A critical evaluation of cystic features in primary glioblastoma as a prognostic factor for survival

Clinical article

Restricted access


The presence of cystic features in glioblastoma (GBM) has been described as a favorable prognostic factor. The aim of this study was to determine the survival outcome in patients undergoing surgery for newly diagnosed primary GBM with a large cystic component as compared with a large cohort of patients with noncystic GBM, while controlling for well-characterized prognostic factors.


A retrospective review of 354 consecutive patients treated with resection of primary GBM was performed using medical records and imaging information obtained at the University of California, San Francisco from 2005 to 2009. Within this cohort, 37 patients with large cysts (≥ 50% of tumor) were identified. Clinical presentations and surgical outcomes were statistically compared between the cystic and noncystic patients.


There were no statistically significant differences in clinical presentation between groups, including differences in age, sex, presenting symptoms, tumor location, or preoperative functional status, with the exception of tumor size, which was marginally larger in the cystic group. Surgical outcomes, including extent of resection and postoperative functional status, were equivalent. The median actuarial survival for the patients with cystic GBM was 17.0 months (95% CI 12.6–21.3 months), and the median survival for patients with noncystic GBM was 15.9 months (95% CI 14.6–17.2 months). There was no significant between-groups difference in survival (p = 0.99, log-rank test). A Cox multivariate regression model was constructed, which identified only age and extent of resection as independent predictors of survival. The presence of a cyst was not a statistically significant prognostic factor.


This study, comprising the largest series of cases of primary cystic GBM reported in the literature to date, demonstrates that the presence of a large cyst in patients with GBM does not significantly affect overall survival as compared with survival in patients without a cyst. Preoperative discussions with patients with GBM should focus on validated prognostic factors. The presence of cystic features does not confer a survival advantage.

Abbreviations used in this paper: BBB = blood-brain barrier; GBM = glioblastoma; KPS = Karnofsky Performance Scale; TMZ = temozolomide.

Article Information

Address correspondence to: Andrew T. Parsa, M.D., Ph.D., 505 Parnassus Avenue, Box 0112, San Francisco, California 94143-0112. email: parsaa@neurosurg.ucsf.edu.

Please include this information when citing this paper: published online July 15, 2011; DOI: 10.3171/2011.5.JNS11128.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Axial Gd-enhanced T1-weighted (A and C) and T2-weighted (B and D) MR images obtained in 2 patients with cystic GBM.

  • View in gallery

    Kaplan-Meier estimates of overall survival in patients with cystic GBM compared with those with noncystic GBM. The differences between the 2 groups are not significant (p = 0.99).



Adn MSaikali SGuegan YHamlat A: Pathophysiology of glioma cyst formation. Med Hypotheses 66:8018042006


Afra DNorman DLevin VA: Cysts in malignant gliomas. Identification by computerized tomography. J Neurosurg 53:8218251980


Barker FG IIChang SMHuhn SLDavis RLGutin PHMc-Dermott MW: Age and the risk of anaplasia in magnetic resonance-nonenhancing supratentorial cerebral tumors. Cancer 80:9369411997


Benito RGil-Benso RQuilis VPerez MGregori-Romero MRoldan P: Primary glioblastomas with and without EGFR amplification: relationship to genetic alterations and clinicopathological features. Neuropathology 30:3924002010


Choi SJHwang HYKim NRLee SWKim JHChoi HY: The radiologic features of cystic versus noncystic glioblastoma multiforme as significant prognostic factors. J Korean Soc Radiol 63:2993062010


Criscuolo GR: The genesis of peritumoral vasogenic brain edema and tumor cysts: a hypothetical role for tumor-derived vascular permeability factor. Yale J Biol Med 66:2773141993


Das PPuri TJha PPathak PJoshi NSuri V: A clinicopathological and molecular analysis of glioblastoma multiforme with long-term survival. J Clin Neurosci 18:66702011


Deorah SLynch CFSibenaller ZARyken TC: Trends in brain cancer incidence and survival in the United States: Surveillance, Epidemiology, and End Results Program, 1973 to 2001. Neurosurg Focus 20:4E12006


Drapkin AJBehar AJBeller AJ: Cystic glioma of the cerebral hemispheres, with long survival. A clinical-pathological study of 7 cases. Acta Neuropathol 26:3533561973


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


Hakan TAker FV: Case report on a patient with neurofibromatosis type 1 and a frontal cystic glioblastoma. Neurol Neurochir Pol 42:3623652008


Hammoud MASawaya RShi WThall PFLeeds NE: Prognostic significance of preoperative MRI scans in glioblastoma multiforme. J Neurooncol 27:65731996


Huddart RTraish DAshley SMoore ABrada M: Management of spinal astrocytoma with conservative surgery and radiotherapy. Br J Neurosurg 7:4734811993


Hulshof MCKoot RWSchimmel ECDekker FBosch DAGonzález González D: Prognostic factors in glioblastoma multiforme. 10 years experience of a single institution. Strahlenther Onkol 177:2832902001


Jyothirmayi RMadhavan JNair MKRajan B: Conservative surgery and radiotherapy in the treatment of spinal cord astrocytoma. J Neurooncol 33:2052111997


Kadota OKohno KOhue SKumon YSakaki SKikuchi K: Discrimination of brain abscess and cystic tumor by in vivo proton magnetic resonance spectroscopy. Neurol Med Chir (Tokyo) 41:1211262001


Kanai RTasaka MSejima HUchida NNakano AAkiyama Y: Brain stem glioblastoma with multiple large cyst formation and leptomeningeal dissemination in a 4-year-old girl. Brain Dev 27:58612005


Karcher SSteiner HHAhmadi RZoubaa SVasvari GBauer H: Different angiogenic phenotypes in primary and secondary glioblastomas. Int J Cancer 118:218221892006


Keles GELamborn KRBerger MS: Low-grade hemispheric gliomas in adults: a critical review of extent of resection as a factor influencing outcome. J Neurosurg 95:7357452001


Kleihues POhgaki H: Primary and secondary glioblastomas: from concept to clinical diagnosis. Neuro Oncol 1:44511999


Kowalczuk AMacdonald RLAmidei CDohrmann G IIIErickson RKHekmatpanah J: Quantitative imaging study of extent of surgical resection and prognosis of malignant astrocytomas. Neurosurgery 41:102810381997


Lacroix MAbi-Said DFourney DRGokaslan ZLShi WDeMonte F: A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival. J Neurosurg 95:1901982001


Laws ERParney IFHuang WAnderson FMorris AMAsher A: Survival following surgery and prognostic factors for recently diagnosed malignant glioma: data from the Glioma Outcomes Project. J Neurosurg 99:4674732003


Laws ER JrTaylor WFBergstralh EJOkazaki HClifton MB: The neurosurgical management of low-grade astrocytoma. Clin Neurosurg 33:5755881986


Laws ER JrTaylor WFClifton MBOkazaki H: Neurosurgical management of low-grade astrocytoma of the cerebral hemispheres. J Neurosurg 61:6656731984


Lohle PNvan Mameren HZwinderman KHTeepen HLGo KGWilmink JT: On the pathogenesis of brain tumour cysts: a volumetric study of tumour, oedema and cyst. Neuroradiology 42:6396422000


Lohle PNVerhagen ITTeelken AWBlaauw EHGo KG: The pathogenesis of cerebral gliomatous cysts. Neurosurgery 30:1801851992


Lohle PNWurzer HASeelen PJKingma LMGo KG: Analysis of fluid in cysts accompanying various primary and metastatic brain tumours: proteins, lactate and pH. Acta Neurochir (Wien) 140:14191998


Maldaun MVSuki DLang FFPrabhu SShi WFuller GN: Cystic glioblastoma multiforme: survival outcomes in 22 cases. J Neurosurg 100:61672004


Pierallini ABonamini MPantano PPalmeggiani FRaguso MOsti MF: Radiological assessment of necrosis in glioblastoma: variability and prognostic value. Neuroradiology 40:1501531998


Reiche WSchuchardt VHagen TIl'yasov KABillmann PWeber J: Differential diagnosis of intracranial ring enhancing cystic mass lesions–role of diffusion-weighted imaging (DWI) and diffusion-tensor imaging (DTI). Clin Neurol Neurosurg 112:2182252010


Rilliet BVernet O: Gliomas in children: a review. Childs Nerv Syst 16:7357412000


Shapiro WRGreen SBBurger PCMahaley MS JrSelker RGVanGilder JC: Randomized trial of three chemotherapy regimens and two radiotherapy regimens and two radiotherapy regimens in postoperative treatment of malignant glioma. Brain Tumor Cooperative Group Trial 8001. J Neurosurg 71:191989


Shibamoto YKitakabu YTakahashi MYamashita JOda YKikuchi H: Supratentorial low-grade astrocytoma. Correlation of computed tomography findings with effect of radiation therapy and prognostic variables. Cancer 72:1901951993


Strugar JGCriscuolo GRRothbart DHarrington WN: Vascular endothelial growth/permeability factor expression in human glioma specimens: correlation with vasogenic brain edema and tumor-associated cysts. J Neurosurg 83:6826891995


Stupp RMason WPvan den Bent MJWeller MFisher BTaphoorn MJ: Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 352:9879962005


Surawicz TSDavis FFreels SLaws ER JrMenck HR: Brain tumor survival: results from the National Cancer Data Base. J Neurooncol 40:1511601998


Utsuki SOka HSuzuki SShimizu STanizaki YKondo K: Pathological and clinical features of cystic and noncystic glioblastomas. Brain Tumor Pathol 23:29342006




All Time Past Year Past 30 Days
Abstract Views 80 80 48
Full Text Views 148 148 26
PDF Downloads 231 231 27
EPUB Downloads 0 0 0


Google Scholar