Survival and treatment patterns of glioblastoma in the elderly: a population-based study

The impact of short-course hypofractionated radiotherapy on multimodality treatment utilisation, compliance, and outcome in glioblastoma patients: a Danish patterns of care study

BACKGROUND

The aim of this retrospective registry-based Danish patterns of care study was (1) to evaluate the real-world utilisation of short-course hypofractionated radiotherapy (HFRT) in glioblastoma (GBM) patients over time, and (2) to evaluate the impact of short-course HFRT by assessing trends in multimodality treatment utilisation, compliance, and outcome.

MATERIAL AND METHODS

Data of all adults with newly diagnosed pathology-confirmed GBM between 2011 and 2019 were extracted from the nationwide Danish Neuro-Oncology Registry. Short-course HFRT was defined as a fraction size of > 2 Gy to a planned dose of > 30 Gy. Patterns of care were assessed. To analyse trends in the assignment to short-course HFRT, and in radiotherapy (RT) compliance, multivariable logistic regression was applied. To analyse trends in survival, multivariable Cox regression was used.

RESULTS

In this cohort of 2416 GBM patients, the utilisation of short-course HFRT significantly increased from ca. 10% in 2011 to 33% in recent years. This coincided with the discontinued use of palliative regimens and a decreased use of conventional fractionation. The proportion of patients proceeding to RT remained stable at ca. 85%. The proportion of patients assigned to chemoradiotherapy (CRT) remained stable at ca. 60%; the use of short-course hypofractionated CRT increased with ca. 10%, while the use of conventionally fractionated CRT decreased with ca. 10%. Compliance with conventionally fractionated and short-course HFRT was respective 92% and 93%, and significantly increasing in recent years. In the complete cohort, the median overall survival remained stable at ca. 11 months. Assignment to short-course HFRT was independently associated with shorter survival.

CONCLUSION

In Denmark, the use of short-course HFRT significantly increased in recent years. Nonetheless, the overall utilisation of RT and chemotherapy did not increase on a population level. Nor did survival change. In contrast, compliance with both conventionally fractionated RT and short-course HFRT increased.

Interactions between ploidy and resource availability shape clonal interference at initiation and recurrence of glioblastoma

Glioblastoma (GBM) is the most aggressive form of primary brain tumor. Complete surgical resection of GBM is almost impossible due to the infiltrative nature of the cancer. While no evidence for recent selection events have been found after diagnosis, the selective forces that govern gliomagenesis are strong, shaping the tumor's cell composition during the initial progression to malignancy with late consequences for invasiveness and therapy response. We present a mathematical model that simulates the growth and invasion of a glioma, given its ploidy level and the nature of its brain tissue micro-environment (TME), and use it to make inferences about GBM initiation and response to standard-of-care treatment. We approximate the spatial distribution of resource access in the TME through integration of in-silico modelling, multi-omics data and image analysis of primary and recurrent GBM. In the pre-malignant setting, our in-silico results suggest that low ploidy cancer cells are more resistant to starvation-induced cell death. In the malignant setting, between first and second surgery, simulated tumors with different ploidy compositions progressed at different rates. Whether higher ploidy predicted fast recurrence, however, depended on the TME. Historical data supports this dependence on TME resources, as shown by a significant correlation between the median glucose uptake rates in human tissues and the median ploidy of cancer types that arise in the respective tissues (Spearman r = -0.70; P = 0.026). Taken together our findings suggest that availability of metabolic substrates in the TME drives different cell fate decisions for cancer cells with different ploidy and shapes GBM disease initiation and relapse characteristics.

Triaxial accelerometer-measured physical activity and functional behaviours among people with High Grade Glioma: The BrainWear Study

BACKGROUND

High-grade gliomas (HGG) account for 60-75% of all adult gliomas. The complexity of treatment, recovery and survivorship creates a need for novel monitoring approaches. Accurate assessment of physical function plays a vital role in clinical evaluation. Digital wearable tools could help us address unmet needs by offering unique advantages such as scale, cost and continuous real-world objective data. We present data from 42 patients enrolled into the BrainWear study.

METHODS

An AX3 accelerometer was worn by patients from diagnosis or at recurrence. Age-, sex-matched UK Biobank control groups were chosen for comparison.

RESULTS

80% of data were categorised as high-quality demonstrating acceptability. Remote, passive monitoring identifies moderate activity reduces both during a course of radiotherapy (69 to 16 minutes/day) and at the time of progressive disease assessed by MRI (72 to 52 minutes/day). Mean acceleration (mg) and time spent walking daily (h/day) correlated positively with the global health quality of life and physical functioning scores and inversely with the fatigue score. Healthy controls walked on average 2.91h/day compared to 1.32h/day for the HGG group on weekdays and 0.91h/day on the weekend. The HGG cohort slept for longer on weekends (11.6h/day) than weekdays (11.2h/day) compared to healthy controls (8.9h/day).

CONCLUSION

Wrist-worn accelerometers are acceptable and longitudinal studies feasible. HGG patients receiving a course of radiotherapy reduce their moderate activity by 4-fold and are at least half as active as healthy controls at baseline. Remote monitoring can provide a more informed and objective understanding of patient activity levels to help optimise health related quality of life (HRQoL) among a patient cohort with an extremely limited lifespan.

Therapeutic effect of natural polyphenols against glioblastoma

Glioblastoma (GBM) is the most common and aggressive tumor of the central nervous system, which has a highly invasive growth pattern, which creates poor prospects for patient survival. Chemotherapy and tumor surgery are limited by anticancer drug resistance and tumor invasion. Evidence suggests that combinations of treatments may be more effective than single drugs alone. Natural polyphenolic compounds have potential as drugs for the treatment of glioblastoma and are considered as potential anticancer drugs. Although these beneficial effects are promising, the efficacy of natural polyphenolic compounds in GBM is limited by their bioavailability and blood-brain barrier permeability. Many of them have a significant effect on reducing the progression of glioblastoma through mechanisms such as reduced migration and cell invasion or chemosensitization. Various chemical formulations have been proposed to improve their pharmacological properties. This review summarizes natural polyphenolic compounds and their physiological effects in glioblastoma models by modulating signaling pathways involved in angiogenesis, apoptosis, chemoresistance, and cell invasion. Polyphenolic compounds are emerging as promising agents for combating the progression of glioblastoma. However, clinical trials are still needed to confirm the properties of these compounds in vitro and in vivo.

Radiotherapy utilisation rates for patients with cancer as a function of age: A systematic review

INTRODUCTION

There is an increasing incidence of cancer in older people, but limited data on radiotherapy uptake, and in particular, radiotherapy utilisation (RTU) rates. The RTU rate for older adults with cancer may be lower than recommended due to lower tolerance for radiotherapy as well as additional comorbidities, reduced life expectancy and travel for treatment. Radiotherapy use must be aligned with best available, age-specific evidence to ensure older adults with cancer receive optimal benefit without harms.

MATERIALS AND METHODS

A systematic review was conducted to synthesise the published data on the actual RTU rate for patients with cancer as a function of age. MEDLINE and EMBASE were systematically searched to identify relevant population-based and hospital-based cohort studies on radiotherapy utilisation for all age groups, published in English, from 1 January 1990 to 1 July 2020. We focused on the following common cancers in older adults for which radiotherapy is recommended: breast, prostate, lung, rectal cancer, glioblastoma multiforme (GBM), and cervical cancer. Age-specific radiotherapy utilisation data were extracted and analysed as a narrative synthesis.

RESULTS

From 2606 studies screened, 75 cohort and population-based studies were identified with age-specific radiotherapy utilisation data. The total number of patients in the 75 studies was 4,792,138. The RTU rate decreased with increasing age for all tumour sites analysed, except for patients receiving curative radiotherapy as definitive treatment for prostate or cervical cancer. This reduction with increasing age was demonstrated in both palliative and curative settings.

DISCUSSION

There is a global reduction in radiotherapy utilisation with increasing age for most tumour sites. The reduction in delivery of radiotherapy warrants further examination and evidence-based guidelines specific to this population.

Quality of life in patients with glioblastoma and their relatives

OBJECTIVES

Glioblastoma is the most aggressive primary brain tumour in adults. The rapid decline of physical and cognitive functions is likely to affect patients and relatives during the entire course of disease. The aim of this study was to describe and compare (a) health-related quality of life (HRQoL) and psychological symptoms between patients with glioblastoma and their relatives, and (b) HRQoL between patients and a general population over time.

METHODS

At baseline, 63 patients and 63 relatives were included. The participants completed the Short Form Health Survey (SF-36) and the Hospital Anxiety and Depression scale (HADS) at seven different occasions from pre-surgery until two years post-surgery. A comparison of SF-36 was made between patients and an age- and gender-matched control group. Descriptive analysis, effect size and Wilcoxon signed-rank test were used.

RESULTS

Relatives scored lower health-related quality of life (HRQoL) and higher symptoms of anxiety than patients, whilst patients scored worse in the physical parts of the SF-36. Three weeks post-surgery, relatives scored their lowest HRQoL and had the highest risk of anxiety symptoms. Comparing patients with controls, the patients rated worse in both the mental and physical component summaries in HRQoL at most time points.

CONCLUSION

Both patients and relatives showed deterioration of HRQoL. In addition, relatives showed high frequency of anxiety symptoms. Our data reveal that relatives of patients with glioblastoma need attention throughout the disease trajectory and they also need support at the right time point.

Prognostic and Predictive Factors in Elderly Patients With Glioblastoma: A Single-Center Retrospective Study

Glioblastoma (GBM) is the most common primary malignant intracranial tumor and the median age at diagnosis is 65 years. However, elderly patients are usually excluded from clinical studies and age is considered as an independent negative prognostic factor for patients with GBM. Therefore, the best treatment method for GBM in elderly patients has remained controversial. Elderly GBM patients (≥ 60 years old) treated between January 2015 and December 2019 were enrolled in this study. Medical records were reviewed retrospectively, and clinicopathological characteristics, treatments, and outcomes were analyzed. A total of 68 patients were included, with a median age of 65.5 years (range: 60–79). The median preoperative Karnofsky performance scale (KPS) score was 90 (range 40–100) and median postoperative KPS score was 80 (range 0–90). Univariate analysis results showed that age, gender, comorbidities, preoperative KPS < 90 and MGMT promoter methylation were not significantly associated with PFS and OS. On the other hand, total resection, postoperative KPS ≥ 80, Ki67 > 25%, and Stupp-protocol treatment were significantly associated with prolonged PFS and OS. Moreover, multivariate analysis found that postoperative KPS ≥ 80, total resection, and Stupp-protocol treatment were prognostic factors for PFS and OS. The findings of this study have suggested that, on the premise of protecting function as much as possible, the more aggressive treatment regimens may prolong survival for elderly patients with GBM. However, further studies, particularly prospective randomized clinical trials, should be conducted to provide more definitive data on the appropriate management of elderly patients, especially for patients with MGMT promoter methylation.

Real-world validity of randomized controlled phase III trials in newly diagnosed glioblastoma: to whom do the results of the trials apply?

Background

The survival rates in population-based series of glioblastoma (GBM) differ substantially from those reported in clinical trials. This discrepancy may be attributed to that patients recruited to trials tend to be younger with better performance status. However, the proportion and characteristics of the patients in a population considered either eligible or ineligible for trials is unknown. The generalizability of trial results is therefore also uncertain.

Methods

Using the Cancer Registry of Norway and the Brain Tumor Database at Oslo University Hospital, we tracked all patients within a well-defined geographical area with newly diagnosed GBM during the years 2012–2017. Based on data from these registries and the medical records, the patients were evaluated for trial eligibility according to criteria employed in recent phase III trials for GBM.

Results

We identified 512 patients. The median survival was 11.7 months. When we selected a potential trial population at the start of concurrent chemoradiotherapy (radiotherapy [RT]/ temozolomide [TMZ]) by the parameters age (18–70 y), passed surgery for a supratentorial GBM, Eastern Cooperative Oncology Group (ECOG) ≤2, normal hematologic, hepatic and renal function, and lack of severe comorbidity, 57% of the patients were excluded. Further filtering the patients who progressed during RT/TMZ and never completed RT/TMZ resulted in exclusion of 59% and 63% of the patients, respectively. The survival of patients potentially eligible for trials was significantly higher than of the patients not fulfilling trial eligibility criteria (P < .0001).

Conclusions

Patients considered eligible for phase III clinical trials represent a highly selected minority of patients in a real-world GBM population.

Outcome prediction in brain tumor surgery: a literature review on the influence of nonmedical factors

The purpose of the present study was to review the existing data on preoperative nonmedical factors that are predictive of outcome in brain tumor surgery. Our hypothesis was that also the individual characteristics (e.g., emotional state, cognitive status, social relationships) could influence the postoperative course in addition to clinical factors usually investigated in brain tumor surgery. PubMed, Embase, and Scopus were searched from 2008 to 2018 using terms relating to brain tumors, craniotomy, and predictors. All types of outcome were considered: clinical, cognitive, and psychological. Out of 6.288 records identified, 16 articles were selected for analysis and a qualitative synthesis of the prognostic factors was performed. The following nonmedical factors were found to be predictive of surgical outcomes: socio-demographic (age, marital status, type of insurance, gender, socio-economic status, type of hospital), cognitive (preoperative language and cognitive deficits, performance at TMT-B test), and psychological (preoperative depressive symptoms, personality traits, autonomy for daily activities, altered mental status). This review showed that nonmedical predictors of outcome exist in brain tumor surgery. Consequently, individual characteristics (e.g., emotional state, cognitive status, social relationships) can influence the postoperative course in addition to clinical factors.

Patterns of care and clinical outcome in assumed glioblastoma without tissue diagnosis: A population-based study of 131 consecutive patients

Background

Elderly patients with glioblastoma and an accumulation of negative prognostic factors have an extremely short survival. There is no consensus on the clinical management of these patients and many may escape histologically verified diagnosis. The primary aim of this study was to characterize this particular subgroup of patients with radiological glioblastoma diagnosis without histological verification. The secondary aim was to evaluate if oncological therapy was of benefit.

Methods

Between November 2012 and June 2016, all consecutive patients presenting with a suspected glioblastoma in the western region of Sweden were registered in a population-based study. Of the 378 patients, 131 (35%) met the inclusion criteria of the present study by typical radiological features of glioblastoma without histological verification.

Results

The clinical characteristics of the 131 patients (72 men, 59 women) were: age ≥ 75 (n = 99, 76%), performance status according to Eastern Cooperative Oncology Group ≥ 2 (n = 93, 71%), significant comorbidity (n = 65, 50%) and multilobular tumors (n = 90, 69%). The overall median survival rate was 3.6 months. A subgroup of 44 patients (34%) received upfront treatment with temozolomide, with an overall radiological response rate of 34% and a median survival of 6.8 months, compared to 2.7 months for those receiving best supportive care only. Good performance status and temozolomide treatment were statistically significant favorable prognostic factors, while younger age was not.

Conclusion

Thirty-five percent of patients with a radiological diagnosis of glioblastoma in our region lacked histological diagnosis. Apart from high age and poor performance status, they had more severe comorbidities and extensive tumor spread. Even for this poor prognostic group upfront treatment with temozolomide was shown of benefit in a subgroup of patients. Our data illustrate the need of non-invasive diagnostic methods to guide optimal individualized therapy for patients considered too fragile for neurosurgical biopsy.

Does preoperative health-related quality of life predict survival in high-grade glioma patients? - a prospective study

Purpose: To explore if preoperative patient-reported health-related quality of life (HRQoL) provides additional prognostic value as a supplement to other preoperatively known clinical factors in patients with high-grade glioma (HGG).Methods: In a prospective explorative study, 114 patients with high-grade glioma were included. The participants completed the generic HRQoL questionnaire EQ-5D 3L, and the disease-specific questionnaires EORTC QLQ-C30 and EORTC QLQ-BN20 1-3 days before surgery. Operating neurosurgeons scored the patient's preoperative functional level by using Karnofsky Performance Status (KPS). Univariate and multivariate Cox regression analyses were performed to identify HRQoL domains that were associated with survival. Kaplan-Meier survival curves and Log-rank tests were used to visualize differences in survival between groups.Results: In addition to preoperative KPS and age, the EORTC QLQ-BN20 subdomains 'seizures' (HR 0.98, p < .006), 'itchy skin' (HR 1.01, p < .036) and 'bladder control' (HR 1.01, p < .023) were statistically significant independent predictors of survival in a multivariate cox model.Conclusions: Our results suggest that in patients with HGG, certain preoperative symptom scales within EORTC QLQ-BN20 may provide additional prognostic information to supplement other clinical prognostic factors. However, further studies are required to validate our findings. Overall the instruments EQ-5D 3L and EORTC QLQ-C30 do not seem to provide much additional valuable prognostic information to already known prognostic factors.

Between-hospital variation in mortality and survival after glioblastoma surgery in the Dutch Quality Registry for Neuro Surgery

Purpose

Standards for surgical decisions are unavailable, hence treatment decisions can be personalized, but also introduce variation in treatment and outcome. National registrations seek to monitor healthcare quality. The goal of the study is to measure between-hospital variation in risk-standardized survival outcome after glioblastoma surgery and to explore the association between survival and hospital characteristics in conjunction with patient-related risk factors.

Methods

Data of 2,409 adults with first-time glioblastoma surgery at 14 hospitals were obtained from a comprehensive, prospective population-based Quality Registry Neuro Surgery in The Netherlands between 2011 and 2014. We compared the observed survival with patient-specific risk-standardized expected early (30-day) mortality and late (2-year) survival, based on age, performance, and treatment year. We analyzed funnel plots, logistic regression and proportional hazards models.

Results

Overall 30-day mortality was 5.2% and overall 2-year survival was 13.5%. Median survival varied between 4.8 and 14.9 months among hospitals, and biopsy percentages ranged between 16 and 73%. One hospital had lower than expected early mortality, and four hospitals had lower than expected late survival. Higher case volume was related with lower early mortality (P = 0.031). Patient-related risk factors (lower age; better performance; more recent years of treatment) were significantly associated with longer overall survival. Of the hospital characteristics, longer overall survival was associated with lower biopsy percentage (HR 2.09, 1.34–3.26, P = 0.001), and not with academic setting, nor with case volume.

Conclusions

Hospitals vary more in late survival than early mortality after glioblastoma surgery. Widely varying biopsy percentages indicate treatment variation. Patient-related factors have a stronger association with overall survival than hospital-related factors.

Electronic supplementary material

The online version of this article (10.1007/s11060-019-03229-5) contains supplementary material, which is available to authorized users.

Age and surgical outcome of low-grade glioma in Sweden

BACKGROUND

Low-grade gliomas (LGG) are slow-growing primary brain tumors that typically affect young adults. Advanced age is widely recognized as a poor prognostic factor in LGG. The impact of age on postoperative outcome in this patient group has not been systemically studied.

METHODS

We performed a nationwide register-based study with data from the Swedish Brain Tumor Registry (SBTR) for all adults diagnosed with a supratentorial LGG (WHO grade II astrocytoma, oligoastrocytoma, or oligodendroglioma) during 2005-2015. Patient- and tumor-related characteristics, postoperative complications, and survival were compared between three different age groups (18-39 years, 40-59 years, and ≥60 years).

RESULTS

We identified 548 patients; 204 patients (37.2%) aged 18-39 years, 227 patients (41.4%) aged 40-59 years, and 117 patients (21.4%) ≥60 years of age. Unfavorable preoperative prognostic factors (eg, functional status and neurological deficit) were more common with increased age (P < .001). In addition, overall survival was significantly impaired in those 60 years and above (P < .001). We observed a clear dose-response for age with separation of survival curves at 50 years. Biopsy was more common in patients ≥60 years (P < .001). Subgroup analysis of patients with resection revealed a higher amount of postoperative neurological deficits in older patients (P = .029).

CONCLUSION

In general, older patients with LGG have several unfavorable prognostic factors compared with younger patients but seem to tolerate surgery in a comparable fashion. However, more neurological deficits were observed following resections in elderly. Our data further support a cutoff at 50 years rather than 40 years for selection of high-risk patients.

Glioblastoma Treatment in the Elderly

Although current treatment advances prolong patient survival, treatment for glioblastoma (GBM) in the elderly has become an emerging issue. The definition of "elderly" differs across articles; GBM predominantly occurs at an age ≥65 years, and the prognosis worsens with increasing age. Regarding molecular markers, isocitrate dehydrogenase (IDH) mutations are less common in the elderly with GBM. Meanwhile, O6-methylguanine DNA methyltransferase (MGMT) promoter methylation has been identified in approximately half of patients with GBM. Surgery should be considered as the first-line treatment even for elderly patients, and maximum safe resection is recommended if feasible. Concurrently, radiotherapy is the standard adjuvant therapy. Hypofractionated radiotherapy (e.g., 40 Gy/15 Fr) is suitable for elderly patients. Studies also supported the concurrent use of temozolomide (TMZ) with radiotherapy. In cases wherein elderly patients cannot tolerate chemoradiation, TMZ monotherapy is an effective option when MGMT promoter methylation is verified. Conversely, tumors with MGMT unmethylated promoter may be treated with radiotherapy alone to reduce the possible toxicity of TMZ. Meanwhile, the efficacy of bevacizumab (BEV) in elderly patients remains unclear. Similarly, further studies on the efficacy of carmustine wafers are needed. Based on current knowledge, we propose a treatment diagram for GBM in the elderly.

CISD2 promotes the proliferation of glioma cells via suppressing beclin‑1‑mediated autophagy and is targeted by microRNA‑449a

CDGSH iron sulfur domain 2 (CISD2) has been found to be important in carcinogenesis. However, the role of CISD2 in glioma remains to be elucidated. The present study aimed to investigate the role of CISD2 in glioma using the reverse transcription-quantitative polymerase chain reaction, western blotting, co-immunoprecipitation assay, immunofluorescence staining and other methods. The results demonstrated that the mRNA and protein levels of CISD2 were found to be upregulated in glioma tissues, compared with the levels in matched normal tissues. Clinical data analysis showed that the level of CISD2 was negatively correlated with the survival rates of patients with glioma. In addition, high levels of CISD2 were associated with advanced clinical stage, relapse, vascular invasion and increased tumor size. The inhibition of CISD2 suppressed the proliferation and survival of glioma cells in vitro and in vivo. Mechanistically, it was found that small interfering RNA-induced knock down of CISD2 inhibited the proliferation of glioma cells through activating beclin-1-mediated autophagy. The results also revealed that CISD2 was a target of microRNA (miR)-449a. Together, the results of the present study demonstrated that CISD2 was increased in glioma samples and was associated with poor prognosis and aggressive tumor behavior. The miR-449a/CISD2/beclin-1-mediated autophagy regulatory network contributed to the proliferation of glioma cells. Targeting this pathway may be a promising strategy for glioma therapy.

Does Pretreatment Tumor Growth Hold Prognostic Information for Patients with Glioblastoma?

BACKGROUND

Glioblastomas are highly aggressive and heterogeneous tumors, both in terms of patient outcome and molecular profile. Magnetic resonance imaging of tumor growth could potentially reveal new insights about tumor biology noninvasively. The aim of this exploratory retrospective study was to investigate the prognostic potential of pretreatment growth rate of glioblastomas, after controlling for known prognostic factors.

METHODS

A growth model derived from clinical pretreatment postcontrast T₁-weighted magnetic resonance imaging images was used to divide 106 glioblastoma patients into 2 groups. The "faster growth" group had tumors growing faster than expected based on their volume at diagnosis, whereas the "slower growth" group had tumors growing slower than expected. Associations between tumor growth and survival were examined by the use of multivariable Cox regression and logistic regression.

RESULTS

None of the known prognostic factors were significantly associated with tumor growth. An extended multivariable Cox model showed that during the first 12 months of follow-up, there was no significant difference in survival between faster and slower growing tumors. Beyond 12 months' follow-up, however, there was a significant, independent survival benefit in having a tumor with slower pretreatment growth. In a multiple logistic regression model including patients receiving both radiotherapy and chemotherapy (n = 82), slower pre-treatment growth of the tumor was shown to be a significant predictor of 2-year survival (odds ratio 4.4).

CONCLUSIONS

Pretreatment glioblastoma growth harbors prognostic information. Patients with slower growing tumors have higher odds of survival beyond 2 years, adjusted for other prognostic factors.

Impact of standard care on elderly glioblastoma patients

Background

Uncertainty persists about the survival advantage of concomitant and adjuvant temozolomide (TMZ) plus radiotherapy (RT) in elderly patients with newly diagnosed glioblastoma (GBM). We compared the clinical outcome of unselected elderly GBM patients treated with 4 adjuvant treatment modalities, including the Stupp protocol.

Methods

From 2010 to 2014, retrospective chart review was performed on 171 GBM patients aged ≥55 who received either concurrent chemoradiation therapy (CCRT) with standard 60 Gy/30 (SRT); CCRT with hypofractionated 40 Gy/15 (HRT); HRT alone; or TMZ alone. Stratification is by age (55-69, ≥70), KPS (<70, ≥70), and resection status (biopsy, resection).

Results

Out of 171 patients identified, 128(75%) had surgical resection, median age was 66(55-83), and median overall survival (mOS) 11.4mo. Majority (109/171) were treated according to the Stupp protocol (CCRT-SRT), and 106/171 received post-CCRT adjuvant TMZ (median of 3 cycles). In our population, age <70yo was a significant prognostic factor (mOS of patients aged 55-69 vs ≥70 yo = 13.3 vs 6.6 mo; P = .001). However, among the population receiving the Stupp regimen, there was no difference in survival between patients aged 55-69 and those ≥70 (respectively, 14.4 vs 13.2 mo; P = .798). Patients ≥70 yo had similar survival when treated with CCRT-HRT and CCRT-SRT (P = .248), although numbers were small.

Conclusions

Our data suggests that, despite having a worse global prognostic than their younger counterparts, GBM patients ≥70yo with a good performance status could be treated according to the Stupp protocol with similar survival. Theses results need prospective confirmation.

Trends in tumors in the central nervous system in elderly in Denmark, 2008-2012

BACKGROUND

Tumors in the central nervous system (CNS) comprise a heterogeneous group of tumors with different treatment strategies and prognoses. Current treatment regimens are based on studies on patients mainly younger than 70 years. The aim of the present study was to analyze and describe trends in incidence, mortality, prevalence, and relative survival in Denmark from 1980 to 2012 focusing on patients older than 70 years.

MATERIAL AND METHODS

Tumors in the CNS were defined as ICD-10 codes C70-72, D32-33 and D42-43. Data with comparable data on cancer incidence, mortality, prevalence and relative survival derived from the NORDCAN database were delivered from the Danish Cancer Registry and the Danish Cause of Death Registry with follow-up for death or emigration until the end of 2013.

RESULTS

During the period 1980-2012 the number of patients with CNS tumors increased from 603 to 1378 patients. The increase is seen mainly in the elderly patients, and especially in women aged 84-89 and 90 + at the time of diagnosis. During the same time period, the mortality rates increased within all age groups, most significantly in patients aged 70 years or older. This may reflect an increased focus on and identification of these patients. Noteworthy; the number of patients living with a CNS tumor increased from 2952 in 1980 to 12 147 patients in 2010.

CONCLUSION

This study suggests that the current treatment strategies in general may have improved survival in patients with CNS tumors, but in order to improve survival further in the increasing group of elderly patients more knowledge about treatment of these patients is needed.

Neurosurgical Care in the Elderly: Increasing Demands Necessitate Future Healthcare Planning

OBJECTIVES

The worldwide elderly population is steadily increasing. It has been recommended that age-appropriate information should be available for older patients, but little exists in neurosurgery. We aim to better understand the clinical characteristics, bed occupancy and outcomes of elderly patients admitted to a UK neurosurgical unit.

METHODS

Retrospective review of medical records of all patients aged 75 years and older admitted for at least 1 night to the Southwest Neurosurgery Centre from 2007 to 2010. Mortality data up to 31 December 2012 were obtained from a national registry.

RESULTS

Eight hundred and eighty-six elderly patients were admitted, for whom 877 records were available. Three hundred and eighty-nine patients were admitted electively; 488 were emergency or urgent; 48.8% had cranial pathology and 50.7% had spinal disease. Emergency cases were significantly older and more likely to be male than elective patients. The median length of stay for emergency patients was significantly longer than that of elective patients (P < 0.0001, 3 vs. 8 days). One elective patient died as an inpatient, compared with 46 emergency patients. Of emergency and elective patients, 25.6% and 3.6%, respectively, had died by 6 months after discharge. Age and length of stay were not associated with early death.

CONCLUSIONS

The demographics and outcomes of the elderly admitted to a UK neurosurgical center are discussed. Differences between elective and emergency groups are attributable to both the pathologic processes and case selection. Neurosurgical treatment should not be denied based on age, however the high risks of emergency surgery in this age group should be acknowledged.

A Comprehensive Analysis of Influence ERCC Polymorphisms Confer on the Development of Brain Tumors

Within DNA repair genes, there lie a number of single nucleotide polymorphisms that may impair protein function and attenuate DNA repair capability, resulting in genomic instability and individual predisposition to malignancies. The purpose of this study was to assess the previously reported inconsistent association of polymorphisms in ERCC1 (rs11615, rs3212986), ERCC2 (rs13181, rs1799793, rs238406), and ERCC5 (rs17655) with the development of brain tumors. In the present work, we carried out a comprehensive meta-analysis of results from all published data (5 data sets for rs11615, 7 for rs3212986, 11 for rs13181, 5 for rs1799793, 3 for rs238406, and 4 for rs17655) to evaluate risk of brain tumors contributed by the polymorphisms being investigated. Either the analytic method described by Mantel and Haenszel or that proposed by DerSimonian and Laird was properly used to summarize the risk estimates (OR and 95% CI). Data analyses were done with Stata version 12.0. Meta-analyses were performed for all polymorphisms, and only rs3212986 in the ERCC1 gene showed a significant association with glioma incidence. In the homozygote comparison, we found 1.26-fold elevated risk of glioma in relation to presence of the AA genotype (OR = 1.26, 95% CI = 1.05-1.52, P OR = 0.013, P heterogeneity = 0.849, I(2) = 0.0%). We also noted that individuals with the rs3212986-AA as compared to those with rs3212986-CC/CA had a 28% higher risk to develop glioma (OR = 1.28, 95% CI = 1.06-1.53, P OR = 0.008, Pheterogeneity = 0.808, I(2) = 0.0%). No major effects were observed for Caucasians or Asians in subgroup analysis by ethnicity. ERCC1 rs3212986 is a common single nucleotide polymorphism and may contribute toward individual susceptibility for glioma. Further research in this filed is required to verify the association obtained based on a relatively small number.

Patient and treatment factors associated with survival among adult glioblastoma patients: A USA population-based study from 2000-2010

In this study, we utilized the USA surveillance, epidemiology, and end results (SEER) database to examine factors influencing survival of glioblastoma multiforme (GBM) patients. GBM is the most common primary malignant brain tumor in adults and despite advances in treatment, prognosis remains poor. Using the SEER database, we defined a cohort of adult patients for the years 2000-2009 with confirmed GBM and minimum follow-up of 12 months. A total of 14,675 patients with GBM met the inclusion criteria. Demographic, clinical, and treatment variables were examined. Death was the primary outcome. Median survival time was 11 months. Patients had increasingly longer survival over the decade span. We found, on multivariate analysis, that significantly worse survival was associated with age >75 years, male sex, unmarried status, and non-Hispanic Caucasian race/ethnicity. Patients in the Northeast had a significantly lower risk of mortality. Patients with tumors that were non-lateralized and >3 cm fared worse. Patients who did not receive adjuvant radiation also had worse outcomes. Gross total resection imparted a survival advantage for patients compared to biopsy or partial resection. Thus, this report adds to the growing body of literature supporting the positive role of maximal resection on patient survival.

Perioperative quality of life in functionally dependent glioblastoma patients: A prospective study

OBJECTIVE

Functionally dependent patients with glioblastoma have a poor prognosis which may in part be due to a negative treatment selection. Prospective data on patient-reported quality of life (QoL) following surgery, together with an updated survival analysis, are lacking with regard to functionally dependent glioblastoma patients.

MATERIALS AND METHODS

Adult patients (≥ 18 years) with a histologically confirmed primary glioblastoma with preoperative Karnofsky Performance Status (KPS) ≤ 60, who were treated between January 1, 2007 and March 30, 2014, were eligible for inclusion. EuroQol 5D (EQ-5D) was scored before surgery and at 4-6 weeks postoperatively. A control group of 20 independent (i.e., KPS ≥ 70) adult primary glioblastoma patients was constructed.

RESULTS

Among the 27 patients included, only 22 patients were willing to participate in QoL research, with complete QoL follow-up data obtained for 16. There were 22 resections and 5 biopsies. In resection cases, the median extent of resection was 93% (IQR 78-99), with gross-total resection achieved in 24%. In the 16 patients with complete QoL data, the EQ-5D index score increased from 0.34 ± 0.38 preoperatively to 0.45 ± 0.32 postoperatively (p = 0.30), with 3 patients that deteriorated in QoL following surgery. Median survival was 7.3 months (95%, CI: 4.6-9.9, n = 27), and the perioperative mortality was 7%. Treatment characteristics between dependent and independent patients were similar, as were the unfavorable outcomes defined as QoL reduction, QoL drop-out, and dead before QoL assessment (41% vs. 45%, p = 0.79). However, a difference was seen in 6-month survival (42% vs. 15%, p = 0.05).

CONCLUSION

In most functionally dependent patients with glioblastoma, cytoreductive surgery is possible, and improved or unchanged postoperative QoL may be seen in approximately half of the cases. This must be weighed against the risk of complications and the modest effect of cytoreductive surgery.

Glioblastoma survival: has it improved? Evidence from population-based studies

PURPOSE OF REVIEW

Glioblastoma is the most common malignant brain tumor in adults and carries a particularly poor prognosis. Since 2005, state-of-the-art therapy consists of maximal well tolerated surgical resection followed by combined radiotherapy and chemotherapy with temozolomide. Over the past decade, further advances have been achieved in various disciplines, most prominently including antiangiogenic treatment with bevacizumab. Still, whether these therapeutic innovations have translated to the general population remains unclear.

RECENT FINDINGS

Population-based outcome and pattern of care (POC) studies have recently documented the rapid dissemination of the treatment standard to community practice across countries. This has resulted in a modest but significant increase in survival at the population level. However, the increase was significantly less marked in elderly patients in whom undertreatment is a concern. Other serious concerns address diverging POC between academic versus nonacademic centers, patients with high-income versus low-income, and racial and marital status disparities. With regard to bevacizumab treatment, there is still insufficient evidence of a beneficial impact on population-based survival, so far.

SUMMARY

Despite the rapid incorporation of the current standard treatment in clinical practice and the thereby achieved modest survival gain at the population-level, prevailing POC needs to be reconsidered and standardized, especially for elderly glioblastoma patients who bear a large disease burden and carry the worst prognosis. Future POC studies are urgently needed and would benefit from the systematic inclusion of quality-of-life data and molecular tumor markers, so that this information could be captured in population-based cancer registries.

Treating glioblastoma in the elderly

The incidence of glioblastoma (GBM) is increasing among the elderly, who now account for up to half of all the adult cases of GBM. This trend has resulted in the recent development of clinical research specifically dedicated to this fragile population. Some studies have investigated surgical resection, radiotherapy and chemotherapy with temozolomide, and ongoing research is currently addressing the use of combined radiochemotherapy in this population. Although older patients with GBM have a significantly worse life expectancy compared with their younger counterparts, etiologic treatments should not be withheld from these patients solely because of their age. On the contrary, results from prospective studies suggest that active care of these patients has a significant positive impact on survival without affecting quality of life or cognition. To optimize both symptomatic and etiologic treatment, neuro-oncology multidisciplinary teams must take into account performance and cognitive status, the resectability of the tumor, and associated comorbidities.

Lack of prognostic significance of C-erbB-2 expression in low- and high- grade astrocytomas

BACKGROUND

Astrocytic tumors, the most common primary glial tumors of the central nervous system, are classified from low to high grade according to the degree of anaplasia and presence of necrosis. Despite advances in therapeutic management of high grade astrocytic tumors, prognosis remains poor. In the present study, the frequency and prognostic significance of c-erb-B2 in astrocytic tumors was investigated.

MATERIALS AND METHODS

Records of 72 patients with low- and high-grade astrocytic tumors were evaluated. The expression of C-erbB-2 was determined immunohistochemically and intensity was recorded as 0 to 3+. Tumors with weak staining (1+) or no staining (0) were considered Her-2 negative, while tumors with moderate (2+) and strong (3+) staining were considered Her-2 positive.

RESULTS

Of the 72 patients, 41 (56.9%) had glioblastoma (GBM), 10 (13.9%) had diffuse astrocytoma, 15 (20.8%) had anaplastic astrocytoma, 6 (8.3%) had pilocytic astrocytoma. C-erbB-2 overexpression was detected in the tumor specimens of 17 patients (23.6%). Six (8.3%) tumors, all GBMs, exhibited strong staining, 2 (2.7%) specimens, both GBMs, exhibited moderate staining, and 9 specimens, 5 of them GBMs (12.5%), exhibited weak staining. No staining was observed in diffuse astrocytoma and pilocytic astrocytoma specimens. Median overall survival of patients with C-erbB-2 negative and C-erbB-2 positive tumors were 30 months (95%CI: 22.5-37.4 months) and 16.9 months (95%CI: 4.3-29.5 months), respectively (p=0.244).

CONCLUSIONS

Although there was no difference in survival, C-erbB-2 overexpression was observed only in the GBM subtype.

Management of elderly patients with gliomas

The current progressive aging of the population is resulting in a continuous increase in the incidence of gliomas in elderly people, especially the most frequent subtype, glioblastoma (GBM). This sociohealth shift, known as the "silver tsunami," has prompted the neuro-oncology community to investigate the role of specific antitumor treatments, such as surgery, radiotherapy, chemotherapy, and other targeted therapies, for these traditionally undertreated patients. Advanced age, a widely recognized poor prognostic factor in both low-grade glioma (LGG) and high-grade glioma patients, should no longer be the sole reason for excluding such older patients from receiving etiologic treatments. Far from it, results from recent prospective trials conducted on elderly patients with GBM demonstrate that active management of these patients can have a positive impact on survival without impairing either cognition or quality of life. Although prospective studies specifically addressing the management of grade 2 and 3 gliomas are lacking and thus needed, the aforementioned tendency toward acknowledging a therapeutic benefit for GBM patients might also apply to the treatment of patients with LGG and anaplastic gliomas. In order to optimize such etiologic treatment in conjunction with symptomatic management, neuro-oncology multidisciplinary boards must individually consider important features such as resectability of the tumor, functional and cognitive status, associated comorbidities, and social support.

Assessment and treatment relevance in elderly glioblastoma patients

Glioblastoma (GBM) is the most common malignant primary brain tumor. Its incidence continues to increase in the elderly because the older segment of the population is growing faster than any other age group. Most clinical studies exclude elderly patients, and "standards of care" do not exist for GBM patients aged >70 years. We review epidemiology, tumor biology/molecular factors, prognostic factors (clinical, imaging data, therapeutics), and their assessments as well as classic and specific endpoints plus recent and ongoing clinical trials for elderly GBM patients. This work includes perspectives and personal opinions on this topic. Although there are no standards of care for elderly GBM patients, we can hypothesize that (i) Karnofsky performance status (KPS), probably after steroid treatment, is one of the most important clinical factors for determining our oncological strategy; (ii) resection is superior to biopsy, at least in selected patients (depending on location of the tumor and associated comorbidities); (iii) specific schedules of radiotherapy yield a modest but significant improvement; (iv) temozolomide has an acceptable tolerance, even when KPS <70, and could be proposed for methylated elderly GBM patients; and (v) the addition of concomitant temozolomide to radiotherapy has not yet been validated but shows promising results in some studies, yet the optimal schedule of radiotherapy remains to be determined. In the future, specific assessments (geriatric, imaging, biology) and use of new endpoints (quality of life and toxicity measures) will aid clinicians in determining the balance of potential benefits and risks of each oncological strategy.

Significant prevalence of antibodies reacting with simian virus 40 mimotopes in sera from patients affected by glioblastoma multiforme

BACKGROUND

Glioblastoma multiforme (GBM) is a rare tumor, which affects 1/100 000 individuals, but it represents 30% of central nervous system malignancies. GBM is a severe tumor responsible for 2% of all cancer-related deaths. Although characterized by genotypic and phenotypic heterogeneities, GBM invariably resists conventional chemo- and radiotherapies. Several chromosome alterations and gene mutations were detected in GBM. Simian virus 40 (SV40), a small DNA tumor virus, has been found in GBM specimens by some studies, while other investigations have not confirmed the association.

METHODS

An indirect enzyme-linked immunosorbent assay with 2 synthetic peptides mimicking SV40 antigens of viral capsid proteins 1-3 was employed to detect specific antibodies against SV40 in serum samples from GBM-affected patients, together with controls represented by patients affected by breast cancer and normal subjects of the same median age.

RESULTS

Our data indicate that in serum samples from GBM-affected patients (n = 44), the prevalence of antibodies against SV40 viral capsid protein antigens is statistically significantly higher (34%, P = .016 and P = .03) than in the control groups (15%), represented by healthy subjects (n = 101) and patients affected by breast cancer (n = 78), respectively.

CONCLUSION

Our data indicate that SV40, or a closely related yet undiscovered human polyomavirus, is associated with a subset of GBM and circulates in humans. Our study can be transferred to the clinical oncology application to discriminate different types of heterogeneous GBM, which in turn may address an innovative therapeutic approach to this fatal cancer.

Treatment outcomes in glioblastoma patients aged 76 years or older: a multicenter retrospective cohort study

Age is one of the most important prognostic factors in glioblastoma patients, but no standard treatment has been established for elderly patients with this condition. We therefore conducted a retrospective cohort study to evaluate treatment regimens and outcomes in elderly glioblastoma patients. The study population consisted of 79 glioblastoma patients aged ≥ 76 years (median age 78.0 years; 34 men and 45 women). The median preoperative Karnofsky performance status (KPS) score was 60. Surgical procedures were classified as biopsy (31 patients, 39.2 %), <95 % resection of the tumor (21 patients, 26.9 %), and ≥ 95 % resection of the tumor (26 patients, 33.3 %). Sixty-seven patients (81.0 %) received radiotherapy and 45 patients (57.0 %) received chemotherapy. The median overall progression-free survival time was 6.8 months, and the median overall survival time was 9.8 months. Patients aged ≥ 78 years were significantly less likely to receive radiotherapy (p = 0.004). Patients with a postoperative KPS score of ≥ 60 were significantly more likely to receive maintenance chemotherapy (p = 0.008). Multivariate analyses identified two independent prognostic factors: postoperative KPS score ≥ 60 (hazard ratio [HR] = 0.531, 95 % confidence interval [CI] 0.315-0.894, p = 0.017) and temozolomide therapy (HR = 0.442, 95 % CI 0.25-0.784, p < 0.001).The findings of this study suggest that postoperative KPS score is an important prognostic factor for glioblastoma patients aged ≥ 76 years, and that these patients may benefit from temozolomide therapy.

Personalized treatment strategies in glioblastoma: MGMT promoter methylation status

The identification of molecular genetic biomarkers considerably increased our current understanding of glioma genesis, prognostic evaluation, and treatment planning. In glioblastoma, the most malignant intrinsic brain tumor entity in adults, the promoter methylation status of the gene encoding for the repair enzyme O6-methylguanine-DNA methyltransferase (MGMT) indicates increased efficacy of current standard of care, which is concomitant and adjuvant chemoradiotherapy with the alkylating agent temozolomide. In the elderly, MGMT promoter methylation status has recently been introduced to be a predictive biomarker that can be used for stratification of treatment regimes. This review gives a short summery of epidemiological, clinical, diagnostic, and treatment aspects of patients who are currently diagnosed with glioblastoma. The most important molecular genetic markers and epigenetic alterations in glioblastoma are summarized. Special focus is given to the physiological function of DNA methylation-in particular, of the MGMT gene promoter, its clinical relevance, technical aspects of status assessment, its correlation with MGMT mRNA and protein expressions, and its place within the management cascade of glioblastoma patients.

Differentiating diffuse World Health Organization grade II and IV astrocytomas with ex vivo magnetic resonance spectroscopy

BACKGROUND

The prognosis and treatment of astrocytomas, which are primary brain tumors, vary depending on the grade of the tumor, necessitating a precise preoperative classification. Magnetic resonance spectroscopy (MRS) provides information about metabolites in tissues and is an emerging noninvasive tool to improve diagnostic accuracy in patients with intracranial neoplasia.

OBJECTIVE

To investigate whether ex vivo MRS could differentiate World Health Organization grade II (A-II) and IV astrocytomas (glioblastomas; GBM) and to correlate MR spectral profiles with clinical parameters.

METHODS

Patients with A-II and GBM (n = 58) scheduled for surgical resection were enrolled. Tumor specimens were collected during surgery and stored in liquid nitrogen before being analyzed with high-resolution magic angle spinning MRS. The tumors were histopathologically classified according to World Health Organization criteria as GBM (n = 48) and A-II (n = 10).

RESULTS

Multivariate analysis of ex vivo proton high-resolution magic angle spinning spectra MRS showed differences in the metabolic profiles of different grades of astrocytomas. A-II had higher levels of glycerophosphocholine and myo-inositol than GBM. The latter had more phosphocholine, glycine, and lipids. We observed a significant metabolic difference between recurrent and nonrecurrent GBM (P < .001). Primary GBM had more phosphocholine than recurrent GBM. A significant correlation (P < .001) between lipid and lactate signals and histologically estimated percentage of necrosis was observed in GBM. Spectral profiles were not correlated with age, survival, or magnetic resonance imaging-defined tumor volume.

CONCLUSION

Ex vivo MRS can differentiate astrocytomas based on their metabolic profiles.

Outcome and prognostic factors in adult cerebellar glioblastoma

Cerebellar glioblastoma multiforme (GBM) occurs rarely in adults, accounting for 0.4-3.4% of all GBM. Current studies have all involved small patient numbers, limiting the clear identification of prognostic factors. Additionally, while few studies have compared cerebellar GBM to their supratentorial counterparts, there is conflicting data regarding their relative prognosis. To better characterize outcome and identify patient and treatment factors which affect survival, the authors analyzed cases of adult cerebellar GBM from the Surveillance, Epidemiology, and End Results database. A total of 247 adult patients with cerebellar GBM were identified, accounting for 0.67% of all adult GBM. Patients with cerebellar GBM were significantly younger than those with supratentorial tumors (56.6 versus 61.8 years, p < 0.0001), but a larger percentage of patients with supratentorial GBM were Caucasian (91.7% versus 85.0%, p < 0.0001). Overall median survival did not differ between those with cerebellar and supratentorial GBM (7 versus 8 months, p = 0.24), with similar rates of long-term (greater than 2 years) survival (13.4% versus 10.6%, p = 0.21). Multivariate analysis revealed age greater than 40 years (hazard ratio [HR]: 2.20; 95% confidence interval [CI]: 1.47-3.28; p = 0.0001) to be associated with worse patient survival, while the use of radiotherapy (HR: 0.33; 95% CI: 0.24-0.47; p < 0.0001) and surgical resection (HR: 0.66; 95% CI: 0.45-0.96; p = 0.028) were seen to be independent favorable prognostic factors. In conclusion, patients with cerebellar GBM have an overall poor prognosis, with radiotherapy and surgical resection significantly improving survival. As with supratentorial GBM, older age is a poor prognostic factor. The lack of differences between supratentorial and cerebellar GBM with respect to overall survival and prognostic factors suggests these tumors to be biologically similar.

Operability of glioblastomas: "sins of action" versus "sins of non-action"

Despite prognosis of glioblastomas is still poor, mounting evidence suggests that more extensive surgical resections are associated with longer life expectancy. However, the surgical indications, at present, are far from uniform and the concept of operability is extremely surgeon-dependant. The results of glioblastoma resection in 104 patients operated on between March 2005 and April 2011 were reviewed with the aim to shed some light on the limits between 'sins of action' (operating upon complex tumors causing a permanent severe deficit) and 'sins of non-action' (considering inoperable tumors that can be resected with good results). Fifty-five patients (54.4 %) (Group 1) presented with a 'disputable' surgical indication because of one or more of the following clinico-radiological aspects: involvement of motor and language areas (39.4 %), deep location (7.7 %), corpus callosum infiltration (13.4 %), or major vessels encasement (8.6 %). Forty-six (42.5 %) patients (Group 2) presented with an 'indisputable' surgical indication (readily accessible tumors in non-eloquent areas). Overall mortality was 2.9 %. The mean overall survival was 19.8 months and not significantly different in the two Groups (20.4 Group 2 and 19.5 months for Group 1; p = 0.7). Patients with GTR and <72 years had a longer survival (p = 0.004 and 0.03, respectively). Seventy patients (69.3 %) showed an uneventful post-operative course, without statistical significance difference between Group 1 and 2. The gross total removal of glioblastoma with many complexities (Group 1) was found to be feasible with acceptable mortality, morbidity and long-term survival rates.