Coincidence vs Cause: Cure in Three Glioblastoma Patients Treated with Brachytherapy

Ten-year survival in glioblastoma. A systematic review

Glioblastoma (GBM) is among the most deadly neoplasms associated with one of the worst 5-year overall survival (OS) rates among all human cancers. The aim of this systematic review is to present all cases with OS of a decade or more and to perform a descriptive analysis of the group. This systematic review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. A comprehensive search for relevant articles was performed on PubMed, Embase and Google Scholar for a period until June 10, 2016, using the following search words: glioblastoma multiforme, glioblastoma, GBM, long-term survival/survivors. Reports containing cases with the long-term survival of 10 years or longer were included in the review. The search produced 36 studies with 162 cases published in the years 1950-2014. The rate of long survivors in the cohort studied was established 0.76%. Mean age at diagnosis, OS and PFS were 31.1 ± 11.1, 15.9 ± 6.3, 11.9 ± 5.6 years respectively. Total and subtotal resections were found in 82 and 58 patients respectively. Nine cases received a biopsy alone. No statistical differences were found in a comparison of PFS, OS and age between total and subtotal resection groups. A regression analysis showed a significant correlation between PFS and OS, with an inverse relationship stated between age at diagnosis and OS. The 10-year survival rate in the cohort studied with GBM was estimated 0.71%. OS was positively correlated with the length of PFS and inversely related with age at diagnosis.

Dissociation of Early and Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage

Background and Purpose—

Cerebral infarction after aneurysmal subarachnoid hemorrhage is a significant cause of substantial morbidity and mortality. Because early and delayed cerebral infarction after aneurysmal subarachnoid hemorrhage may be mediated by different processes, we evaluated whether aneurysm-securing methods contributed to infarcts and whether long-term outcomes differ between early and delayed infarcts.

Methods—

A post hoc analysis of the CONSCIOUS-1 study (Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage) was performed. Using multivariate logistic regression analysis and propensity matching, independent clinical risk factors associated with infarctions were identified, and the contribution of cerebral infarcts to long-term outcomes was evaluated.

Results—

Within the cohort of 413 subjects, early infarcts were present in 76 subjects (18%), whereas delayed infarcts occurred in 79 subjects (19%), and 36 subjects (9%) had new infarctions that were present on both early and delayed imaging. Propensity score matching revealed a significantly higher proportion of early infarcts after clipping (odds ratio, 4.62; 95% confidence interval, 1.99–11.57; P =0.00012). Multivariate logistic regressions identified clipping as an independent risk factor for early cerebral infarction (odds ratio, 0.26; 95% confidence interval, 0.15–0.48; P <0.001), and angiographic vasospasm was an independent risk factor for delayed cerebral infarction (odds ratio, 1.79; 95% confidence interval, 1.03–3.13; P =0.039). Early infarcts were a significant independent risk factor for poor long-term outcomes at 3 months (odds ratio, 2.34; 95% confidence interval, 1.18–4.67; P =0.015).

Conclusions—

Clipping is an independent risk factor for the development of early cerebral infarcts, whereas delayed cerebral infarcts are associated with angiographic vasospasm. Early cerebral infarcts are stronger predictors of worse outcome than delayed infarction.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00111085.

Primary Endoscopic Transnasal Transsphenoidal Surgery for Magnetic Resonance Image-Positive Cushing Disease: Outcomes of a Series over 14 Years

BACKGROUND

There are scant data of endoscopic transsphenoidal surgery (ETS) with adjuvant therapies of Cushing disease (CD).

OBJECTIVE

To report the remission rate, secondary management, and outcomes of a series of CD patients.

METHODS

Patients with CD with magnetic resonance imaging (MRI)-positive adenoma who underwent ETS as the first and primary treatment were included. The diagnostic criteria were a combination of 24-hour urine-free cortisol, elevated serum cortisol levels, or other tests (e.g., inferior petrosal sinus sampling). All clinical and laboratory evaluations and radiological examinations were reviewed.

RESULTS

Forty consecutive CD patients, with an average age of 41.0 years, were analyzed with a mean follow-up of 40.2 ± 29.6 months. These included 22 patients with microadenoma and 18 with macroadenoma, including 9 cavernous invasions. The overall remission rate of CD after ETS was 72.5% throughout the entire follow-up. Patients with microadenoma or noninvasive macroadenoma had a higher remission rate than those who had macroadenoma with cavernous sinus invasion (81.8% or 77.8% vs. 44.4%, P = 0.02). After ETS, the patients who had adrenocorticotropic hormone-positive adenoma had a higher remission rate than those who had not (76.5% vs. 50%, P = 0.03). In the 11 patients who had persistent/recurrent CD after the first ETS, 1 underwent secondary ETS, 8 received gamma-knife radiosurgery (GKRS), and 2 underwent both. At the study end point, two (5%) of these CD patients had persistent CD and were under the medication of ketoconazole.

CONCLUSION

For MRI-positive CD patients, primary (i.e., the first) ETS yielded an overall remission rate of 72.5%. Adjuvant therapies, including secondary ETS, GKRS, or both, yielded an ultimate remission rate of 95%.

Prognostic factors for long-term survival after glioblastoma

Long-term survivors of glioblastoma (GB) are rare. Several variables besides tumor size and location determine a patient's survival chances: age at diagnosis, where younger patients often receive more aggressive treatment that is multimodal; functional status, which has a significant negative correlation with age; and histologic and genetic markers.

PERSISTENT OUTPATIENT HYPERGLYCEMIA IS INDEPENDENTLY ASSOCIATED WITH DECREASED SURVIVAL AFTER PRIMARY RESECTION OF MALIGNANT BRAIN ASTROCYTOMAS

OBJECTIVE

Patients with malignant brain astrocytomas are at high risk for developing hyperglycemia secondary to frequent corticosteroid administration. Several clinical studies have shown that hyperglycemia is associated with poor outcome in multiple disease states. Furthermore, hyperglycemia augments in vitro astrocytoma growth, whereas hypoglycemia attenuates in vitro astrocytoma cell growth. We hypothesized that persistent hyperglycemic states in the outpatient setting may serve as a prognostic marker of decreased survival in patients with malignant brain astrocytomas.

METHODS

We retrospectively reviewed 367 cases of craniotomy for malignant brain astrocytomas (World Health Organization Grade III or IV). Persistent hyperglycemia was defined as serum glucose greater than 180 mg/dL occurring three or more times between 1 and 3 months postoperatively. Isolated hyperglycemia was defined as an isolated occurrence of serum glucose greater than 180 mg/dL. The independent association of outpatient glucose levels and recorded clinical and treatment variables with overall survival was assessed via multivariate proportional-hazards regression analysis.

RESULTS

A total of 367 craniotomies (209 primary, 158 secondary) were performed for malignant brain astrocytomas (glioblastoma multiforme, 297; anaplastic astrocytomas, 70); 68 (19%) and 28 (8%) of the patients experienced isolated or persistent outpatient hyperglycemia, respectively. Patients experiencing persistent hyperglycemia were older (59 ± 13 versus 51 ± 14 yr), were diabetic more frequently (7 [25%] versus 10 [3%]), continued to receive corticosteroids more frequently (21 [75%] versus 35 [10%]); and received temozolomide less often (4 [14%] versus 116 [34%]). Adjusting for intergroup differences and variables associated with survival in this model, age (P = 0.001), Karnofsky Performance Scale score (P = 0.001), tumor grade (P = 0.001), primary versus secondary resection (P = 0.008), temozolomide (P = 0.007), subsequent resection (P = 0.07), and continued outpatient dexamethasone therapy, persistent outpatient hyperglycemia (relative risk, 1.79; 95% confidence interval, 1.05–3.05, P = 0.03) remained independently associated with decreased survival. Median survival for persistently hyperglycemic versus normal-glycemic cohorts was 5 and 11 months, respectively.

CONCLUSION

In our experience, persistent outpatient hyperglycemia was associated with decreased survival in patients undergoing surgical resection for malignant astro- cytomas and was independent of the degree of disability, tumor grade, diabetes, prolonged dexamethasone use, or subsequent treatment modalities. Increased glucose control is warranted in this patient population and may contribute to improved outcomes in the treatment of malignant brain astrocytomas.