Recursive partitioning analysis of prognostic factors in WHO grade III glioma patients treated with radiotherapy or radiotherapy plus chemotherapy

Postoperative prognostic nomogram for adult grade II/III astrocytoma in the Chinese Han population

Background

Prognostic models of glioma have been the focus of many studies. However, most of them are based on Western populations. Additionally, because of the complexity of healthcare data in China, it is important to select a suitable model based on existing clinical data. This study aimed to develop and independently validate a nomogram for predicting the overall survival (OS) with newly diagnosed grade II/III astrocytoma after surgery.

Methods

Data of 472 patients with astrocytoma (grades II-III) were collected from Qilu Hospital as training cohort while data of 250 participants from Linyi People's Hospital were collected as validation cohort. Cox proportional hazards model was used to construct the nomogram and individually predicted 1-, 3-, and 5-year survival probabilities. Calibration ability, and discrimination ability were analyzed in both training and validation cohort.

Results

Overall survival was negatively associated with histopathology, age, subtotal resection, multiple tumors, lower KPS and midline tumors. Internal validation and external validation showed good discrimination (The C-index for 1-, 3-, and 5-year survival were 0.791, 0.748, 0.733 in internal validation and 0.754, 0.735, 0.730 in external validation, respectively). The calibration curves showed good agreement between the predicted and actual 1-, 3-, and 5-year OS rates.

Conclusion

This is the first nomogram study that integrates common clinicopathological factors to provide an individual probabilistic prognosis prediction for Chinese Han patients with astrocytoma (grades II-III). This model can serve as an easy-to-use tool to advise patients and establish optimized surveillance approaches after surgery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13755-023-00223-0.

Four-protein model for predicting prognostic risk of lung cancer

Patients with lung cancer at the same stage may have markedly different overall outcome and a lack of specific biomarker to predict lung cancer outcome. Heat-shock protein 90 β (HSP90β) is overexpressed in various tumor cells. In this study, the ELISA results of HSP90β combined with CEA, CA125, and CYFRA21-1 were used to construct a recursive partitioning decision tree model to establish a four-protein diagnostic model and predict the survival of patients with lung cancer. Survival analysis showed that the recursive partitioning decision tree could distinguish the prognosis between high- and low-risk groups. Results suggested that the joint detection of HSP90β, CEA, CA125, and CYFRA21-1 in the peripheral blood of patients with lung cancer is plausible for early diagnosis and prognosis prediction of lung cancer.

Prediction of Gastric Gastrointestinal Stromal Tumors before Operation: A Retrospective Analysis of Gastric Subepithelial Tumors

Gastrointestinal stromal tumors (GISTs), leiomyomas, and schwannomas are the most common gastric subepithelial tumors (GSETs) with similar endoscopic findings. Preoperative prediction of GSETs is difficult. This study analyzed and predicted GSET diagnosis through a retrospective review of 395 patients who underwent surgical resection of GISTs, leiomyomas, and schwannomas measuring 2–10 cm. GSETs were divided by size (group 2–5, >2 and ≤5 cm; group 5–10, >5 and ≤10 cm) for analysis. Demographics, clinical symptoms, and images were analyzed. A recursive partitioning analysis (RPA) was used to identify optimal classifications for specific GSET diagnoses. GIST patients were relatively older than other patients. Both groups had higher proportions of UGI bleeding, lower hemoglobin (Hb) levels, and a higher ratio of necrosis on their computed tomography (CT) scans. The RPA tree showed that (a) age ≤ 55, Hb ≥ 10.7, and CT necrosis; (b) age ≤ 55 and Hb < 10.7; (c) age >55 and Hb < 12.9; and (d) age >55 and CT hetero-/homogeneity can predict high GIST risk in group 2–5. Positive or negative CT necrosis, with age >55, can predict high GIST risk in group 5–10. GIST patients were older and presented with low Hb levels and tumor necrosis. In RPA, the accuracy reached 85% and 89% in groups 2–5 and 5–10, respectively.

Radiotherapy of Grade III Gliomas: Identification of Clinical Prognostic Factors for Local Tumor Control and Survival

BACKGROUND/AIM

The prognoses of patients with grade III gliomas require improvement, which may be achieved with personalized care. We aimed to identify prognostic factors to facilitate the process of treatment personalization.

PATIENTS AND METHODS

Eight factors were analyzed for local tumor control and survival in 44 patients irradiated for grade III glioma. These factors included location and size of glioma, number of glioma sites, performance status, gender, age, neurosurgical intervention and chemotherapy.

RESULTS

In the Cox regression analyses, frontal location (risk ratio=4.41, p=0.048) and unifocal glioma (risk ratio=4.65, p=0.034) were associated with improved local control, and unifocal glioma with improved survival (risk ratio=6.12, p=0.033). In addition, trends for better survival were observed for frontal location (p=0.093), age ≤49 years (p=0.070), upfront resection (p=0.099) and chemotherapy (p=0.066) on univariate analyses.

CONCLUSION

Independent predictors of local tumor control and survival were identified that can be helpful for personalizing treatment and designing clinical trials.

Race influences survival in glioblastoma patients with KPS ≥ 80 and associates with genetic markers of retinoic acid metabolism

PURPOSE

To study whether the clinical outcome and molecular biology of gliomas in African-American patients fundamentally differ from those occurring in Whites.

METHODS

The clinical information and molecular profiles (including gene expression array, non-silent somatic mutation, DNA methylation and protein expression) were downloaded from The Cancer genome atlas (TCGA). Electronic medical records were abstracted from Northwestern Medicine Enterprise Data Warehouse (NMEDW) for analysis as well. Grade II-IV Glioma patients were all included.

RESULTS

931 Whites and 64 African-American glioma patients from TCGA were analyzed. African-American with Karnofsky performance score (KPS) ≥ 80 have significantly lower risk of death than similar white Grade IV Glioblastoma (GBM) patients [HR (95% CI) = 0.47 (0.23, 0.98), P = 0.0444, C-index = 0.68]. Therefore, we further compared gene expression profiles between African-American GBM patients and Whites with KPS ≥ 80. Extrapolation of genes significantly associated with increased African-American patient survival revealed a set of 13 genes with a possible role in this association, including elevated expression of genes previously identified as increased in African-American breast and colon cancer patients (e.g. CRYBB2). Furthermore, gene set enrichment analysis revealed retinoic acid (RA) metabolism as a pathway significantly upregulated in African-American GBM patients who survive longer than Whites (Z-score = - 2.10, Adjusted P-value = 0.0449).

CONCLUSIONS

African Americans have prolonged survival with glioma which is influenced only by initial KPS score. Genes previously associated with both racial disparities in cancer and pathways associated with RA metabolism may play an important role in glioma etiology. In the future exploration of these genes and pathways may inform novel therapies for this incurable disease.

Recursive partitioning analysis of lymph node ratio in breast cancer patients

Lymph node ratio (LNR) is a powerful prognostic factor for breast cancer. We conducted a recursive partitioning analysis (RPA) of the LNR to identify the prognostic risk groups in breast cancer patients. Records of newly diagnosed breast cancer patients between 2002 and 2006 were searched in the Taiwan Cancer Database. The end of follow-up was December 31, 2009. We excluded patients with distant metastases, inflammatory breast cancer, survival <1 month, no mastectomy, or missing lymph node status. Primary outcome was 5-year overall survival (OS). For univariate significant predictors, RPA were used to determine the risk groups. Among the 11,349 eligible patients, we identified 4 prognostic factors (including LNR) for survival, resulting in 8 terminal nodes. The LNR cutoffs were 0.038, 0.259, and 0.738, which divided LNR into 4 categories: very low (LNR ≤ 0.038), low (0.038 < LNR ≤ 0.259), moderate (0.259 < LNR ≤ 0.738), and high (0.738 < LNR). Then, 4 risk groups were determined as follows: Class 1 (very low risk, 8,265 patients), Class 2 (low risk, 1,901 patients), Class 3 (moderate risk, 274 patients), and Class 4 (high risk, 900 patients). The 5-year OS for Class 1, 2, 3, and 4 were 93.2%, 83.1%, 72.3%, and 56.9%, respectively (P< 0.001). The hazard ratio of death was 2.70, 4.52, and 8.59 (95% confidence interval 2.32-3.13, 3.49-5.86, and 7.48-9.88, respectively) times for Class 2, 3, and 4 compared with Class 1 (P < 0.001). In conclusion, we identified the optimal cutoff LNR values based on RPA and determined the related risk groups, which successfully predict 5-year OS in breast cancer patients.

KPNA2 predicts long term survival in patients with anaplastic oligoastrocytomas

The family of karyopherins comprises importins and exportins which are both involved in nucleocytoplasmic shuttling. Increased levels of karyopherin a2/importin 1 (KPNA2) and chromosome region maintenance protein 1/exportin 1 (CRM1) have been associated with poorer prognosis in patients with infiltrative astrocytomas. Isocitrate dehydrogenase 1 gene (IDH1) R132H mutation status was also recently identified as a prognostic factor for malignant gliomas. We evaluated KPNA2 and CRM1, as well as the IDH1 mutation status, as possible novel biomarkers for World Health Organization grade III anaplastic oligoastrocytomas (AOA). We analyzed nuclear expression of KPNA2 by immunohistochemistry in 72 primary anaplastic gliomas (29 AOA, 24 anaplastic astrocytomas, 19 anaplastic oligodendrogliomas). The IDH1 mutation status was also determined in patients with anaplastic astrocytomas and AOA, and AOA patients were additionally evaluated for CRM1 nuclear expression. Long term survivors (LTS; >8 years) with AOA showed lower KPNA2 expression levels compared to non-LTS (p=0.005). KPNA2 expression (⩾ 5% versus <5%, 1-<5%, median) was found to correlate inversely with overall survival (OS) and progression-free survival (PFS) in our overall series as well as in the AOA group (anaplastic gliomas: OS p=0.017; PFS p=0.033; AOA: OS p=0.017, PFS p=0.040). Mutant IDH1-R132H was detected in 69% of the AOA cohort; a combination of KPNA2 low expression and mutant IDH1-R132H was only seen in LTS (p=0.050). No differences between the histological subtypes were observed in terms of KPNA2 expression and IDH1-R132H mutation status. To our knowledge this is the first time it has been shown that KPNA2 expression may have potential as a prognostic biomarker for AOA as well.

1p/19q codeletion and IDH1/2 mutation identified a subtype of anaplastic oligoastrocytomas with prognosis as favorable as anaplastic oligodendrogliomas

BACKGROUND

Anaplastic astrocytoma (AA), anaplastic oligoastrocytoma (AOA), and anaplastic oligodendroglioma (AO) are the major histological subtypes of World Health Organization grade III gliomas. More evidence suggests that AOA is unlikely to be a distinct entity, and re-evaluation of this issue has been recommended. In this study, we divided AOA into 2 subgroups, according to molecular biomarkers, and compared the survivals between them.

METHODS

One hundred nine patients with histological diagnosis of anaplastic gliomas enrolled in the study. Molecular biomarkers evaluated included 1p/19q codeletion and IDH1/2 mutation. Kaplan-Meier plots were compared by log-rank method.

RESULTS

There was no significant difference between AA and AOA with regard to the frequencies of biomarkers and survival plots. According to the status of biomarkers, AOA was classified into 2 subgroups (AOA1 and AOA2), for which Kaplan-Meier plots were significantly different (P = .001 for both progression-free survival [PFS] and overall survival [OS]). AOA1 with 1p/19q codeletion and/or IDH1/2 mutation showed similar Kaplan-Meier plots with AO (P = .169 for PFS and P = .523 for OS). AOA2 without either biomarker showed similar Kaplan-Meier plots with AA (P = .369 for PFS and P = .271 for OS). In addition, patients with AO and AOA1 had significantly longer PFS and OS than did patients with AA and AOA2 (P < .001 for both PFS and OS).

CONCLUSIONS

AOA is a heterogeneous group and can be divided into 2 subgroups with significantly different prognoses according to the status of 1p/19q and IDH1/2. This will be helpful in estimating patients' prognosis and guiding reasonable therapy for patients with anaplastic gliomas.

The prognosis of anaplastic astrocytoma with radiologic necrosis mimicking glioblastoma

Anaplastic astrocytoma (AA) sometimes shows a rapid poor course like glioblastoma. In this study, we investigated the prognosis of AA with radiologic necrosis which is the representative radiologic finding of glioblastoma. From 1995 to 2010, we operated on 26 patients who were confirmed to have AA. The male:female ratio was 13:13, and the median age was 47.23 years. The mean follow-up period was 3 years. We analyzed the prognostic significance of radiologic necrosis with age, sex, KPS, tumour location, radiologic findings, extent of removal and radiation therapy oncology group recursive partitioning analysis (RTOG-RPA) classification. The median progression-free survival (PFS) was 0.5 (± 0.17) years and the median overall survival (OS) was 1.6 (± 0.40) years. In univariate analysis, the clinical variables of younger age (p = 0.030) and RTOG-RPA class III (p = 0.043) correlated with longer PFS, and KPS (p = 0.038), radiologic necrosis (p = 0.013) and the extent of removal (p = 0.041) correlated with OS. The median OS was 1.0 (± 0.21) year in AA with radiologic necrosis compared to AA without radiologic necrosis, which showed 2.1 (± 0.29) years median OS. On multivariate analysis, there was no statistically significant prognostic factor. However, Cox's regression model revealed that gross total removal was associated with a longer OS (hazard ratio = 0.136; 95% CI, 0.018 to 1.046; p = 0.055) compared to partial removal or biopsy. Gross total resection was associated with good prognosis, and AA with radiologic necrosis had poor prognosis like glioblastoma.

Radiotherapy and temozolomide in anaplastic astrocytoma: a retrospective multicenter study by the Central Nervous System Study Group of AIRO (Italian Association of Radiation Oncology)

Although the evidence for the benefit of adding temozolomide (TMZ) to radiotherapy (RT) is limited to glioblastoma patients, there is currently a trend toward treating anaplastic astrocytomas (AAs) with combined RT + TMZ. The aim of the present study was to describe the patterns of care of patients affected by AA and, particularly, to compare the outcome of patients treated exclusively with RT with those treated with RT + TMZ. Data of 295 newly diagnosed AAs treated with postoperative RT ± TMZ in the period from 2002 to 2007 were reviewed. More than 75% of patients underwent a surgical removal. All the patients had postoperative RT; 86.1% of them were treated with 3D-conformal RT (3D-CRT). Sixty-seven percent of the entire group received postoperative chemotherapy with TMZ (n = 198). One-hundred sixty-six patients received both concomitant and sequential TMZ. Prescription of postoperative TMZ increased in the most recent period (2005-2007). One- and 4-year survival rates were 70.2% and 28.6%, respectively. No statistically significant improvement in survival was observed with the addition of TMZ to RT (P = .59). Multivariate analysis showed the statistical significance of age, presence of seizures, Recursive Partitioning Analysis classes I-III, extent of surgical removal, and 3D-CRT. Changes in the care of AA over the past years are documented. Currently there is not evidence to justify the addition of TMZ to postoperative RT for patients with newly diagnosed AA outside a clinical trial. Results of prospective and randomized trials are needed.

The impact of extent of resection and histological subtype on the outcome of adult patients with high-grade gliomas

OBJECTIVE

We reviewed the relationship between extent of resection and survival of patients with high-grade gliomas with special consideration of an oligodendroglial component.

METHODS

A retrospective review was performed on 160 adult patients with histological diagnosis of high-grade gliomas since 2000. All histological slides were categorized as high-grade astrocytomas or oligodendroglial tumors. Extent of resection was assessed by early post-operative magnetic resonance imaging and classified as complete resection, incomplete resection and biopsy. Measured outcomes were overall survival and progression-free survival. The independent association of extent of resection and survival was analyzed by the multivariate proportional hazard model adjusting for prognostic factors.

RESULTS

The lesions were classified as high-grade astrocytomas in 93 patients and high-grade oligodendroglial tumors in 67 patients. In high-grade astrocytomas, the median survival after complete resection (n = 36), incomplete resection (n = 36) and biopsy (n = 21) was 23.4, 15.3 and 12.6 months, respectively. Complete resection was independently associated with increased overall survival (P < 0.001) and progression-free survival (P = 0.002) compared with incomplete resection, while incomplete resection was not associated with survival benefit compared with biopsy by multivariate analysis. On the other hand, in high-grade oligodendroglial tumors, the majority of patients were still alive and there is no significant difference in the survival between complete resection (n = 24) and incomplete resection (n = 33), while even incomplete resection had a significantly longer overall survival (P < 0.001) and progression-free survival (P = 0.006) compared with biopsy (n = 10).

CONCLUSIONS

Maximal cytoreduction improves the survival of high-grade gliomas, although our data indicated that the impact of extent of resection in high-grade astrocytomas is different from that in high-grade oligodendroglial tumors.

Risk groups defined by Recursive Partitioning Analysis of patients with colorectal adenocarcinoma treated with colorectal resection

BACKGROUND

To define different prognostic groups of surgical colorectal adenocarcinoma patients derived from recursive partitioning analysis (RPA).

METHODS

Ten thousand four hundred ninety four patients with colorectal adenocarcinoma underwent colorectal resection from Taiwan Cancer Database during 2003 to 2005 were included in this study. Exclusion criteria included those patients with stage IV disease or without number information of lymph nodes. For the definition of risk groups, the method of classification and regression tree was performed. Main primary outcome was 5-year cancer-specific survival.

RESULTS

We identified six prognostic factors for cancer-specific survival, resulting in seven terminal nodes. Four risk groups were defined as following: Group 1 (mild risk, 1,698 patients), Group 2 (moderate risk, 3,129 patients), Group 3 (high risk, 4,605 patients) and Group 4 (very high risk, 1,062 patients). The 5-year cancer-specific survival for Group 1, 2, 3, and 4 was 86.6%, 62.7%, 55.9%, and 36.6%, respectively (p < 0.001). Hazard ratio of death was 2.13, 5.52 and 10.56 (95% confidence interval 1.74-2.60, 4.58-6.66 and 8.66-12.9, respectively) times for Group 2, 3, and 4 as compared to Group 1. The predictive capability of these grouping was also similar in terms of overall and progression-free survival.

CONCLUSION

The use of RPA offered an alternative grouping method that could predict the survival of patients who underwent surgery for colorectal adenocarcinoma.

Serum YKL-40 following resection for cerebral glioblastoma

The lack of serum biomarkers for assessing the prognosis of patients with cerebral glioblastoma multiforme (GBM) prompted the present study in order to evaluate the significance of serum YKL-40 values in patients operated on for glioblastoma. An homogeneous population of 60 patients who underwent surgical removal of GBM underwent a standard treatment (surgery, radiotherapy, chemotherapy in the same schedule) and standard radiological monitoring (same MRI sequences at pre-defined stages). Serum YKL-40 levels (Quidel Corporation, San Diego, CA) were evaluated after dividing patients into two groups on the basis of the extent of resection (total or sub-total) according to the MRI results obtained within 48 h following surgery. YKL-40 serum values, significantly higher in GBM patients than in healthy subjects, were also higher among patients who had undergone subtotal resection than in patients who underwent extensive resection. The effect of YKL-40 on overall survival was analyzed by comparing the change in marker concentration occurring in the first postoperative week with the baseline value. A significant (P = 0.04) hazards ratio of 1.97 was found at multivariate analysis. A significant association with shorter outcome (median survival time, 76 days) was found in patients whose postoperative YKL-40 concentration increases higher than, or equal to, 100%; a 50% increase can still be considered a negative prognostic index. The evaluation of the biochemical marker YKL-40 might provide earlier and additional information to that obtained using traditional factors and be a further aid in establishing the prognosis of GBM patients who have undergone surgery.