As the population ages, the incidence of glioblastoma multiforme (GBM) among older patients (age > 65 years) will increase. Older patients, unlike their younger counterparts, are not often offered aggressive surgery because of their age, comorbidities, and potential inability to tolerate surgery. The goal of this study was to identify preoperative factors associated with decreased survival for older patients who underwent resection of a GBM. The identification of these factors may provide insight into which patients would benefit most from aggressive surgery.
All patients older than 65 years who underwent nonbiopsy resection of an intracranial GBM at a single institution between 1997 and 2007 were retrospectively reviewed. Factors associated with overall survival were assessed using multivariate proportional hazards regression analysis after controlling for peri- and postoperative factors known to be associated with outcome (extent of resection, carmustine wafer implantation, temozolomide chemotherapy, and radiation therapy). Variables with p < 0.05 were considered statistically significant.
A total of 129 patients with an average age of 73 ± 5 years met the inclusion/exclusion criteria. At last follow-up, all 129 patients had died, with a median survival of 7.9 months. The preoperative factors that were independently associated with decreased survival were Karnofsky Performance Scale (KPS) score less than 80 (p = 0.001), chronic obstructive pulmonary disease (p = 0.01), motor deficit (p = 0.01), language deficit (p = 0.005), cognitive deficit (p = 0.02), and tumor size larger than 4 cm (p = 0.002). Patients with 0–1 (Group 1), 2–3 (Group 2), and 4–6 (Group 3) of these factors had statistically different survival times, where the median survival was 9.2, 5.5, and 4.4 months, respectively. In log-rank analysis, the median survival for Group 1 was significantly longer than that for Group 2 (p = 0.004) and Group 3 (p < 0.0001), while Group 2 had longer survival than Group 3 (p = 0.02).
Older patients with an increasing number of these factors may not benefit as much from aggressive surgery as patients with fewer factors. This may provide insight into identifying which patients older than 65 years of age may benefit from aggressive surgery.
Abbreviations used in this paper: COPD = chronic obstructive pulmonary disease; GBM = glioblastoma multiforme; GTR = gross-total resection; IQR = interquartile range; KPS = Karnofsky Performance Scale; LOS = length of stay; NTR = near-total resection; STR = subtotal resection.
BrandesAAFranceschiETosoniABeneventoFScopeceLMazzocchiV: Temozolomide concomitant and adjuvant to radiotherapy in elderly patients with glioblastoma: correlation with MGMT promoter methylation status. Cancer115:3512–35182009
BremHPiantadosiSBurgerPCWalkerMSelkerRVickNA: Placebo-controlled trial of safety and efficacy of intraoperative controlled delivery by biodegradable polymers of chemotherapy for recurrent gliomas. Lancet345:1008–10121995
ChaichanaKParkerSOliviAQuiñones-HinojosaA: A proposed classification system that projects outcomes based on preoperative variables for adult patients with glioblastoma multiforme. Clinical article. J Neurosurg112:997–10042010
CurranWJJrScottCBHortonJNelsonJSWeinsteinASFischbachAJ: Recursive partitioning analysis of prognostic factors in three Radiation Therapy Oncology Group malignant glioma trials. J Natl Cancer Inst85:704–7101993
DuttaDVanerePGuptaTMunshiAJalaliR: Factors influencing activities of daily living using FIM-FAM scoring system before starting adjuvant treatment in patients with brain tumors: results from a prospective study. J Neurooncol94:103–1102009
MarijnenCAvan den BergSMvan DuinenSGVoormolenJHNoordijkEM: Radiotherapy is effective in patients with glioblastoma multiforme with a limited prognosis and in patients above 70 years of age: a retrospective single institution analysis. Radiother Oncol75:210–2162005
McGirtMJChaichanaKLGathinjiMAttenelloFJThanKOliviA: Independent association of extent of resection with survival in patients with malignant brain astrocytoma. Clinical article. J Neurosurg110:156–1622009
McGirtMJMukherjeeDChaichanaKLThanKDWeingartJDQuiñones-HinojosaA: Association of surgically acquired motor and language deficits on overall survival after resection of glioblastoma multiforme. Neurosurgery65:463–4702009
SungTMillerDCHayesRLAlonsoMYeeHNewcombEW: Preferential inactivation of the p53 tumor suppressor pathway and lack of EGFR amplification distinguish de novo high grade pediatric astrocytomas from de novo adult astrocytomas. Brain Pathol10:249–2592000
WrenschMRiceTMiikeRMcMillanALambornKRAldapeK: Diagnostic, treatment, and demographic factors influencing survival in a population-based study of adult glioma patients in the San Francisco Bay Area. Neuro Oncol8:12–262006