Surgical Management of Malignant Glioma in the Elderly

Abstract

BackgroundThe median age for diagnosis of glioblastoma is 64 years and the incidence rises with increasing age to a peak at 75-84 years. As the total number of high-grade glioma patients is expected to increase with an aging population, neuro-oncological surgery faces new treatment challenges, especially regarding aggressiveness of the surgical approach and extent of resection. In the elderly, aspects like frailty and functional recovery time have to be taken into account before performing surgery.Material & MethodsPatients undergoing surgery for malignant glioma (WHO grade III and IV) at our institution between 2015 and 2020 were compiled in a centralized tumor database and analyzed retrospectively. Karnofsky Performance Scale (KPS) and Clinical Frailty Scale (CFS) were used to determine functional performance pre- and postoperatively. Overall survival (OS) was compared between age groups of 65-69 years, 70-74 years, 75-79 years, 80-84 years and >85 years in view of extent of resection (EOR). Furthermore, we performed a literature evaluation focusing on surgical treatment of newly diagnosed malignant glioma in the elderly.ResultsWe analyzed 121 patients aged 65 years and above (range 65 to 88, mean 74 years). Mean overall survival (OS) was 10.35 months (SD = 11.38). Of all patients, only a minority (22.3%) received tumor biopsy instead of gross total resection (GTR, 61.2%) or subtotal resection (STR, 16.5%). Postoperatively, 52.9% of patients were treated according to the Stupp protocol. OS differed significantly between extent of resection (EOR) groups (4.0 months after biopsy vs. 8.3 after STR vs. 13.8 after GTR, p < 0.05 and p < 0.001 correspondingly). No significant difference was observed regarding EOR across different age groups.ConclusionGTR should be the treatment of choice also in elderly patients with malignant glioma as functional outcome and survival after surgery are remarkably better compared to less aggressive treatment. Elderly patients who received GTR of high-grade gliomas survived significantly longer compared to patients who underwent biopsy and STR. Age seems to have little influence on overall survival in selected surgically extensive treated patients, but high preoperative functional performance is mandatory.

Age-Dependent Impact of Concomitant Radio-Chemotherapy and MGMT Promotor Methylation on PFS and OS in Patients with IDH Wild-Type Glioblastoma: The Real-Life Data

“…According to our data, resection instead of biopsy is associated with longer PFS and OS in the entire cohort. This data are concordant with the literature [ 16 , 26 , 27 ]. In our sub-group analysis, patients older than 65 years of age showed additional 12.4 months of survival, if resection instead of biopsy only was performed.…”

“…Nowadays, biological but not chronological age in combination with frailty have more impact on the decision making in cases of malignant glioma [ 16 , 17 ]. Thus, our center generally offers aggressive tumor resection and concomitant radio-chemotherapy to elderly patients with low frailty.…”

Impact of function-guided glioma treatment on oncological outcome in the elderly

“…We showed that the interdisciplinary treatment of older glioma patients seems to be less depending on age but must be adjusted based on the functional status of each patient. Furthermore, our findings are congruent with other studies regarding higher survival rates in patients treated with GTR compared to STR and biopsy, showing that maximum resection remains the first step of an optimal neurooncological treatment regardless of age ( Klingenschmid et al, 2022 ; Chaichana et al, 2011 ). Klingenschmid et al found that the overall survival after biopsy was shorter than after STR and GTR for elderly patients ( Klingenschmid et al, 2022 ).…”

“…Furthermore, our findings are congruent with other studies regarding higher survival rates in patients treated with GTR compared to STR and biopsy, showing that maximum resection remains the first step of an optimal neurooncological treatment regardless of age ( Klingenschmid et al, 2022 ; Chaichana et al, 2011 ). Klingenschmid et al found that the overall survival after biopsy was shorter than after STR and GTR for elderly patients ( Klingenschmid et al, 2022 ). These data are supported by multiple other studies, including the systematic review and meta-analysis by Almenawer et al analyzing >12,000 older patients regarding functional recovery and tumor progression and mortality or morbidity after GTR compared to biopsy.…”

“…In deciding on the extent of resection, not the age but the individual preoperative performance status of each patient must be considered. Maximal resection leads to a longer overall survival and better functional outcome, as shown in this study and pre-existing data ( Laigle-Donadey and Greffard, 2020 ; Pessina et al, 2018 ; Klingenschmid et al, 2022 ). Additionally, the balance between treatment efficacy and quality of life must be maintained due to the shorter life expectancy of older patients.…”