Brain metastases in the elderly – Impact of residual tumor volume on overall survival

Baumgart, Lea; Aftahy, Amir Kaywan; Anetsberger, Aida; Thunstedt, Dennis; Wiestler, Benedikt; Bernhardt, Denise; Combs, Stephanie E.; Meyer, Bernhard; Meyer, Hans Jonas; Gempt, Jens

doi:10.3389/fonc.2023.1149628

Cited by 5 publications

(9 citation statements)

References 29 publications

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“…Moreover, changes in the molecular profile of the primary tumor established another important role of surgical resection in obtaining histopathological samples for further analysis ( 36 ). Maximal cytoreduction is an independent prognostic factor in the treatment of BM ( 37 – 39 ).…”

Section: Discussionmentioning

confidence: 99%

Enhancing outcomes: neurosurgical resection in brain metastasis patients with poor Karnofsky performance score - a comprehensive survival analysis

Goldberg,

Mondragon-Soto,

Altawalbeh

et al. 2024

Front. Oncol.

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BackgroundA reduced Karnofsky performance score (KPS) often leads to the discontinuation of surgical and adjuvant therapy, owing to a lack of evidence of survival and quality of life benefits. This study aimed to examine the clinical and treatment outcomes of patients with KPS < 70 after neurosurgical resection and identify prognostic factors associated with better survival.MethodsPatients with a preoperative KPS < 70 who underwent surgical resection for newly diagnosed brain metastases (BM) between 2007 and 2020 were retrospectively analyzed. The KPS, age, sex, tumor localization, cumulative tumor volume, number of lesions, extent of resection, prognostic assessment scores, adjuvant radiotherapy and systemic therapy, and presence of disease progression were analyzed. Univariate and multivariate logistic regression analyses were performed to determine the factors associated with better survival. Survival > 3 months was considered favorable and ≤ 3 months as poor.ResultsA total of 140 patients were identified. Median overall survival was 5.6 months (range 0-58). There was no difference in the preoperative KPS between the groups of > 3 and ≤ 3 months (50; range, 20–60 vs. 50; range, 10–60, p = 0.077). There was a significant improvement in KPS after surgery in patients with a preoperative KPS of 20% (20 vs 40 ± 20, p = 0.048). In the other groups, no significant changes in KPS were observed. Adjuvant radiotherapy was associated with better survival (44 [84.6%] vs. 32 [36.4%]; hazard ratio [HR], 0.0363; confidence interval [CI], 0.197–0.670, p = 0.00199). Adjuvant chemotherapy and immunotherapy resulted in prolonged survival (24 [46.2%] vs. 12 [13.6%]; HR 0.474, CI 0.263–0.854, p = 0.013]. Systemic disease progression was associated with poor survival (36 [50%] vs. 71 [80.7%]; HR 5.975, CI 2.610–13.677, p < 0.001].ConclusionNeurosurgical resection is an appropriate treatment modality for patients with low KPS. Surgery may improve functional status and facilitate further tumor-specific treatment. Combined treatment with adjuvant radiotherapy and systemic therapy was associated with improved survival in this cohort of patients. Systemic tumor progression has been identified as an independent factor for a poor prognosis. There is almost no information regarding surgical and adjuvant treatment in patients with low KPS. Our paper provides novel data on clinical outcome and survival analysis of patients with BM who underwent surgical treatment.

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Section: Discussionmentioning

confidence: 99%

Enhancing outcomes: neurosurgical resection in brain metastasis patients with poor Karnofsky performance score - a comprehensive survival analysis

Goldberg,

Mondragon-Soto,

Altawalbeh

et al. 2024

Front. Oncol.

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“…These findings underscore the significant clinical advantage of incorporating surgery into the management of single brain metastases, particularly in improving patient survival and reducing the risk of recurrence [25]. There are also increasing data supporting surgical resection in patients with multiple BMs [26][27][28][29][30].…”

Section: Introductionmentioning

confidence: 91%

“…The decision to perform surgery was based on the mass effect, bleeding, development of new neurological deficits, and uncertainty regarding the nature of the tumor. For a detailed description, refer to previously published data [28,29]. All postoperative T1 MRI sequences with contrast enhancement obtained within 72 h postoperatively were analyzed.…”

Section: Surgical Procedures and Imaging Analysismentioning

confidence: 99%

“…Kaplan-Meier and log-rank tests showed a significant difference in survival among the four subgroups (Figure 1). The median OS for GPA 0-1 was 4 months (95% confidence interval (CI) 4-5); for GPA 1.5-2, it was 12 months (95% CI 9-13); for GPA 2.5-3, it was 21 months (95% CI [16][17][18][19][20][21][22][23][24][25][26][27][28][29]; and for GPA 3.5-4, it was 38 (95% CI 14-114) (Table 3).…”

Section: Patient Characteristicsmentioning

confidence: 99%

“…Previous studies [26][27][28][29] have highlighted the significance of the residual tumor burden (RTB) and the extent of resection as robust indicators of extended overall survival (OS) in patients with brain metastases, irrespective of age or cancer type. Postoperative magnetic resonance imaging (MRI) is utilized to assess the extent of resection as an objective measure of surgical outcomes.…”

Section: Introductionmentioning

confidence: 99%

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Navigating Post-Operative Outcomes: A Comprehensive Reframing of an Original Graded Prognostic Assessment in Patients with Brain Metastases

Goldberg,

Mondragon-Soto,

Dieringer

et al. 2024

Cancers

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Background: Graded Prognostic Assessment (GPA) has been proposed for various brain metastases (BMs) tailored to the primary histology and molecular profiles. However, it does not consider whether patients have been operated on or not and does not include surgical outcomes as prognostic factors. The residual tumor burden (RTB) is a strong predictor of overall survival. We validated the GPA score and introduced “volumetric GPA” in the largest cohort of operated patients and further explored the role of RTB as an additional prognostic factor. Methods: A total of 630 patients with BMs between 2007 and 2020 were included. The four GPA components were analyzed. The validity of the original score was assessed using Cox regression, and a modified index incorporating RTB was developed by comparing the accuracy, sensitivity, specificity, F1-score, and AUC parameters. Results: GPA categories showed an association with survival: age (p < 0.001, hazard ratio (HR) 2.9, 95% confidence interval (CI) 2.5–3.3), Karnofsky performance status (KPS) (p < 0.001, HR 1.3, 95% CI 1.2–1.5), number of BMs (p = 0.019, HR 1.4, 95% CI 1.1–1.8), and the presence of extracranial manifestation (p < 0.001, HR 3, 95% CI 1.6–2.5). The median survival for GPA 0–1 was 4 months; for GPA 1.5–2, it was 12 months; for GPA 2.5–3, it was 21 months; and for GPA 3.5–4, it was 38 months (p < 0.001). RTB was identified as an independent prognostic factor. A cut-off of 2 cm3 was used for further analysis, which showed a median survival of 6 months (95% CI 4–8) vs. 13 months (95% CI 11–14, p < 0.001) for patients with RTB > 2 cm3 and <2 cm3, respectively. RTB was added as an additional component for a modified volumetric GPA score. The survival rates with the modified GPA score were: GPA 0–1: 4 months, GPA 1.5–2: 7 months, GPA 2.5–3: 18 months, and GPA 3.5–4: 34 months. Both scores showed good stratification, with the new score showed a trend towards better discrimination in patients with more favorable prognoses. Conclusion: The prognostic value of the original GPA was confirmed in our cohort of patients who underwent surgery for BM. The RTB was identified as a parameter of high prognostic significance and was incorporated into an updated “volumetric GPA”. This score provides a novel tool for prognosis and clinical decision making in patients undergoing surgery. This method may be useful for stratification and patient selection for further treatment and in future clinical trials.

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Defining the role of surgery for patients with multiple brain metastases

Ersoy,

Brainman,

Coras

et al. 2024

J Neurooncol

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Purpose To better define the role of surgery, we investigated survival and functional outcomes in patients with multiple brain metastases. Methods Pertinent clinical and radiological data of 131 consecutive patients (156 surgeries) were analyzed retrospectively. Results Surgical indications included mass effect (84.6%) and need for tissue acquisition (44.9%, for molecularly informed treatment: 10 patients). Major (i.e. CTCAE grade 3–5) neurological, surgical and medical complication were observed in 6 (3.8%), 12 (7.7%), and 12 (7.7%) surgical cases. Median preoperative and discharge KPS were 80% (IQF: 60–90%). Median overall survival (mOS) was 7.4 months. However, estimated 1 and 2 year overall survival rates were 35.6% and 25.1%, respectively. Survival was dismal (i.e. mOS ≤ 2.5 months) in patients who had no postoperative radio- and systemic therapy, or who incurred major complications. Multivariate analysis with all parameters significantly correlated with survival as univariate parameters revealed female sex, oligometastases, no major new/worsened neurological deficits, and postoperative radio- and systemic therapy as independent positive prognostic parameters. Univariate positive prognostic parameters also included histology (best survival in breast cancer patients) and less than median (0.28 cm3) residual tumor load. Conclusions Surgery is a reasonable therapeutic option in many patients with multiple brain metastases. Operations should primarily aim at reducing mass effect thereby preserving the patients’ functional health status which will allow for further local (radiation) and systemic therapy. Surgery for the acquisition of metastatic tissue (more recently for molecularly informed treatment) is another important surgical indication. Cytoreductive surgery may also carry a survival benefit by itself.

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Brain metastases in the elderly – Impact of residual tumor volume on overall survival

Cited by 5 publications

References 29 publications

Enhancing outcomes: neurosurgical resection in brain metastasis patients with poor Karnofsky performance score - a comprehensive survival analysis

Enhancing outcomes: neurosurgical resection in brain metastasis patients with poor Karnofsky performance score - a comprehensive survival analysis

Navigating Post-Operative Outcomes: A Comprehensive Reframing of an Original Graded Prognostic Assessment in Patients with Brain Metastases

Defining the role of surgery for patients with multiple brain metastases

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