Assessment and treatment relevance in elderly glioblastoma patients

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.

Epilepsy as primary tumor manifestation correlates with patient status, age, and tumor volume but not with survival in elderly glioblastoma patients: a retrospective bicentric analysis

Assessment of the potential impact of epilepsy as primary tumor manifestation on survival in elderly glioblastoma multiforme (GBM) patients. Two academic neurosurgical centers retrospectively analyzed all GBM patients aged 65 years and older with de-novo tumors, who underwent surgery between 2006 and 2021. Epidemiological, histopathological, imaging and survival data were obtained from patients' electronic charts, and screened for the presence of epilepsy preoperatively and during follow-up. Patient status was assessed by the Karnofsky Performance Scale (KPS), epilepsy was evaluated using the Engel classification. Patients were categorized in an epilepsy cohort (i.e. patients with epilepsy as primary GBM manifestation, and a reference cohort (i.e. patients with no initial epilepsy). This study analyzed 451 GBM patients (55% males); median age at tumor diagnosis was 73 years. The epilepsy cohort was younger (71.0 vs. 74.0 year; p = 0.001), had better KPS (80 vs. 70; p = 0.039), and had smaller tumors (127 vs. 221 cm3; p = 0.001) compared to the reference cohort. There were no differences with regard to neurosurgical treatment (i.e. resection vs. biopsy), tumor biomarkers, surgery-associated complications, and performed adjuvant treatment (all p > 0.05). We did not detect a significant difference in median survival between the epilepsy and reference cohorts (8 vs. 6 months; p = 0.21). New epilepsy during follow-up often coincided with tumor recurrence/progression, but also did not significantly affect survival. The majority of patients (98%) achieved seizure freedom by a combination of tumor-specific treatments and antiseizure medication. Epilepsy as primary tumor manifestation does not correlate with survival in elderly GBM patients.

Prediction of Survival in the Elderly Patients with Glioblastoma using Cumulative Inflammatory Markers Score

Objectives  This retrospective study aimed to explore the prognostic effect of cumulative score based on neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and fibrinogen in older adults diagnosed with glioblastoma (GBM). Design  Retrospective study. Setting  Huashan Hospital. Participants  Patients aged over 60 years and diagnosed with GBM between 2010 and 2017. Main Outcome Measures  Results of preoperative routine biochemistry and coagulation blood examinations were reviewed from medical records. Overall survival (OS) was considered a period from first resection surgery until death. Progression-free survival (PFS) was considered a period from initial operation until the date of tumor progression demonstrated in brain magnetic resonance imaging or death from any cause. If no event occurred, the last follow-up appointment was the end of the observation for OS or PFS. The Kaplan-Meier method was used to evaluate survival curves, and prognostic factors were analyzed by the Cox proportional hazards model. Results  A total of 289 patients were included. Patients with higher levels of fibrinogen, NLR, and PLR had significantly shorter median OS ( p  = 0.001, p  = 0.016, and p  = 0.002, respectively) and PFS ( p  = 0.004, p  = 0.022, and p  = 0.009, respectively) compared with those with lower levels. Multivariate analyses showed a significant association between higher F-NLR-PLR score and reduced OS (adjusted hazard ratios [aHRs]: 1.356, 95% confidence interval [CI] 1.009-1.822 for scores 1-2 compared with 0; 5.974, 95% CI 2.811-12.698 for score 3 compared with 0). Similarly, a significant association between higher F-NLR-PLR score and reduced PFS was observed (aHR: 1.428, 95% CI 1.066-1.912 for scores 1-2 compared with 0; aHR: 2.860, 95% CI 1.315-6.223 for score 3 compared with 0). Conclusion  Higher F-NLR-PLR score is associated with reduced OS and PFS in older adults with GBM, which helps identify patients at high risk and guide the individualized treatment in clinical practice.

Intraoperative ex-vivo epifluorescent diagnostics of stereotactic brain biopsies using EndoScell scanner: diagnostic accuracy study

Brain biopsy is commonly employed for the histological diagnosis of complex intracranial diseases. To improve the positive diagnostic rate, the precision of intraoperative tissue sampling is critical. This study evaluated the accuracy of fluorescence imaging technology in rapidly distinguishing tumours from nontumour tissue during surgery, thus providing real-time feedback to surgeons and optimizing the surgical workflow. Biopsy samples from 65 patients were selected for this study. The lesion tissues were sequentially stained with sodium fluorescein and methylene blue, followed by fluorescence imaging via a handheld EndoScell scanner under an intraoperative cellular microscope. Frozen section examinations and haematoxylin-eosin (HE) staining were performed on the same lesion tissue by the pathology department. The time required for fluorescence imaging and pathology of frozen sections was recorded. The results of fluorescence imaging (whether the tissue was a tumour or nontumour tissue) and frozen pathology (whether the tissue was a tumour or nontumour tissue) were also recorded. The HE staining results were used as the final gold standard for diagnosis. The sensitivity, specificity, area under the curve (AUC), Kappa consistency test, and diagnostic efficiency of both methods were calculated. Lesion tissue and diagnostic results were successfully obtained from all 65 patients. When HE-stained histopathology was used as the gold standard, the sensitivity of fluorescence imaging was 100% (95% CI: 0.917-1.000), and the specificity was 63.6% (95% CI: 0.316-0.876). In comparison, the sensitivity of frozen section pathology was 88.9% (95% CI: 0.767-0.954), and the specificity was 100% (95% CI: 0.679-1.000). Both methods demonstrated high diagnostic accuracy. ROC curve analysis revealed that the AUCs for fluorescence imaging and frozen pathology were 0.818 and 0.944, respectively, with no significant difference observed in diagnostic performance (Z = 1.597, P > 0.05). Kappa consistency tests indicated that the Kappa value for frozen pathology compared with HE staining was 0.730 (P < 0.001); for fluorescence imaging compared with HE staining, the Kappa value was 0.744 (P < 0.001), thus demonstrating strong agreement with the HE staining results for both methods. In terms of time efficiency, fluorescence imaging was significantly faster than frozen section pathology [6 (4, 7) min vs. 48 (46, 55) min, Z=-9.856, P < 0.001], thus showing a clear advantage regarding time efficiency for fluorescence imaging. Intraoperative fluorescence imaging via an EndoScell scanner, which represents a novel method for histopathological diagnosis, has high diagnostic accuracy and efficiency. This method provides real-time guidance for tissue sampling strategies in brain biopsy, thereby improving the positive diagnostic rate and reducing surgical risk.

The Evolving Role of Palliative Care in Older People with Glioblastoma

Glioblastoma multiforme (GBM) is the most common and aggressive primary brain tumor in older adults and has a poor prognosis and limited response to treatment. The growing impact of palliative care on older people undergoing neurosurgery is becoming increasingly important. Palliative care aims to improve the quality of life for people and their families by addressing their physical, psychosocial, and spiritual needs. The prevalence of GBM peaks between 65 and 84 years of age, and treatment options may be hindered by chronic multiple conditions in older people. Older people are at risk of receiving suboptimal end-of-life care due to factors such as a focus on curative medicine, acceptance of terminal illness, which may discourage the person, and lack of awareness of palliative care for people with a noncancer diagnosis. People with GBM experience a significant illness burden, including neurological symptoms, mood disturbances, and cognitive impairment. A multidisciplinary approach, including palliative care, is recommended to improve treatment outcomes and quality of life. However, palliative care is often not consistently included in multidisciplinary teams despite the lack of curative treatment options and significant symptom burden. The palliative care needs of people with GBM can be complex, and published evidence in this area is limited. Nonetheless, there are similarities between the needs of people with GBM and those with other, more common cancer diagnoses and nonmalignant chronic neurologic illnesses. The integration of palliative care into the management of older people with GBM during neurosurgery is crucial for addressing their unique needs and improving their quality of life. In this review, we aimed to comprehensively evaluate the impact of palliative care on people with GBM and its importance.

Risk Factors and Predictive Nomogram for Survival in Elderly Patients with Brain Glioma

OBJECTIVE

To determine the factors that contribute to the survival of elderly individuals diagnosed with brain glioma and develop a prognostic nomogram.

METHODS

Data from elderly individuals (age ≥65 years) histologically diagnosed with brain glioma were sourced from the Surveillance, Epidemiology, and End Results (SEER) database. The dataset was randomly divided into a training cohort and an internal validation cohort at a 6:4 ratio. Additionally, data obtained from Tangdu Hospital constituted an external validation cohort for the study. The identification of independent prognostic factors was achieved through the least absolute shrinkage and selection operator (LASSO) and multivariate Cox regression analysis, enabling the construction of a nomogram. Model performance was evaluated using C-index, ROC curves, calibration plot and decision curve analysis (DCA).

RESULTS

A cohort of 20 483 elderly glioma patients was selected from the SEER database. Five prognostic factors (age, marital status, histological type, stage, and treatment) were found to significantly impact overall survival (OS) and cancer-specific survival (CSS), with tumor location emerging as a sixth variable independently linked to CSS. Subsequently, nomogram models were developed to predict the probabilities of survival at 6, 12, and 24 months. The assessment findings from the validation queue indicate a that the model exhibited strong performance.

CONCLUSION

Our nomograms serve as valuable prognostic tools for assessing the survival probability of elderly glioma patients. They can potentially assist in risk stratification and clinical decision-making.

Management of glioblastoma in elderly patients: A review of the literature

High grade gliomas are the most common primary aggressive brain tumours with a very poor prognosis and a median survival of less than 2 years. The standard management protocol of newly diagnosed glioblastoma patients involves surgery followed by radiotherapy, chemotherapy in the form of temozolomide and further adjuvant temozolomide. The recent advances in molecular profiling of high-grade gliomas have further enhanced our understanding of the disease. Although the management of glioblastoma is standardised in newly diagnosed adult patients there is a lot of debate regarding the best treatment approach for the newly diagnosed elderly glioblastoma patients. In this review article we attempt to summarise the findings regarding surgery, radiotherapy, chemotherapy, and their combination in order to offer the best possible management modality for this group of patients. Elderly patients 65-70 with an excellent functional level could be considered as candidates for the standards treatment consisting of surgery, standard radiotherapy with concomitant and adjuvant temozolomide. Similarly, elderly patients above 70 with good functional status could receive the above with the exception of receiving a shorter course of radiotherapy instead of standard. In elderly GBM patients with poorer functional status and MGMT promoter methylation temozolomide chemotherapy can be considered. For elderly patients who cannot tolerate chemotherapy, hypofractionated radiotherapy is an option. In contrast to the younger adult patients, it seems that a careful individualised approach is a key element in deciding the best treatment options for this group of patients.

CDC14B is a favorable biomarker for recurrence and prognosis of GBM

BACKGROUND

Glioblastoma (GBM) is the most common and lethal primary brain tumor in adults. The treatment options of GBM are quite few and the prognosis of GBM is very dismal. Identifying the effective and prognostic biomarker is important for molecular classification and individual treatment of patients. CDC14 is a conserved dual specificity phosphatase functioning mainly in mitosis and DNA respiration. The expression and function of CDC14 family in tumor progression is still elusive.

MATERIALS AND METHODS

In our study, we established a retrospective GBM cohort consisting of 135 patients who underwent the surgery and received standard treatment therapy. We compared the expression of CDC14A and CDC14B in GBM and tumor-adjacent tissues by retrieving data from TCGA and qPCR. With immunohistochemistry (IHC), we detected the expression of CDC14B in the cohort, and analyzed the correlation between CDC14B and clinicopathological factors by chi-square test. The significance of CDC14B on GBM recurrence and prognosis was assessed by univariate and multivariate analyses.

RESULTS

CDC14B, but not CDC14A, had a higher expression in GBM tissues than in tumor-adjacent tissues. High CDC14B was correlated with high progression-free survival (PFS) rate and overall survival (OS) rate of GBM. In the Cox-regression model, CDC14B was an independent and favorable biomarker indicating low risk of recurrence and GBM-related death.

CONCLUSIONS

High CDC14B is correlated with high GBM PFS and OS rate, and CDC14B is an independent biomarker of GBM, indicating low recurrence and favorable prognosis. Our study reveals a new biomarker of GBM which could indicate the recurrence and prognosis of GBM. This may help stratify the high-risk patients and modify the prognostic assessment based on molecular features.

Surgical and oncological score to estimate the survival benefit of resection and chemoradiotherapy in elderly (≥70 years) glioblastoma patients: a preliminary analysis

Background

Elderly patients with glioblastoma are perceived to face a poor prognosis with perceptions surrounding older age and a relative lack of randomized data contributing. This study evaluated survival prognosticators in elderly glioblastoma patients to more accurately guide their treatment.

Methods

The records of 169 elderly (≥70 years) patients with a new diagnosis of glioblastoma who had undergone neurosurgical intervention were retrospectively examined for patient sex, age, performance status, comorbidities, MGMT promoter methylation, surgical intervention, and chemoradiation regime. The adjusted survival impact of these factors was determined using Cox proportional hazards model and used to devise a two-stage scoring system to estimate patient survival at the stage of surgical (Elderly Glioblastoma Surgical Score, EGSS) and oncological management (Elderly Glioblastoma Oncological Score, EGOS).

Results

The median overall survival (mOS) of the cohort was 28.8 weeks. Gross-total and subtotal resection were associated with improved survival compared to biopsy alone (respective mOS 65.3 and 28.1 vs 15.7 weeks, P < .001). Hypofractionated radiotherapy (40Gy in 15 fractions) with Temozolomide was noninferior to the Stupp protocol, P = .72. Exploratory subgroup analysis revealed a significant benefit of Temozolomide-based approaches in MGMT-methylated patients as well as a trend towards improved survival in MGMT-unmethylated patients. Our EGSS and EGOS scores successfully estimated survival in this retrospective cohort with 65% and 73% accuracy.

Conclusions

Where appropriate and safe, elderly glioblastoma patients may benefit from surgical resection and combined chemoradiotherapy with Temozolomide. The proposed EGSS and EGOS scores take into account important prognostic factors to help guide which patients should receive such treatment.

High Grade Glioma Treatment in Elderly People: Is It Different Than in Younger Patients? Analysis of Surgical Management Guided by an Intraoperative Multimodal Approach and Its Impact on Clinical Outcome

OBJECTIVE

Age is considered a negative prognostic factor for High Grade Gliomas (HGGs) and many neurosurgeons remain skeptical about the benefits of aggressive treatment. New surgical and technological improvements may allow extended safe resection, with lower level of post-operative complications. This opportunity opens the unsolved question about the most appropriate HGG treatment in elderly patients. The aim of this study is to analyze if HGG maximal safe resection guided by an intraoperative multimodal imaging protocol coupled with neuromonitoring is associated with differences in outcome in elderly patients versus younger ones.

METHODS

We reviewed 100 patients, 53 (53%) males and 47 (47%) females, with median (IQR) age of 64 (57; 72) years. Eight patients were diagnosed with Anaplastic Astrocytoma (AA), 92 with Glioblastoma (GBM). Surgery was aimed to achieve safe maximal resection. An intraoperative multimodal imaging protocol, including neuronavigation, neurophysiological monitoring, 5-ALA fluorescence, 11C MET-PET, navigated i-US system and i-CT, was used, and its impact on EOTR and clinical outcome in elderly patients was analyzed. We divided patients in two groups according to their age: <65 and >65 years, and surgical and clinical results (EOTR, post-operative KPS, OS and PFS) were compared. Yet, to better understand age-related differences, the same patient cohort was also divided into <70 and >70 years and all the above data reanalyzed.

RESULTS

In the first cohort division, we did not found KPS difference over time and survival analysis did not show significant difference between the two groups (p = 0.36 for OS and p = 0.49 for PFS). Same results were obtained increasing the age cut-off for age up to 70 years (p = 0.52 for OS and p = 0.92 for PFS).

CONCLUSIONS

Our data demonstrate that there is not statistically significant difference in post-operative EOTR, KPS, OS, and PFS between younger and elderly patients treated with extensive tumor resection aided by a intraoperative multimodal protocol.

Guiding Treatment Choices for Elderly Patients with Glioblastoma by a Comprehensive Geriatric Assessment

PURPOSE OF REVIEW

The incidence of glioblastoma multiforme (GBM) increases with age; more than half of newly diagnosed patients are older than 65 years. Due to age-dependent decreasing organ functions, comorbidities, functional decline, and increasing risk of social isolation, not all patients are able to tolerate standard therapy of GBM with 6 weeks of radiochemotherapy.

RECENT FINDINGS

A set of alleviated therapies, e.g., chemotherapy or radiotherapy alone, hypofractionated radiotherapies with different total doses and variable fractionation regimens as well as hypofractionated radiotherapy with concomitant and adjuvant chemotherapy, have been evaluated during the last years. However, clinicians are still unsure which therapy would fit best to a given patient. Recently, the predictive value of comprehensive geriatric assessment regarding tolerance of chemotherapy and prediction of early mortality has been validated for older GBM patients in a retrospective trial. Thus, it appears that neuro-oncology is now ready for the prospective implementation of geriatric assessment to guide treatment planning for elderly GBM patients.

Novel predictive epigenetic signature for temozolomide in non-G-CIMP glioblastomas

Objective

To identify novel epigenetic signatures that could provide predictive information that is complementary to promoter methylation status of the O-6-methylguanine-DNA methyltransferase (MGMT) gene for predicting temozolomide (TMZ) response, among glioblastomas (GBMs) without glioma-CpGs island methylator phenotype (G-CIMP)

Methods

Different cohorts of primary non-G-CIMP GBMs with genome-wide DNA methylation microarray data were included for discovery and validation of a multimarker signature, combined using a RISK score model. Different statistical analyses and functional experiments were performed for clinical and biological validation.

Results

By employing discovery cohorts with radiotherapy (RT) and TMZ versus RT alone and a strict multistep selection strategy, we identified seven CpGs, each of which was significantly correlated with overall survival (OS) of non-G-CIMP GBMs with RT/TMZ, independent of age, MGMT promoter methylation status, and other identified CpGs. A RISK score signature of the 7 CpGs was developed and validated to distinguish non-G-CIMP GBMs with differential survival outcomes to RT/TMZ, but not to RT alone. The interaction analyses also showed differential outcomes to RT/TMZ versus RT alone within the RISK score-based subgroups. The signature could also improve the risk classification by age and MGMT promoter methylation status. Functional experiments showed that HSBP2 appeared to be epigenetically regulated by one identified CpG and was associated with TMZ resistance, but it was not associated with cell proliferation or apoptosis in GBM cell lines. The predictive value of the single CpG methylation of HSBP2 by pyrosequencing was observed in a local cohort of isocitrate dehydrogenase 1 (IDH1) ^R132H wild-type GBMs.

Conclusions

This novel epigenetic signature might be a promising predictive (but not a general prognostic) biomarker and be helpful for refining the MGMT-based guiding approach to TMZ usage in non-G-CIMP GBMs.

Electronic supplementary material

The online version of this article (10.1186/s13148-019-0670-9) contains supplementary material, which is available to authorized users.

Safety of resident training in the microsurgical resection of intracranial tumors: Data from a prospective registry of complications and outcome

The aim of the present study was to assess the safety of microsurgical resection of intracranial tumors performed by supervised neurosurgical residents. We analyzed prospectively collected data from our institutional patient registry and dichotomized between procedures performed by supervised neurosurgery residents (defined as teaching procedures) or board-certified faculty neurosurgeons (defined as non-teaching procedures). The primary endpoint was morbidity at discharge, defined as a postoperative decrease of ≥10 points on the Karnofsky Performance Scale (KPS). Secondary endpoints included 3-month (M3) morbidity, mortality, the in-hospital complication rate, and complication type and severity. Of 1,446 consecutive procedures, 221 (15.3%) were teaching procedures. Patients in the teaching group were as likely as patients in the non-teaching group to experience discharge morbidity in both uni- (OR 0.85, 95%CI 0.60-1.22, p = 0.391) and multivariate analysis (adjusted OR 1.08, 95%CI 0.74-1.58, p = 0.680). The results were consistent at time of the M3 follow-up and in subgroup analyses. In-hospital mortality was equally low (0.24 vs. 0%, p = 0.461) and the likelihood (p = 0.499), type (p = 0.581) and severity of complications (p = 0.373) were similar. These results suggest that microsurgical resection of carefully selected intracranial tumors can be performed safely by supervised neurosurgical residents without increasing the risk of morbidity, mortality or perioperative complications. Appropriate allocation of operations according to case complexity and the resident's experience level, however, appears essential.

Association of patterns of care, prognostic factors, and use of radiotherapy-temozolomide therapy with survival in patients with newly diagnosed glioblastoma: a French national population-based study

Background

Glioblastoma is the most frequent primary malignant brain tumor. In daily practice and at whole country level, oncological care management for glioblastoma patients is not completely known.

Objectives

To describe oncological patterns of care, prognostic factors, and survival for all patients in France with newly-diagnosed and histologically confirmed glioblastoma, and evaluate the impact of extended temozolomide use at the population level.

Methods

Nationwide population-based cohort study including all patients with newly-diagnosed and histologically confirmed glioblastoma in France in 2008 and followed until 2015.

Results

Data from 2053 glioblastoma patients were analyzed (male/female ratio 1.5, median age 64 years). Median overall survival (OS) was 11.2 [95% confidence interval (CI) 10.7–11.9] months. The first-line therapy and corresponding median survival (MS, in months) were: 13% did not receive any oncological treatment (biopsy only) (MS = 1.8, 95% CI 1.6–2.1), 27% received treatment without the combination of radiotherapy (RT)–temozolomide (MS = 5.9, 95% CI 5.5–6.6), 60% received treatment including the initiation of the concomitant phase of RT–temozolomide (MS = 16.4, 95% CI 15.2–17.4) whom 44% of patients initiated the temozolomide adjuvant phase (MS = 18.9, 95% CI 18.0–19.8). Only 22% patients received 6 cycles or more of adjuvant temozolomide (MS = 25.5, 95% CI 24.0–28.3). The multivariate analysis showed that the risk of mortality was significantly higher for the non-progressive patients who stopped at 6 cycles (standard protocol) than those who continued the treatment, hazard ratio = 1.5 (95% CI 1.2–1.9).

Conclusion

In non-progressive patients, prolonging the adjuvant temozolomide beyond 6 cycles may improve OS.

Electronic supplementary material

The online version of this article (10.1007/s11060-018-03065-z) contains supplementary material, which is available to authorized users.

Treatment outcomes of hypofractionated radiotherapy combined with temozolomide followed by bevacizumab salvage therapy in glioblastoma patients aged > 75 years

BACKGROUND

The optimal treatment for elderly patients with glioblastoma has not been established.

METHODS

We retrospectively analyzed the safety and efficacy of hypofractionated radiotherapy (45 Gy/15 fr) combined with temozolomide (TMZ) followed by bevacizumab (BEV) salvage treatment in 18 glioblastoma patients aged > 75 years.

RESULTS

All of the patients received safe hypofractionated radiotherapy and concomitant TMZ (75 mg/m²), and 14 of 18 patients received maintenance TMZ. We administered BEV to 17 of 18 patients because their Karnofsky Performance Status scores declined and/or recurrence was detected. During the follow-up period (median duration: 17.5 months, range 3-33 months), 12 patients died of their disease. While the median progression-free survival period was 2.5 months, the median overall survival period was 20 months. Adverse events (National Cancer Institute Common Terminology Criteria for Adverse Events grade 3 or 4) occurred in 5 patients.

CONCLUSION

Hypofractionated radiotherapy combined with TMZ and BEV salvage treatment was found to be safe and effective in glioblastoma patients aged > 75 years.

Investigation of the usefulness of fluorescein sodium fluorescence in stereotactic brain biopsy

BACKGROUND

Intraoperative frozen section assessment, to confirm acquisition of pathological tissues, is used in stereotactic brain biopsy to minimise sampling errors. Limitations include the dependence on dedicated neuro-oncology pathologists and an increase in operative duration. We investigated the use of intraoperative fluorescein sodium, and compared it to frozen section assessment, for confirming pathological tissue samples in the stereotactic biopsy of gadolinium-contrast-enhancing brain lesions.

METHODS

This prospective observational study consisted of 18 consecutive patients (12 men; median age, 63 years) who underwent stereotactic biopsy of gadolinium-contrast-enhancing brain lesions with intravenous fluorescein sodium administration. Twenty-three specimens were obtained and examined for the presence of fluorescence using a microscope with fluorescence visualisation capability. Positive and negative predictive values were calculated based on the fluorescence status of the biopsy samples with its corresponding intraoperative frozen section and definitive histopathological diagnosis.

RESULTS

Nineteen specimens (83%) were fluorescent and four (17%) were non-fluorescent. All 19 fluorescent specimens were confirmed to be lesional on intraoperative frozen section assessment and were suitable for histopathological diagnosis. Three of the non-fluorescent specimens were confirmed to be lesional on intraoperative frozen section assessment. One non-fluorescent specimen was non-diagnostic on frozen section and histological assessments. The positive predictive value was 100% and the negative predictive value was 25%.

CONCLUSIONS

Fluorescein sodium fluorescence is as accurate as frozen section assessment in confirming sampling of pathological tissue in the stereotactic biopsy of gadolinium-contrast-enhancing brain lesions. Fluorescein sodium fluorescence-guided stereotactic biopsy is a useful addition to the neurosurgical armamentarium.

A Model to Predict the Feasibility of Concurrent Chemoradiotherapy With Temozolomide in Glioblastoma Multiforme Patients Over Age 65

OBJECTIVES

It is controversial whether concurrent chemoradiotherapy (CRT) with temozolomide is feasible and beneficial in elderly patients with glioblastoma.

MATERIALS AND METHODS

Retrospective analysis of 74 elderly glioblastoma patients (65 y and above) treated with concurrent CRT with temozolomide. Factors influencing prognosis and feasibility of CRT were investigated.

RESULTS

The median overall survival was 11.3 months. Univariate analysis showed a significant difference in median overall survival for cumulative dose of concurrent temozolomide (optimal cutoff, 2655 mg/m; 13.9 mo for >2655 mg/m vs. 4.9 mo for ≤2655 mg/m; P=0.0216, adjusted for multiple testing). Furthermore, cumulative dose of concurrent temozolomide >2655 mg/m was a significant independent prognostic parameter in multivariate analysis (hazard ratio, 0.33; P=0.002). Hematotoxicity was the most common cause of treatment interruption or discontinuation in patients with an insufficient cumulative temozolomide dose. Prognostic factors for successful performance of CRT with a cumulative dose of concurrent temozolomide >2655 mg/m were female sex (odds ratio [OR], 0.174; P=0.006), age (OR, 0.826 per year; P=0.017), and pretreatment platelet count (OR, 1.013 per 1000 platelets/µL; P=0.001). For easy clinical application of the model an online calculator was developed, which is available at http://www.OldTMZ.com.

CONCLUSIONS

The probability of successful performance of concurrent CRT with temozolomide can be estimated based on the patient's age, sex, and pretreatment platelet count using the model developed in this study. Thus, a subgroup of elderly glioblastoma patients suitable for chemoradiation with temozolomide can be identified.

Treatment of Glioblastoma in Older Adults

Glioblastoma is the most common primary malignant brain tumor diagnosed in the USA and is associated with a poor prognosis. The outcomes in elderly patients (more than 65 years of age) are worse when compared to those younger than age 65 at the time of diagnosis. Older patients are not always offered treatments that would otherwise be considered standard of care due to comorbidities and concerns about toxicity and tolerability. The initial European Organization for Research and Treatment of Cancer study that led to approval of temozolomide in glioblastoma excluded patients more than 70 years of age. This review outlines challenges that arise in the treatment of glioblastoma in the elderly population and discusses results of recent studies that established the role of adjuvant chemotherapy in addition to radiation and surgery. There is evidence that these patients can benefit from a more aggressive and safe resection, from hypofractionated radiation treatments, and from adjuvant temozolomide.

Management of glioblastoma in elderly patients

Glioblastoma (GBM) is the most common primary malignant brain tumor in adults over 55years of age. The median age of diagnosis for patients with GBM is 64years old, with the incidence of patients between 75 and 85 increasing. The optimal treatment paradigm for elderly GBM patients continues to evolve due to the higher frequency of age-related and/or medical co-morbidities. Geriatric GBM patients have historically been excluded from larger, controlled clinical trials due to their presumed decreased likelihood of a sustained treatment response and/or a prolonged good outcome. Here, we highlight current treatment considerations of elderly GBM patients with respect to surgical, radiotherapeutic and systemic modalities, with considerations for improving future clinical outcomes for this patient population.

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.

Elderly patients with newly diagnosed glioblastoma: can preoperative imaging descriptors improve the predictive power of a survival model?

The purpose of this study was to identify independent prognostic factors among preoperative imaging features in elderly glioblastoma patients and to evaluate whether these imaging features, in addition to clinical features, could enhance the predictive power of survival models. This retrospective study included 108 patients ≥65 years of age with newly diagnosed glioblastoma. Preoperative clinical features (age and KPS), postoperative clinical features (extent of surgery and postoperative treatment), and preoperative MRI features were assessed. Univariate and multivariate cox proportional hazards regression analyses for overall survival were performed. The integrated area under the receiver operating characteristic curve (iAUC) was calculated to evaluate the added value of imaging features in the survival model. External validation was independently performed with 40 additional patients ≥65 years of age with newly diagnosed glioblastoma. Eloquent area involvement, multifocality, and ependymal involvement on preoperative MRI as well as clinical features including age, preoperative KPS, extent of resection, and postoperative treatment were significantly associated with overall survival on univariate Cox regression. On multivariate analysis, extent of resection and ependymal involvement were independently associated with overall survival and preoperative KPS showed borderline significance. The model with both preoperative clinical and imaging features showed improved prediction of overall survival compared to the model with preoperative clinical features (iAUC, 0.670 vs. 0.600, difference 0.066, 95% CI 0.021-0.121). Analysis of the validation set yielded similar results (iAUC, 0.790 vs. 0.670, difference 0.123, 95% CI 0.021-0.260), externally validating this observation. Preoperative imaging features, including eloquent area involvement, multifocality, and ependymal involvement, in addition to clinical features, can improve the predictive power for overall survival in elderly glioblastoma patients.

Survival Outcomes With Short-Course Radiation Therapy in Elderly Patients With Glioblastoma: Data From a Randomized Phase 3 Trial

PURPOSE

To perform a subset analysis of survival outcomes in elderly patients with glioblastoma from a randomized phase 3 trial comparing 2 short-course radiation therapy (RT) regimens in elderly and/or frail patients.

METHODS AND MATERIALS

The original trial population included elderly and/or frail patients with a diagnosis of glioblastoma. Patients joined the phase 3, randomized, multicenter, prospective, noninferiority trial; were assigned to 1 of 2 groups in a 1:1 ratio, either short-course RT (25 Gy in 5 fractions, arm 1) or commonly used RT (40 Gy in 15 fractions, arm 2); and were stratified by age (<65 years and ≥65 years), Karnofsky Performance Status (KPS), and extent of surgery. For the subset analysis in this study, only patients aged ≥65 years were evaluated (elderly and frail patients were defined as patients aged ≥65 years with KPS of 50%-70%; elderly and non-frail patients were defined as patients aged ≥65 years with KPS of 80%-100%); 61 of the 98 initial patients comprised the patient population, with 26 patients randomized to arm 1 and 35 to arm 2.

RESULTS

In this unplanned analysis, the short-course RT results were not statistically significantly different from the results of commonly used RT in elderly patients. The median overall survival time was 6.8 months (95% confidence interval [CI], 4.5-9.1 months) in arm 1 and 6.2 months (95% CI, 4.7-7.7 months) in arm 2 (P=.936). The median progression-free survival time was 4.3 months (95% CI, 2.6-5.9 months) in arm 1 and 3.2 months (95% CI, 0.1-6.3 months) in arm 2 (P=.706).

CONCLUSIONS

A short-course RT regimen of 25 Gy in 5 fractions is an acceptable treatment option for patients aged ≥65 years, mainly those with a poor performance status or contraindication to chemotherapy, which would be indicated in cases of methylated O6 methylguanine-DNA-methyltransferase promoter tumors.

Improved survival for elderly married glioblastoma patients : Better treatment delivery, less toxicity, and fewer disease complications

OBJECTIVES

Marital status is a well-described prognostic factor in patients with gliomas but the observed survival difference is unexplained in the available population-based studies.

METHODS

A series of 57 elderly glioblastoma patients (≥70 years) were analyzed retrospectively. Patients received radiotherapy or chemoradiation with temozolomide. The prognostic significance of marital status was assessed. Disease complications, toxicity, and treatment delivery were evaluated in detail.

RESULTS

Overall survival was significantly higher in married than in unmarried patients (median, 7.9 vs. 4.0 months; p = 0.006). The prognostic significance of marital status was preserved in the multivariate analysis (HR, 0.41; p = 0.011). Married patients could receive significantly higher daily temozolomide doses (mean, 53.7 mg/m² vs. 33.1 mg/m²; p = 0.020), were more likely to receive maintenance temozolomide (45.7 % vs. 11.8 %; p = 0.016), and had to be hospitalized less frequently during radiotherapy (55.0 % vs. 88.2 %; p = 0.016). Of the patients receiving temozolomide, married patients showed significantly lower rates of hematologic and liver toxicity. Most complications were infectious or neurologic in nature. Complications of any grade were more frequent in unmarried patients (58.8 % vs. 30.0 %; p = 0.041) with the incidence of grade 3-5 complications being particularly elevated (47.1 % vs. 15.0 %; p = 0.004).

CONCLUSION

We found poorer treatment delivery as well as an unexpected severe increase in toxicity and disease complications in elderly unmarried glioblastoma patients. Marital status may be an important predictive factor for clinical decision-making and should be addressed in further studies.

Age alone is not a predictor for survival in glioblastoma

Over half of glioblastoma (GBM) cases are diagnosed in patients older than 65 years. Their median overall survival (OS) is 4-5 months, compared with 12-14 months in patients younger than 70 years. This retrospective audit aims to identify patterns of care and survival of patients diagnosed with GBM at a single institution in Melbourne, Australia. Consecutive histological diagnoses of adult primary GBM from January 2010 to December 2012 were retrospectively identified from medical records. Demographic, treatment and survival characteristics were recorded until death, with follow-up to January 1st 2015. Survival was estimated by Kaplan-Meier method. Planned, sub-group analyses were conducted using multivariate Cox proportional hazards model to identify differences between elderly and younger cohorts, as well as ECOG. 165 patients were identified (36 % aged ≥70 years). Those ≥70 years had a poorer performance status (ECOG 3-4: 27 vs 10 %, p = .005); poorer median OS (2.6 vs 11.5 months, p < .001); and were less likely to receive adjuvant treatment (no treatment: 40 vs 16 %, p < .001) compared with patients <70 years. Age was not a significant predictor of poorer os (HR 1.0; 0.99-1.03; p > .05), after adjusting for other clinical factors. Significant predictors of poorer os were poor performance status (p = .001), bilateral tumours (p = .04), biopsy only (p = .001), and no adjuvant treatment (p < .001). In patients diagnosed with GBM, those older than 70 years often present with poor performance status, are less likely to receive adjuvant treatment and have inferior os compared with younger patients. Treatment recommendations should be based on performance status/fitness, not age alone.

Conditional survival after diagnosis with malignant brain and central nervous system tumor in the United States, 1995-2012

General population-based survival statistics for primary malignant brain or other central nervous system (CNS) tumors do not provide accurate estimations of prognosis for individuals who have survived for a significant period of time. For these persons, the use of conditional survival percentages provides more accurate information to estimate potential outcomes. Using information from the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) program from 1995 to 2012, conditional survival percentages were calculated for 1 or 5 years of additional survival for all primary malignant brain and CNS tumors overall and by gender, race, ethnicity and age. Rates were calculated to include 1, 2, 3, 4, 5, 10 and 15 years post diagnosis. Conditional survival was also calculated in intervals from 1995-2004 to 2005-2012, to examine the potential effect that the introduction of new treatment protocols may have had on survival rates. The percentage of patients surviving one or five additional years varied by histology, age at diagnosis, gender, race and ethnicity. Younger persons (age <15 years at diagnosis) had higher conditional survival percentages for all histologies as compared to all histologies in older patients (age ≥15 years at diagnosis). The longer the amount of time post-diagnosis of a malignant brain or other CNS tumor, the higher the conditional survival. Younger persons at diagnosis had the highest conditional survival irrespective of histology. Use of conditional survival rates provides relevant additional information for patients and their families, as well as for clinicians and researchers, and helps with understanding prognosis.

IDH1/2 Mutation and MGMT Promoter Methylation - the Relevant Survival Predictors in Czech Patients with Brain Gliomas

Gliomas are a heterogeneous group of tumours varying in prognosis, treatment approach, and overall survival. Recently, novel markers have been identified which are linked to patient prognosis and therapeutic response. Especially the mutation of the enzyme isocitrate dehydrogenase 1 or 2 (IDH1/2) gene and the O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status seem to be the most important predictors of survival. From 2012 to 2015, 94 Czech patients with primary brain tumours were enrolled into the study. The IDH1/2 mutation was detected by denaturing capillary electrophores.The methylation status of the MGMT gene and other 46 genes was revealed by MS-MLPA. In all 94 patients, the clinical data were correlated with molecular markers by Kaplan-Meier analyses and Cox regression model. The MGMT promoter methylation status was established and compared to clinical data. In our study eight different probes were used to elucidate the MGMT methylation status; hypermethylation was proclaimed if four and more probes were positive. This 3 : 5 ratio was tested and confirmed by Kaplan-Meier and Cox analyses. The study confirmed the importance of the IDH1/2 mutation and hypermethylation of the MGMT gene promoter being present in tumour tissue. Both markers are independent positive survival predictors; in the Cox model the IDH hazard ratio was 0.10 and in the case of MGMT methylation it reached 0.32. The methylation analysis of the panel of additional 46 genes did not reveal any other significant epigenetic markers; none of the candidate genes have been confirmed in the Cox regression analyses as an independent prognostic factor.

International Atomic Energy Agency Randomized Phase III Study of Radiation Therapy in Elderly and/or Frail Patients With Newly Diagnosed Glioblastoma Multiforme

Purpose

The optimal radiotherapy regimen for elderly and/or frail patients with newly diagnosed glioblastoma remains to be established. This study compared two radiotherapy regimens on the outcome of these patients.

Patients and Methods

Between 2010 and 2013, 98 patients (frail = age ≥ 50 years and Karnofsky performance status [KPS] of 50% to 70%; elderly and frail = age ≥ 65 years and KPS of 50% to 70%; elderly = age ≥ 65 years and KPS of 80% to 100%) were prospectively randomly assigned to two arms in a 1:1 ratio, stratified by age (< and ≥ 65 years old), KPS, and extent of surgical resection. Arm 1 received short-course radiotherapy (25 Gy in five daily fractions over 1 week), and arm 2 received commonly used radiotherapy (40 Gy in 15 daily fractions over 3 weeks).

Results

The short-course radiotherapy was noninferior to commonly used radiotherapy. The median overall survival time was 7.9 months (95% CI, 6.3 to 9.6 months) in arm 1 and 6.4 months (95% CI, 5.1 to 7.6 months) in arm 2 (P = .988). Median progression-free survival time was 4.2 months (95% CI, 2.5 to 5.9) in arm 1 and 4.2 months (95% CI, 2.6 to 5.7) in arm B (P = .716). With a median follow-up time of 6.3 months, the quality of life between both arms at 4 weeks after treatment and 8 weeks after treatment was not different.

Conclusion

There were no differences in overall survival time, progression-free survival time, and quality of life between patients receiving the two radiotherapy regimens. In view of the reduced treatment time, the short 1-week radiotherapy regimen may be recommended as a treatment option for elderly and/or frail patients with newly diagnosed glioblastoma.

Patterns of care in recurrent glioblastoma in Switzerland: a multicentre national approach based on diagnostic nodes

Despite moderate improvements in outcome of glioblastoma after first-line treatment with chemoradiation recent clinical trials failed to improve the prognosis of recurrent glioblastoma. In the absence of a standard of care we aimed to investigate institutional treatment strategies to identify similarities and differences in the pattern of care for recurrent glioblastoma. We investigated re-treatment criteria and therapeutic pathways for recurrent glioblastoma of eight neuro-oncology centres in Switzerland having an established multidisciplinary tumour-board conference. Decision algorithms, differences and consensus were analysed using the objective consensus methodology. A total of 16 different treatment recommendations were identified based on combinations of eight different decision criteria. The set of criteria implemented as well as the set of treatments offered was different in each centre. For specific situations, up to 6 different treatment recommendations were provided by the eight centres. The only wide-range consensus identified was to offer best supportive care to unfit patients. A majority recommendation was identified for non-operable large early recurrence with unmethylated MGMT promoter status in the fit patients: here bevacizumab was offered. In fit patients with late recurrent non-operable MGMT promoter methylated glioblastoma temozolomide was recommended by most. No other majority recommendations were present. In the absence of strong evidence we identified few consensus recommendations in the treatment of recurrent glioblastoma. This contrasts the limited availability of single drugs and treatment modalities. Clinical situations of greatest heterogeneity may be suitable to be addressed in clinical trials and second opinion referrals are likely to yield diverging recommendations.

Predictors of survival and effect of short (40 Gy) or standard-course (60 Gy) irradiation plus concomitant temozolomide in elderly patients with glioblastoma: a multicenter retrospective study of AINO (Italian Association of Neuro-Oncology)

The efficacy of temozolomide (TMZ) plus radiation therapy (RT) in elderly patients with glioblastoma is unclear. We performed a large multicenter retrospective study to analyze prognostic factors and clinical outcome in these patients. Inclusion criteria were age ≥65 years, newly histologically confirmed glioblastoma, ECOG PS 0-2, adjuvant treatment with RT plus TMZ. We enrolled 237 patients; the average age was 71 and ECOG PS was 0-1 in 196 patients; gross total resection was performed in 174 cases. MGMT was analyzed in 151 persons and was methylated in 56 %. IDH1 was assessed in 100 patients and was mutated in 6 %. Seventy-one patients were treated with RT 40 Gy and 166 with RT 60 Gy. Progression-free survival and overall survival (OS) were 11.3 and 17.3 months, respectively. Overall survival was 19.4 vs 13.8 months for patients treated with RT 60 Gy and 40 Gy (p = 0.02); OS was 17.7 versus 16.1 months for patients treated with gross total resection vs partial surgery (p = 0.02); OS was 21.2 versus 13.6 months for methylated and unmethylated MGMT (p < 0.001). On multivariate analysis, gross total resection, RT 60 Gy, methylated MGMT and ECOG PS 0-1 were independent predictors of longer survival. Twenty-five patients (10 %) had grade 3-4 haematological toxicity during the concomitant treatment. We showed that, in elderly patients in good clinical condition treated with concomitant treatment, standard-course irradiation might be more effective than short-course irradiation. Methylated MGMT remains the most important prognostic factor.

Brain Tumor Epidemiology - A Hub within Multidisciplinary Neuro-oncology. Report on the 15th Brain Tumor Epidemiology Consortium (BTEC) Annual Meeting, Vienna, 2014

The Brain Tumor Epidemiology Consortium (BTEC) is an open scientific forum, which fosters the development of multi-center, international and inter-disciplinary collaborations. BTEC aims to develop a better understanding of the etiology, outcomes, and prevention of brain tumors (http://epi.grants.cancer.gov/btec/). The 15th annual Brain Tumor Epidemiology Consortium Meeting, hosted by the Austrian Societies of Neuropathology and Neuro-oncology, was held on September 9 - 11, 2014 in Vienna, Austria. The meeting focused on the central role of brain tumor epidemiology within multidisciplinary neuro-oncology. Knowledge of disease incidence, outcomes, as well as risk factors is fundamental to all fields involved in research and treatment of patients with brain tumors; thus, epidemiology constitutes an important link between disciplines, indeed the very hub. This was reflected by the scientific program, which included various sessions linking brain tumor epidemiology with clinical neuro-oncology, tissue-based research, and cancer registration. Renowned experts from Europe and the United States contributed their personal perspectives stimulating further group discussions. Several concrete action plans evolved for the group to move forward until next year's meeting, which will be held at the Mayo Clinic at Rochester, MN, USA.

International Differences in Treatment and Clinical Outcomes for High Grade Glioma

BACKGROUND

High grade gliomas are the most common type of malignant brain tumor, and despite their rarity, cause significant morbidity and mortality. This study aimed to compare the treatment patterns of high grade glioma to examine survival patterns in patients who receive specific treatments between cohorts in Ohio and Taiwan.

METHOD

Patients aged 18 years and older at age of diagnosis with World Health Organization (WHO) grade III or IV astrocytoma from 2007-2012 were selected from the Ohio Brain Tumor Study and the Taiwan Cancer Registry. The treatment information was derived from medical chart reviews in Ohio and National Health Insurance Research Data in Taiwan. Treatment examined included surgical procedure (brain biopsy and/or resection), radiotherapy (radiation and/or radiosurgery), and alkylating chemotherapy. Kaplan-Meier and parametric survival models were used to examine the effect of treatment on survival, adjusted for age, sex, and comorbidities.

RESULTS

294 patients in Ohio and 1,097 patients in Taiwan met the inclusion criteria. 70.3% patients in Ohio and 51.4% in Taiwan received surgical resection, followed by concurrent chemoradiation. Patients who received this treatment had the highest survival rate, with a 1-year survival rate of 72.8% in Ohio and 73.4% in Taiwan. Patients who did not receive surgical resection, followed by concurrent chemoradiation had an increased risk of death (hazard ratio of 5.03 [95% confidence interval (CI): 3.61-7.02] in Ohio and 1.49 [95% CI: 1.31-1.71] in Taiwan) after adjustment for age, sex, and comorbidities.

CONCLUSION

Surgical resection followed by concurrent chemoradiation was associated with higher survival rate of patients with high grade glioma in both Ohio and Taiwan; however, one-third of patients in Ohio and half in Taiwan did not receive this treatment.

Factors associated with increased survival after surgical resection of glioblastoma in octogenarians

Elderly patients with glioblastoma represent a clinical challenge for neurosurgeons and oncologists. The data available on outcomes of patients greater than 80 undergoing resection is limited. In this study, factors linked to increased survival in patients over the age of 80 were analyzed. A retrospective chart review of all patients over the age of 80 with a new diagnosis of glioblastoma and who underwent surgical resection with intent for maximal resection were examined. Patients who had only stereotactic biopsies were excluded. Immunohistochemical expression of oncogenic drivers (p53, EGFR, IDH-1) and a marker of cell proliferation (Ki-67 index) performed upon routine neuropathological examination were recorded. Stepwise logistic regression and Kaplan Meier survival curves were plotted to determine correlations to overall survival. Fifty-eight patients fit inclusion criteria with a mean age of 83 (range 80–93 years). The overall median survival was 4.2 months. There was a statistically significant correlation between Karnofsky Performance Status (KPS) and overall survival (P < 0.05). There was a significantly longer survival among patients undergoing either radiation alone or radiation and chemotherapy compared to those who underwent no postoperative adjuvant therapy (p < 0.05). There was also an association between overall survival and lack of p53 expression (p < 0.001) and lack of EGFR expression (p <0.05). In this very elderly population, overall survival advantage was conferred to those with higher preoperative KPS, postoperative adjuvant therapy, and lack of protein expression of EGFR and p53. These findings may be useful in clinical decision analysis for management of patients with glioblastoma who are octogenarians, and also validate the critical role of EGFR and p53 expression in oncogenesis, particularly with advancing age.

Comparison of radiation regimens in the treatment of Glioblastoma multiforme: results from a single institution

Background

The optimal fractionation schedule of radiotherapy (RT) for Glioblastoma multiforme (GBM) is yet to be determined. We aim to compare different fractionation regimens and identify prognostic factors to better tailor RT for newly diagnosed GBM patients.

Methods

All data for patients who underwent surgery for GBM between January 2005 and December 2012 were compiled. Clinical information was collected using patient charts and government registry. Cox analysis was used to identify variables affecting survival and treatment outcome.

Results

The median follow-up time was 13.2 months. Two hundred and seventy-six patients met the inclusion criteria, including 147 patients in the 60 Gy in 30 fractions (ConvRT) group, 86 patients in the 60 Gy in 20 fractions (HF60) group, and 43 patients in the 40 Gy in 15 fractions (HF40) group. Median survival (MS) was 16.0 months with a median progression-free survival (PFS) of 9.23 months in the ConvRT group. This was comparable to outcome in the HF60 group with MS 15.0 months and a median PFS of 9.1 months. Patients in the HF40 group had MS of 8 months, with a median PFS 5.4 months. Cox analysis showed no significant difference in OS between the ConvRT and HF60 groups but worse outcome in the HF40 group (HR 2.22, P = 0.04). MGMT methylation, extent of resection, use of chemotherapy, and repeat surgery were found to be significant independent prognostic factors for survival.

Conclusions

HF60 constitutes a safe RT approach that shows survival comparable to standard RT while allowing for a shorter treatment time.

The clinico-oncologic outcomes of elderly patients with glioblastoma after surgical resection followed by concomitant chemo-radiotherapy

Background

There have been controversies in the treatment of elderly patients with glioblastoma. We introduce the outcome of the treatment of elderly patients with glioblastoma comparing with younger patients.

Methods

The author's hospital database was used to identify patients with histologically confirmed glioblastoma after surgery between January 2006 and December 2013. Forty-eight patients (control group) were under age 65 and 16 patients (elderly group) were aged 65 years or over at the time of surgery.

Results

The median age of the elderly group was 71 years and control group was 50 years. Mean number of medical comorbidities was 1.8 in the elderly group vs. 0.5 in the control group. The median progression free survival (PFS) was 5.6 months and the median overall survival (OS) was 19.9 months in all patients. The elderly group had a median PFS of 4.2 months vs. 8 months for the control group (log-rank test, p=0.762). Median OS was 8.2 months in the elderly group vs. 20.9 months in the control group (log-rank test, p=0.457). Major complications occurred in 5 cases (7.8%) for all patients. The ratio of completion of concomitant chemo-radiotherapy (CCRT) was 81.3% and was the same between the two groups. In multivariable analysis, extent of resection (p=0.034) and completion of CCRT (p=0.023) were statistically significant, independent prognostic factors only for PFS in all patients by Cox proportional hazards model. Age was not an independent prognostic factor. As for OS, there was no significant factor.

Conclusion

Surgical resection and CCRT were well tolerated in elderly patients with glioblastoma, and maximal safe resection followed by timely CCRT could improve clinic-oncologic outcomes.