Extent of resection and survival outcomes of geriatric patients with glioblastoma: Is there benefit from aggressive surgery?

Lopez‐Rivera, Victor; Dono, Antonio; Lewis, Cole T.; Chandra, Ankush; Abdelkhaleq, Rania; Sheth, Sunil A; Ballester, Leomar Y.; Esquenazi, Yoshua

doi:10.1016/j.clineuro.2021.106474

Cited by 17 publications

(14 citation statements)

References 25 publications

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“…Additionally, preexisting comorbidities may influence neurosurgical decision making to withhold elderly patients from aggressive resections with the aim of GTR [ 40 ]. However, recent studies showed that complete GBM resection has the greatest benefit for survival among all age subgroups [ 41 , 42 ].…”

Section: Discussionmentioning

confidence: 99%

Efficacy, Outcome, and Safety of Elderly Patients with Glioblastoma in the 5-ALA Era: Single Center Experience of More Than 10 Years

Kiesel

Wadiura

Mischkulnig

et al. 2021

Cancers

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Background: In the next decades, the incidence of patients with glioblastoma (GBM) will increase due to the growth of the elderly population. Fluorescence-guided resection using 5-aminolevulinic acid (5-ALA) is widely applied to achieve maximal safe resection of GBM and is identified as a novel intraoperative marker for diagnostic tissue during biopsies. However, detailed analyses of the use of 5-ALA in resections as well as biopsies in a large elderly cohort are still missing. The aim of this study was thus to investigate the efficacy, outcome, and safety of surgically- treated GBM in the 5-ALA era in a large elderly cohort. Methods: All GBM patients aged 65 years or older who underwent neurosurgical intervention between 2007 and 2019 were included. Data on 5-ALA application, intraoperative fluorescence status, and 5-ALA-related side effects were derived from our databank. In the case of resection, the tumor resectability and the extent of resection were determined. Potential prognostic parameters relevant for overall survival were analyzed. Results: 272 GBM patients with a median age of 71 years were included. Intraoperative 5-ALA fluorescence was applied in most neurosurgical procedures (n = 255/272, 88%) and visible fluorescence was detected in most cases (n = 252/255, 99%). In biopsies, 5-ALA was capable of visualizing tumor tissue by visible fluorescence in all but one case (n = 91/92, 99%). 5-ALA administration did not result in any severe side effects. Regarding patient outcome, smaller preoperative tumor volume (<22.75 cm3), gross total resection, single lesions, improved postoperative neurological status, and concomitant radio-chemotherapy showed a significantly longer overall survival. Conclusions: Our data of this large elderly cohort demonstrate the clinical utility and safety of 5-ALA fluorescence in GBM for improved tumor visualization in both resections as well as biopsies. Therefore, we recommend the use of 5-ALA not only in resections, but also in open/stereotactic biopsies to optimize the neurosurgical management of elderly GBM patients.

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Section: Discussionmentioning

confidence: 99%

Efficacy, Outcome, and Safety of Elderly Patients with Glioblastoma in the 5-ALA Era: Single Center Experience of More Than 10 Years

Kiesel

Wadiura

Mischkulnig

et al. 2021

Cancers

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“…The reported prognostic factors for GBM-e did not differ from those reported for younger patients. The extent of resection stands as a major prognostic factor for GBM-e [ 12 18 19 20 21 ]. Supratotal (hazard ratio [HR] 0.65; p <0.0001) and gross total resection (HR 0.61; p <0.0001) were shown to significantly lower the risk of death in GBM-e aged ≥65 years compared to biopsy or local excision, which was a consistent finding across all age groups, except for GBM-e aged ≥90 years, based on data from the Surveillance, Epidemiology, and End Results Program [ 18 ].…”

Section: Prognostic Factors In Elderly Patients With Newly Diagnosed Gbmmentioning

confidence: 99%

“…The extent of resection stands as a major prognostic factor for GBM-e [ 12 18 19 20 21 ]. Supratotal (hazard ratio [HR] 0.65; p <0.0001) and gross total resection (HR 0.61; p <0.0001) were shown to significantly lower the risk of death in GBM-e aged ≥65 years compared to biopsy or local excision, which was a consistent finding across all age groups, except for GBM-e aged ≥90 years, based on data from the Surveillance, Epidemiology, and End Results Program [ 18 ]. In a recent meta-analysis involving 13 retrospective studies, gross total resection significantly improved OS in GBM-e compared with subtotal resection (HR 0.70; p <0.001) [ 19 ].…”

Section: Prognostic Factors In Elderly Patients With Newly Diagnosed Gbmmentioning

confidence: 99%

Radiotherapy for Newly Diagnosed Glioblastoma in the Elderly: What Is the Standard?

Wee

2022

Brain Tumor Res Treat

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Nearly half of the patients with newly diagnosed glioblastomas are aged ≥65 years. Unfortunately, these elderly patients with glioblastoma (GBM-e) demonstrate detrimental survival. However, the optimal treatment for GBM-e after surgery remains controversial. Conventionally fractionated radiotherapy (CFRT) of 60 Gy, hypofractionated radiotherapy (HFRT), temozolomide (TMZ), or a combination of these treatments with or without tumor treating fields can be considered. Although evidence has indicated a non-inferiority of HFRT compared to CFRT in GBM-e treated with radiotherapy (RT) alone throughout the past, the optimal RT scheme (CFRT vs. HFRT), when combined with TMZ, has never been investigated in a prospective randomized fashion for GBM-e patients suitable for radiochemotherapy. Several other issues make the treatment of GBM-e even more challenging. In this review, current evidence regarding RT in GBM-e, as well as issues that need to be addressed, is discussed.

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“…Elderly high-grade glioma patients show a worse overall survival (OS) compared to younger patients, with reduced ability to tolerate therapeutic interventions and higher rates of unfavorable biomarker status [3,4]. Only moderate effects of gross total resection (GTR) -especially compared to biopsy alone -on OS have been demonstrated in patients older than 65 years [5][6][7][8][9][10]. Considering this background any surgery-related morbidity in elderly GBM patients might mitigate the potential benefits of aggressive surgical treatment [8,[10][11][12][13][14][15].…”

Section: Introductionmentioning

confidence: 99%

“…Only moderate effects of gross total resection (GTR) -especially compared to biopsy alone -on OS have been demonstrated in patients older than 65 years [5][6][7][8][9][10]. Considering this background any surgery-related morbidity in elderly GBM patients might mitigate the potential benefits of aggressive surgical treatment [8,[10][11][12][13][14][15].…”

Section: Introductionmentioning

confidence: 99%

Surgeon experience in glioblastoma surgery of the elderly—a multicenter, retrospective cohort study

Pöppe

Machegger²,

Steinbacher³

et al. 2023

J Neurooncol

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Purpose To assess the impact of individual surgeon experience on overall survival (OS), extent of resection (EOR) and surgery-related morbidity in elderly patients with glioblastoma (GBM), we performed a retrospective case-by-case analysis. Methods GBM patients aged ≥ 65 years who underwent tumor resection at two academic centers were analyzed. The experience of each neurosurgeon was quantified in three ways: (1) total number of previously performed glioma surgeries (lifetime experience); (2) number of surgeries performed in the previous five years (medium-term experience) and (3) in the last two years (short-term experience). Surgeon experience data was correlated with survival (OS) and surrogate parameters for surgical quality (EOR, morbidity). Results 198 GBM patients (median age 73.0 years, median preoperative KPS 80, IDH-wildtype status 96.5%) were included. Median OS was 10.0 months (95% CI 8.0–12.0); median EOR was 89.4%. Surgery-related morbidity affected 19.7% patients. No correlations of lifetime surgeon experience with OS (P = .693), EOR (P = .693), and surgery-related morbidity (P = .435) were identified. Adjuvant therapy was associated with improved OS (P < .001); patients with surgery-related morbidity were less likely to receive adjuvant treatment (P = .002). In multivariable testing, adjuvant therapy (P < .001; HR = 0.064, 95%CI 0.028–0.144) remained the only significant predictor for improved OS. Conclusion Less experienced neurosurgeons achieve similar surgical results and outcome in elderly GBM patients within the setting of academic teaching hospitals. Adjuvant treatment and avoidance of surgery-related morbidity are crucial for generating a treatment benefit for this cohort.

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Extent of resection and survival outcomes of geriatric patients with glioblastoma: Is there benefit from aggressive surgery?

Cited by 17 publications

References 25 publications

Efficacy, Outcome, and Safety of Elderly Patients with Glioblastoma in the 5-ALA Era: Single Center Experience of More Than 10 Years

Efficacy, Outcome, and Safety of Elderly Patients with Glioblastoma in the 5-ALA Era: Single Center Experience of More Than 10 Years

Radiotherapy for Newly Diagnosed Glioblastoma in the Elderly: What Is the Standard?

Surgeon experience in glioblastoma surgery of the elderly—a multicenter, retrospective cohort study

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