Optimal managements of elderly patients with glioblastoma

Neutrophil-to-lymphocyte ratio dynamics: prognostic value and potential for surveilling glioblastoma recurrence

PURPOSE

Glioblastoma (GBM) is a challenging malignancy with a poor prognosis. While the neutrophil-to-lymphocyte ratio (NLR) is reported to correlate with the prognosis, the significance of changes in the NLR and its prognostic value in GBM remain unclear. This study aims to evaluate changes in the NLR and its predictive value for GBM prognosis and recurrence.

METHODS

The cohort included 69 newly-diagnosed GBM patients undergoing a standard treatment protocol. NLR was assessed at multiple time points. The dynamic change in NLR (dNLR), defined as the NLR at the point of interest (post-CCRT or post-Stupp) divided by the preoperative NLR, also was assessed. Univariate and multivariate COX regression analyses were conducted to assess the association between the NLR, dNLR and overall survival (OS) and progression-free survival (PFS).

RESULTS

Univariate analysis revealed that age at diagnosis ≥ 70 (p = 0.019) and post-Stupp dNLR ≥ 1.3 (p = 0.006) were significantly associated with shorter OS. Significant correlations were found between pre-operative KPS ≥ 60 (p = 0.017), gross total resection (p = 0.042), post-Stupp dNLR ≥ 1.3 (p = 0.043) and PFS. Multivariate analysis showed age at diagnosis ≥ 70, pre-operative KPS ≥ 60, post-Stupp NLR ≥ 5 and dNLR ≥ 1.3 were significantly associated with a shorter OS. Significant correlation was found between pre-operative KPS ≥ 60 and PFS.

CONCLUSION

This study revealed that post-Stupp NLR ≥ 5 and dNLR ≥ 1.3 correlated significantly with a worse glioblastoma prognosis in OS, and dNLR might be more reliable. These two parameters are potentially surveilling markers for glioblastoma recurrence, however further studies are warranted.

Clinical Predictors of Overall Survival in Very Elderly Patients With Glioblastoma: A National Cancer Database Multivariable Analysis

BACKGROUND AND OBJECTIVES

Surgery for the very elderly is a progressively important paradigm as life expectancy continues to rise. Patients with glioblastoma multiforme often undergo surgery, radiotherapy (RT), and chemotherapy (CT) to prolong overall survival (OS). However, the efficacy of these treatment modalities in patients aged 80 years and older has yet to be fully assessed in the literature.

METHODS

The National Cancer Database was used to retrospectively identify patients aged 65 years and older with glioblastoma multiforme (1989-2016). All available patient demographic characteristics, disease characteristics, and clinical outcomes were collected. To study OS, bivariable survival models were created using Kaplan-Meier estimates. A Cox proportional-hazards model was used for final adjusted analyses.

RESULTS

A total of 578 very elderly patients (aged 80 years and older) and 2836 elderly patients (aged 65-79 years) were identified. Compared with elderly patients, very elderly patients were more likely to have Medicare (odds ratio [OR] 1.899 [95% CI: 1.417-2.544], P < .001) while less likely to have private insurance status (OR 0.544 [95% CI: 0.401-0.739], P < .001). In addition, very elderly patients were more likely to travel the least distance for treatment and have multiple tumors ( P < .001). When controlling for demographic and disease characteristics, very elderly patients were less likely to receive gross total resection (GTR) (OR 0.822 [95% CI: 0.681-0.991], P < .041), RT (OR 0.385 [95% CI: 0.319-0.466], P < .001), or postoperative CT (OR 0.298 [95% CI: 0.219-0.359], P < .001) relative to elderly counterparts. Within very elderly patients, GTR, RT, and CT all independently and significantly predicted improved OS ( P < .001 for all). These predictive models were deployed in an online calculator ( https://spine.shinyapps.io/GBM_elderly ).

CONCLUSION

Very elderly patients are less likely to receive GTR, RT, or CT when compared with elderly counterparts despite use of these therapies conferring improved OS. Selected very elderly patients may benefit from more aggressive attempts at surgical and adjuvant treatment.

The Karnofsky Performance Status at Discharge Is a Prognostic Indicator of Life Expectancy in Patients With Glioblastoma

Background Glioblastoma (GBM) is the most frequent invasive brain tumor and a rapidly progressive disease with a poor prognosis that predominantly affects middle-aged and older adults. The relationship between daily functioning and prognosis in patients with GBM will become more important as advances in multimodality treatment are expected to increase the number of long-term survivors. Methods Sixty-seven patients were initially diagnosed with GBM at our hospital between December 2013 and December 2022. All patients were divided into two groups: those who survived for one year or longer from the date of discharge (Group A) and those who died within one year from the date of discharge (Group B). Muscle strength, nutritional status, and Karnofsky Performance Status (KPS) were examined upon admission (p1), post-surgery (p2), and discharge (p3), and their relationships with prognosis were investigated. Results Group A was significantly younger than Group B, with a significant difference in the total radiation dose. There were no significant differences in the anatomical tumor location, whether the tumor occurred on the left or right side, or tumor size. KPS at discharge (p3) and the degree of improvement in the KPS between p1 and p3 were associated with a good prognosis. Conclusions The KPS varies throughout the treatment. When considering the KPS as a prognostic indicator, the KPS at discharge is the most important, given the structure of the disability and the course of treatment for GBM.

Diagnostic and Prognostic Value of Circulating DNA Fragments in Glioblastoma Multiforme Patients

Novel blood-circulating molecules, as potential biomarkers for glioblastoma multiforme (GBM) diagnosis and monitoring, are attracting particular attention due to limitations of imaging modalities and invasive tissue biopsy procedures. This study aims to assess the diagnostic and prognostic values of circulating cell-free DNA (cfDNA) in relation to inflammatory status in GBM patients and to determine the concentration and average size of DNA fragments typical of tumour-derived DNA fractions. Preoperative plasma samples from 40 patients (GBM 65.0 ± 11.3 years) and 40 healthy controls (HC 70.4 ± 5.4 years) were compared. The cfDNA concentrations and lengths were measured using the electrophoresis platform, and inflammatory indices (NLR, PLR, LMR, and SII) were calculated from complete blood cell analysis. More fragmented cfDNA and 4-fold higher 50-700 bp cfDNA concentrations were detected in GBM patients than in healthy controls. The average cfDNA size in the GBM group was significantly longer (median 336 bp) than in the HC group (median 271 bp). Optimal threshold values were 1265 pg/μL for 50-700 bp cfDNA (AUC = 0.857) and 290 bp for average cfDNA size (AUC = 0.814). A Kaplan-Meier survival curves analysis also demonstrated a higher mortality risk in the GBM group with a cut-off >303 bp cfDNA. This study is the first to have revealed glioblastoma association with high levels of cfDNA > 1000 pg/μL of 50-700 bp in length, which can be aggravated by immunoinflammatory reactivity.