Cystic glioblastoma multiforme: survival outcomes in 22 cases

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Object. The goal of this study was to determine whether the presence of a large tumor cyst was associated with improved outcome in patients undergoing surgery for newly diagnosed glioblastomas multiforme (GBMs) by comparing these patients with a matched cohort of patients with noncystic GBMs in clinical features, tumor imaging characteristics, survival, and time to tumor recurrence after surgery.

Methods. A retrospective analysis was conducted in 22 patients by using imaging information and chart reviews of operative reports of GBMs with large cysts (≥ 50% of tumor volume) at The University of Texas M. D. Anderson Cancer Center between 1993 and 2002. Clinical and neurosurgical outcomes and recurrence rates were studied. A statistical comparison was made with a matching cohort of 22 patients with noncystic GBMs.

No significant differences in clinical variables were found between the cohort with cystic GBMs and the matched cohort with noncystic GBMs. To avoid bias in preoperative assessment of tumor volume, the tumor burden was compared in patients whose tumors had cysts (excluding the cystic mass) and in patients whose tumors did not contain cysts. There was no statistically significant difference between the two groups (p = 0.8). In patients with cystic GBMs the median survival time after surgery was 18.2 months (95% confidence interval [CI] 11.9–24.5 months) and at 2 years 43% of the patients were still alive. In comparison, in patients with noncystic GBMs, the median survival time was 14.3 months (95% CI 12.1–16.4 months) and only 16% of patients were alive at 2 years. The median time to tumor recurrence was 7.6 months (95% CI 0.01–18 months) in patients harboring cystic GBMs and 4.2 months (95% CI 1.8–6.6 months) in the matched cohort (log-rank test, p = 0.04). In the cystic GBM group, no recurrence was observed in 53% of patients at 6 months, 45% at 1 year, and 38% at 2 years after surgery, whereas the corresponding numbers for the noncystic group were 36, 14, and 9%, respectively.

Conclusions. The results indicate that patients harboring a GBM that contains a large cyst survive longer and have a longer time to recurrence than those who lack such a cyst. This is the first such observation in the literature.

Article Information

Address reprint requests to: Raymond Sawaya, M.D., Department of Neurosurgery-442, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Houston, Texas 77030. email: rsawaya@mdanderson.org.

© AANS, except where prohibited by US copyright law.

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Figures

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    Axial Gd-enhanced T1-weighted MR images obtained in three patients with cystic GBMs. Upper: Preoperative images revealing a cystic tumor with an enhancing wall. Lower: Images obtained after resection. In all cases the cyst wall was completely resected.

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    Graph showing Kaplan—Meier estimates of overall survival in patients with cystic GBMs and those with noncystic GBMs. The differences between the two groups' curves are not significant (p = 0.1).

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    Graph showing freedom from recurrent disease in patients with cystic GBMs and those with noncystic GBMs. The differences between the two groups' curves are significant (p = 0.04).

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    Photomicrographs demonstrating the cyst wall of a cystic GBM. A: The cyst lumen (L) is bordered by a cuff of GBM (GM) measuring only 0.5 cm in maximal thickness. B: At a higher magnification, limited infiltration of the surrounding brain parenchyma (P) is seen (arrows indicate tumor interface with surrounding neuropil). H & E, original magnification × 20 (A) and × 40 (B).

References

  • 1.

    Afra DNorman DLevin VA: Cysts in malignant gliomas. Identification by computerized tomography. J Neurosurg 53:8218251980Afra D Norman D Levin VA: Cysts in malignant gliomas. Identification by computerized tomography. J Neurosurg 53:821–825 1980

    • Search Google Scholar
    • Export Citation
  • 2.

    Barker FG IIChang SMHuhn SLet al: Age and the risk of anaplasia in magnetic resonance-nonenhancing supratentorial cerebral tumors. Cancer 80:9369411997Barker FG II Chang SM Huhn SL et al: Age and the risk of anaplasia in magnetic resonance-nonenhancing supratentorial cerebral tumors. Cancer 80:936–941 1997

    • Search Google Scholar
    • Export Citation
  • 3.

    Berens MERutka JTRosenblum ML: Brain tumor epidemiology, growth, and invasion. Neurosurg Clin N Am 1:1181990Berens ME Rutka JT Rosenblum ML: Brain tumor epidemiology growth and invasion. Neurosurg Clin N Am 1:1–18 1990

    • Search Google Scholar
    • Export Citation
  • 4.

    Burger PCHeinz ERShibata Tet al: Topographic anatomy and CT correlations in the untreated glioblastoma multiforme. J Neurosurg 68:6987041988Burger PC Heinz ER Shibata T et al: Topographic anatomy and CT correlations in the untreated glioblastoma multiforme. J Neurosurg 68:698–704 1988

    • Search Google Scholar
    • Export Citation
  • 5.

    Burton ECLamborn KRForsyth Pet al: Aberrant p53, mdm2, and proliferation differ in glioblastomas from long-term compared with typical survivors. Clin Cancer Res 8:1801872002Burton EC Lamborn KR Forsyth P et al: Aberrant p53 mdm2 and proliferation differ in glioblastomas from long-term compared with typical survivors. Clin Cancer Res 8:180–187 2002

    • Search Google Scholar
    • Export Citation
  • 6.

    Chandler KLPrados MDMalec Met al: Long-term survival in patients with glioblastoma multiforme. Neurosurgery 32:7167201993Chandler KL Prados MD Malec M et al: Long-term survival in patients with glioblastoma multiforme. Neurosurgery 32:716–720 1993

    • Search Google Scholar
    • Export Citation
  • 7.

    De Clerck YAShimada HGonzalez-Gomez Iet al: Tumoral invasion in the central nervous system. J Neurooncol 18:1111211994De Clerck YA Shimada H Gonzalez-Gomez I et al: Tumoral invasion in the central nervous system. J Neurooncol 18:111–121 1994

    • Search Google Scholar
    • Export Citation
  • 8.

    Dropcho EJSoong SJ: The prognostic impact of prior low grade histology in patients with anaplastic gliomas: a case-control study. Neurology 47:6846901996Dropcho EJ Soong SJ: The prognostic impact of prior low grade histology in patients with anaplastic gliomas: a case-control study. Neurology 47:684–690 1996

    • Search Google Scholar
    • Export Citation
  • 9.

    Engel UGottschalk SNiehaus Let al: Cystic lesions of the pineal region—MRI and pathology. Neuroradiology 42:3994022000Engel U Gottschalk S Niehaus L et al: Cystic lesions of the pineal region—MRI and pathology. Neuroradiology 42:399–402 2000

    • Search Google Scholar
    • Export Citation
  • 10.

    Giese ALoo MARief MDet al: Substrates for astrocytoma invasion. Neurosurgery 37:2943021995Giese A Loo MA Rief MD et al: Substrates for astrocytoma invasion. Neurosurgery 37:294–302 1995

    • Search Google Scholar
    • Export Citation
  • 11.

    Giese AWestphal M: Glioma invasion in the central nervous system. Neurosurgery 39:2352521996Giese A Westphal M: Glioma invasion in the central nervous system. Neurosurgery 39:235–252 1996

    • Search Google Scholar
    • Export Citation
  • 12.

    Hammoud MASawaya RShi Wet al: Prognostic significance of preoperative MRI scans in glioblastoma multiforme. J Neurooncol 27:65731996Hammoud MA Sawaya R Shi W et al: Prognostic significance of preoperative MRI scans in glioblastoma multiforme. J Neurooncol 27:65–73 1996

    • Search Google Scholar
    • Export Citation
  • 13.

    Hulshof MCKoot RWSchimmel ECet al: Prognostic factors in glioblastoma multiforme. 10 years experience of a single institution. Strahlenther Onkol 177:2832902001Hulshof MC Koot RW Schimmel EC et al: Prognostic factors in glioblastoma multiforme. 10 years experience of a single institution. Strahlenther Onkol 177:283–290 2001

    • Search Google Scholar
    • Export Citation
  • 14.

    Kadota OKohno KOhue Set al: Discrimination of brain abscess and cystic tumor by in vivo proton magnetic resonance spectroscopy. Neurol Med Chir 41:1211262001Kadota O Kohno K Ohue S et al: Discrimination of brain abscess and cystic tumor by in vivo proton magnetic resonance spectroscopy. Neurol Med Chir 41:121–126 2001

    • Search Google Scholar
    • Export Citation
  • 15.

    Kaplan ELMeier P: Nonparametric estimation from incomplete observations. J Am Stat Assoc 53:4754811958Kaplan EL Meier P: Nonparametric estimation from incomplete observations. J Am Stat Assoc 53:475–481 1958

    • Search Google Scholar
    • Export Citation
  • 16.

    Karnofsky DABurchenal JH: The clinical evaluation of chemotherapeutic agents in cancer in MacLeod CM (ed): Evaluation of Chemotherapeutic Agents. New York: Columbia University Press1949 pp 191205Karnofsky DA Burchenal JH: The clinical evaluation of chemotherapeutic agents in cancer in MacLeod CM (ed): Evaluation of Chemotherapeutic Agents. New York: Columbia University Press 1949 pp 191–205

    • Search Google Scholar
    • Export Citation
  • 17.

    Keles GELamborn KRBerger MS: Low-grade hemispheric gliomas in adults: a critical review of extent of resection as a factor influencing outcome. J Neurosurg 95:7357452001Keles GE Lamborn KR Berger MS: Low-grade hemispheric gliomas in adults: a critical review of extent of resection as a factor influencing outcome. J Neurosurg 95:735–745 2001

    • Search Google Scholar
    • Export Citation
  • 18.

    Kleihues POhgaki H: Primary and secondary glioblastomas: from concept to clinical diagnosis. Neuro-oncol 1:44511999Kleihues P Ohgaki H: Primary and secondary glioblastomas: from concept to clinical diagnosis. Neuro-oncol 1:44–51 1999

    • Search Google Scholar
    • Export Citation
  • 19.

    Kowalczuk AMacdonald RLAmidei Cet al: Quantitative imaging study of extent of surgical resection and prognosis of malignant astrocytomas. Neurosurgery 41:102810381997Kowalczuk A Macdonald RL Amidei C et al: Quantitative imaging study of extent of surgical resection and prognosis of malignant astrocytomas. Neurosurgery 41:1028–1038 1997

    • Search Google Scholar
    • Export Citation
  • 20.

    Kraus JAWenghoefer MSchmidt MCet al: Long-term survival of glioblastoma multiforme: importance of histopathological reevaluation. J Neurol 247:4554602000Kraus JA Wenghoefer M Schmidt MC et al: Long-term survival of glioblastoma multiforme: importance of histopathological reevaluation. J Neurol 247:455–460 2000

    • Search Google Scholar
    • Export Citation
  • 21.

    Lacroix MAbi-Said DFourney DRet al: A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival. J Neurosurg 95:1901982001Lacroix M Abi-Said D Fourney DR et al: A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis extent of resection and survival. J Neurosurg 95:190–198 2001

    • Search Google Scholar
    • Export Citation
  • 22.

    Laws ER Jr: The conservative management of primary gliomas of the brain. Clin Neurosurg 36:3673741990Laws ER Jr: The conservative management of primary gliomas of the brain. Clin Neurosurg 36:367–374 1990

    • Search Google Scholar
    • Export Citation
  • 23.

    Laws ER JrShaffrey ME: The inherent invasiveness of cerebral gliomas: implications for clinical management. Int J Dev Neurosci 17:4134201999Laws ER Jr Shaffrey ME: The inherent invasiveness of cerebral gliomas: implications for clinical management. Int J Dev Neurosci 17:413–420 1999

    • Search Google Scholar
    • Export Citation
  • 24.

    Laws ER JrTaylor WFBergstralh EJet al: The neurosurgical management of low-grade astrocytoma. Clin Neurosurg 33:5755881986Laws ER Jr Taylor WF Bergstralh EJ et al: The neurosurgical management of low-grade astrocytoma. Clin Neurosurg 33:575–588 1986

    • Search Google Scholar
    • Export Citation
  • 25.

    Laws ER JrTaylor WFClifton MBet al: Neurosurgical management of low-grade astrocytoma of the cerebral hemispheres. J Neurosurg 61:6656731984Laws ER Jr Taylor WF Clifton MB et al: Neurosurgical management of low-grade astrocytoma of the cerebral hemispheres. J Neurosurg 61:665–673 1984

    • Search Google Scholar
    • Export Citation
  • 26.

    Lohle PNvan Mameren HZwinderman KHet al: On the pathogenesis of brain tumour cysts: a volumetric study of tumour, oedema and cyst. Neuroradiology 42:6396422000Lohle PN van Mameren H Zwinderman KH et al: On the pathogenesis of brain tumour cysts: a volumetric study of tumour oedema and cyst. Neuroradiology 42:639–642 2000

    • Search Google Scholar
    • Export Citation
  • 27.

    Lohle PNVerhagen ITTeelken AWet al: The pathogenesis of cerebral gliomatous cysts. Neurosurgery 30:1801851992Lohle PN Verhagen IT Teelken AW et al: The pathogenesis of cerebral gliomatous cysts. Neurosurgery 30:180–185 1992

    • Search Google Scholar
    • Export Citation
  • 28.

    Mork SJWester K: Malignant gliomas: histological features, invasion, and relation to clinical symptoms in Mikkelsen TBjerkvig RLaerum ODet al (eds): Brain Tumor Invasion: Biological Clinical and Therapeutic Considerations. New York: John Wiley & Sons1998 pp 89110Mork SJ Wester K: Malignant gliomas: histological features invasion and relation to clinical symptoms in Mikkelsen T Bjerkvig R Laerum OD et al (eds): Brain Tumor Invasion: Biological Clinical and Therapeutic Considerations. New York: John Wiley & Sons 1998 pp 89–110

    • Search Google Scholar
    • Export Citation
  • 29.

    Niranjan AWitham TKondziolka Det al: The role of stereotactic cyst aspiration for glial and metastatic brain tumors. Can J Neurol Sci 27:2292352000Niranjan A Witham T Kondziolka D et al: The role of stereotactic cyst aspiration for glial and metastatic brain tumors. Can J Neurol Sci 27:229–235 2000

    • Search Google Scholar
    • Export Citation
  • 30.

    Pierallini ABonamini MBozzao Aet al: Supratentorial diffuse astrocytic tumours: proposal of an MRI classification. Eur Radiol 7:3953991997Pierallini A Bonamini M Bozzao A et al: Supratentorial diffuse astrocytic tumours: proposal of an MRI classification. Eur Radiol 7:395–399 1997

    • Search Google Scholar
    • Export Citation
  • 31.

    Pierallini ABonamini MOsti MFet al: Supratentorial glioblastoma: neuroradiological findings and survival after surgery and radiotherapy. Neuroradiology 38 (Suppl 1):S26S301996Pierallini A Bonamini M Osti MF et al: Supratentorial glioblastoma: neuroradiological findings and survival after surgery and radiotherapy. Neuroradiology 38 (Suppl 1):S26–S30 1996

    • Search Google Scholar
    • Export Citation
  • 32.

    Pierallini ABonamini MPantano Pet al: Radiological assessment of necrosis in glioblastoma: variability and prognostic value. Neuroradiology 40:1501531998Pierallini A Bonamini M Pantano P et al: Radiological assessment of necrosis in glioblastoma: variability and prognostic value. Neuroradiology 40:150–153 1998

    • Search Google Scholar
    • Export Citation
  • 33.

    Puzzilli FRuggeri AMastronardi Let al: Long-term survival in cerebral glioblastoma. Case report and critical review of the literature. Tumori 84:69741998Puzzilli F Ruggeri A Mastronardi L et al: Long-term survival in cerebral glioblastoma. Case report and critical review of the literature. Tumori 84:69–74 1998

    • Search Google Scholar
    • Export Citation
  • 34.

    Reddy ATPacker RJ: Chemotherapy for low-grade gliomas. Childs Nerv Syst 15:5065131999Reddy AT Packer RJ: Chemotherapy for low-grade gliomas. Childs Nerv Syst 15:506–513 1999

    • Search Google Scholar
    • Export Citation
  • 35.

    Rees JHSmirniotopoulos JGJones RVet al: Glioblastoma multiforme: radiologic-pathologic correlation. Radiographics 16:141314381996Rees JH Smirniotopoulos JG Jones RV et al: Glioblastoma multiforme: radiologic-pathologic correlation. Radiographics 16:1413–1438 1996

    • Search Google Scholar
    • Export Citation
  • 36.

    Rilliet BVernet O: Gliomas in children: a review. Childs Nerv Syst 16:7357412000Rilliet B Vernet O: Gliomas in children: a review. Childs Nerv Syst 16:735–741 2000

    • Search Google Scholar
    • Export Citation
  • 37.

    Salvati MCervoni LArtico Met al: Long-term survival in patients with supratentorial glioblastoma. J Neurooncol 36:61641998Salvati M Cervoni L Artico M et al: Long-term survival in patients with supratentorial glioblastoma. J Neurooncol 36:61–64 1998

    • Search Google Scholar
    • Export Citation
  • 38.

    Sawaya R: Extent of resection in malignant gliomas: a critical summary. J Neurooncol 42:3033051999Sawaya R: Extent of resection in malignant gliomas: a critical summary. J Neurooncol 42:303–305 1999

    • Search Google Scholar
    • Export Citation
  • 39.

    Sawaya RHammoud MSchoppa Det al: Neurosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors. Neurosurgery 42:104410561998Sawaya R Hammoud M Schoppa D et al: Neurosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors. Neurosurgery 42:1044–1056 1998

    • Search Google Scholar
    • Export Citation
  • 40.

    Scott JNRewcastle NBBrasher PMet al: Long-term glioblastoma multiforme survivors: a population-based study. Can J Neurol Sci 25:1972011998Scott JN Rewcastle NB Brasher PM et al: Long-term glioblastoma multiforme survivors: a population-based study. Can J Neurol Sci 25:197–201 1998

    • Search Google Scholar
    • Export Citation
  • 41.

    Scott JNRewcastle NBBrasher PMet al: Which glioblastoma multiforme patient will become a long-term survivor? A population-based study. Ann Neurol 46:1831881999Scott JN Rewcastle NB Brasher PM et al: Which glioblastoma multiforme patient will become a long-term survivor? A population-based study. Ann Neurol 46:183–188 1999

    • Search Google Scholar
    • Export Citation
  • 42.

    Shapiro WRGreen SBBurger PCet al: Randomized trial of three chemotherapy regimens and two radiotherapy regimens in postoperative treatment of malignant glioma. Brain Tumor Cooperative Group Trial 8001. J Neurosurg 71:191989Shapiro WR Green SB Burger PC et al: Randomized trial of three chemotherapy regimens and two radiotherapy regimens in postoperative treatment of malignant glioma. Brain Tumor Cooperative Group Trial 8001. J Neurosurg 71:1–9 1989

    • Search Google Scholar
    • Export Citation
  • 43.

    Steiger HJGotz CSchmid-Elsaesser Ret al: Thalamic astrocytomas: surgical anatomy and results of a pilot series using maximum microsurgical removal. Acta Neurochir 142:132713362000Steiger HJ Gotz C Schmid-Elsaesser R et al: Thalamic astrocytomas: surgical anatomy and results of a pilot series using maximum microsurgical removal. Acta Neurochir 142:1327–1336 2000

    • Search Google Scholar
    • Export Citation
  • 44.

    Surawicz TSDavis FFreels Set al: Brain tumor survival: results from the National Cancer Data Base. J Neurooncol 40:1511601998Surawicz TS Davis F Freels S et al: Brain tumor survival: results from the National Cancer Data Base. J Neurooncol 40:151–160 1998

    • Search Google Scholar
    • Export Citation
  • 45.

    Thorsen FTysnes BB: Brain tumor cell invasion, anatomical and biological considerations. Anticancer Res 17:412141261997Thorsen F Tysnes BB: Brain tumor cell invasion anatomical and biological considerations. Anticancer Res 17:4121–4126 1997

    • Search Google Scholar
    • Export Citation
  • 46.

    Valery CASeilhean DBoyer Oet al: Long-term survival after gene therapy for a recurrent glioblastoma. Neurology 58:110911122002Valery CA Seilhean D Boyer O et al: Long-term survival after gene therapy for a recurrent glioblastoma. Neurology 58:1109–1112 2002

    • Search Google Scholar
    • Export Citation
  • 47.

    Vertosick FT JrSelker RG: Long-term survival after the diagnosis of malignant glioma: a series of 22 patients surviving more than 4 years after diagnosis. Surg Neurol 38:3593631992Vertosick FT Jr Selker RG: Long-term survival after the diagnosis of malignant glioma: a series of 22 patients surviving more than 4 years after diagnosis. Surg Neurol 38:359–363 1992

    • Search Google Scholar
    • Export Citation

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