Brain Tumor Resection in Elderly Patients: Potential Factors of Postoperative Worsening in a Predictive Outcome Model

Simple Summary

Brain tumor surgery in older patients is becoming more relevant, considering that the proportion of older adults being treated for cancer is rising, whereas some pivotal studies in neuro-oncology comprised young patients only. The knowledge of possible predictors of outcome should be included in the preoperative assessment to make the best possible decision in terms of management. We present a case series of 143 patients older than 65 years, intending to identify the possible factors predicting the risk of clinical worsening after elective surgical resection of intracranial tumors in elderly patients. We found that postoperative complications occurrence and preoperative surgical complexity significantly influence the outcome in this subgroup of patients, whereas postoperative complications were the only factor with an impact also at long-term follow-up.

Abstract

The decision of whether to operate on elderly patients with brain tumors is complex, and influenced by pathology-related and patient-specific factors. This retrospective cohort study, based on a prospectively collected surgical database, aims at identifying possible factors predicting clinical worsening after elective neuro-oncological surgery in elderly patients. Therefore, all patients ≥65 years old who underwent BT resection at a tertiary referral center between 01/2018 and 12/2019 were included. Age, smoking, previous radiotherapy, hypertension, preoperative functional status, complications occurrence, surgical complexity and the presence of comorbidities were prospectively collected and analyzed at discharge and the 3-month follow-up. The series included 143 patients (mean 71 years, range 65–86). Sixty-five patients (46%) had at least one neurosurgical complication, whereas 48/65 (74%) complications did not require invasive treatment. Forty-two patients (29.4%) worsened at discharge; these patients had a greater number of complications compared to patients with unchanged/improved performance status. A persistent worsening at three months of follow-up was noted in 20.3% of patients; again, this subgroup presented more complications than patients who remained equal or improved. Therefore, postoperative complications and surgical complexity seem to influence significantly the early outcome in elderly patients undergoing brain tumor surgery. In contrast, postoperative complications alone are the only factor with an impact on the 3-month follow-up.

Adverse Events in Neurosurgery: The Novel Therapy-Disability-Neurology Grade

BACKGROUND

The most widely used classifications of adverse events (AEs) in neurosurgery define their severity according to the therapy used to treat them. This concept has substantial shortcomings because it does not reflect the severity of AEs that are not treated, such as new neurological deficits.

OBJECTIVE

To present a novel multidimensional and patient-centered classification of the severity of AE in neurosurgery and evaluate its applicability.

METHODS

The Therapy-Disability-Neurology (TDN) grading system classifies AEs depending on the associated therapy, disability, and neurological deficits. We conducted a 2-center retrospective observational study on 6071 interventions covering the whole neurosurgical spectrum with data prospectively recorded between 2013 and 2019 at 2 institutions from 2 countries.

RESULTS

Using the first patient cohort (4680 interventions), a positive correlation was found between severity of AE and LOS as well as treatment cost. Each grade was associated with a greater deterioration of the Karnofsky Performance Status Scale (KPS) at discharge and at follow-up. When using the same methods on the external validation cohort (1391 interventions), correlations between the grades of AE, LOS, and KPS at discharge were even more pronounced.

CONCLUSION

Our results suggest that the TDN grade is consistent with clinical and economic repercussions of AE and thus reflects AE severity. It is easily interpreted and enables comparison between different medical centers. The standardized report of the severity of AE in the scientific literature could constitute an important step forward toward a more critical, patient-centered, and evidence-based decision-making in neurosurgery.

The association of patient age with postoperative morbidity and mortality following resection of intracranial tumors

Introduction

The postoperative functional status of patients with intracranial tumors is influenced by patient-specific factors, including age.

Research question

This study aimed to elucidate the association between age and postoperative morbidity or mortality following the resection of brain tumors.

Material and methods

A multicenter database was retrospectively reviewed. Functional status was assessed before and 3–6 months after tumor resection by the Karnofsky Performance Scale (KPS). Uni- and multivariable linear regression were used to estimate the association of age with postoperative change in KPS. Logistic regression models for a ≥10-point decline in KPS or mortality were built for patients ≥75 years.

Results

The total sample of 4864 patients had a mean age of 56.4 ​± ​14.4 years. The mean change in pre-to postoperative KPS was −1.43. For each 1-year increase in patient age, the adjusted change in postoperative KPS was −0.11 (95% CI -0.14 - - 0.07). In multivariable analysis, patients ≥75 years had an odds ratio of 1.51 to experience postoperative functional decline (95%CI 1.21–1.88) and an odds ratio of 2.04 to die (95%CI 1.33–3.13), compared to younger patients.

Discussion

Patients with intracranial tumors treated surgically showed a minor decline in their postoperative functional status. Age was associated with this decline in function, but only to a small extent.

Conclusion

Patients ≥75 years were more likely to experience a clinically meaningful decline in function and about two times as likely to die within the first 6 months after surgery, compared to younger patients.

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A multicenter database of patients with intracranial tumors is analyzed in this study.

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Age is associated with a minor decline in the postoperative functional status & mortality.

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Patients ≥75 years are more likely to experience a clinically meaningful decline in function and to die.

Snake-Eye Myelopathy and Surgical Prognosis: Case Series and Systematic Literature Review

The prognostic value of "snake-eyes" sign in spinal cord magnetic resonance imaging (MRI) is unclear and the correlation with different pathological conditions has not been completely elucidated. In addition, its influence on surgical outcome has not been investigated in depth. A literature review according to PRISMA (Preferred reporting items for systematic review and meta-analysis protocols) guidelines on the prognostic significance of "snake-eyes" sign in operated patients was performed. Clinical, neuroradiological, and surgical data of three institutional patients, were also retrospectively collected. The three patients, with radiological evidence of "snake-eyes" myelopathy, underwent appropriate surgical treatment for their condition, with no new post-operative neurological deficits and good outcome at follow-up. The literature review, however, reported conflicting results: the presence of "snake-eyes" sign seems a poor prognostic factor in degenerative cervical myelopathy, even if some cases can improve after surgery. "Snake-eyes" myelopathy represents a rare form of myelopathy; pathophysiology is still unclear. The frequency of this myelopathy may be greater than previously thought and according to our literature review it is mostly a negative prognostic factor. However, from our experience, prognosis might not be so dire, especially when tailored surgical intervention is performed; therefore, surgery should always be considered and based on the complete clinical, neurophysiological, and radiological data.

Development and external validation of a clinical prediction model for functional impairment after intracranial tumor surgery

OBJECTIVE

Decision-making for intracranial tumor surgery requires balancing the oncological benefit against the risk for resection-related impairment. Risk estimates are commonly based on subjective experience and generalized numbers from the literature, but even experienced surgeons overestimate functional outcome after surgery. Today, there is no reliable and objective way to preoperatively predict an individual patient's risk of experiencing any functional impairment.

METHODS

The authors developed a prediction model for functional impairment at 3 to 6 months after microsurgical resection, defined as a decrease in Karnofsky Performance Status of ≥ 10 points. Two prospective registries in Switzerland and Italy were used for development. External validation was performed in 7 cohorts from Sweden, Norway, Germany, Austria, and the Netherlands. Age, sex, prior surgery, tumor histology and maximum diameter, expected major brain vessel or cranial nerve manipulation, resection in eloquent areas and the posterior fossa, and surgical approach were recorded. Discrimination and calibration metrics were evaluated.

RESULTS

In the development (2437 patients, 48.2% male; mean age ± SD: 55 ± 15 years) and external validation (2427 patients, 42.4% male; mean age ± SD: 58 ± 13 years) cohorts, functional impairment rates were 21.5% and 28.5%, respectively. In the development cohort, area under the curve (AUC) values of 0.72 (95% CI 0.69-0.74) were observed. In the pooled external validation cohort, the AUC was 0.72 (95% CI 0.69-0.74), confirming generalizability. Calibration plots indicated fair calibration in both cohorts. The tool has been incorporated into a web-based application available at https://neurosurgery.shinyapps.io/impairment/.

CONCLUSIONS

Functional impairment after intracranial tumor surgery remains extraordinarily difficult to predict, although machine learning can help quantify risk. This externally validated prediction tool can serve as the basis for case-by-case discussions and risk-to-benefit estimation of surgical treatment in the individual patient.

Repeated craniotomies for intracranial tumors: is the risk increased? Pooled analysis of two prospective, institutional registries of complications and outcomes

Purpose

Deciding whether to re-operate patients with intracranial tumor recurrence or remnant is challenging, as the data on safety of repeated procedures is limited. This study set out to evaluate the risks for morbidity, mortality, and complications after repeated operations, and to compare those to primary operations.

Methods

Retrospective observational two-center study on consecutive patients undergoing microsurgical tumor resection. The data derived from independent, prospective institutional registries. The primary endpoint was morbidity at 3 months (M3), defined as significant decrease on the Karnofsky Performance Scale (KPS). Secondary endpoints were mortality, rate and severity of complications according to the Clavien–Dindo Grade (CDG).

Results

463/2403 (19.3%) were repeated procedures. Morbidity at M3 occurred in n = 290 patients (12.1%). In univariable analysis, patients undergoing repeated surgery were 98% as likely as patients undergoing primary surgery to experience morbidity (OR 0.98, 95% CI 0.72–1.34, p = 0.889). In multivariable analysis adjusted for age, sex, tumor size, histology and posterior fossa location, the relationship remained stable (aOR 1.25, 95% CI 0.90–1.73, p = 0.186). Mortality was n = 10 (0.4%) at discharge and n = 95 (4.0%) at M3, without group differences. At least one complication occurred in n = 855, and the rate (35.5% vs. 35.9%, p = 0.892) and severity (CDG; p = 0.520) was similar after primary and repeated procedures. Results were reproduced in subgroup analyses for meningiomas, gliomas and cerebral metastases.

Conclusions

Repeated surgery for intracranial tumors does not increase the risk of morbidity. Mortality, and both the rate and severity of complications are comparable to primary operations. This information is of value for patient counseling and the informed consent process.

Electronic supplementary material

The online version of this article (10.1007/s11060-018-03058-y) contains supplementary material, which is available to authorized users.