Is age an additional factor in the treatment of elderly patients with glioblastoma? A new stratification model: an Italian Multicenter Study

Abstract

OBJECTIVEApproximately half of glioblastoma (GBM) cases develop in geriatric patients, and this trend is destined to increase with the aging of the population. The optimal strategy for management of GBM in elderly patients remains controversial. The aim of this study was to assess the role of surgery in the elderly (≥ 65 years old) based on clinical, molecular, and imaging data routinely available in neurosurgical departments and to assess a prognostic survival score that could be helpful in stratifying the prognosis for elderly GBM patients.METHODSClinical, radiological, surgical, and molecular data were retrospectively analyzed in 322 patients with GBM from 9 neurosurgical centers. Univariate and multivariate analyses were performed to identify predictors of survival. A random forest approach (classification and regression tree [CART] analysis) was utilized to create the prognostic survival score.RESULTSSurvival analysis showed that overall survival (OS) was influenced by age as a continuous variable (p = 0.018), MGMT (p = 0.012), extent of resection (EOR; p = 0.002), and preoperative tumor growth pattern (evaluated with the preoperative T1/T2 MRI index; p = 0.002). CART analysis was used to create the prognostic survival score, forming six different survival groups on the basis of tumor volumetric, surgical, and molecular features. Terminal nodes with similar hazard ratios were grouped together to form a final diagram composed of five classes with different OSs (p < 0.0001). EOR was the most robust influencing factor in the algorithm hierarchy, while age appeared at the third node of the CART algorithm. The ability of the prognostic survival score to predict death was determined by a Harrell’s c-index of 0.75 (95% CI 0.76–0.81).CONCLUSIONSThe CART algorithm provided a promising, thorough, and new clinical prognostic survival score for elderly surgical patients with GBM. The prognostic survival score can be useful to stratify survival risk in elderly GBM patients with different surgical, radiological, and molecular profiles, thus assisting physicians in daily clinical management. The preliminary model, however, requires validation with future prospective investigations. Practical recommendations for clinicians/surgeons would strengthen the quality of the study; e.g., surgery can be considered as a first therapeutic option in the workflow of elderly patients with GBM, especially when the preoperative estimated EOR is greater than 80%.

Surgical Management of Intracranial Meningiomas in the Elderly: Early and Long-term Outcomes

“…Advances in medical care and surgical technique prompt important questions about the indications for surgery and treatment results in the geriatric population not only after surgery for intracranial meningiomas, but also for other tumors occurring in the central nervous system. The most important prognostic factors highlighted in many reports related to glioma surgery in the elderly patients include increasing age, 36,37 the extent of resection, [36][37][38] cognitive function, 37 functional status, 37,38 nutritional status, 37 and the presence and severity of comorbidities. 37 The overall and progression-free survival times are significantly longer in cases of complete tumor resection compared to partial resection or biopsy alone.…”

“…37 The overall and progression-free survival times are significantly longer in cases of complete tumor resection compared to partial resection or biopsy alone. [36][37][38] O-6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status [36][37][38] and isocitrate dehydrogenase (IDH) gene mutation 37,38 are also important prognostic factors, as with nonelderly patients. In the group of 322 patients above 65 years of age operated on for intracranial glioblastoma, Ius et al 36 found the one-year overall survival and progression-free survival rates of 42.07% and 24.8%, respectively.…”

“… 36–38 O-6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status 36–38 and isocitrate dehydrogenase (IDH) gene mutation 37 , 38 are also important prognostic factors, as with nonelderly patients. In the group of 322 patients above 65 years of age operated on for intracranial glioblastoma, Ius et al 36 found the one-year overall survival and progression-free survival rates of 42.07% and 24.8%, respectively. Younger age, higher extent of resection, no corpus callosum involvement, lower T1/T2 MRI index, and the presence of MGMT promoter methylation were independent survival risk factors in their cohort.…”

Brain Tumor Resection in Elderly Patients: Potential Factors of Postoperative Worsening in a Predictive Outcome Model

“…Whether to operate on elderly patients with BT is sometimes a difficult decision, which is influenced by several patient-specific factors, including preoperative functional status and pathology-related aspects, such as presumed histology and preoperative surgical complexity [ 8 , 9 , 10 ]. Other factors to consider are life expectancy and quality of life; amidst all this complexity, the knowledge of possible predictors of outcome should be included in the preoperative assessment to make the best possible decision in terms of management.…”

“…Recently, several studies about the safety of neurosurgical procedures in the elderly have been presented, but most of the existing literature on this issue measures surgical outcome only in terms of mortality, perioperative complications, and early postoperative outcome [ 5 , 8 , 9 , 11 , 12 ]. Moreover, some pivotal studies in neuro-oncology comprised patients younger than 70 y.o., excluding older ones [ 13 ].…”