completion of adjuvant radiotherapy or radio-chemotherapy.

Results

102 patients were included, mean age was 76.2 ± 4.2 years. The median extent of contrast-enhancing tumor volume was 99.1 ± 5.9 %. Surgical morbidity and mortality prohibited beginning of adjuvant treatment in 19 patients (18.6 %) and overall discontinuation of treatment before completion of radiotherapy was observed in 26/87 patients (29.9 %). Treatment failure was associated with increasing patient age (p = 0.04) and greater comorbidity scores. The mFI-5 and mFI-11 outperformed the CCI and the CHA2DS2-VASc Score. Two or more points in the 5- and 11-item mFI were significantly associated with increased risk of treatment failure (p = 0.004 and p = 0.001, respectively).

Conclusion

In Glioblastoma patients, advanced age and comorbidities are relevant confounders and put patients at risk for surgery-related morbidity. Nevertheless, it can be aimed at a maximum safe resection with acceptable surgical morbidity.

Clinical Predictors of Overall Survival in Very Elderly Patients With Glioblastoma: A National Cancer Database Multivariable Analysis

BACKGROUND AND OBJECTIVES

Surgery for the very elderly is a progressively important paradigm as life expectancy continues to rise. Patients with glioblastoma multiforme often undergo surgery, radiotherapy (RT), and chemotherapy (CT) to prolong overall survival (OS). However, the efficacy of these treatment modalities in patients aged 80 years and older has yet to be fully assessed in the literature.

METHODS

The National Cancer Database was used to retrospectively identify patients aged 65 years and older with glioblastoma multiforme (1989-2016). All available patient demographic characteristics, disease characteristics, and clinical outcomes were collected. To study OS, bivariable survival models were created using Kaplan-Meier estimates. A Cox proportional-hazards model was used for final adjusted analyses.

RESULTS

A total of 578 very elderly patients (aged 80 years and older) and 2836 elderly patients (aged 65-79 years) were identified. Compared with elderly patients, very elderly patients were more likely to have Medicare (odds ratio [OR] 1.899 [95% CI: 1.417-2.544], P < .001) while less likely to have private insurance status (OR 0.544 [95% CI: 0.401-0.739], P < .001). In addition, very elderly patients were more likely to travel the least distance for treatment and have multiple tumors ( P < .001). When controlling for demographic and disease characteristics, very elderly patients were less likely to receive gross total resection (GTR) (OR 0.822 [95% CI: 0.681-0.991], P < .041), RT (OR 0.385 [95% CI: 0.319-0.466], P < .001), or postoperative CT (OR 0.298 [95% CI: 0.219-0.359], P < .001) relative to elderly counterparts. Within very elderly patients, GTR, RT, and CT all independently and significantly predicted improved OS ( P < .001 for all). These predictive models were deployed in an online calculator ( https://spine.shinyapps.io/GBM_elderly ).

CONCLUSION

Very elderly patients are less likely to receive GTR, RT, or CT when compared with elderly counterparts despite use of these therapies conferring improved OS. Selected very elderly patients may benefit from more aggressive attempts at surgical and adjuvant treatment.

Surgical resection of glioblastoma in the very elderly: An analysis of survival outcomes using the surveillance, epidemiology, and end results database

OBJECTIVE

Patients with glioblastoma (GBM) often undergo surgery to prolong survival. However, the use of surgery, and more specifically achieving gross total resection (GTR), in patients >80 years old has yet to be fully assessed. Using the Surveillance, Epidemiology, and End Results (SEER) database, we aim to assess the efficacy of surgical resection, radiotherapy (RT) and chemotherapy (CT) on overall survival (OS) in very elderly GBM patients compared to elderly counterparts (age 65-79 years).

METHODS

The SEER database was queried for all patients >65 years old with GBM (2000-2020). Patients not undergoing surgery or biopsy were excluded. Patients were stratified by age, and demographic relationships were assessed with chi-squared testing for categorical variables. Bivariable models were created using Kaplan-Meier survival estimates. All significant variables from bivariable analysis were included on multivariable Cox survival regression models to determine independent associations between clinical variables and OS.

RESULTS

A total of 27,090 operative GBM patients were identified; 1868 patients (15.92 %) were very elderly and 10,092 patients (84.38 %) were elderly. Very elderly patients were less likely to undergo GTR (28 % vs 35 %, p<0.001), RT (59 % vs 78 %, p<0.001) and CT (40 % vs 66 %, p<0.001). In multivariable Cox regression analysis, very elderly patients who achieved GTR (HR=.696, p<0.001), received RT (HR=0.583, p<0.001) and underwent CT (HR=0.4197, p<0.001) had significantly improved OS compared to very elderly patients that did not undergo these treatment options.

CONCLUSION

Currently, very elderly GBM patients undergo lower rates of aggressive surgery, RT and CT. However, very elderly patients that undergo surgery, RT and CT may have a survival advantage. These treatments should be considered as potential options for this patient population.

Variable screening and model construction for prognosis of elderly patients with lower-grade gliomas based on LASSO-Cox regression: a population-based cohort study

Background

This study aimed to identify prognostic factors for survival and develop a prognostic nomogram to predict the survival probability of elderly patients with lower-grade gliomas (LGGs).

Methods

Elderly patients with histologically confirmed LGG were recruited from the Surveillance, Epidemiology, and End Results (SEER) database. These individuals were randomly allocated to the training and validation cohorts at a 2:1 ratio. First, Kaplan-Meier survival analysis and subgroup analysis were performed. Second, variable screening of all 13 variables and a comparison of predictive models based on full Cox regression and LASSO-Cox regression analyses were performed, and the key variables in the optimal model were selected to construct prognostic nomograms for OS and CSS. Finally, a risk stratification system and a web-based dynamic nomogram were constructed.

Results

A total of 2307 elderly patients included 1220 males and 1087 females, with a median age of 72 years and a mean age of 73.30 ± 6.22 years. Among them, 520 patients (22.5%) had Grade 2 gliomas, and 1787 (77.5%) had Grade 3 gliomas. Multivariate Cox regression analysis revealed four independent prognostic factors (age, WHO grade, surgery, and chemotherapy) that were used to construct the full Cox model. In addition, LASSO-Cox regression analysis revealed five prognostic factors (age, WHO grade, surgery, radiotherapy, and chemotherapy), and a LASSO model was constructed. A comparison of the two models revealed that the LASSO model with five variables had better predictive performance than the full Cox model with four variables. Ultimately, five key variables based on LASSO-Cox regression were utilized to develop prognostic nomograms for predicting the 1-, 2-, and 5-year OS and CSS rates. The nomograms exhibited relatively good predictive ability and clinical utility. Moreover, the risk stratification system based on the nomograms effectively divided patients into low-risk and high-risk subgroups.

Conclusion

Variable screening based on LASSO-Cox regression was used to determine the optimal prediction model in this study. Prognostic nomograms could serve as practical tools for predicting survival probabilities, categorizing these patients into different mortality risk subgroups, and developing personalized decision-making strategies for elderly patients with LGGs. Moreover, the web-based dynamic nomogram could facilitate its use in the clinic.

Impact of function-guided glioma treatment on oncological outcome in the elderly

Introduction

Many patients with high-grade gliomas (HGG) are of older age.

Research question

We hypothesize that pre- and intraoperative mapping and monitoring preserve functional status in elderly patients while gross total resection (GTR) is the aim, resulting in overall survival (OS) rates comparable to the general population with HGG.

Material and methods

We subdivided a prospective cohort of 168 patients above 65 years with eloquent high-grade gliomas into four groups ([years/cases] 1: 65-69/58; 2: 70-74/47; 3: 75-79/43; 4: >79/20). All patients underwent preoperative noninvasive mapping, which was also used for decision-making, intraoperative neuromonitoring in 138 cases, direct cortical and/or subcortical motor mapping in 66 and 50 cases, and awake language mapping in 11 cases.

Results

GTR and subtotal resection (STR) could be achieved in 65% and 28%, respectively. Stereotactic biopsy was performed in 8% of cases. Postoperatively, we found transient and permanent functional deficits in 13% and 11% of cases. Postoperative Karnofsky Performance Scale (KPS) did not differ between subgroups. Patients with long-term follow-up (51%) had a progression-free survival of 5.5 (1-47) months and an overall survival of 10.5 (0-86) months.

Discussion and conclusion

The interdisciplinary glioma treatment in the elderly is less age-dependent but must be adjusted to the functional status. Function-guided surgical resections could be performed as usual, with maximal tumor resection being the primary goal. However, less network capacity in the elderly to compensate for deficits might cause higher rates of permanent deficits in this group of patients with more fast-growing malignant gliomas.

PDGFRA, KIT, and KDR Gene Amplification in Glioblastoma: Heterogeneity and Clinical Significance

Glioblastoma (GBM) is the most frequent tumor of the central nervous system, and its heterogeneity is a challenge in treatment. This study examined tumoral heterogeneity involving PDGFRA, KIT, and KDR gene amplification (GA) in 4q12 and its association with clinical parameters. Specimens from 22 GBM cases with GA for the 4q12 amplicon detected by FISH were investigated for homogeneous or heterogeneous coamplification patterns, diffuse or focal distribution of cells harboring GA throughout tumor sections, and pattern of clustering of fluorescence signals. Sixteen cases had homogenously amplification for all three genes (45.5%), for PDGFRA and KDR (22.7%), or only for PDGFRA (4.6%); six cases had heterogeneous GA patterns, with subpopulations including GA for all three genes and for two genes - PDGFRA and KDR (13.6%), or GA for all three and for only one gene - PDGFRA (9.1%) or KIT (4.6%). In 6 tumors (27.3%), GA was observed in focal tumor areas, while in the remaining 16 tumors (72.7%) it was diffusely distributed throughout the pathological specimen. Amplification was universally expressed as double minutes and homogenously stained regions. Coamplification of all three genes PDGFRA, KIT, and KDR, age ≥ 60 years, and total tumor resection were statistically associated with poor prognosis. FISH proved effective for detailed interpretation of molecular heterogeneity. The study uncovered an even more diverse range of amplification patterns involving the 4q12 oncogenes in GBM than previously described, thus highlighting a complex tumoral heterogeneity to be considered when devising more effective therapies.

Treatment of Older Adult Patients with Glioblastoma: Moving towards the Inclusion of a Comprehensive Geriatric Assessment for Guiding Management

Glioblastoma (GBM) is the most common primary malignant brain tumor in adults, and over half of patients with newly diagnosed GBM are over the age of 65. Management of glioblastoma in older patients includes maximal safe resection followed by either radiation, chemotherapy, or combined modality treatment. Despite recent advances in the treatment of older patients with GBM, survival is still only approximately 9 months compared to approximately 15 months for the general adult population, suggesting that further research is required to optimize management in the older population. The Comprehensive Geriatric Assessment (CGA) has been shown to have a prognostic and predictive role in the management of older patients with other cancers, and domains of the CGA have demonstrated an association with outcomes in GBM in retrospective studies. Furthermore, the CGA and other geriatric assessment tools are now starting to be prospectively investigated in older GBM populations. This review aims to outline current treatment strategies for older patients with GBM, explore the rationale for inclusion of geriatric assessment in GBM management, and highlight recent data investigating its implementation into practice.

Clinical and Molecular Characterization of Adult Glioblastomas in Southern Brazil

We investigated 113 adult Brazilian patients with glioblastoma (GBM) for comparison with patients from distinct geographical areas and evaluation of suitability for novel targeted therapies. Patients were assessed for clinical features and tumor genomic characteristics such as ROS1 and NTRK1 rearrangements, KIT, PDGFRA, and KDR amplification, and RB1 deletion using multicolor fluorescence in situ hybridization. The majority of patients were male (53%), over 40 years (94%), with tumor located in single site (64%), in the right cerebral hemisphere (60%), and underwent partial resection (71%); 14% presented complications after surgery. The main clinical sign at diagnosis was focal abnormality (57%); frontal (31%); and temporal (20%) regions were most commonly affected. Median hospitalization time was 20 days, median survival was 175 days. One tumor was positive for rearrangement in NTRK1 and another in ROS1 (0.9% each). PDGFRA was amplified in 20% of cases, often co-amplified with KDR (>90%) and KIT (>60%). RB1 was deleted in 16% of patients. There was no association between these molecular abnormalities and patient survival. However, older age, complications after surgery, and right-sided tumors were independent variables associated with patient survival. This study contributes information on the molecular profile of glioblastomas in Latin America possibly supporting new target therapies.

Patterns of care and clinical outcome in assumed glioblastoma without tissue diagnosis: A population-based study of 131 consecutive patients

Background

Elderly patients with glioblastoma and an accumulation of negative prognostic factors have an extremely short survival. There is no consensus on the clinical management of these patients and many may escape histologically verified diagnosis. The primary aim of this study was to characterize this particular subgroup of patients with radiological glioblastoma diagnosis without histological verification. The secondary aim was to evaluate if oncological therapy was of benefit.

Methods

Between November 2012 and June 2016, all consecutive patients presenting with a suspected glioblastoma in the western region of Sweden were registered in a population-based study. Of the 378 patients, 131 (35%) met the inclusion criteria of the present study by typical radiological features of glioblastoma without histological verification.

Results

The clinical characteristics of the 131 patients (72 men, 59 women) were: age ≥ 75 (n = 99, 76%), performance status according to Eastern Cooperative Oncology Group ≥ 2 (n = 93, 71%), significant comorbidity (n = 65, 50%) and multilobular tumors (n = 90, 69%). The overall median survival rate was 3.6 months. A subgroup of 44 patients (34%) received upfront treatment with temozolomide, with an overall radiological response rate of 34% and a median survival of 6.8 months, compared to 2.7 months for those receiving best supportive care only. Good performance status and temozolomide treatment were statistically significant favorable prognostic factors, while younger age was not.

Conclusion

Thirty-five percent of patients with a radiological diagnosis of glioblastoma in our region lacked histological diagnosis. Apart from high age and poor performance status, they had more severe comorbidities and extensive tumor spread. Even for this poor prognostic group upfront treatment with temozolomide was shown of benefit in a subgroup of patients. Our data illustrate the need of non-invasive diagnostic methods to guide optimal individualized therapy for patients considered too fragile for neurosurgical biopsy.

Validation of effectiveness of keyhole clipping in nonfrail elderly patients with unruptured intracranial aneurysms

OBJECTIVE

Advanced age is known to be associated with a poor prognosis after surgical clipping of unruptured intracranial aneurysms (UIAs). Keyhole clipping techniques have been introduced for less invasive treatment of UIAs. In this study, the authors compared the complications and clinical and radiological outcomes after keyhole clipping between nonfrail elderly patients (≥ 70 years) and nonelderly patients.

METHODS

Keyhole clipping (either supraorbital or pterional) was performed to treat 260 cases of relatively small (≤ 10 mm) anterior circulation UIAs. There were 62 cases in the nonfrail elderly group (mean age 72.9 ± 2.6 years [± SD]) and 198 cases in the nonelderly group (mean age 59.5 ± 7.6 years). The authors evaluated mortality and morbidity (modified Rankin Scale score > 2 or Mini–Mental State Examination [MMSE] score < 24) at 3 months and 1 year after the operation, the general cognitive function by MMSE at 3 months and 1 year, anxiety and depression by the Beck Depression Inventory (BDI) and Hamilton Rating Scale for Depression (HAM-D) at 3 months, and radiological abnormalities and recurrence at 1 year.

RESULTS

Basic characteristics including comorbidities, frailty, and BDI and HAM-D scores were not significantly different between the 2 groups, whereas the MMSE score was slightly but significantly lower in the elderly group. Aneurysm location, largest diameter, type of keyhole surgery, neck clipping rate, and hospitalization period were not significantly different between the 2 groups. The incidence of chronic subdural hematoma was not significantly higher in the elderly group than in the nonelderly group (8.1% vs 4.5%, p = 0.332); rates of other complications including stroke and epilepsy were not significantly different. Lacunar infarction occurred in 3.2% of the elderly group and 3.0% of the nonelderly group. No patient in the elderly group required re-treatment or demonstrated recurrence of clipped aneurysms. The MMSE score at 3 months significantly improved in the nonelderly group but did not change in the elderly group. The BDI and HAM-D scores at 3 months were significantly improved in both groups. No patient died in either group. The morbidity at 3 months and 1 year in the elderly group (1.6% and 4.8%, respectively) was not significantly different from that in the nonelderly group (2.0% and 1.5%, respectively).

CONCLUSIONS

Keyhole clipping for nonfrail elderly patients with relatively small anterior circulation UIAs did not significantly increase the complication, mortality, or morbidity rate; hospitalization period; or aneurysm recurrence compared with nonelderly patients, and it was associated with improvement in anxiety and depression. Keyhole clipping to treat UIAs in the nonfrail elderly is an effective and long-lasting treatment.

Reoperation for Recurrent Glioblastoma and Its Association With Survival Benefit

BACKGROUND

Glioblastoma is the most common and aggressive primary brain tumor. Despite current treatment, recurrence is inevitable. There are no clear guidelines for treatment of recurrent glioblastoma.

OBJECTIVE

To investigate factors at initial surgery predictive of reoperation, and the prognostic variables associated with survival, including reoperation for recurrence.

METHODS

A retrospective cohort study was performed, including adult patients diagnosed with glioblastoma between January 2010 and December 2013. Student t test and Fisher exact test compared continuous and categorical variables between reoperation and nonreoperation groups. Univariable and Cox regression multivariable analysis was performed.

RESULTS

In a cohort of 204 patients with de novo glioblastoma, 49 (24%) received reoperation at recurrence. The median overall survival in the reoperation group was 20.1 months compared with 9.0 months in the nonreoperation group (P = .001). Reoperation was associated with longer overall survival in our total population (hazard ratio, 0.646; 95% confidence interval, 0.543-0.922; P = .016) but subject to selection bias. Subgroup analyses excluding patients unlikely to be considered for reoperation suggested a much less significant effect of reoperation on survival, which warrants further study with larger cohorts. Factors at initial surgery predictive for reoperation were younger age, smaller tumor size, initial extent of resection ≥50%, shorter inpatient stay, and maximal initial adjuvant therapy. When unfavorable patient characteristics are excluded, reoperation is not an independent predictor of survival.

CONCLUSION

Patients undergoing reoperation have favorable prognostic characteristics, which may be responsible for the survival difference observed. We recommend that a large clinical registry be developed to better aid consistent and homogenous data collection.

ABBREVIATIONS

ECOG, Eastern Cooperative Oncology GroupEOR, extent of resectionIDH-1, isocitrate dehydrogenase 1IP, inpatientMGMT, O-methylguanine methyltransferaseOS, overall survivalPFS, progression-free survivalRMH, Royal Melbourne Hospital.

Glioblastoma in the elderly: treatment patterns and survival

AIM

The optimal treatment for elderly glioblastoma patients is unclear. We conducted a retrospective review of the California Cancer Registry to examine treatment patterns and survival by age.

METHODS

We identified 2670 adult patients from the California Cancer Registry with glioblastoma. We compared the extent of resection, treatment type and modality.

RESULTS

Elderly patients had the greatest overall survival (OS) with combined surgery, radiation and chemotherapy. However, they were more likely to undergo biopsy and less likely to receive combined radiation and chemotherapy than patients <70.

CONCLUSION

OS was maximized in elderly patients who were able to get some surgical resection and undergo combined radiation and chemotherapy. OS survival in some elderly patients may be improved by more extensive therapy.