International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationsOutcome in elderly patients undergoing definitive surgery and radiation therapy for supratentorial glioblastoma multiforme at a tertiary care institution
Introduction
Glioblastoma multiforme (GBM) is an aggressive neoplasm with a poor prognosis despite surgical, radiation, or chemotherapeutic treatment. A steep increase in the incidence of central nervous system (CNS) tumors has been seen in the elderly population (1). The diagnostic rate of primary brain tumors has nearly doubled in the 65–74-year-old population and has more than doubled in those aged 75–84 years (2). The treatment of glioblastoma multiforme in elderly patients is controversial, with some authors suggesting that modest forms of therapy, such as a short course of radiation, are more appropriate than the conventional aggressive surgery and standard 6 weeks of radiation so as to contain cost, time, and to lessen caregiver stress (3). In the three trials that serve as the Radiation Therapy Oncology Group (RTOG) database, the upper age limit of eligibility was 70 years. Consequently, the elderly patient cohort with perhaps the worst prognosis has been virtually ignored in the literature (4), and whether these patients should be aggressively treated is uncertain. In patients 65 years or older with glioblastoma multiforme, the reported difference in mean survival between patients undergoing stereotactic biopsy and radiation versus patients undergoing tumor resection and radiation is 13 weeks, with the best possible prognosis being a mean survival of 30 weeks after resection plus radiotherapy (5).
The present study retrospectively analyzes survival after aggressive resection, after stereotactic biopsy plus definitive radiation, and after surgery plus palliative radiation. We used the RTOG prognostic groupings as determined by recursive partitioning analysis to compare our survival results with those of the RTOG study (6).
Section snippets
Patient population
Patients with histopathologically proven glioblastoma multiforme (GBM) between 1977 and 1996 were identified from the Department of Pathology database. Patients were included only if they had their initial evaluation and surgery at our institution and if they met pathologic criteria of GBM. Patients were excluded if they were diagnosed before 1977, as computed tomography (CT) scans were not available prior to that time, if they had received previous treatment for glioblastoma, if they did not
Results
Of the 476 patients identified with glioblastoma multiforme, 103 patients were aged 70 or more; however, medical records were not obtainable in 1 patient, therefore, the study group consisted of 102 patients, of whom 62 were men. The mean patient age was 74.5 years (range 70–87). Initial symptoms included seizures in 22 patients and motor deficit in 48 patients. The mean KPS score was 70.5, and the mental status examination was abnormal in 18 patients. The tumor was most often located in the
Discussion
Age strongly influences survival for patients with high-grade gliomas 14, 15, 16. For high-grade supratentorial malignant gliomas, external beam radiation therapy modestly increases survival (17). Within specific histological grades of malignant gliomas, the patient’s age at diagnosis seems to have a greater influence than any therapeutic modality (18). This finding among histologically similar tumors is in part explained by the relationship between age and growth potential. Growth potential
Conclusion
We conclude that the proper selection of cases for definitive treatment influences the outcome in elderly patients. Patients with a KPS score of at least 70 with no coexisting medical conditions are suitable candidates and have a longer survival with aggressive management.
References (25)
- et al.
Astrocytoma resection using an interactive frameless stereotactic wand. An early experience
J Clin Neurosci
(1994) - et al.
Management of patients aged over 60 years with supratentorial gliomaLessons from an audit
Surg Neurol
(1991) - et al.
An analysis of dose effect relationships in the radiotherapy of malignant gliomas
Int J Radiat Oncol Biol Phys
(1979) - et al.
Short-course radiotherapy is an appropriate option for most malignant glioma patients
Int J Radiat Oncol Biol Phys
(1997) - et al.
Age-related chemosensitivity of stem cells from human malignant brain tumors
Lancet
(1982) - et al.
Increasing incidence of primary malignant brain tumorsInfluence of diagnostic methods
J Natl Cancer Inst
(1992) - Davis DL, Hoel D, Fox J; et al. International trends in cancer mortality in France, West Germany, Italy, Japan, Wales...
Malignant gliomas in older adults with poor prognostic signs, getting nowhere, and taking a long time to do it
Oncology
(1995)Supratentorial malignant gliomasRisk patterns and therapy
J Natl Cancer Inst
(1993)- et al.
The limited value of cytoreductive surgery in elderly patients with malignant gliomas
Neurosurgery
(1994)