Advertisement

Journal of Neuro-Oncology

, Volume 103, Issue 3, pp 611–618 | Cite as

Glioblastoma multiforme of the elderly: the prognostic effect of resection on survival

  • Christian Ewelt
  • Mathias Goeppert
  • Marion Rapp
  • Hans-Jakob Steiger
  • Walter Stummer
  • Michael Sabel
Clinical Study – Patient Study

Abstract

According to recent developments the best treatment options for glioblastoma (GBM) consist in maximum safe resection and additional adjuvant treatment with radiotherapy (RT) and alkylating chemotherapy (CHX). These options have been evaluated for populations with a median age of approximately 58 years. We therefore addressed the issue of whether elderly patients (>65years) could also benefit from cytoreductive surgery (CS) and adjuvant treatment using alkylating chemotherapy. One-hundred and three patients suffering from newly diagnosed, primary supratentorial glioblastoma multiforme >65 years (median 70.8 years) were identified in our single-center glioma database (2002–2007) and retrospectively divided into group A (n = 31) treated with surgery alone (biopsy, BY, n = 21, CS n = 10), group B (n = 37) surgery plus radiation (BY n = 18, CS n = 19), and group C (n = 35) surgery, RT and CHX (BY n = 4, CS n = 31). Progression-free survival (PFS) and overall survival (OAS) were determined in each group and correlated to age, Karnofsky performance score (KPS), and extent of resection (biopsy (BY), partial (PR), and complete resection (CR)). Progression was defined according the Macdonald criteria. For all patients PFS and OAS were 3.2 months and 5.1 months (m) respectively. PFS and OAS for groups A/B/C were 1.8/3.2/6.4 m (P = 0.000) and 2.2/4.4/15.0 m (P = 0.000), respectively. Median age for groups A/B/C was 74.4/70.6/68.5 years and median KPS was 60/70/80. Age (<75, ≥75) was inversely correlated with OAS (5.8/2.5 m, P = 0.01). KPS (<70, ≥70) was correlated with OAS 2.4/6.5 m (P = 0.000). Extent of resection (BY, PR, or CR) correlated with PFS (2.1/3.4/6.4 m, P = 0,000) and OS (2.2/7.0/13.9 m, P = 0,000), respectively. Our study shows that elderly GBM patients can benefit from maximum treatment procedures with cytoreductive microsurgery, radiation therapy, and chemotherapy. Treatment options are obviously affected by KPS and age. The most impressive outcome predictor in this population was the extent of microsurgical resection for patients treated with adjuvant radiotherapy and chemotherapy. To conclude, elderly GBM patients should not be per se excluded from intensive treatment procedures.

Keywords

Glioblastoma multiforme Elderly Cytoreductive surgery Radiotherapy Temozolomide 

References

  1. 1.
    Barker FG II, Chang SM, Larson DA, Sneed PK, Wara WM, Wilson CB, Prados MD (2001) Age and radiation response in glioblastoma multiforme. Neurosurgery 49(6):1288–1297, discussion 1297-8CrossRefGoogle Scholar
  2. 2.
    Bohman LE, Gallardo J, Hankinson TC, Waziri AE, Mandigo CE, McKhann GM II, Sisti MB, Canoll P, Bruce JN (2009) The survival impact of postoperative infection in patients with glioblastoma multiforme. Neurosurgery 64(5):828–834, discussion 834-5PubMedCrossRefGoogle Scholar
  3. 3.
    Brandes AA, Monfardini S (2003) The treatment of elderly patients with high-grade gliomas. Semin Oncol 30(6 Suppl 19):77–80PubMedGoogle Scholar
  4. 4.
    Brandes AA, Vastola F, Basso U, Berti F, Pinna G, Rotilio A, Gardiman M, Scienza R, Monfardini S, Ermani M (2003) A prospective study on glioblastoma in the elderly. Cancer 97(3):657–662PubMedCrossRefGoogle Scholar
  5. 5.
    Brandes AA, Franceschi E, Tosoni A, Benevento F, Scopece L, Mazzocchi V, Bacci A, Agati R, Calbucci F, Ermani M (2009) Temozolomide concomitant and adjuvant to radiotherapy in elderly patients with glioblastoma: correlation with MGMT promoter methylation status. Cancer 115(15):3512–3518PubMedCrossRefGoogle Scholar
  6. 6.
    Burger PC, Green SB (1987) Patient age, histologic features and length of survival in patients with glioblastoma multiforme. Cancer 59(9):1617–1625PubMedCrossRefGoogle Scholar
  7. 7.
    Caloglu M, Yurut-Caloglu V, Karagol H, Bayir-Angin G, Turan FN, Uzal C (2009) Prognostic factors other than the performance status and age for glioblastoma multiforme: a single-institution experience. J BUON 14(2):211–218PubMedGoogle Scholar
  8. 8.
    Chinot OL, Barrie M, Frauger E, Dufour H, Figarella-Branger D, Palmari J, Braguer D, Honag-Xuan K, Moktan K, Peragut JC, Martin PM, Grisoli F (2004) Phase II study of temozolomide without radiotherapy in newly diagnosed glioblastoma multiforme in an elderly populations. Cancer 100(10):2208–2214PubMedCrossRefGoogle Scholar
  9. 9.
    Coffey RJ, Lunsford LD, Taylor FH (1988) Survival after stereotactic biopsy of malignant gliomas. Neurosurgery 22(3):465–473PubMedCrossRefGoogle Scholar
  10. 10.
    DeAnglis LM (2001) Brain tumors. N Engl J Med 344:112–114Google Scholar
  11. 11.
    Fiorica F, Berretta M, Colosimo C, Stefanelli A, Ursino S, Zanet E, Palmucci T, Maugeri D, Malaguarnera M, Palmucci S, Grasso M, Tirelli U, Cartei F (2010) Glioblastoma in elderly patients: safety and efficacy of adjuvant radiotherapy with concomitant temozolomide. Arch Gerontol Geriatr 51(1):31–35 PubMedCrossRefGoogle Scholar
  12. 12.
    Glantz M, Chamberlain M, Liu Q, Litofsky NS, Recht LD (2003) Temozolomide as an alternative to irradiation for elderly patients with newly diagnosed malignant gliomas. Cancer 97(9):2262–2266PubMedCrossRefGoogle Scholar
  13. 13.
    Halperin EC (1995) Malignant gliomas in older adults with poor prognostic signs. Getting nowhere, and taking a long time to do it. Oncology 9(3):229–234PubMedGoogle Scholar
  14. 14.
    Iwamoto FM, Reiner AS, Panageas KS, Elkin EB, Abrey LE (2009) Patterns of care in elderly glioblastoma patients. Ann Neurol 64(6):628–634CrossRefGoogle Scholar
  15. 15.
    Iwamoto FM, Cooper AR, Reiner AS, Nayak L, Abrey LE (2009) Glioblastoma in the elderly: the Memorial Sloan-Kettering Cancer Center Experience (1997–2007). Cancer. 115(16):3758–3766PubMedCrossRefGoogle Scholar
  16. 16.
    Iwamoto FM, Reiner AS, Nayak L, Panageas KS, Elkin EB, Abrey LE (2009) Prognosis and patterns of care in elderly patients with glioma. Cancer 115(23):5534–5540PubMedCrossRefGoogle Scholar
  17. 17.
    Kelly PJ, Hunt C (1994) The limited value of cytoreductive surgery in elderly patients with malignant gliomas. Neurosurgery 34(1):62–67PubMedCrossRefGoogle Scholar
  18. 18.
    Kimple RJ, Grabowski S, Papez M, Collichio F, Ewend MG, Morris DE (2010) Concurrent temozolomide and radiation, a reasonable option for elderly patients with glioblastoma multiforme? Am J Clin Oncol 33(3):265–270PubMedGoogle Scholar
  19. 19.
    Lacroix M, Abi-Said D, Fourney DR, Gokaslan ZL, Shi W, DeMonte F, Lang FF, McCutcheon IE, Hassenbusch SJ, Holland E, Hess K, Michael C, Miller D, Sawaya R (2001) A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival. J Neurosurg 95:190–198PubMedCrossRefGoogle Scholar
  20. 20.
    Laigle-Donadey F, Figarella-Branger D, Chinot O, Taillandier L, Cartalat-Carel S, Honnorat J, Kaloshi G, Delattre JY, Sanson M (2010) Up-front temozolomide in elderly patients with glioblastoma. J Neurooncol 99(1):89–94 PubMedCrossRefGoogle Scholar
  21. 21.
    Lamers LM, Stupp R, van den Bent MJ, Al MJ, Gorlia T, Wasserfallen JB, Mittmann N, Jin Seung S, Crott R, Uyl-de Groot CA, EORTC 26981/22981 NCI-C CE3 Intergroup Study (2008) Cost-effectiveness of temozolomide for the treatment of newly diagnosed glioblastoma multiforme: a report from the EORTC 26981/22981 NCI-C CE3 Intergroup Study. Cancer 112(6):1337–1344PubMedCrossRefGoogle Scholar
  22. 22.
    Macdonald DR, Cascino TL, Schold SC Jr, Cairncross JG (1990) Response criteria for phase II studies of supratentorial malignant glioma. J Clin Oncol 8(7):1277–1280PubMedGoogle Scholar
  23. 23.
    Mohan DS, Suh JH, Phan JL, Kupelian PA, Cohen BH, Barnett GH (1998) Outcome in elderly patients undergoing definitive surgery and radiation therapy for supratentorial glioblastoma multiforme at a tertiary care institution. Int J Radiat Oncol Biol Phys 42(5):981–987PubMedCrossRefGoogle Scholar
  24. 24.
    Nazzaro JM, Neuwelt EA (1990) The role of surgery in the management of supratentorial intermediate and high-grade astrocytomas in adults. J Neurosurg 73(3):331–344PubMedCrossRefGoogle Scholar
  25. 25.
    Pierga JY, Hoang-Xuan K, Feuvret L, Simon JM, Cornu P, Baillet F, Mazeron JJ, Delattre JY (1999) Treatment of malignant gliomas in the elderly. J Neurooncol 43(2):187–193PubMedCrossRefGoogle Scholar
  26. 26.
    Roa W, Xing JZ, Small C, Kortmann R, Miriamanoff R, Okunieff P, Shibamoto Y, Jeremic B (2009) Current developments in the radiotherapy approach to elderly and frail patients with glioblastoma multiforme. Expert Rev Anticancer Ther 9(11):1643–1650PubMedCrossRefGoogle Scholar
  27. 27.
    Stark AM, Nabavi A, Mehdorn HM (2005) Glioblastoma multiforme—report of 267 cases treated at a single institution. Surg Neurol 63:162–169PubMedCrossRefGoogle Scholar
  28. 28.
    Stark AM, Hedderich J, Held-Feindt J, Mehdorn HM (2007) Glioblastoma–the consequences of advanced patient age on treatment and survival. Neurosurg Rev 30(1):56–61, discussion 61-2.PubMedCrossRefGoogle Scholar
  29. 29.
    Stummer W, Pichlmeier U, Meinel T, Wiestler OD, Zanella F, Reulen HJ, ALA-Glioma Study Group (2006) Fluorescence-guided surgery with 5-aminolevulinic acid for resection of malignant glioma: a randomised controlled multicentre phase III trial. Lancet Oncol 7(5):392–401PubMedCrossRefGoogle Scholar
  30. 30.
    Stupp R, Mason WP, van den Bent MJ, Weller M, Fisher B, Taphoorn MJ, Belanger K, Brandes AA, Marosi C, Bogdahn U, Curschmann J, Janzer RC, Ludwin SK, Gorlia T, Allgeier A, Lacombe D, Cairncross JG, Eisenhauer E, Mirimanoff RO, European Organisation for Research and Treatment of Cancer Brain Tumor and Radiotherapy Groups, National Cancer Institute of Canada Clinical Trials Group (2005) Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 352(10):987–996PubMedCrossRefGoogle Scholar
  31. 31.
    Tengs TO (2004) Cost-effectiveness versus cost-utility analysis of interventions for cancer: does adjusting for health-related quality of life really matter? Value Health 7(1):70–78PubMedCrossRefGoogle Scholar
  32. 32.
    Trotti A, Colevas AD, Setser A, Rusch V, Jaques D, Budach V, Langer C, Murphy B, Cumberlin R, Coleman CN, Rubin P (2003) CTCAE v3.0: development of a comprehensive grading system for the adverse effects of cancer treatment. Semin Radiat Oncol 13(3):176–181PubMedCrossRefGoogle Scholar
  33. 33.
    Vuorinen V, Hinkka S, Färkkilä M, Jääskeläinen J (2003) Debulking or biopsy of malignant glioma in elderly people—a randomized study. Acta Neurochir (Wien) 145(1):5–10CrossRefGoogle Scholar
  34. 34.
    Whittle IR, Basu N, Grant R, Walker M, Gregor A (2002) Management of patients aged >60 years with malignant glioma: good clinical status and radiotherapy determine outcome. Br J Neurosurg 16(4):343–347PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC. 2010

Authors and Affiliations

  • Christian Ewelt
    • 1
    • 2
  • Mathias Goeppert
    • 1
  • Marion Rapp
    • 1
  • Hans-Jakob Steiger
    • 1
  • Walter Stummer
    • 2
  • Michael Sabel
    • 1
  1. 1.Department of NeurosurgeryHeinrich Heine UniversityDüsseldorfGermany
  2. 2.Department of NeurosurgeryWestfälische Wilhelms UniversityMünsterGermany

Personalised recommendations