Correlates of survival and the Daumas-Duport grading system for astrocytomas

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✓ In order to examine the correlation between prognosis and the histological features of nuclear atypia, mitosis, endothelial proliferation, and necrosis in supratentorial adult astrocytomas, the authors reviewed 251 such cases treated at the Massachusetts General Hospital between 1972 and 1980. One point was given for the presence of each feature. The total number of features was translated into a grade as follows: none of the four features = Grade 1 (one patient), one feature = Grade 2 (36 patients), two features = Grade 3 (33 patients), and three or four features = Grade 4 (181 patients). The period of survival was significantly associated with grade, the presence or absence of each of the four histological features, patient's age, type of operation, radiation therapy, and extent of tumor (log rank, p < 0.05). The variables associated with grade were age (p < 0.001) and radiation therapy (p < 0.02). After adjustment for these variables using a Cox proportional-hazards model, the difference in overall survival time between patients in Grades 2 and 3 was not statistically significant. When comparable groups of patients were examined in terms of age or receipt of radiation therapy, the median survival times differed markedly. Patients 50 years of age or less had a median survival time of 68 months (Grade 2 tumors), 29 months (Grade 3 tumors), and 13 months (Grade 4 tumors). Patients over 50 years of age had a median survival time of 6 months (Grade 2 and 4 tumors) and 9 months (Grade 3 tumors). Those patients who had received radiation therapy had a median survival time of 68 months (Grade 2 tumors), 21 months (Grade 3 tumors), and 11 months (Grade 4 tumors). Those patients who did not receive radiation therapy had a median survival time of 1 month (Grade 2 tumors) and 2 months (Grade 3 and 4 tumors); over half of these patients died within 2 months of surgery. This grading system, originally proposed by Daumas-Duport, et al., is simple, objective, and reproducible, and correlates well with survival times. The authors recommend that astrocytomas be graded on a scale of 1 to 4, with Grade 1 reserved for the rare adult supratentorial astrocytoma with none of the four histological features.

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Address reprint requests to: E. Tessa Hedley-Whyte, M.D., C. S. Kubik Laboratory for Neuropathology, Massachusetts General Hospital, Boston, Massachusetts 02114.

© AANS, except where prohibited by US copyright law.

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Figures

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    Photomicrograph showing mild nuclear atypia. Mild increased cellularity can be seen, with increased numbers of hyperchromatic nuclei. H & E, × 313.

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    Photomicrographs showing bipolar (left) and tripolar (right) abnormal mitoses. H & E, × 1250.

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    Photomicrograph showing endothelial proliferation of blood vessels in which the endothelial cell layer is more than two cells thick. H & E, × 125.

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    Photomicrograph showing tumor necrosis with pseudopalisading of nuclei around the edge of the necrosis. H & E, × 125.

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    Histograms of the age distributions by decade for patients with each of the astrocytoma grades. The patients with Grade 2 tumors are younger than those with Grade 4 tumors; patients with Grade 3 tumors fall in between, and have a wider spread of ages. For a description of the grading system see text. n = number of patients.

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    Postoperative Kaplan-Meier survival curves for patients whose tumors contained one, two, three, or four histological features. The 85% confidence limits at 2 and 5 years are shown. The estimate of the confidence limits is plotted at the nearest event in the curve. Survival time is significantly associated with increasing numbers of histological features: that is, grade (overall log rank, p < 0.0001). However, the difference in survival by the log rank test between those tumors with one or two features only approaches statistical significance (log rank, p = 0.07). There is no difference in the survival curves for patients whose tumors contained either three or all four of the histological features. However, the 85% confidence limits for the tumors with one and two features or with two and three features do not overlap at 2 years, indicating a significant difference in survival at that time. n = number of patients.

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    Kaplan-Meier survival curves from date of appearance of the first symptoms, with 85% confidence limits at 3 and 5 years. The estimate of the confidence limits is plotted at the nearest event in the curve. The overall difference in survival is highly significant (log rank, p < 0.0001).

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    Postoperative Kaplan-Meier survival curves for tumors with and without mitoses, with 85% confidence limits. Patients whose tumor contained mitoses had a significantly poorer outcome. n = number of patients.

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    Postoperative Kaplan-Meier survival curves for tumors with and without endothelial proliferation (endothel. prolif.), with 85% confidence limits. n = number of patients.

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    Postoperative Kaplan-Meier survival curves for tumors with and without necrosis, with 85% confidence limits. Patients whose tumor contained necrosis had a significantly poorer outcome. n = number of patients.

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    Postoperative Kaplan-Meier survival curves comparing biopsy (BX), partial excision (PE), and total excision (EX) for the entire patient population, ignoring the grade of the tumor. There is no difference in survival time between patients whose tumor was biopsied or partially excised; however, the patients whose tumor was said to be totally excised survived significantly longer than the other two groups combined.

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    Postoperative Kaplan-Meier survival curves for each grade in patients aged 50 years or less (left) and over 50 years (right). There is no difference in the overall survival time between patients aged 50 years or under with either a Grade 2 or a Grade 3 tumor, but there is a significantly worse survival rate for those with a Grade 4 tumor. Patients presenting over the age of 50 years had a poorer survival rate regardless of the tumor grade. For a description of the grading system see text. n = number of patients.

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