Brain tumor surgery in geriatric patients: a critical analysis in 44 patients over 80 years

Preoperative Laboratory Values Are Predictive of Adverse Postoperative Outcomes in Patients Older Than 65 Years Undergoing Brain Tumor Resection: A National Surgical Quality Improvement Program Study

OBJECTIVE

In this study, we used a large national database to assess the effect of preoperative laboratory value (PLV) derangements on postoperative outcomes in patients older than 65 years undergoing brain tumor resection.

METHODS

Data was collected for patients >65 years old undergoing brain tumor resection from 2015 to 2019 (N = 10,525). Univariate and multivariate analysis were performed for 11 PLVs and 6 postoperative outcomes.

RESULTS

Hypernatremia (odds ratio [OR], 4.707; 95% confidence interval [CI], 1.695-13.071; P < 0.01) and increased creatinine level (OR, 2.556; 95% CI, 1.291-5.060; P < 0.01) were the most significant predictors of 30-day mortality. The most significant predictor of Clavien-Dindo grade IV complications was increased creatinine level (OR, 1.667; 95% CI, 1.064-2.613; P < 0.05), whereas, significant predictors of major complications were hypoalbuminemia (OR, 1.426; 95% CI, 1.132-1.796; P < 0.05) and leukocytosis (OR, 1.347; 95% CI, 1.075-1.688; P < 0.05). Predictors of readmission were anemia (OR, 1.326; 95% CI, 1.047-1.680; P < 0.05) and thrombocytopenia (OR, 1.387; 95% CI, 1.037-1.856; P < 0.05), whereas, hypoalbuminemia (OR, 1.787; 95% CI, 1.280-2.495; P < 0.001) was predictive of reoperation. Increased partial thromboplastin time and hypoalbuminemia were predictors of extended length of stay (OR, 2.283, 95% CI, 1.360-3.834, P < 0.01 and OR, 1.553, 95% CI, 1.553-1.966, P < 0.001, respectively). Hypernatremia (OR, 2.115; 95% CI, 1.181-3.788; P < 0.05) and hypoalbuminemia (OR, 1.472; 95% CI, 1.239-1.748; P < 0.001) were the most significant predictors of NHD. Seven of 11 PLVs were associated with adverse postoperative outcomes.

CONCLUSIONS

PLV derangements were significantly associated with adverse postoperative outcomes in patients older than 65 years undergoing brain tumor resection. The most significant predictors of adverse postoperative outcomes were hypoalbuminemia and leukocytosis.

Impact of age on postsurgical outcomes of nonfunctioning pituitary adenomas

PURPOSE

The management of pituitary adenomas in the elderly has become a relevant clinical issue, in relationship with improved life expectancy and spreading use of imaging techniques. In this single-center and retrospective study, we investigated the impact of age on peri- and postsurgical outcomes in patients undergoing transnasal sphenoidal (TNS) surgery for pituitary adenomas.

METHODS

One-hundred-sixty-nine patients (62% males) undergoing endoscopic transphenoidal (TNS) surgery for nonfunctioning pituitary adenomas (NFPAs) were enrolled. Patients were subdivided into three groups according to age tertiles: ≤56 (group 1), 57-69 (group 2), and ≥70 (group 3) years. Postsurgical and endocrinological outcomes were evaluated and compared among the three age groups.

RESULTS

37/169 patients (21.9%) developed at least one perisurgical complication, without significant association with the patients' age (P = 0.838), Charlson co-morbidity score (P = 0.326), and American Society of Anesthesiologist score (P = 0.616). In the multivariate regression analysis, the adenoma size resulted the only determinant of perisurgical complication (odds ratio [OR] 1.07, 95% confidence interval [C.I.] 1.00-1.13; P = 0.044). The development and the recovery of at least one pituitary hormone deficiency were observed in 12.2% and 14.2% of patients, respectively. The risk of developing new pituitary hormone deficiencies was correlated with cavernous sinus invasion as evaluated by magnetic resonance imaging (hazard ratio [HR] 4.19, 95% C.I. 1.39-12.66; P = 0.010), whereas the probability to normalize at least one pituitary hormone deficiency was significantly correlated with younger age of patients (HR 0.27, 95% CI 0.12-0.61; P = 0.002).

CONCLUSIONS

The results of this study reinforce the concept that endoscopic TNS surgery is a safe therapeutic option in the elderly patients with NFPA, even in presence of comorbidities and high anesthetic risk.

A novel online calculator predicting short-term postoperative outcomes in patients with metastatic brain tumors

Purpose

Establishing predictors of hospital length of stay (LOS), discharge deposition, and total hospital charges is essential to providing high-quality, value-based care. Though previous research has investigated these outcomes for patients with metastatic brain tumors, there are currently no tools that synthesize such research findings and allow for prediction of these outcomes on a patient-by-patient basis. The present study sought to develop a prediction calculator that uses patient demographic and clinical information to predict extended hospital length of stay, non-routine discharge disposition, and high total hospital charges for patients with metastatic brain tumors.

Methods

Patients undergoing surgery for metastatic brain tumors at a single academic institution were analyzed (2017–2019). Multivariate logistic regression was used to identify independent predictors of extended LOS (> 7 days), non-routine discharge, and high total hospital charges (> $ 46,082.63). p < 0.05 was considered statistically significant. C-statistics and the Hosmer–Lemeshow test were used to assess model discrimination and calibration, respectively.

Results

A total of 235 patients were included in our analysis, with a mean age of 62.74 years. The majority of patients were female (52.3%) and Caucasian (76.6%). Our models predicting extended LOS, non-routine discharge, and high hospital charges had optimism-corrected c-statistics > 0.7, and all three models demonstrated adequate calibration (p > 0.05). The final models are available as an online calculator (https://neurooncsurgery.shinyapps.io/brain_mets_calculator/).

Conclusions

Our models predicting postoperative outcomes allow for individualized risk-estimation for patients following surgery for metastatic brain tumors. Our results may be useful in helping clinicians to provide resource-conscious, high-value care.

Central nervous system hemangioblastomas in the elderly (over 65 years): Clinical characteristics and outcome analysis

OBJECTIVES

Hemangioblastomas (HBs) in the elderly are very uncommon and have rarely been studied. This retrospective study aimed to identify clinical features, optimal treatment, surgical outcomes and long-term prognostic factors in these rare lesions.

PATIENTS AND METHODS

We performed a retrospective analysis of HBs patients over 65 years old who underwent surgery from 2008 to 2018 at our department. Clinical data was retrospectively reviewed and statistically analyzed.

RESULTS

Thirty-three elderly patients with a mean age of 68.76 years were included in this study. Cerebellum, brainstem, and spinal cord locations accounted for 72.7 %, 18.2 % and 9.1 %. Two patients (6.1 %) were diagnosed as von Hippel-Lindau (VHL) syndrome. After mean follow-up of 37.95 ± 22.12 months, clinical symptoms improved in 22 patients (67 %), unchanged in seven patients (21 %) and aggravated in 4 patients (12 %). Only 1(3 %) patient experienced local recurrence during follow-up. Univariate analysis showed tumor size (P = 0.044) and tumor characteristic (cystic or solid) (P = 0.034) were significantly related to long-term outcomes, while multiple logistic regression analysis depicted tumor characteristics were exclusively correlated with outcomes (P = 0.04).

CONCLUSIONS

Our study suggests elderly hemangioblastomas may be different from their younger counterparts in that they often display solid configuration with large size and include more cerebellar tumors. HBs should be included in the differential diagnosis of elderly patients presenting with cerebellar mass. Despite many challenges involved, surgical removal of HBs in this age group is a safe procedure with acceptable risks. They may do not require as frequent follow-up as younger counterparts due to the low associations with VHL disease and tumor recurrence rate.

Skull base versus non-skull base meningioma surgery in the elderly

To compare outcomes after surgery for skull base meningiomas (SBMs) with non-skull base meningiomas (NSBMs) in the elderly. Overall, 128 consecutive patients ≥ 70 years of age with intracranial SBMs operated between 1990 and 2010 were compared to 193 consecutive patients ≥ 70 years of age with NSBMs operated within the same time period. Median age at surgery was 75.0 years (mean 75.7, range 70.0-92.4). Follow-up was complete with median 4.7 years (mean 5.5, range 0-19). The female-to-male ratio was 2.8 for SBMs and 1.3 for NSBMs (p < 0.005). The groups had similar preoperative KPS (median 80, range 20-100), but SBMs presented significantly more frequently with raised ICP (RR = 2.2, p < 0.005) and less frequently with seizures (RR = 0.6, p < 0.05). WHO I was significantly more frequent in SBMs (p < 0.005). Gross-total resection (GTR) was less frequent in SBMs (63 vs 82%) (RR = 2.1, p < 0.0001). SBMs were similar to NSBMs with respect to neurological outcome at 6-12 months, reoperations for hematomas, postoperative infections, and 30-day mortality. Retreatment rates and time to retreatments were also similar. There were no differences between the two groups with respect to risk of retreatment and overall survival (OS) at 5, 10, 15, and 20 years. In elderly patients with SBMs selected to surgical treatment, the risks of surgery, risk of retreatment, and OS were similar to NBSMs. Therefore, surgery for SBMs may be considered as safe as NSBMs in the elderly population.

Endoscopic endonasal transsphenoidal surgery in elderly patients with pituitary adenomas

OBJECT

With the increase in the average life expectancy, medical care of elderly patients with symptomatic pituitary adenoma (PA) will continue to grow. Little information exists in the literature about the surgical treatment of these patients. The aim of this study was to present the results of a single pituitary center in the surgical treatment of PAs in patients > 70 years of age.

METHODS

In this retrospective study, 55 consecutive elderly patients (age ≥ 70 years) with nonfunctioning PAs underwent endoscopic transsphenoidal surgery at the General Hospital of Fortaleza, Brazil, between May 2000 and December 2012. The clinical and radiological results in this group were compared with 2 groups of younger patients: < 60 years (n = 289) and 60-69 years old (n = 30).

RESULTS

Fifty-five patients ≥ 70 years of age (average age 72.5 years, range 70-84 years) underwent endoscopic surgery for treatment of PAs. The mean follow-up period was 50 months (range 12-144 months). The most common symptoms were visual impairment in 38 (69%) patients, headache in 16 (29%) patients, and complete ophthalmoplegia in 6 (10.9%). Elderly patients presented a higher incidence of ophthalmoplegia (p = 0.032) and a lower frequency of pituitary apoplexy before surgery (p < 0.05). Tumors with cavernous sinus invasion were treated surgically less frequently than in younger patients. Although patients with an American Society of Anesthesiologists score of 3 were more common in the elderly group (p < 0.05), no significant difference regarding surgical time, extent of resection, and hospitalization were observed. Elderly patients presented with more complications than patients < 60 years (32.7% vs 10%, p < 0.05). Complications observed in the elderly group included 5 CSF leaks (9%), 2 permanent diabetes insipidus cases (3.6%), 4 postoperative refractory hypertension cases (7.2%), 1 myocardial ischemia (1.8%), and 1 death (1.8%). Postoperative new anterior pituitary deficit was more common in the younger group (< 60 years old: 17.7%) than in the elderly (≥ 70 years old: 12.7%); however, there was no statistical difference.

CONCLUSIONS

Endoscopic transsphenoidal surgery for elderly patients with PAs may be associated with higher complication rates, especially secondary to early transitory complications, when compared with surgery performed in younger patients. Although the worst preoperative clinical status might be observed in this group, age alone is not associated with a worst final prognosis after endoscopic removal of nonfunctioning PAs.

Complications and death among elderly patients undergoing pituitary tumour surgery

BACKGROUND

Preoperative determinants of surgical risk in elderly patients with pituitary tumour are not fully defined. The aim of this study was to quantify operative risk for these patients.

DESIGN AND METHODS

We performed a retrospective analysis of the Nationwide Inpatient Sample (1998-2005), a database containing discharge information from a stratified, random sample of 20% of all non-federal hospitals in 37 states. Patients >65 years old who underwent pituitary tumour resection were identified by ICD-9 coding. Primary outcome was inpatient death. Other outcomes included post-operative complications, length of stay (LOS) and total charges.

RESULTS

A total of 8400 patients (53.7% male) were identified. Mean age was 72.2. Mean co-morbidity score was 5.3. A majority were white (82.0%) admitted to academic hospitals (69.5%) for elective procedures (55.7%). Inpatient mortality was 3.8%. The most common complication was fluid and electrolyte abnormalities (14.3%). Mean LOS was 8.5 days. In multivariate analysis, patients >80 years old had 30% greater odds of death, relative to 65-69 year old counterparts. Each complication increased LOS by an average of at least 4 days. These associations were statistically significant (P-values <0.05).

CONCLUSIONS

New clinically relevant risk stratification information is now available to assist clinicians in operative decision-making for elderly patients with pituitary tumour considering operative intervention.

Predictors of inpatient death and complications among postoperative elderly patients with metastatic brain tumors

OBJECTIVE

Risks of brain surgery in elderly patients with brain metastases are not well defined. This study was designed to quantify the postoperative risk for these patients after brain surgery for metastatic disease to the brain.

METHODS

We performed a retrospective analysis of the Nationwide Inpatient Sample (1998-2005). Patients aged 65 years or older who underwent tumor resection of brain metastases were identified by ICD-9 coding. Primary outcome was inpatient death. Other outcomes included systemic postoperative complications, length of stay (LOS), and total charges.

RESULTS

A total of 4,907 patients (53.6% men) were identified. Mean age was 72.1 years. Mean Charlson comorbidity score was 7.8. Inpatient mortality was 4%. The most common adverse events were pulmonary complications (3.4%). Mean length of stay was 9.2 days. Mean total charges were $57,596.39. In multivariate analysis, patients up to age 80 years had no significantly greater odds of inpatient death, relative to their 65- to 69-year-old counterparts. Each 1-point increase in Charlson score was associated with 12% increased odds of death, 0.52 days increased LOS, and $1,710.61 higher hospital charges. Postoperative pulmonary complications, stroke, or thromboembolic events increased LOS and total charges by up to 9.6 days and $57,664.42, respectively. These associations were statistically significant (P < 0.05).

CONCLUSIONS

Surgical resection of brain metastases among the elderly up to the ninth decade of life is feasible. Age older than 80 years and higher Charlson comorbidity scores were found to be important prognostic factors for inpatient outcome. Incorporating these factors into preoperative decision making may help to select appropriately those elderly candidates for neurosurgical intervention.

Transsphenoidal surgery for pituitary adenoma in elderly patients

BACKGROUND

As the population continues to age, the number of elderly patients with symptomatic pituitary tumours will continue to increase. Little information exists as to the safety of pituitary surgery in this patient population. The current study was undertaken to evaluate the presentation and perioperative risk associated with transsphenoidal surgery in patients over the age of 70.

METHODS

A retrospective chart review was undertaken for patients over the age of 70 undergoing transsphenoidal surgery at the Penn State Hershey Medical Center between 1995 and 2005.

FINDINGS

Sixty-four patients over the age of 70 were identified with an average age of 73.4 years (range 70-84). The average follow-up period was 44 months (range 14-104). Symptoms of mass effect were the presenting complaint in 72% of patients while 9% had documentation of growth on imaging studies. Twelve percent presented with a history consistent with apoplexy. Three patients (5%) presented with acromegaly. Post-operative hospital stay averaged 2.6 days (range 2-7). Eight patients had new hormonal deficits post-operatively (1 ACTH, 3 TSH, 2 ACTH/TSH, 2 vasopressin). There were no cardiopulmonary complications and no deaths within 90 days of surgery.

CONCLUSIONS

Transsphenoidal surgery can be performed in patients over the age of 70 without undo significant risks. Surgical removal of pituitary adenomas should be considered the mainstay of treatment in elderly patients in whom treatment is necessary. Patients who are medically suitable candidates should be offered surgical resection as would their younger counterparts.

Impact of age on complications and outcome in meningioma surgery

BACKGROUND

Surgery for benign brain tumors in elderly patients without severe general health problems is an acceptable practice, as results are comparable with the ones of younger patients. Nevertheless, the hypothesis that operative complications and perioperative incidents could differ between the 2 age groups should be controlled; and age-specific strategies in operative technique and perioperative care may be useful.

METHODS

Medical records of 348 patients were reviewed. Demographic data (age, sex), rate of excision, complications of the immediate postoperative period, neurological outcome, and mortality were recorded; and statistical evaluation comparing 2 age groups (19-64 and 65-84 years of age) was performed.

RESULTS

The "young" age group consisted of 240 patients, whereas the "elderly" one had 108. Tumor removal rate was not significantly different in the 2 groups. The elderly age group included significantly more "complicated cases." Regarding each complication, postoperative hematoma, infections, and deep vein thrombosis were more frequent in elderly patients, presenting various degrees of statistical significance, whereas postoperative brain edema, hydrocephalus, and cardiorespiratory incidents presented no statistically significant difference. Finally, more elderly patients presented neurological deterioration, although mortality was not significantly different.

CONCLUSIONS

Operation for intracranial meningioma in elderly patients is justified as long as detailed preoperative evaluation is performed. Planning of modified protocols including intraoperative technical aspects, careful use of steroids antibiotics, and prophylactic low molecular weight heparin, and early mobilization is necessary for optimizing operative outcome of elderly patients.

Glioblastoma in the elderly: current and future trends

Data from a prospective trial large enough to provide a reliable analysis of outcome and prognostic factors in elderly patients with glioblastoma (GBM) are not yet available in the literature. Extensive tumor removal appears to offer patients the best possible chance of a speedy neurological recovery. Adequate radiotherapy (RT) should always be given to elderly patients if they have undergone gross total debulking and have maintained a good performance status. It is, however important to bear in mind that the risk of long-term cognitive impairment may be higher in patients on high-dose RT and that a short course of accelerated RT can achieve the same survival. Rather than being ruled out on principle, chemotherapy should be considered on the basis of an accurate assessment of the factors that might compromise the individual patient's tolerance to drugs administered. Temozolomide appears to be the best available chemotherapy in this population of patients.

Brain tumors in the older person

BACKGROUND

The incidence of brain tumors is increasing rapidly, particularly in the older population. Advances in molecular biology help to explain differences in biologic behavior and response to therapy of brain tumors in the elderly compared with younger patients. The number of elderly patients who desire and receive therapy for brain tumors and are included in clinical trials is increasing.

METHODS

This article reviews the literature on the epidemiology, clinical aspects, and therapy of brain tumors, with emphasis on the older patient population.

RESULTS

The increased incidence of brain tumors in the elderly is principally due to the increasing number of people who comprise the older population. Age and performance status are important independent prognostic indicators, together with tumor histology. Surgery, radiation therapy, and chemotherapy can benefit elderly patients with brain tumors with favorable histologies, tumor location, and good performance status. The response rates to available therapies are less favorable than in younger patients, and only a small number of elderly patients are enrolled in clinical studies addressing new treatment modalities.

CONCLUSIONS

Brain tumors in the elderly have specific characteristics that determine their biologic behavior and response to therapy. There is a need for clinical studies designed for treatment of brain tumors in older patients, and requirements for rehabilitation and support systems for the elderly need to be addressed.