Surgical strategies for older patients with glioblastoma

Abstract

Objective While adjuvant treatment regimens have been modified for older patients with glioblastoma (GBM), surgical strategies have not been tailored. Methods Clinical data of 48 consecutive patients aged 70 years or older, who underwent surgical resection for GBM with intraoperative ultrasonography (IoUS) alone or combination with intraoperative MRI (IoMRI) at Yale New Haven Hospital were retrospectively reviewed. Variables were analyzed, and comparative analyses were performed. Results The addition of IoMRI was not superior to IoUS alone in terms of overall survival (OS) (P = 0.306), Karnofsky Performance Score (KPS) at postoperative 6 weeks (P = 0.704) or extent of resection (P = 0.263). Length of surgery (LOSx), however, was significantly longer (P = 0.0002) in the IoMRI group. LOSx (P = 0.015) and hospital stay (P = 0.025) were predictors of postoperative complications. Increased EOR (GTR or NTR) (P = 0.030), postoperative adjuvant treatment (P < 0.0001) and postoperative complications (P = 0.006) were predictive for OS. Patients with relatively lower preoperative KPS scores (<70) showed significant improvement at postoperative 6 weeks (P<0.0001). Patients with complications (P = 0.038) were more likely to have lower KPS at postoperative 6 weeks. Conclusions Aggressive management with surgical resection should be considered in older patients with GBM, even those with relatively poor KPS. The use of ioMRI in this population does not appear to confer any measurable benefit over ioUS in experienced hands, but prolongs the length of surgery significantly, which is a preventable prognostic factor for impeding care.

Automatic rigid image Fusion of preoperative MR and intraoperative US acquired after craniotomy

“…The echograph is integrated with the neuronavigation system (Ultrasound Navigation, Brainlab AG, Germany) which provides user-guided continuous, optically tracked iUS sampling and can be used to reconstruct a patient-registered 3D iUS dataset for neuronavigation. [ 19 , 21 ] However, changes to the registration system and thus inconsistencies between the patient-registered MR and separately registered iUS scan may affect the superposition of both modalities, i.e. RBF, and re-registration using an automatic image co-registration, i.e.…”

“…[11][12][13][14][15][16][17] Neuronavigation systems enable reconstruction and integration of 3D iUS imaging (Ultrasound Navigation, Brainlab AG, Germany) by means of tracked ultrasound probes and intelligent image reconstruction enabling the surgeon to use this modality in parallel to previously patient-registered MRI data. [18][19][20][21] To this end, the iUS software creates a new patient registration, links it to a previously created registration, i.e. registration-based fusion (RBF) and superimposes iUS and MRI scans in the neuronavigation system.…”

Frailty: Implications for Neuroanesthesia

“…• Predictive ability on a par with other tools • RAI-C could be a rapid, costeffective way to preoperatively screen entire elective surgery populations • More effective than previously used frailty tools for patients for brain tumor surgery classifying patients as to their level of functional impairment) can still show significant improvement postoperatively. 23 However, the lack of validated frailty tools together with the highly progressive nature of malignant brain tumors makes the role of using frailty to guide care in this population unclear at this time.…”

“…Some authors have argued that elderly patients with significant comorbidity may be less likely to tolerate surgery or adjuvant chemotherapy, and may also be less likely to be offered aggressive treatment, both of which may contribute to worse prognoses for this demographic 22 . A recent study suggested that frailty should not hinder offering treatment as elderly patients with low Karnofsky Performance Status scores (a percentage-based score classifying patients as to their level of functional impairment) can still show significant improvement postoperatively 23 . However, the lack of validated frailty tools together with the highly progressive nature of malignant brain tumors makes the role of using frailty to guide care in this population unclear at this time.…”

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

“…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].…”