A prospective study of quality of life in adults with newly diagnosed high-grade gliomas: the impact of the extent of resection on quality of life and survival

Multiple craniotomies in the management of multifocal and multicentric glioblastoma

Object

Multiple craniotomies have been performed for resection of multiple brain metastases in the same surgical session with satisfactory outcomes, but the role of this procedure in the management of multifocal and multicentric glioblastomas is undetermined, although it is not the standard approach at most centers.

Methods

The authors performed a retrospective analysis of data prospectively collected between 1993 and 2008 in 20 patients with multifocal or multicentric glioblastomas (Group A) who underwent resection of all lesions via multiple craniotomies during a single surgical session. Twenty patients who underwent resection of solitary glioblastoma (Group B) were selected to match Group A with respect to the preoperative Karnofsky Performance Scale (KPS) score, tumor functional grade, extent of resection, age at time of surgery, and year of surgery. Clinical and neurosurgical outcomes were evaluated.

Results

In Group A, the median age was 52 years (range 32–78 years); 70% of patients were male; the median preoperative KPS score was 80 (range 50–100); and 9 patients had multicentric glioblastomas and 11 had multifocal glioblastomas. Aggressive resection of all lesions in Group A was achieved via multiple craniotomies in the same session, with a median extent of resection of 100%. Groups A and B were comparable with respect to all the matching variables as well as the amount of tumor necrosis, number of cysts, and the use of intraoperative navigation. The overall median survival duration was 9.7 months in Group A and 10.5 months in Group B (p = 0.34). Group A and Group B (single craniotomy) had complication rates of 30% and 35% and 30-day mortality rates of 5% (1 patient) and 0%, respectively.

Conclusions

Aggressive resection of all lesions in selected patients with multifocal or multicentric glioblastomas resulted in a survival duration comparable with that of patients undergoing surgery for a single lesion, without an associated increase in postoperative morbidity. This finding may indicate that conventional wisdom of a minimal role for surgical treatment in glioblastoma should at least be questioned.

A biobehavioral perspective on depressive symptoms in patients with cerebral astrocytoma

More than 51,000 individuals are diagnosed with a primary brain tumor in the United States each year, and for those with the most common type of malignant tumor, an astrocytoma, almost 75% will die within 5 years of diagnosis. Although surgery, radiation, and chemotherapy have improved length of survival, mortality remains high, which underscores the need to understand how other factors affect the disease trajectory. Several recent studies have shown that depressive symptoms are independently associated with reduced quality of life and survival time after controlling for other variables in patients with an astrocytoma. Thus, depressive symptoms represent a significant risk factor for adverse outcomes in this patient population. A growing body of evidence indicates that depressive symptoms are linked to underlying biological phenomena, particularly inflammatory activation modulated through increased peripheral levels of proinflammatory cytokines. Recent research has shown that neoplastic astrocytes respond to elevated proinflammatory cytokine levels by secreting immune mediators within the central nervous system, including cytokines and glial fibrillary acidic protein that promote astrogliosis and angiogenesis and may increase tumor growth and metastasis. However, because these biological factors have not as yet been measured in conjunction with depressive symptoms in these patients, little is known about the interactions that potentially influence the treatment trajectory. To guide future research and to provide a deeper understanding of the factors that may influence depressive symptoms and length of survival in patients with an astrocytoma, a review of the literature was undertaken. Publications over the past 10 years were analyzed to examine the theoretical models and measures of depressive symptoms used in previous research. Although numerous studies have documented the relationship between depression and reduced length of survival, there were several methodological concerns identified, and there were no studies that included biological variables. Yet, research in the basic sciences provides compelling evidence of specific neuroendocrine-immune interactions orchestrated by astrocytes that can cause depressive symptoms and alter the tumor microenvironment so that standard treatments are not as effective. These findings support the need for clinically based research so that we can begin to understand the potentially modifiable biobehavioral mechanisms underlying depressive symptoms in patients with an astrocytoma. Grounded in the biobehavioral research paradigm of psychoneuroimmunology, a novel research program is presented that may provide a new level of understanding regarding the high prevalence of depressive symptoms in patients with an astrocytoma and lead to new treatment strategies, with possible implications for improved symptom management and quality of life in patients with brain tumors.

FACT-MNG: tumor site specific web-based outcome instrument for meningioma patients

To formulate Functional Assessment of Cancer Therapy-Meningioma (FACT-MNG), a web-based tumor site-specific outcome instrument for assessing intracranial meningioma patients following surgical resection or stereotactic radiosurgery. We surveyed the relevant literature available on intracranial meningioma surgery and subsequent outcomes (38 papers), making note of which, if any, QOL/outcome instruments were utilized. None of the surgveyed papers included QOL assessment specific to tumor site. We subsequently developed questions that were relevant to the signs and symptoms that characterize each of 11 intracranial meningioma sites, and incorporated them into a modified combination of the Functional Assessment of Cancer Therapy-Brain (FACT-BR) and SF36 outcome instruments, thereby creating a new tumor site-specific outcome instrument, FACT-MNG. With outcomes analysis of surgical and radiosurgical treatments becoming more important, measures of the adequacy and success of treatment are needed. FACT-MNG represents a first effort to formalize such an instrument for meningioma patients. Questions specific to tumor site will allow surgeons to better assess specific quality of life issues not addressed in the past by more general questionnaires.

Health-related quality of life in glioma patients in China

BACKGROUND

Health-related quality of life (HRQOL) has been increasingly emphasized in cancer patients. There are no reports comparing baseline HRQOL of different subgroups of glioma patients prior to surgery.

METHODS

HRQOL assessments by the standard Chinese version of the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire 30 (EORTC QLQ-C30, version 3.0), the Mini-Mental State Examination and Karnofsky Performance Status were obtained from glioma patients prior to surgery.

RESULTS

Ninety-two pathologically confirmed glioma patients were recruited. There were 84.8% patients with emotional impairment, 75% with social and cognitive impairment, 70.7% with physical impairment, and 50% with role impairment. Eighty-two percent of patients reported fatigue symptoms, 72.8% reported pain, 50% reported appetite loss, 39.1% reported insomnia, and 36.9% reported nausea/vomiting, whereas other symptoms (dyspnea, diarrhea, constipation) in the QLQ-C30 were reported by fewer than 30% of patients. Fatigue and pain symptoms and all "functioning" scales were strongly correlated with global health status/quality of life (QoL). Fatigue was strongly related to all functioning scales, pain, appetite loss, and global health status/QoL. No difference in baseline HRQOL prior to surgery was reported between females and males, among different lesion locations, or between normal- and abnormal-cognition subgroups of glioma patients. Age, KPS, WHO grade, and tumor recurrence significantly affected HRQOL in glioma patients.

CONCLUSIONS

These data provided the baseline HRQOL in glioma patients prior to surgery in China. Most pre-surgery glioma patients indicated emotional, social, cognitive, physical, and role impairment. Fatigue, pain, appetite loss, insomnia, and nausea/vomiting were common in these patients. The fatigue and pain symptoms and all types of functioning strongly affected global health status/QoL. Old age, worse performance status, WHO grade IV and tumor recurrence had deleterious effects on HRQOL.

A multivariate analysis of prognostic factors for health-related quality of life in patients with surgically managed meningioma

The objective of this study was to examine the prognostic significance of health-related quality of life (HQOL) parameters combined with baseline clinical factors in patients undergoing neurosurgery for treatment of meningioma. A total of 147 patients (61 male, 86 female; mean age 43 years, range 5-77 years) who underwent resection of a meningioma between January 2002 and December 2004 were studied. HQOL was evaluated using a modified questionnaire based on the World Health Organization Quality of Life-100 Scale and the Karnofsky Performance Scale. The relationships between HQOL and clinical history, radiological findings, extent of resection, histological grade and recurrence were investigated using multivariate analysis. The mean HQOL score was 73.94+/-1.79 for preoperative patients with meningioma, 84.88+/-2.14 for postoperative patients, and 91.13+/-1.61 for healthy controls. HQOL for patients with meningioma was significantly lower than that for normal controls (P<0.001), and postoperative patients had a more satisfactory HQOL than preoperative (P<0.05). Cox proportional hazards analysis showed that significant predictors of health-related quality of life were tumor size, extent of surgical excision, and histologic grade. Multivariate backward logistic regression yielded the regression equation HQOL=119.1097 - 1.5002X(3) - 8.6650X(6) - 10.4210X(7) (R=0.7466; where X(3) is tumor size, X(6) is extent of surgical excision, and X(7) is the histologic grade of the tumor). This equation can be used preoperatively to predict the HQOL of meningioma patients after neurosurgery. A specialized HQOL questionnaire for patients with meningioma provides useful information when planning the operative procedure, and may make it more likely that patients have a satisfactory HQOL after surgery.

Factors involved in maintaining prolonged functional independence following supratentorial glioblastoma resection. Clinical article

OBJECT

The median survival duration for patients with glioblastoma is approximately 12 months. Maximizing quality of life (QOL) for patients with glioblastoma is a priority. An important, yet understudied, QOL component is functional independence. The aims of this study were to evaluate functional outcomes over time for patients with glioblastoma, as well as identify factors associated with prolonged functional independence.

METHODS

All patients who underwent first-time resection of either a primary (de novo) or secondary (prior lower grade glioma) glioblastoma at a single institution from 1996 to 2006 were retrospectively reviewed. Patients with a Karnofsky Performance Scale (KPS) score ≥ 80 were included. Kaplan-Meier, log-rank, and multivariate proportional hazards regression analyses were used to identify associations (p < 0.05) with functional independence (KPS score ≥ 60) following glioblastoma resection.

RESULTS

The median follow-up duration time was 10 months (interquartile range [IQR] 5.6-17.0 months). A patient's preoperative (p = 0.02) and immediate postoperative (within 2 months) functional status was associated with prolonged survival (p < 0.0001). Of the 544 patients in this series, 302 (56%) lost their functional independence at a median of 10 months (IQR 6-16 months). Factors independently associated with prolonged functional independence were: preoperative KPS score ≥ 90 (p = 0.004), preoperative seizures (p = 0.002), primary glioblastoma (p < 0.0001), gross-total resection (p < 0.0001), and temozolomide chemotherapy (p < 0.0001). Factors independently associated with decreased functional independence were: older age (p < 0.0001), coexistent coronary artery disease (p = 0.009), and incurring a new postoperative motor deficit (p = 0.009). Furthermore, a decline in functional status was independently associated with tumor recurrence (p = 0.01).

CONCLUSIONS

The identification and consideration of these factors associated with prolonged functional outcome (preoperative KPS score ≥ 90, seizures, primary glioblastoma, gross-total resection, temozolomide) and decreased functional outcome (older age, coronary artery disease, new postoperative motor deficit) may help guide treatment strategies aimed at improving QOL for patients with glioblastoma.

Review on quality of life issues in patients with primary brain tumors

Health-related quality of life (HRQOL) has become an important outcome measure in clinical trials in primary brain tumor (i.e., glioma) patients, because they have an incurable disease. HRQOL is assessed using self-reported, validated questionnaires, addressing physical, psychological, emotional, and social issues. In addition to generic HRQOL instruments, disease-specific questionnaires have been developed, including for brain tumor patients. For the analysis and interpretation of HRQOL measurements, low compliance and missing data are methodological challenges. HRQOL in glioma patients may be negatively affected by the disease itself as well as by side effects of treatment. But treatment with surgery, radiotherapy, and chemotherapy may improve patient functioning and HRQOL, in addition to extending survival. Although HRQOL has prognostic significance in brain tumor patients, it is not superior to well-known clinical parameters, such as age and performance status. In clinical practice, assessing HRQOL may be helpful in the communication between doctor and patient and may facilitate treatment decisions.

Intraoperative stimulation techniques for functional pathway preservation and glioma resection

Although a primary tenet of neurosurgical oncology is that survival can improve with greater tumor resection, this principle must be tempered by the potential for functional loss following a radical removal. Preoperative planning with functional and physiological imaging paradigms, combined with intraoperative strategies such as cortical and subcortical stimulation mapping, can effectively reduce the risks associated with operating in eloquent territory. In addition to identifying critical motor pathways, these techniques can be adapted to identify language function reliably. The authors review the technical nuances of intraoperative mapping for low- and high-grade gliomas, demonstrating their efficacy in optimizing resection even in patients with negative mapping data. Collectively, these surgical strategies represent the cornerstone for operating on gliomas in and around functional pathways.

Pattern recognition of MRSI data shows regions of glioma growth that agree with DTI markers of brain tumor infiltration

Gliomas are the most common primary brain tumors and the majority are highly malignant, with one of the worst prognoses for patients. Gliomas are characterized by invasive growth into normal brain tissue that makes complete surgical resection and accurate radiotherapy planning extremely difficult. We have performed independent component analysis of magnetic resonance spectroscopy imaging data from human gliomas to segment brain tissue into tumor core, tumor infiltration, and normal brain, with confirmation by diffusion tensor imaging analysis. Our data are consistent with previous studies that compared anomalies in isotropic and anisotropic diffusion images to determine regions of potential glioma infiltration. We show that coefficients of independent components can be used to create colored images for easy visual identification of regions of infiltrative tumor growth.

Optimizing costs of intraoperative magnetic resonance imaging. A series of 29 glioma cases

PURPOSE

The goal of this study was to develop a method to reduce the costs of intraoperative high-field magnet resonance imaging (iMRI). The results of a series of 29 gliomas removed with this technique are presented.

METHODS

A series of 29 patients with brain gliomas were operated on using a low-cost method of high-field intraoperative MRI (Signa 1.5 T. MR Excite, GE Inc.). The patients were transported during surgery to the neuroradiological department through a specially located lift in order to perform the intraoperative examinations ("outside iMRI"). The time required for the procedure as well as the possible related complications, such as infection, were analyzed.

RESULTS

After studying the intraoperative images, additional tumor resection was needed in 12 of the 29 patients. The median time required to perform the iMRI was 25 min. There was no infection or other complications related to the procedure in this series.

CONCLUSIONS

This method offers all clinical advantages of high-field iMRI inside of the operating room, with very low costs and additional advantage of integrating the neurosurgical/ neuroradiological teams. This strategy will give an alternative to several neurosurgical departments in the world to perform high-quality iMRI at very low cost.

Quality of life data as prognostic indicators of survival in cancer patients: an overview of the literature from 1982 to 2008

BACKGROUND

Health-related quality of life and survival are two important outcome measures in cancer research and practice. The aim of this paper is to examine the relationship between quality of life data and survival time in cancer patients.

METHODS

A review was undertaken of all the full publications in the English language biomedical journals between 1982 and 2008. The search was limited to cancer, and included the combination of keywords 'quality of life', 'patient reported-outcomes' 'prognostic', 'predictor', 'predictive' and 'survival' that appeared in the titles of the publications. In addition, each study was examined to ensure that it used multivariate analysis. Purely psychological studies were excluded. A manual search was also performed to include additional papers of potential interest.

RESULTS

A total of 451 citations were identified in this rapid and systematic review of the literature. Of these, 104 citations on the relationship between quality of life and survival were found to be relevant and were further examined. The findings are summarized under different headings: heterogeneous samples of cancer patients, lung cancer, breast cancer, gastro-oesophageal cancers, colorectal cancer, head and neck cancer, melanoma and other cancers. With few exceptions, the findings showed that quality of life data or some aspects of quality of life measures were significant independent predictors of survival duration. Global quality of life, functioning domains and symptom scores - such as appetite loss, fatigue and pain - were the most important indicators, individually or in combination, for predicting survival times in cancer patients after adjusting for one or more demographic and known clinical prognostic factors.

CONCLUSION

This review provides evidence for a positive relationship between quality of life data or some quality of life measures and the survival duration of cancer patients. Pre-treatment (baseline) quality of life data appeared to provide the most reliable information for helping clinicians to establish prognostic criteria for treating their cancer patients. It is recommended that future studies should use valid instruments, apply sound methodological approaches and adequate multivariate statistical analyses adjusted for socio-demographic characteristics and known clinical prognostic factors with a satisfactory validation strategy. This strategy is likely to yield more accurate and specific quality of life-related prognostic variables for specific cancers.

ASSOCIATION OF SURGICALLY ACQUIRED MOTOR AND LANGUAGE DEFICITS ON OVERALL SURVIVAL AFTER RESECTION OF GLIOBLASTOMA MULTIFORME

OBJECTIVE

Balancing the benefits of extensive tumor resection with the consequence of potential postoperative deficits remains a challenge in malignant astrocytoma surgery. Although studies have suggested that increasing extent of resection may benefit survival, the effect of new postoperative deficits on survival remains unclear. We set out to determine whether new-onset postoperative motor or speech deficits were associated with survival in our institutional experience with glioblastoma multiforme (GBM).

METHODS

We retrospectively reviewed records of all patients (age range, 18–70 years; Karnofsky Performance Scale score, 80–100) who had undergone GBM resection between 1996 and 2006 at a single institution. Survival was compared between patients who had experienced surgically acquired motor or language deficits versus those who did not experience these deficits.

RESULTS

Three hundred six consecutive patients (age, 54 ± 11 years; median Karnofsky Performance Scale score, 80) underwent primary GBM resection. Nineteen patients (6%) developed surgically acquired motor deficits and 15 (5%) developed surgically acquired language deficits. Median survival was decreased in patients who acquired language deficits (9.6 months; P &lt; 0.05) or motor deficits (9.0 months; P &lt; 0.05) versus patients without surgically acquired deficits (12.8 months). Two-year survival was 8% and 0% for patients with surgically acquired motor or language deficits, respectively, versus 23% for patients without new-onset deficits.

CONCLUSION

In our experience, the development of new perioperative motor or language deficits was associated with decreased overall survival despite similar extent of resection and adjuvant therapy. Although it is well known that surgically induced neurological deficits affect quality of life, our results suggest that these surgical morbidities may also affect survival. Care should be taken to avoid surgically induced deficits in the management of GBM.

Operative techniques for gliomas and the value of extent of resection

Refinement of neurosurgical technique has enabled safer operations with more aggressive outcomes. One cornerstone of modern-day practice is the utilization of intraoperative stimulation mapping. In addition to identifying critical motor pathways, this technique can be adapted to reliably identify language pathways. Given the individual variability of cortical language localization, such awake language mapping is essential to minimize language deficits following tumor resection. Our experience suggests that cortical language mapping is a safe and efficient adjunct to optimize tumor resection while preserving essential language sites, even in the setting of negative mapping data. However, the value of maximizing glioma resections remains surprisingly unclear, as there is no general consensus in the literature regarding the efficacy of extent of glioma resection in improving patient outcome. While the importance of resection in obtaining tissue diagnosis and alleviating symptoms is clear, a lack of Class I evidence prevents similar certainty in assessing the influence of extent of resection. Beyond an analysis of modern intraoperative mapping techniques, we examine every major clinical publication since 1990 on the role of extent of resection in glioma outcome. The mounting evidence suggests that, despite persistent limitations in the quality of available studies, a more extensive surgical resection is associated with longer life expectancy for both low-grade and high-grade gliomas.

Distress and quality of life in primary high-grade brain tumor patients

GOALS OF WORK

We report on the routine use of the NCCN Distress Thermometer and the Functional Assessment of Cancer Therapy-Brain (FACT-Br) to assess patient distress and quality of life in GBM patients. The purpose of this study was to examine the relationship between patient quality of life and distress.

MATERIALS AND METHODS

Data from 50 GBM patients presenting to a neuro-oncology clinic were evaluated. Descriptive statistics and correlations between the distress score and the FACT-Br subscale scores were generated.

MAIN RESULTS

The mean distress score was 2.15 (std 2.66), and 28.9% of brain tumor patients identified a distress score of 4 or above. The mean FACT-Br total was 127.34 (std 21.29), with patients scoring lowest in the EWB (18.95 std 4.4) and FWB (15.06 std 6.80) subscales. No differences between demographic groups were identified with regard to distress or quality of life. Statistically significant correlations were identified between the distress score and the SWB (R = -0.46, P = 0.001) and EWB (R = -0.56, P = 0.001) subscales of the FACT-Br. Fifty percent of participants who did not complete the FACT-Br reported clinically significant distress, but this did not differ significantly from participants who completed it.

CONCLUSIONS

Assessment of distress in brain tumor patients provides clinically relevant information and suggests interventions that may support quality of life. Further research is needed to explore the relationship between distress and quality of life. Current approaches to measuring quality of life in brain tumor patients may systematically undersample patients with advanced illness or significant psychosocial distress.

The relationships between depression and brain tumors

Depression is a common complication/co-morbidity in patients with brain tumors. Better understanding of the relationships between brain tumors and depression should lead to improvement in patient care. This paper reviews these relationships in order to direct further study to improve patient care, and hopefully, outcome. Both anatomic and physiological perturbations in the brain are likely involved in the associations between depression and brain tumors. Tumor treatments are also associated with depression. Depression has a significant negative impact on outcome in brain tumor patients. The role of treatment of depression in brain tumor patients has been scantly studied. Further investigation directed to these areas of knowledge deficit should benefit depressed patients with brain tumors.

Assessment of self-reported and health-related quality of life in patients with brain tumours using a modified questionnaire

Assessment of quality of life (QoL) in patients who undergo surgery for brain tumours helps to guide surgery, reduce recurrence and minimize morbidity. This study validated a 25-item, modified QoL questionnaire based on the Medical Outcomes Survey SF-36 and the Karnofsky Performance Scale. The aims were for it to be brain tumour specific for Chinese patients, hence more sensitive, more acceptable, briefer and more easily used. A total of 431 patients with brain tumours were compared with 96 age-matched healthy controls. A surgery-related QoL curve was used to help identify a threshold satisfaction point for QoL. Physiological function, psychological function, satisfaction with medical care and self-care ability of the patients were compared pre-operatively and post-operatively. Cronbach's alpha-coefficient was 0.9521 and the correlation coefficient was 0.8685, suggesting good reliability and repeatability. With the exception of psychological function, which deteriorated, the modified QoL showed significant improvement in physiological function, satisfaction with medical care and self-care ability, and serves to stress the importance of post-operative psychological support.

Quality of life in adults with brain tumors: current knowledge and future directions

Quality of life is an important area of clinical neurooncology that is increasingly relevant as survivorship increases and as patients experience potential morbidities associated with new therapies. This review of quality-of-life studies in the brain tumor population aims to summarize what is currently known about quality of life in patients with both low-grade and high-grade tumors and suggest how we may use this knowledge to direct future research. To date, reports on quality of life have been primarily qualitative and focused on specific symptoms such as fatigue, sleep disorders, and cognitive dysfunction, as well as some symptom clusters. However, the increasing interest in exploring quality of life as a primary end point for cancer therapy has established a need for prospective, controlled studies to assess baseline and serial quality-of-life parameters in brain tumor patients in order to plan and evaluate appropriate and timely interventions for their symptoms.

North Central Cancer Treatment Group--achievements and perspectives

The North Central Cancer Treatment Group (NCCTG) was founded in 1977 as a regional cooperative group to allow cancer patients in the upper Midwest of the United States to gain access to clinical trials in oncology by establishing a network of community oncology practices with one academic research base, the Mayo Clinic. Since then, the NCCTG has grown into an international cooperative group with 43 members in 33 US states and Canada. This article details 30 years of achievements of the NCCTG, including important scientific contributions from disease-specific and treatment modality committees, the cancer control program, patient-reported outcomes and quality-of-life research, and biostatisticians that support the NCCTG's specific aims: to improve the duration and quality of life of cancer patients, to enhance our understanding of the biological consequences of cancer and its treatment, and to improve methods for clinical trial conduct.

Association of preoperative depression and survival after resection of malignant brain astrocytoma

BACKGROUND

Clinical depression has been shown to negatively influence the morbidity and mortality of multiple disease states. It remains unclear if clinical depression affects survival after surgical management of malignant brain astrocytoma. We set out to determine whether patients with a diagnosis of clinical depression before surgery experienced decreased survival independent of treatment modality or degree of disability.

METHODS

One thousand fifty-two patients undergoing surgical management for malignant brain astrocytoma (WHO grade 3 or 4) performed at a single institution from 1995 to 2006 were retrospectively reviewed. The independent association of depression prior to surgery and subsequent survival was assessed via multivariate proportional hazards regression analysis.

RESULTS

Surgical management consisted of primary resection in 605 (58%) patients, secondary resection in 410 (39%), and biopsy in 37 patients (3.5%). Pathology was WHO grade IV in 829 (79%) and grade III in 223 (21%). Forty-nine patients (5%) carried the diagnosis of depression at the time of surgery. Mean age and KPS on admission was 51 +/- 16 and 80 +/- 10 years, respectively. Two hundred ninety patients (28%) received Gliadel (BCNU MGI Pharma, Inc., Bloomington, MN, USA) wafer implantation and 274 (26%) received postoperative temozolomide (concomitant in 102, delayed adjuvant in 172 patients). Subsequent resection was performed at the time of recurrence in 135 (13%) patients a mean of 10 +/- 6 months after surgery. Adjusting for all variables associated with survival in this model, age (P < .001), KPS (P < .001), WHO grade III vs IV (P < .001), primary versus secondary resection (P < .001), gross-total resection (P < .001), Gliadel wafer implantation (P = .048), postoperative temozolomide therapy (P < .001), and subsequent resection at time of recurrence (P < .001); preoperative depression was independently associated with decreased survival (relative risk [95% CI]: 1.41 [1.1-1.96], P < .05). The difference in percent survival between the depression and nondepression cohorts was most notable at 12 months (15% vs 41%) and 20 months (0% vs 21%) after surgery.

CONCLUSION

In our experience, patients who are actively depressed at the time of surgery were associated with decreased survival after surgical management of malignant astrocytoma, independent of degree of disability, tumor grade, or subsequent treatment modalities. In our opinion, the presence of an association between preoperative depression and survival warrants further investigation.

Functional outcomes and quality of life after tumor-related hemipelvectomy

BACKGROUND AND PURPOSE

Hemipelvectomy is a life-changing treatment for pelvic malignancies. This study compared functional outcomes and quality of life of patients following internal or external hemipelvectomies.

SUBJECTS

Ninety-seven patients who underwent tumor-related internal (n=39) or external (n=58) hemipelvectomy surgery between January 1, 1988, and December 31, 2004, participated in the study.

METHODS

Using a descriptive retrospective cohort study design, functional status was evaluated with the Barthel Index at 3 time points. Quality-of-life parameters were evaluated at follow-up using the Linear Analog Self-Assessment tool (LASA).

RESULTS

Data were collected on all 97 patients at rehabilitation consultation and hospital discharge. Follow-up data were obtained via survey on 44% of the original group at a median of 5.8 years (interquartile range [IRQ]=1.7-10.4) after surgery. Median total Barthel Index scores were similar between the internal and external hemipelvectomy groups at the initial physical medicine and rehabilitation assessment (10 [IQR=10-15] versus 10 [IQR=3.75-15]), at discharge (40 [IQR=30-65] versus 50 [IQR=35-66.25]), and at follow-up (92.5 [IQR=76.25-100] versus 92.5 [IQR=78.75-96.25]). Participants with external hemipelvectomies were less independent in bladder function and experienced greater pain severity at follow-up compared with those with internal hemipelvectomies. Overall quality-of-life parameters were similar between the groups.

DISCUSSION AND CONCLUSION

Despite significant differences in surgical procedures, immediate and long-term functional outcomes and quality-of-life parameters were similar among participants with internal and external hemipelvectomies.

Glioma extent of resection and its impact on patient outcome

OBJECTIVE

There is still no general consensus in the literature regarding the role of extent of glioma resection in improving patient outcome. Although the importance of resection in obtaining tissue diagnosis and alleviating symptoms is clear, a lack of Class I evidence prevents similar certainty in assessing the influence of extent of resection.

METHODS

We reviewed every major clinical publication since 1990 on the role of extent of resection in glioma outcome.

RESULTS

Twenty-eight high-grade glioma articles and 10 low-grade glioma articles were examined in terms of quality of evidence, expected extent of resection, and survival benefit.

CONCLUSION

Despite persistent limitations in the quality of data, mounting evidence suggests that more extensive surgical resection is associated with longer life expectancy for both low- and high-grade gliomas.

Molecular strategies for the treatment of malignant glioma--genes, viruses, and vaccines

The standard treatment paradigm of surgery, radiation, and chemotherapy for malignant gliomas has only a modest effect on survival. It is well emphasized in the literature that despite aggressive multimodal therapy, most patients survive approximately 1 year after diagnosis, and less than 10% survive beyond 2 years. This dismal prognosis provides the impetus for ongoing investigations in search of improved therapeutics. Standard multimodal therapy has largely reached a plateau in terms of effectiveness, and there is now a growing body of literature on novel molecular approaches for the treatment of malignant gliomas. Gene therapy, oncolytic virotherapy, and immunotherapy are the major investigational approaches that have demonstrated promise in preclinical and early clinical studies. These new molecular technologies each have distinct advantages and limitations, and none has yet demonstrated a significant survival benefit in a phase II or III clinical trial. Molecular approaches may not lead to the discovery of a "magic bullet" for these aggressive tumors, but they may ultimately prove synergistic with more conventional approaches and lead to a broadening of the multimodal approach that is the current standard of care. This review will discuss the scientific background, therapeutic potential, and clinical limitations of these novel strategies with a focus on those that have made it to clinical trials.

Motivational readiness for physical activity and quality of life in long-term lung cancer survivors

Little is known about the relationship between motivational readiness for physical activity and quality of life (QOL) in long-term lung cancer survivors. Long-term survivors are considered those who are living 5 years or more following a cancer diagnosis. This project examined the relationship between a self-report measure of motivational readiness for physical activity and QOL in a sample of 272 long-term lung cancer survivors. Participants (54% male, average age 70 years old) completed the mailed survey an average of 6 years after being diagnosed with lung cancer. Survey measures included the stage of change for physical activity and a set of single item QOL and symptom scales. Thirty-seven percent of respondents reported they currently engaged in regular physical activity (a total of 30 min or more per day, at least 5 days per week). Kruskal-Wallis tests revealed that those who reported engaging in regular physical activity reported a better overall QOL, better QOL on all five domains of QOL functioning (mental, physical, social, emotional, and spiritual), and fewer symptoms compared to those with a sedentary lifestyle. Physical activity level may have important QOL and symptom management benefits for long-term lung cancer survivors.

Functional outcome after language mapping for glioma resection

BACKGROUND

Language sites in the cortex of the brain vary among patients. Language mapping while the patient is awake is an intraoperative technique designed to minimize language deficits associated with brain-tumor resection.

METHODS

To study language function after brain-tumor resection with language mapping, we examined 250 consecutive patients with gliomas. Positive language sites (i.e., language regions in the cortex of the brain, 1 cm by 1 cm, which were temporarily inactivated by means of a bipolar electrode) were identified and categorized into cortical language maps. The tumors were resected up to 1 cm from the cortical areas where intraoperative stimulation produced a disturbance in language. Our resection strategy did not require identification of the stimulation-induced language sites within the field of exposure.

RESULTS

A total of 145 of the 250 patients (58.0%) had at least one site with an intraoperative stimulation-induced speech arrest, 82 patients had anomia, and 23 patients had alexia. Overall, 3094 of 3281 cortical sites (94.3%) were not associated with stimulation-induced language deficits. A total of 159 patients (63.6%) had intact speech preoperatively. One week after surgery, baseline language function remained in 194 patients (77.6%), it worsened in 21 patients (8.4%), and 35 patients (14.0%) had new speech deficits. However, 6 months after surgery, only 4 of 243 surviving patients (1.6%) had a persistent language deficit. Cortical maps generated with intraoperative language data also showed surprising variability in language localization within the dominant hemisphere.

CONCLUSIONS

Craniotomies tailored to limit cortical exposure, even without localization of positive language sites, permit most gliomas to be aggressively resected without language deficits. The composite language maps generated in our study suggest that our current models of human language organization insufficiently account for observed language function.

Validation of single-item linear analog scale assessment of quality of life in neuro-oncology patients

Assessment of patient quality of life (QOL) requires balancing the details provided by multi-item assessments with the reduced burden of single-item assessments. In this project, we investigated the psychometric properties of single-item Linear Analog Scale Assessments (LASAs) for patients with newly diagnosed high-grade gliomas. Measures included QOL LASAs (overall, physical, emotional, spiritual, intellectual), Symptom Distress Scale (SDS), Profile of Mood States (POMS; overall, confusion, fatigue), and Functional Assessment of Cancer Therapy-Brain (FACT-Br; overall, brain, physical, emotional). Associations of LASA measures with SDS, POMS, and FACT-Br domains and with Eastern Cooperative Oncology Group performance score (PS) and Mini-Mental State Examination (MMSE) were assessed. Repeated measures ANOVA models compared the change over time of LASAs and SDS, POMS, and FACT-Br. Two hundred five patients completed the assessments across three time points. To allow comparison across measures, all scores were converted to a scale of 0-100, with higher scores indicating better QOL. LASA mean scores ranged from 60 to 78; SDS, POMS, and FACT-Br ranged from 62 to 81. FACT-Br physical (P<0.001) and POMS fatigue subscale (P=0.005) decreased over time, as did LASA physical (P=0.08). LASA scales were strongly associated with corresponding scales on SDS, POMS, and FACT-Br (0.44<rho<0.65; P<0.001). LASA was negatively associated with PS and positively with MMSE, with associations similar in magnitude to the other QOL and psychosocial measures. The data suggest that the single-item LASA scales are valid for assessing QOL of cancer patients and are an appropriate alternative when a shorter instrument is warranted.

Optimising Radiation Therapy Techniques for Tumours of the Central Nervous System

Introduction: This study aims to assess the early tumour outcome and morbidity associated with radiation therapy (RT) in tumours of the central nervous system (CNS). Materials and Methods: Patients receiving RT with radical intent were entered on a prospective database. Tumour types were categorised into glioma, base of skull, pituitary, germ cell or primitive neuroectodermal tumour (PNET) and other malignant CNS tumours. Study endpoints were overall survival and progression free survival. Acute and late toxicity endpoints included Common Terminology Criteria version 3.0 (CTC) grade 3 or 4 events, need for admission during RT and change in performance status at 12 months. Results: One hundred and fifty-two patients with CNS tumours were managed with radical intent over the 4-year period. The median age was 49 years and 68.4% were Eastern Co-operative Group (ECOG) 0-1 performance status. The major pathology groups were glioma (59.9%) and base of skull tumours (17.1%). Gross total resection was performed in 28.3% only and RT was delayed after diagnosis until time of progression in 19.7%. For the 91 patients with glioma, the median survival and 2-year survival rate was 19.1 months and 44.1%, respectively. The 2-year survival rates for the subgroups of WHO Grade I or II, III and IV were 100%, 52% and 35%, respectively. For the non-glioma tumour groups, the relapse varied with pathology. Toxicity was minimal with only 3 acute and 3 late CTC grade 3 or 4 events occurring. Overall, 47 or 31% of patients required some inpatient hospitalisation during RT, although this was determined to have some causative relationship to RT in only 12 or 8% of patients. In the 12 months post-RT, performance status was stable or improved in 76.2% of patients, and most deterioration was associated with tumour relapse. Conclusions: RT for CNS tumours using modern techniques was well-tolerated with good tumour outcome and minimal morbidity. Key words: Brain, Glioma, Radiotherapy, Toxicity

Improvements in Quality of Care Resulting From a Formal Multidisciplinary Tumour Clinic in the Management of High-grade Glioma

Introduction: There is increasing belief that a formal protocol-based multidisciplinary care model should be adopted as an optimal care model in oncology. However, there is minimal outcome evidence to demonstrate an improvement in patient care. The aim of this study was to compare clinical quality outcomes between patients with high-grade glioma managed at one hospital using a formal neuro-oncology multidisciplinary tumour clinic (MTC) and a second hospital with a traditional on-call referral pattern (non-MTC). Materials and Methods: Patients with high-grade glioma managed radically with radiation therapy at 2 Singapore hospitals from May 2002 to May 2006 were entered into a prospective database. Patients were grouped into management via MTC or non-MTC. Four clinical quality indicators were chosen retrospectively to assess the variation in practice: a) Use of computed tomography (CT) or magnetic resonance (MR) imaging post-resection (POI) for assessment of residual disease; b) Commencement of radiation therapy (RT) within 28 days of surgery; c) Adjuvant chemotherapy use for glioblastoma multiforme (CTGBM) and d) Median survival. Results: Sixty-seven patients were managed radically, with 47 by MTC and by 20 by non-MTC. MTC patients were more likely to have POI (P = 0.042), and CTGBM (P = 0.025). Although the RT start time was similar for the whole cohort (60% versus 45%: P = 0.296); for GBM patients, the RT start was earlier (63% vs 33% P = 0.024). The median survival for the MTC group was 18.7 months versus 11.9 months for the non-MTC group (P = 0.11). Conclusion: Clinical quality outcomes were significantly improved in patients with high-grade glioma managed in this neuro-oncology MTC. Key words: Chemotherapy, Indicators, Neuro-oncology, Radiotherapy

Improved Median Survival for Glioblastoma Multiforme Following Introduction of Adjuvant Temozolomide Chemotherapy

Introduction: The use of adjuvant temozolomide (TMZ) in patients managed with surgery and adjuvant radiation therapy (RT) for glioblastoma multiforme (GBM) has been demonstrated to improve median and 2-year survival in a recent large international multicentre study. To confirm this result in routine clinical practice, an audit of the management and outcome of patients with GBM at The Cancer Institute Radiation Oncology was performed. Materials and Methods: All patients with GBM managed radically at The Cancer Institute Radiation Oncology from May 2002 to 2006 were entered into a prospective database. Patient, tumour and treatment factors were analysed for association with the outcome of median survival (MS). Survival was calculated using the Kaplan-Meier technique and correlation was assessed using Cox proportional hazards regression. Results: Forty-one patients with GBM were managed with radical intent over the 4year period. The median age was 54 years and 66% were Eastern Cooperative Oncology Group (ECOG) 0-1 performance status. Macroscopic, subtotal and biopsy alone procedures were performed in 61%, 29% and 10% of patients, respectively. The median time from surgery to RT was 26 days. Adjuvant TMZ was used in 44% of patients (n = 18). The MS of the total group was 13.6 months, with a 24% 2-year overall survival. The use of TMZ was associated with improved MS (19.6 versus 12.8 months; P = 0.035) and improved 2-year survival (43% versus 0%). A requirement of dexamethasone dose greater than 4 mg at the end of RT (P = 0.012) was associated with worse survival, but there was no association of MS with age, ECOG, tumour size or extent of surgery. Conclusion: The median and 2-year survival outcomes are comparable to the results of the European Multicentre Study and justify the continued use of TMZ in routine clinical practice. Key words: Adjuvant, Glioblastoma, Temozolomide

Decreased quality of life and depression as predictors for shorter survival among patients with low-grade gliomas: a follow-up from 1990 to 2003

OBJECTIVES

To assess the long-term survival of brain tumor patients, and in particular to evaluate the relation of quality of life (QOL) to survival among low-grade glioma patients.

METHODS

The postoperative survival of 101 brain tumor patients was followed from surgery (1990-1992) until the end of the year 2003. Depression was evaluated by the Beck Depression Inventory (BDI) and QOL with Sintonen's 15D scale before operation and at one year as well as at five years after operation.

RESULTS

The mean survival times in years (SD) were significantly related to tumor malignancy, being the shortest, 1.9 (0.6), for patients with high-grade gliomas, while patients with low-grade gliomas or a benign brain tumor had mean survival times of 9.1 (1.0) and 11.6 (0.5), respectively. At all follow-ups, depressed low-grade glioma patients had a significantly shorter survival time, 3.3-5.8 years, compared to non-depressed low-grade glioma patients, 10.0-11.7 years. A decreased level of QOL in low-grade glioma patients was significantly related to the shorter survival.

CONCLUSIONS

The results suggest that depression and decreased QOL among low-grade glioma patients is related to shorter survival at long-term follow-up. Decreased QOL may serve as an indicator for poor prognosis in low-grade glioma patients.

Neurosurgical uses for intraprocedural magnetic resonance imaging

Neurosurgical procedures demand precision, and efforts to create accurate neurosurgical navigation have been central to the profession through its history. Magnetic resonance image (MRI)-guided navigation offers the possibility of real-time, image-based stereotactic information for the neurosurgeon, which makes possible a number of diagnostic and therapeutic procedures. This article will review both current options for intraoperative MRI operative suite arrangements and the current therapeutic/diagnostic uses of intraoperative MRI.

Health Status Measurements at Diagnosis As Predictors of Survival Among Adults With Brain Tumors

Purpose

The intent of this study was to determine whether baseline measures of functional capacity and performance could be used to predict survival in adults following the diagnosis of brain tumors.

Patients and Methods

Comprehensive health status and health-related quality of life (HRQL) were measured using the Health Utilities Index (HUI; McMaster University, Hamilton, Canada) system by a self-assessment questionnaire in a survey of 100 consecutive patients. The Karnofsky Performance Score (KPS) and Folstein's Mini-Mental State Examination (MMSE) scores were measured by a physician blinded to the HUI results. The patients were observed for up to 5 years to recorded dates of death.

Results

An HUI questionnaire was completed for 93% of the patients and 69% died within 5 years of assessment. The HUI revealed a burden of morbidity and complexity of disability that far exceeded that reported for the general population. KPS and MMSE correlated strongly with each other (r = 0.52; P < .001). A decrease of 0.1 units in HUI Mark 2 (HUI2) self-care single-attribute utility score was associated with an increased hazard of death of 30% (P = .023) for patients with low-grade tumors (n=25). For patients with high-grade tumors (n=56), a 10 unit decrease in the KPS, a 5 unit decrease in MMSE, and a 0.1 decrease in HUI Mark 3 (HUI3) speech and dexterity single-attribute scores were associated with an increased hazard of death of 20% (P = .022), 26% (P = .015), 36% (P = .021), and 18% (P = .035), respectively.

Conclusion

Scores derived from the measurement of HRQL following diagnosis can predict survival in adults with brain tumors.

Intraoperative high-field MRI: anatomical and functional imaging

Intraoperative high-field magnetic resonance (MR) imaging with integrated microscope-based navigation is at present one of the most sophisticated technical methods providing a reliable immediate intraoperative quality control. It enables intraoperative imaging at high quality that is up to the standard of up to date pre- and postoperative neuroradiological routine diagnostics. The major indications are pituitary tumor surgery and glioma surgery. In pituitary tumor surgery intraoperative MRI helps to localize hidden tumor remnants that would be otherwise overlooked. The same is true for glioma surgery, where the optimal extent of resection by simultaneous preservation of functional integrity can be achieved. This is possible since high-field MR imaging offers various modalities beyond standard anatomical imaging, such as MR spectroscopy, diffusion tensor imaging, and functional MR imaging which may also be applied intraoperatively, providing not only data on the extent of resection and localization of tumor remnants but also on metabolic changes, tumor invasion, and localization of functional eloquent cortical and deep-seated brain areas.