A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival

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Object. The extent of tumor resection that should be undertaken in patients with glioblastoma multiforme (GBM) remains controversial. The purpose of this study was to identify significant independent predictors of survival in these patients and to determine whether the extent of resection was associated with increased survival time.

Methods. The authors retrospectively analyzed 416 consecutive patients with histologically proven GBM who underwent tumor resection at the authors' institution between June 1993 and June 1999. Volumetric data and other tumor characteristics identified on magnetic resonance (MR) imaging were collected prospectively.

Conclusions. Five independent predictors of survival were identified: age, Karnofsky Performance Scale (KPS) score, extent of resection, and the degree of necrosis and enhancement on preoperative MR imaging studies. A significant survival advantage was associated with resection of 98% or more of the tumor volume (median survival 13 months, 95% confidence interval [CI] 11.4–14.6 months), compared with 8.8 months (95% CI 7.4–10.2 months; p < 0.0001) for resections of less than 98%. Using an outcome scale ranging from 0 to 5 based on age, KPS score, and tumor necrosis on MR imaging, we observed significantly longer survival in patients with lower scores (1–3) who underwent aggressive resections, and a trend toward slightly longer survival was found in patients with higher scores (4–5). Gross-total tumor resection is associated with longer survival in patients with GBM, especially when other predictive variables are favorable.

Article Information

Address reprint requests to: Raymond Sawaya, M.D., Department of Neurosurgery, Box 442, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030.

© AANS, except where prohibited by US copyright law.

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Figures

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    Grades of tumor necrosis adapted from Hammoud, et al. are demonstrated on MR images. The amount of tumor necrosis, which appears as an area of decreased signal intensity on T1-weighted images, was divided into four grades as follows: Grade 0, no necrosis apparent on the MR image; Grade I, amount of necrosis less than 25% of the tumor volume; Grade II, amount of necrosis 25 to 50% of the tumor volume; and Grade III, amount of necrosis greater than 50% of the tumor volume.

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    Axial T1- (left) and T2-weighted MR images (right) obtained in a patient with GBM. There was no enhancement of the tumor on the gadolinium-enhanced T1-weighted images. In such cases, tumor volume was defined as the region of T2 signal abnormality corresponding to the mass seen on both T1- and T2-weighted images (excluding the ill-defined hyperintense signal abnormality surrounding the mass on T2-weighted images).

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    Contrast-enhanced axial T1-weighted MR images obtained in a patient with GBM. Preoperative (left) and postoperative images (right) demonstrate a gross-total tumor resection.

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    Graph showing Kaplan—Meier estimates of overall survival after index surgery in all patients. Overall survival time was significantly longer among patients who underwent resection of 98% or more of the tumor volume (197 of 416, p < 0.0001) than among patients with a less than 98% tumor resection (219 of 416).

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    Graph showing Kaplan—Meier estimates of survival after index surgery for the entire patient population with respect to the different outcome groups. Log-rank test probability value is less than 0.0001.

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    Graphs showing Kaplan—Meier estimates of survival after index surgery for the entire patient population with respect to different outcome groups and by extent of tumor resection. A trend toward longer survival was found in Group A patients (A) who underwent resection of 98% or more of the tumor volume; however, the number of patients was too small to reveal significance. The median survival time was longer in Group B patients (B) who underwent resection of 98% or more of the tumor volume (p = 0.001) than in those whose resections were below that level; the same was found in Group C patients (C) (p = 0.005). There was a trend toward slightly longer survival times after more aggressive resections in Group D patients (D) (p = 0.13).

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