Supratentorial low-grade gliomas in older patients

Low grade gliomas guide-lines elaborated by the tumor section of Spanish Society of Neurosurgery

Adult low-grade gliomas (Low Grade Gliomas, LGG) are tumors that originate from the glial cells of the brain and whose management involves great controversy, starting from the diagnosis, to the treatment and subsequent follow-up. For this reason, the Tumor Group of the Spanish Society of Neurosurgery (GT-SENEC) has held a consensus meeting, in which the most relevant neurosurgical issues have been discussed, reaching recommendations based on the best scientific evidence. In order to obtain the maximum benefit from these treatments, an individualised assessment of each patient should be made by a multidisciplinary team. Experts in each LGG treatment field have briefly described it based in their experience and the reviewed of the literature. Each area has been summarized and focused on the best published evidence. LGG have been surrounded by treatment controversy, although during the last years more accurate data has been published in order to reach treatment consensus. Neurosurgeons must know treatment options, indications and risks to participate actively in the decision making and to offer the best surgical treatment in every case.

Isocitrate-dehydrogenase-mutant lower grade glioma in elderly patients: treatment and outcome in a molecularly characterized contemporary cohort

PURPOSE

Lower-grade glioma (LGG) is rare among patients above the age of 60 ("elderly"). Previous studies reported poor outcome, likely due to the inclusion of isocitrate dehydrogenase (IDH) wildtype astrocytomas and advocated defensive surgical and adjuvant treatment. This study set out to question this paradigm analyzing a contemporary cohort of patients with IDH mutant astrocytoma and oligodendroglioma WHO grade 2 and 3.

METHODS

Elderly patients treated in our department for a supratentorial, hemispheric LGG between 2009 and 2019 were retrospectively analyzed for patient-, tumor- and treatment-related factors and progression-free survival (PFS) and compared to patients aged under 60. Inclusion required the availability of subtype-defining molecular data and pre- and post-operative tumor volumes.

RESULTS

207 patients were included, among those 21 elderlies (10%). PFS was comparable between elderly and younger patients (46 vs. 54 months; p = 0.634). Oligodendroglioma was more common in the elderly (76% vs. 46%; p = 0.011). Most patients underwent tumor resection (elderly: 81% vs. younger: 91%; p = 0.246) yielding comparable residual tumor volumes (elderly: 7.8 cm³; younger: 4.1 cm³; p = 0.137). Adjuvant treatment was administered in 76% of elderly and 61% of younger patients (p = 0.163). Uni- and multi-variate survival analyses identified a tumor crossing the midline, surgical strategy, and pre- and post-operative tumor volumes as prognostic factors.

CONCLUSION

Elderly patients constitute a small fraction of molecularly characterized LGGs. In contrast to previous reports, favorable surgical and survival outcomes were achieved in our series comparable to those of younger patients. Thus, intensified treatment including maximal safe resection should be advocated in elderly patients whenever feasible.

Acute progression of cerebral amyloid angiopathy-related inflammation diagnosed by biopsy in an elderly patient: A case report

Background:

Cerebral amyloid angiopathy-related inflammation (CAA-I) presents with slowly progressive nonspecific neurological symptoms, such as headache, cognitive function disorder, and seizures. Pathologically, the deposition of amyloid-β proteins at the cortical vascular wall is a characteristic and definitive finding. Differential diagnoses include infectious encephalitis, neurosarcoidosis, primary central nervous system lymphoma, and glioma. Here, we report a case of CAA-I showing acute progression, suggesting a glioma without enhancement, in which a radiological diagnosis was difficult using standard magnetic resonance imaging.

Case Description:

An 80-year-old woman was admitted due to transient abnormal behavior. Her initial imaging findings were similar to those of a glioma. She presented with rapid progression of the left hemiplegia and disturbance of consciousness for 6 days after admission and underwent emergent biopsy with a targeted small craniotomy under general anesthesia despite her old age. Intraoperative macroscopic findings followed by a pathological study revealed CAA-I as the definitive diagnosis. Steroid pulse therapy with methylprednisolone followed by oral prednisolone markedly improved both the clinical symptoms and imaging findings.

Conclusion:

Differential diagnosis between CAA-I and nonenhancing gliomas may be difficult using standard imaging studies in cases presenting with acute progression. A pathological diagnosis under minimally invasive small craniotomy may be an option, even for elderly patients.

Analysis of Prognostic Factors of Low-Grade Gliomas in Adults Using Time-Dependent Competing Risk Models: A Population Study Based on the Surveillance, Epidemiology, and End Results Database

BACKGROUND

Because of multiple competing death outcomes and time-varying coefficients, using a Cox regression model to analyze the prognostic factors of low-grade gliomas (LGG) may lead to a possible bias. Therefore, we adopted time-dependent competing risk models to obtain accurate prognostic factors for LGG.

METHODS

In this retrospective cohort study, data were extracted from patients enrolled in the Surveillance, Epidemiology, and End Results (SEER) database between 2000 and 2018. Univariate analysis was performed using the cumulative incidence function (CIF) and Kaplan-Meier (KM) function. Time-dependent competing risk and Cox regression models were used in the multivariable analysis.

RESULTS

A total of 2581 patients were diagnosed with low-grade glioma, among whom 889 died from low-grade glioma, 114 died from other causes, and the rest were alive. The time-dependent competing risk models indicated that age, sex, marital status, primary tumor site, histological type, tumor diameter, surgery, and year of diagnosis were significantly associated with low-grade glioma-specific death, and the relative effect of age, tumor diameter, surgery, oligodendroglioma, and mixed glioma on low-grade glioma-specific death changed over time. Compared with the competing risk models, the Cox regression model misestimated the hazard ratio (HR) of covariates on the outcome and even produced false-negative results.

CONCLUSIONS

The time-dependent competing risk models were better than the Cox regression model for evaluating the impact of covariates on low-grade glioma-specific mortality in the presence of competing risks and time-varying coefficients. The models identified the prognostic factors of LGG more accurately than the Cox regression model.

A Novel Six Autophagy-Related Genes Signature Associated With Outcomes and Immune Microenvironment in Lower-Grade Glioma

Since autophagy and the immune microenvironment are deeply involved in the tumor development and progression of Lower-grade gliomas (LGG), our study aimed to construct an autophagy-related risk model for prognosis prediction and investigate the relationship between the immune microenvironment and risk signature in LGG. Therefore, we identified six autophagy-related genes (BAG1, PTK6, EEF2, PEA15, ITGA6, and MAP1LC3C) to build in the training cohort (n = 305 patients) and verify the prognostic model in the validation cohort (n = 128) and the whole cohort (n = 433), based on the data from The Cancer Genome Atlas (TCGA). The six-gene risk signature could divide LGG patients into high- and low-risk groups with distinct overall survival in multiple cohorts (all p < 0.001). The prognostic effect was assessed by area under the time-dependent ROC (t-ROC) analysis in the training, validation, and whole cohorts, in which the AUC value at the survival time of 5 years was 0.837, 0.755, and 0.803, respectively. Cox regression analysis demonstrated that the risk model was an independent risk predictor of OS (HR > 1, p < 0.05). A nomogram including the traditional clinical parameters and risk signature was constructed, and t-ROC, C-index, and calibration curves confirmed its robust predictive capacity. KM analysis revealed a significant difference in the subgroup analyses' survival. Functional enrichment analysis revealed that these autophagy-related signatures were mainly involved in the phagosome and immune-related pathways. Besides, we also found significant differences in immune cell infiltration and immunotherapy targets between risk groups. In conclusion, we built a powerful predictive signature and explored immune components (including immune cells and emerging immunotherapy targets) in LGG.

Age is associated with unfavorable neuropathological and radiological features and poor outcome in patients with WHO grade 2 and 3 gliomas

With the rising life expectancy and availability of neuroimaging, increased number of older patients will present with diffuse and anaplastic gliomas. The aim of our study was therefore to investigate age-related prognostic clinical, neuropathological and radiological features of lower-grade gliomas. All consecutive patients with diffuse or anaplastic glioma WHO grade 2 and 3 who underwent first tumor resection between 2010 and 2018, were selected from the institutional neuro-oncological database and evaluated. The mean age of 55 males and 44 females was 46 years (SD ± 16). Wild-type IDH1 (p = 0.012), persistent nuclear ATRX expression (p = 0.012) and anaplasia (p < 0.001) were significantly associated with higher age. The CE volume before resection was found to be increased in older patients (r = 0.42, p < 0.0001), and CE rate was higher in the IDH wild-type population only (p = 0.02). The extent of resection did not differ with age. Overall, one year of life resulted in a PFS reduction of 9 days (p = 0.047); in IDH sub-group analysis, this dependency was confirmed only in wild-type tumors (p = 0.05). OS was significantly reduced in older patients (p = 0.033). In conclusion, behavior and prognosis of WHO grade 2 and 3 glioma were unfavorable in correlation to patient’s age, even if the extent of resection was comparable. Older age imparted a poorer PFS and higher CE rate only in the IDH wild-type population.

Current clinical management of elderly patients with glioma

INTRODUCTION

The incidence of gliomas is increasing in elderly patients. Clinical factors, such as age, performance status, and comorbidities contribute when choosing adequate treatment in older patients.

AREAS COVERED

This review covers the main pathological and molecular features of gliomas in elderly patients, as well as the neurological and geriatric assessment to select patients for surgery and antineoplastic treatments. The results from the most relevant clinical trials in both lower-grade (LGGs) and high-grade gliomas (HGGs) are reviewed.

EXPERT OPINION

Different clinical and biological factors need to be integrated into prognostic scales in order to better stratify the elderly population. Both Stupp and Perry regimens can be proposed to fit patients with GBM aged < 70 years. Conversely, for patients aged ≥ 70 years, the Perry regimen should be preferred. For unfit and frail patients, temozolomide alone when MGMT is methylated or hypofractionated RT alone when MGMT is unmethylated, are the optimal choice. Few data are available regarding the optimal management of elderly patients with LGGs. The benefit of an extensive resection and presence of methylation of the MGMT promoter need to be further investigated to confirm their role in improving the OS.

Effect of seizure timing on long-term survival in patients with brain tumor

OBJECTIVE

Seizures often occur in patients with primary brain tumor (BT). The aim of this study was to determine if there is an association between the time of occurrence of seizures during the course of BT and survival of these patients.

METHODS

This retrospective cohort study at Henry Ford Hospital, an urban tertiary referral center, included all patients who were diagnosed with primary BTs at Henry Ford Health System between January 2006 and December 2014. Timing of seizure occurrence, if occurred at presentation or after the tumor diagnosis during follow-up period, in different grades of BTs, and survival of these patients were analyzed.

RESULTS

Of the 901 identified patients, 662 (53% male; mean age: 56 years) were included in final analysis, and seizures occurred in 283 patients (43%). Patients with World Health Organization (WHO) grade III BT with seizures as a presenting symptom only had better survival (adjusted hazard ratio (HR): 0.27; 95% confidence interval (CI), 0.11-0.67; P = 0.004). Seizures that occurred after tumor diagnosis only (adjusted HR: 2.11; 95% CI, 1.59-2.81; P < 0.001) in patients with WHO grade II tumors (adjusted HR: 3.41; 95% CI, 1.05-11.1; P = 0.041) and WHO grade IV tumors (adjusted HR: 2.14; 95% CI, 1.58-2.90; P < 0.001) had higher mortality. Seizures that occurred at presentation and after diagnosis also had higher mortality (adjusted HR: 1.34; 95% CI, 1.00-1.80; P = 0.049), in patients with meningioma (adjusted HR: 6.19; 95% CI, 1.30-29.4; P = 0.021) and grade III tumors (adjusted HR: 6.19; 95% CI, 2.56-15.0; P < 0.001).

CONCLUSION

Seizures occurred in almost half of the patients with BTs. The association between seizures in patients with BT and their survival depends on the time of occurrence of seizures, if occurring at presentation or after tumor diagnosis, and the type of tumor. Better survival was noted in patients with WHO grade III BTs who had seizures at presentation at the time of diagnosis, while higher mortality was noted in WHO grade II tumors who had seizure at presentation and after tumor diagnosis, and in grade IV tumors after tumor diagnosis.

Defining Undertreatment and Overtreatment in Older Adults With Cancer: A Scoping Literature Review

PURPOSE

The terms undertreatment and overtreatment are often used to describe inappropriate management of older adults with cancer. We conducted a comprehensive scoping review of the literature to clarify the meanings behind the use of the terms.

METHODS

We searched PubMed (National Center for Biotechnology Information), Embase (Elsevier), and CINAHL (EBSCO) for titles and abstracts that included the terms undertreatment or overtreatment with regard to older adults with cancer. We included all types of articles, cancer types, and treatments. Definitions of undertreatment and overtreatment were extracted, and categories underlying these definitions were derived through qualitative analysis. Within a random subset of articles, C.D. and K.P.L. independently performed this analysis to determine final categories and then independently assigned these categories to assess inter-rater reliability.

RESULTS

Articles using the terms undertreatment (n = 236), overtreatment (n = 71), or both (n = 51) met criteria for inclusion in our review (n = 256). Only 14 articles (5.5%) explicitly provided formal definitions; for the remaining, we inferred the implicit definitions from the terms' surrounding context. There was substantial agreement (κ = 0.81) between C.D. and K.P.L. in independently assigning categories of definitions within a random subset of 50 articles. Undertreatment most commonly implied less than recommended therapy (148; 62.7%) or less than recommended therapy associated with worse outcomes (88; 37.3%). Overtreatment most commonly implied intensive treatment of an older adult in whom the harms of treatment outweigh the benefits (38; 53.5%) or intensive treatment of a cancer not expected to affect an older adult in his/her remaining lifetime (33; 46.5%).

CONCLUSION

Undertreatment and overtreatment of older adults with cancer are imprecisely defined concepts. We propose new, more rigorous definitions that account for both oncologic factors and geriatric domains.

Integration of dynamic parameters in the analysis of 18F-FDopa PET imaging improves the prediction of molecular features of gliomas

PURPOSE

¹⁸F-FDopa PET imaging of gliomas is routinely interpreted with standardized uptake value (SUV)-derived indices. This study aimed to determine the added value of dynamic ¹⁸F-FDopa PET parameters for predicting the molecular features of newly diagnosed gliomas.

METHODS

We retrospectively included 58 patients having undergone an ¹⁸F-FDopa PET for establishing the initial diagnosis of gliomas, whose molecular features were additionally characterized according to the WHO 2016 classification. Dynamic parameters, involving time-to-peak (TTP) values and curve slopes, were tested for the prediction of glioma types in addition to current static parameters, i.e., tumor-to-normal brain or tumor-to-striatum SUV ratios and metabolic tumor volume (MTV).

RESULTS

There were 21 IDH mutant without 1p/19q co-deletion (IDH+/1p19q-) gliomas, 16 IDH mutants with 1p/19q co-deletion (IDH+/1p19q+) gliomas, and 21 IDH wildtype (IDH-) gliomas. Dynamic parameters enabled differentiating the gliomas according to these molecular features, whereas static parameters did not. In particular, a longer TTP was the single best independent predictor for identifying (1) IDH mutation status (area under the curve (AUC) of 0.789, global accuracy of 74% for the criterion of a TTP ≥ 5.4 min) and (2) 1p/19q co-deletion status (AUC of 0.679, global accuracy of 69% for the criterion of a TTP ≥ 6.9 min). Moreover, the TTP from IDH- gliomas was significantly shorter than those from both IDH+/1p19q- and IDH+/1p19q+ (p ≤ 0.007).

CONCLUSION

Prediction of the molecular features of newly diagnosed gliomas with ¹⁸F-FDopa PET and especially of the presence or not of an IDH mutation, may be obtained with dynamic but not with current static uptake parameters.

Diffuse Low-Grade Glioma - Changing Concepts in Diagnosis and Management: A Review

Though diffuse low-grade gliomas (dLGGs) represent only 15% of gliomas, they have been receiving increasing attention in the past decade. Significant advances in knowledge of the natural history and clinical diversity have been documented, and an improved pathological classification of gliomas that integrates histological features with molecular markers has been issued by the WHO. Advances in the radiological assessment of dLGG, particularly new magnetic resonance imaging scanning sequences, allow improved diagnostic and prognostic information. The management paradigms are evolving from “wait and watch” of the past to more active interventional therapy to obviate the risk of malignant transformation. New surgical technologies allow more aggressive surgical resections with a reduction of morbidity. Many reports suggest the association of gross total resection with longer overall survival and progression-free survival in addition to better seizure control. The literature also shows the use of chemotherapeutics and radiation therapy as important adjuncts to surgery. The goals of management have has been increasing survival with increasing stress on quality of life. Our review highlights the recent advances in the molecular diagnosis and management of dLGG with trends toward multidisciplinary and multimodality management of dLGG with an aim to surgically resect the primary disease, followed by chemoradiation in cases of progressive or recurrent disease.

Age and surgical outcome of low-grade glioma in Sweden

BACKGROUND

Low-grade gliomas (LGG) are slow-growing primary brain tumors that typically affect young adults. Advanced age is widely recognized as a poor prognostic factor in LGG. The impact of age on postoperative outcome in this patient group has not been systemically studied.

METHODS

We performed a nationwide register-based study with data from the Swedish Brain Tumor Registry (SBTR) for all adults diagnosed with a supratentorial LGG (WHO grade II astrocytoma, oligoastrocytoma, or oligodendroglioma) during 2005-2015. Patient- and tumor-related characteristics, postoperative complications, and survival were compared between three different age groups (18-39 years, 40-59 years, and ≥60 years).

RESULTS

We identified 548 patients; 204 patients (37.2%) aged 18-39 years, 227 patients (41.4%) aged 40-59 years, and 117 patients (21.4%) ≥60 years of age. Unfavorable preoperative prognostic factors (eg, functional status and neurological deficit) were more common with increased age (P < .001). In addition, overall survival was significantly impaired in those 60 years and above (P < .001). We observed a clear dose-response for age with separation of survival curves at 50 years. Biopsy was more common in patients ≥60 years (P < .001). Subgroup analysis of patients with resection revealed a higher amount of postoperative neurological deficits in older patients (P = .029).

CONCLUSION

In general, older patients with LGG have several unfavorable prognostic factors compared with younger patients but seem to tolerate surgery in a comparable fashion. However, more neurological deficits were observed following resections in elderly. Our data further support a cutoff at 50 years rather than 40 years for selection of high-risk patients.

Prognosis of older patients with low-grade glioma: A retrospective study

Introduction

Clinical behavior, treatment parameters, and prognostic factors are less well defined in older adults with low-grade gliomas (LGG). We conducted a two-institution retrospective review of older patients with LGG to better understand disease characteristics and prognosis in this population.

Methods

Northwestern University (NU) and The University of Washington (UW) clinical research databases were queried for patients ≥ 50 years of age with a diagnosis of WHO grade II glioma between January 1, 2000 and December 2012 (UW). Medical records were reviewed and data relevant to diagnosis, treatment and outcomes were collected. PFS and OS with respect to prognostic factors were calculated. Log-rank test and multivariate proportional hazards models were calculated for multiple tumor characteristics.

Results

Thirty-five patients with a diagnosis of LGG (WHO grade II) were identified; 15 women and 20 men had a median age of 55 (range 50-78). Fourteen had astrocytomas, fourteen had oligodendrogliomas and seven had oligoastrocytomas. Eight patients had contrast enhancement on neuroimaging, 9 of 21 tested had 1p19q co-deletion and 5 of 14 tested had an IDH1 mutation. Five year PFS was 21% with median PFS of 17 months; 20 patients had died (5 year OS=43%, median OS=48 months). On univariate analysis There was a statistically significant improvement in OS for patients with mixed histology (p=0.001), no midline shift at diagnosis (p=0.002) and with IDH1 mutation (p=0.003).

Conclusion

LGG appear more aggressive in older patients. Treatment following surgical resection should be considered; ongoing studies may clarify the most appropriate treatments for this age group.

Decline in executive functions and speed in suspected low-grade gliomas: A 3-year follow-up of a clinical cohort

Changes over time in information processing speed and executive functions (EFs) were studied in patients with suspected low-grade gliomas (LGG) 3 years after diagnosis. Using a person-oriented approach, the study aimed at focusing solely on two cognitive domains known to be significant in the understanding of the impact of white matter diseases. The Barkley's hybrid model of EFs was used as a theoretical framework for the evaluation of EFs. The majority of the patients showed a decline in at least one of these two cognitive domains indicating that the progress of diffuse brain injury cannot be neglected in understanding neuropsychological changes over time in patients with LGG. In our sample, higher age and radiological signs of radiotherapy-induced brain atrophy were seen in patients with a decline in both domains.

Predictors and mechanisms of epilepsy occurrence in cerebral gliomas: What to look for in clinicopathology

Gliomas, especially low-grade gliomas, are highly epileptogenic brain tumors. Histopathological information is valuable in evaluating the diagnosis and/or biologic behavior of various gliomas. Here we explored the clinical data and histopathological predictors of the occurrence of epilepsy in patients with gliomas. A retrospective study examined 310 consecutive patients who had undergone surgical treatment for gliomas in our institution from January 2013 to January 2015. Clinical data and pathological examination results were analyzed. Literatures regarding the predictors and etiology of glioma associated epileptic seizures in the period of 1995-2015 were also reviewed. A total of 234 (75.5%) astrocytic tumors and 76 (24.5%) oligodendrial tumors were included. At diagnosis, 33.6% of patients had epileptic seizures. Multivariate analysis revealed cortex involvement (OR=7.991, 95%CI=1.599-39.926), lower World Health Organization grade (OR=3.584, 95%CI=1.032-12.346) and topoisomerase II (TopoII) positivity (OR=0.943, 95%CI=0.903-0.982) were strong predictors for preoperative epileptic seizures. Gender, disease course, tumor classification, location or volume did not significantly affect epileptic seizure occurrence. Forty-three publications involved glioma-associated epilepsy were found in PubMed online database and key data were extracted and summarized. The present studies on glioma-related epilepsy are relatively limited and inconsistent. Low-grade gliomas, cortex involvement and TopoII positivity were independent predictors of a history of epileptic seizures at diagnosis. Further studies to examine the underlying mechanism of topoisomerase II as well as other molecules in epilepsy occurrence in brain gliomas are needed in the future.

Awake surgery for hemispheric low-grade gliomas: oncological, functional and methodological differences between pediatric and adult populations

INTRODUCTION

Brain mapping through a direct cortical and subcortical electrical stimulation during an awake craniotomy has gained an increasing popularity as a powerful tool to prevent neurological deficit while increasing extent of resection of hemispheric diffuse low-grade gliomas in adults. However, few case reports or very limited series of awake surgery in children are currently available in the literature.

METHODS

In this paper, we review the oncological and functional differences between pediatric and adult populations, and the methodological specificities that may limit the use of awake mapping in pediatric low-grade glioma surgery.

RESULTS

This could be explained by the fact that pediatric low-grade gliomas have a different epidemiology and biologic behavior in comparison to adults, with pilocytic astrocytomas (WHO grade I glioma) as the most frequent histotype, and with WHO grade II gliomas less prone to anaplastic transformation than their adult counterparts. In addition, aside from the issue of poor collaboration of younger children under 10 years of age, some anatomical and functional peculiarities of children developing brain (cortical and subcortical myelination, maturation of neural networks and of specialized cortical areas) can influence direct electrical stimulation methodology and sensitivity, limiting its use in children.

CONCLUSIONS

Therefore, even though awake procedure with cortical and axonal stimulation mapping can be adapted in a specific subgroup of children with a diffuse glioma from the age of 10 years, only few pediatric patients are nonetheless candidates for awake brain surgery.

The role of radiotherapy in the management of patients with diffuse low grade glioma: A systematic review and evidence-based clinical practice guideline

QUESTIONS

(1) What is the optimal role of external beam radiotherapy in the management of adult patients with newly diagnosed low-grade glioma (LGG) in terms of improving outcome (i.e., survival, complications, seizure control or other reported outcomes of interest)? (2) Which radiation strategies (dose, timing, fractionation, stereotactic radiation, brachytherapy, chemotherapy) improve outcomes compared to standard external beam radiation therapy in the initial management of low grade gliomas in adults? (3) Do specific factors (e.g., age, volume, extent of resection, genetic subtype) identify subgroups with better outcomes following radiation therapy than the general population of adults with newly diagnosed low-grade gliomas?

TARGET POPULATION

These recommendations apply to adults with newly diagnosed diffuse LGG.

RECOMMENDATIONS

OUTCOMES IN ADULT PATIENTS WITH NEWLY DIAGNOSED LOW GRADE GLIOMA TREATED WITH RADIOTHERAPY: Level I Radiotherapy is recommended in the management of newly diagnosed low-grade glioma in adults to prolong progression free survival, irrespective of extent of resection. Level II Radiotherapy is recommended in the management of newly diagnosed low grade glioma in adults as an equivalent alternative to observation in preserving cognitive function, irrespective of extent of resection. Level III Radiotherapy is recommended in the management of newly diagnosed low grade glioma in adults to improve seizure control in patients with epilepsy and subtotal resection. Level III Radiotherapy is recommended in the management of newly diagnosed low-grade glioma in adults to prolong overall survival in patients with subtotal resection. Level III Consideration of the risk of radiation induced morbidity, including cognitive decline, imaging abnormalities, metabolic dysfunction and malignant transformation, is recommended when the delivery of radiotherapy is selected in the management of newly diagnosed low-grade glioma in adults. STRATEGIES OF RADIOTHERAPY IN ADULT PATIENTS WITH NEWLY DIAGNOSED LOW GRADE GLIOMA: Level I Lower dose radiotherapy is recommended as an equivalent alternative to higher dose immediate postoperative radiotherapy (45-50.4 vs. 59.4-64.8 Gy) in the management of newly diagnosed low-grade glioma in adults with reduced toxicity. Level III Delaying radiotherapy until recurrence or progression is recommended as an equivalent alternative to immediate postoperative radiotherapy in the management of newly diagnosed low-grade glioma in adults but may result in shorter time to progression. Level III The addition of chemotherapy to radiotherapy is not recommended over whole brain radiotherapy alone in the management of low-grade glioma, as it provides no additional survival benefit. Level III Limited-field radiotherapy is recommended over whole brain radiotherapy in the management of low-grade glioma. Level III Either stereotactic radiosurgery or brachytherapy are recommended as acceptable alternatives to external radiotherapy in selected patients. PROGNOSTIC FACTORS IN ADULT PATIENTS WITH NEWLY DIAGNOSED LOW GRADE GLIOMA TREATED WITH RADIOTHERAPY: Level II It is recommended that age greater than 40 years, astrocytic pathology, diameter greater than 6 cm, tumor crossing the midline and preoperative neurological deficit be considered as negative prognostic indicators when predicting overall survival in adult low grade glioma patients treated with radiotherapy. Level II It is recommended that smaller tumor size, extent of surgical resection and higher mini-mental status exam be considered as positive prognostic indicators when predicting overall survival and progression free survival in patients in adult low grade glioma patients treated with radiotherapy. Level III It is recommended that seizures at presentation, presence of oligodendroglial histological component and 1p19q deletion (along with additional relevant factors-see Table 1) be considered as positive prognostic indicators when predicting response to radiotherapy in adults with low grade gliomas. Level III It is recommended that increasing age, decreasing performance status, decreasing cognition, presence of astrocytic histological component (along with additional relevant factors (see Tables 1, 2) be considered as negative prognostic indicators when predicting response to radiotherapy.

Treating glioblastoma in the elderly

The incidence of glioblastoma (GBM) is increasing among the elderly, who now account for up to half of all the adult cases of GBM. This trend has resulted in the recent development of clinical research specifically dedicated to this fragile population. Some studies have investigated surgical resection, radiotherapy and chemotherapy with temozolomide, and ongoing research is currently addressing the use of combined radiochemotherapy in this population. Although older patients with GBM have a significantly worse life expectancy compared with their younger counterparts, etiologic treatments should not be withheld from these patients solely because of their age. On the contrary, results from prospective studies suggest that active care of these patients has a significant positive impact on survival without affecting quality of life or cognition. To optimize both symptomatic and etiologic treatment, neuro-oncology multidisciplinary teams must take into account performance and cognitive status, the resectability of the tumor, and associated comorbidities.

Presenting symptoms of glioma in adults

OBJECTIVE

Studies on the presenting symptoms of glioma in adults in the age of readily available MRI imaging are scarce. This study investigates presenting symptoms of glioma and assesses the correlations of the presenting symptoms with patient age and histopathological class of the tumor.

MATERIALS AND METHODS

A retrospective review of the medical records of histologically verified glioma patients treated in Turku University Hospital, during 2006-2010, was conducted. The associations between the presenting symptoms and other covariates were assessed individually.

RESULTS

One hundred and fifty patients were ascertained. The most common presenting symptoms of glioma were seizure and cognitive disorder. Patients presenting with seizures were younger than patients with cognitive disorders, and the grade of the tumor was also found to significantly correlate with the most common presenting symptoms. Age group and tumor grade were statistically significant factors of cognitive disorder (P = 0.0037 and P = 0.0069) and age group of seizure (P = 0.0065). The associations between the presenting symptoms and the anatomical location, spread into adjacent brain areas, or laterality of the tumor or site of diagnosis were found to be statistically insignificant. Headache was not a common presenting symptom in glioma patients.

CONCLUSIONS

The main presenting symptoms of glioma in adults in the MRI age still are seizures and cognitive disorder. Patient age and tumor grade correlate positively with the incidence of cognitive disorder and patient age negatively with incidence of seizure as a presenting symptom. Headache is an uncommon manifestation and does not appear as a sole symptom.

Management of elderly patients with gliomas

The current progressive aging of the population is resulting in a continuous increase in the incidence of gliomas in elderly people, especially the most frequent subtype, glioblastoma (GBM). This sociohealth shift, known as the "silver tsunami," has prompted the neuro-oncology community to investigate the role of specific antitumor treatments, such as surgery, radiotherapy, chemotherapy, and other targeted therapies, for these traditionally undertreated patients. Advanced age, a widely recognized poor prognostic factor in both low-grade glioma (LGG) and high-grade glioma patients, should no longer be the sole reason for excluding such older patients from receiving etiologic treatments. Far from it, results from recent prospective trials conducted on elderly patients with GBM demonstrate that active management of these patients can have a positive impact on survival without impairing either cognition or quality of life. Although prospective studies specifically addressing the management of grade 2 and 3 gliomas are lacking and thus needed, the aforementioned tendency toward acknowledging a therapeutic benefit for GBM patients might also apply to the treatment of patients with LGG and anaplastic gliomas. In order to optimize such etiologic treatment in conjunction with symptomatic management, neuro-oncology multidisciplinary boards must individually consider important features such as resectability of the tumor, functional and cognitive status, associated comorbidities, and social support.

Seizures in low-grade gliomas: natural history, pathogenesis, and outcome after treatments

Seizures represent a common symptom in low-grade gliomas; when uncontrolled, they significantly contribute to patient morbidity and negatively impact quality of life. Tumor location and histology influence the risk for epilepsy. The pathogenesis of tumor-related epilepsy is multifactorial and may differ among tumor histologies (glioneuronal tumors vs diffuse grade II gliomas). Gross total resection is the strongest predictor of seizure freedom in addition to clinical factors, such as preoperative seizure duration, type, and control with antiepileptic drugs (AEDs). Epilepsy surgery may improve seizure control. Radiotherapy and chemotherapy with alkylating agents (procarbazine + CCNU+ vincristine, temozolomide) are effective in reducing the frequency of seizures in patients with pharmacoresistant epilepsy. Newer AEDs (levetiracetam, topiramate, lacosamide) seem to be better tolerated than the old AEDs (phenobarbital, phenytoin, carbamazepine), but there is lack of evidence regarding their superiority in terms of efficacy.

Factors influencing overall survival specific to adult low-grade astrocytoma: a population-based study

AIMS

We report a population-based overall survival and prognostic factor analysis specific to adult patients diagnosed with low-grade astrocytoma (LGA).

MATERIALS AND METHODS

All histologically confirmed cases of LGA diagnosed between 1992 and 1996 in the province of Ontario, Canada, were identified from the Ontario Cancer Registry and reviewed.

RESULTS

In total, 182 patients were identified; the mean age was 50 years and the mean survival time was 4.1 years (standard deviation = 5.1 years). Fifty-four per cent of patients had a surgical excision and 46% were biopsied alone. Both univariate and multivariate analyses showed that patients aged <30 years were significantly more likely to undergo an excision as compared with a biopsy alone (odds ratio = 4.26, 95% confidence interval 1.54-11.77). For the entire cohort, we observed a significant relationship between decreasing survival as a function of increasing age at diagnosis. In the biopsy sub-group, relative to patient's age <30 years, the hazard of dying increased significantly according to age when stratified by decade. However, in those patients having had a primary surgical excision, the hazard of dying relative to patient's age <30 years was similar for those aged 30-49 years and then significantly greater as patient age surpassed 50 years.

CONCLUSIONS

Age is a significant prognostic factor for LGA. Our analysis suggests that in those patients amenable to a primary tumour excision, a survival benefit may be confined to those under age 50 years.

Relative survival of patients with supratentorial low-grade gliomas

We sought to assess the population-based estimates of age-standardized survival among patients with low-grade gliomas (LGG) and to determine the impact of age and time on relative survival (RS). Data from the Surveillance, Epidemiology, and End Results (SEER) program of NCI from 1973 through 2006 were analyzed to assess survival among 5037 patients. Relationships were modeled using Dickman's piecewise constant hazards RS model. The 3- and 10-year age-standardized RS were 67% and 37%, respectively. When analyzed by age group, the 10-year overall survival (OS) and RS for children (age, <16 years), young adults (age, 16-39 years), adults (age, 40-64 years), and older patients (age, ≥65 years) were 86% and 86%, 61% and 62%, 40% and 43%, and 10% and 14%, respectively. The observed difference between OS and RS was larger among older patients (4%) and smallest among children (<1%). Older patients were 30.5 times (excess hazard ratio [eHR]; 95% confidence interval [CI], 20.3-50.0) as likely as young adults to die during the first year and 18.2 times as likely to die during the second year. Adults were 5.3 (eHR; 95% CI, 3.5-8.1) times as likely to die during their first year as young adults. In the remaining years, the observed survival differences were substantially decreased, and the presence of an age-by-follow-up interaction was observed. Survival among older patients with LGG was substantially different from the one computed for young adults and children. Despite the hazards across age groups not being proportional, RS does not provide additional information, compared with OS, in patients with LGG.

[Glioblastoma in the elderly]

The incidence of malignant gliomas in the aging population of industrialized countries is increasing. This observation justifies an important ongoing clinical research effort specifically dedicated to this population. The first results of prospective studies have showed the interest of radiotherapy and chemotherapy with temozolomide. The effect of combined concomitant and adjuvant chemotherapy with radiotherapy is currently being evaluated in a phase III study. The likely beneficial effect of surgical resection needs to be formally demonstrated in this fragile population. Initial functional status, quality of life and concomitant systemic pathologies are important factors to tailor the treatment according to patients status.

Conditional survival of all primary brain tumor patients by age, behavior, and histology

BACKGROUND

Survival statistics commonly reflect survival from the time of diagnosis but do not take into account survival already achieved after a diagnosis. The objective of this study was to provide conditional survival estimates for brain tumor patients as a more accurate measure of survival for those who have already survived for a specified amount of time after diagnosis.

METHODS

Data on primary malignant and nonmalignant brain tumor cases diagnosed from 1985-2005 from selected SEER state cancer registries were obtained. Relative survival up to 15 years postdiagnosis and varying relative conditional survival rates were computed using the life-table method.

RESULTS

The overall 1-year relative survival estimate derived from time of diagnosis was 67.8% compared to the 6-month relative conditional survival rate of 85.7% for 6-month survivors (the probability of surviving to 1 year given survival to 6 months). The 10-year overall relative survival rate was 49.5% from time of diagnosis compared to the 8-year relative conditional survival rate of 79.2% for 2-year survivors. Conditional survival estimates and standard survival estimates varied by histology, behavior, and age at diagnosis. The 5-year relative survival estimate derived from time of diagnosis for glioblastoma was 3.6% compared to the 3-year relative conditional survival rate of 36.4% for 2-year survivors. For most nonmalignant tumors, the difference between relative survival and the corresponding conditional survival estimates were minimal. Older age groups had greater numeric gains in survival but lower conditional survival estimates than other age groups. Similar findings were seen for other conditional survival intervals.

CONCLUSIONS

Conditional survival is a useful disease surveillance measure for clinicians and brain tumor survivors to provide them with better 'real-time' estimates and hope.

Epilepsy and brain tumors

PURPOSE OF REVIEW

To present an overview of the recent findings in pathophysiology and management of epileptic seizures in patients with brain tumors.

RECENT FINDINGS

Low-grade gliomas are the most epileptogenic brain tumors. Regarding pathophysiology, the role of peritumoral changes [hypoxia and acidosis, blood-brain barrier (BBB) disruption, increase or decrease of neurotransmitters and receptors] are of increasing importance. Tumor-associated epilepsy and tumor growth could have some common molecular pathways. Total/subtotal surgical resection (with or without epilepsy surgery) allows a seizure control in a high percentage of patients. Radiotherapy and chemotherapy as well have a role. New antiepileptic drugs are promising, both in terms of efficacy and tolerability. The resistance to antiepileptic drugs is still a major problem: new insights into pathogenesis are needed to develop strategies to manipulate the pharmakoresistance.

SUMMARY

Epileptic seizures in brain tumors have been definitely recognized as one of the major problems in patients with brain tumors, and need specific and multidisciplinary approaches.

Primary brain tumors in the elderly

The incidence of primary brain tumors is highest in elderly patients, and advanced age often is a negative prognostic factor. Nevertheless, large randomized studies in this population are scarce. Elderly patients with primary brain tumors also present unique challenges, such as the presence of multiple comorbidities and polypharmacy, decreased tolerance to chemotherapy, and an increased risk for radiation-induced neurotoxicity. This review gives an overview of the treatment options for older patients with glioblastoma and other gliomas, primary central nervous system lymphomas (PCNSLs), and meningiomas. Selected elderly glioblastoma patients with good performance status may benefit from aggressive treatment with surgical resection, radiotherapy, and possibly chemotherapy. For older patients with PCNSLs, high-dose methotrexate-based chemotherapy should be the mainstay option; whole-brain radiation therapy should be avoided in chemosensitive tumors because of the high risk of irreversible and progressive neurotoxicity. Meningiomas often may be followed up in elderly patients, as they usually are asymptomatic and have a slow growth rate. Treatment for elderly patients with primary brain tumors should be individualized, and age alone should not preclude the use of more aggressive treatments.