Surgical Management of Malignant Glioma in the Elderly

Overview

Journal Front Oncol

Specialty Oncology

Date 2022 Jun 13

PMID 35692808

Authors

Julia Klingenschmid

Aleksandrs Krigers

Johannes Kerschbaumer

Claudius Thome

Daniel Pinggera

Christian F Freyschlag

Affiliations

Soon will be listed here.

Abstract

Background: The 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 & Methods: Patients 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.

Results: We 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.

Conclusion: GTR 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.

Citing Articles

Epilepsy as primary tumor manifestation correlates with patient status, age, and tumor volume but not with survival in elderly glioblastoma patients: a retrospective bicentric analysis.

Demetz M, Hecker C, Salim H, Krigers A, Steinbacher J, Machegger L Neurosurg Rev. 2025; 48(1):264.

PMID: 39994084 PMC: 11850559. DOI: 10.1007/s10143-025-03397-1.

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

Albrecht C, Baumgart L, Schroeder A, Wiestler B, Meyer B, Krieg S Brain Spine. 2024; 4:102742.

PMID: 38510620 PMC: 10951774. DOI: 10.1016/j.bas.2023.102742.

Treatment outcome of IDH1/2 wildtype CNS WHO grade 4 glioma histologically diagnosed as WHO grade II or III astrocytomas.

Keric N, Krenzlin H, Kalasauskas D, Freyschlag C, Schnell O, Misch M J Neurooncol. 2024; 167(1):133-144.

PMID: 38326661 PMC: 10978634. DOI: 10.1007/s11060-024-04585-7.

Frailty and postoperative outcomes in brain tumor patients: a systematic review subdivided by tumor etiology.

Qureshi H, Tabor J, Pickens K, Lei H, Vasandani S, Jalal M J Neurooncol. 2023; 164(2):299-308.

PMID: 37624530 PMC: 10522517. DOI: 10.1007/s11060-023-04416-1.

A Study on the Role of Intraoperative Corticobulbar Motor Evoked Potentials for Improving Safety of Cerebellopontine Angle Surgery in Elderly Patients.

DAlessandris Q, Menna G, Stifano V, Pepa G, Burattini B, di Domenico M Diagnostics (Basel). 2023; 13(4).

PMID: 36832198 PMC: 9955429. DOI: 10.3390/diagnostics13040710.

References

Lorimer C, Hanna C, Saran F, Chalmers A, Brock J . Challenges to Treating Older Glioblastoma Patients: the Influence of Clinical and Tumour Characteristics on Survival Outcomes. Clin Oncol (R Coll Radiol). 2017; 29(11):739-747. DOI: 10.1016/j.clon.2017.05.010. View

Chaichana K, Garzon-Muvdi T, Parker S, Weingart J, Olivi A, Bennett R . Supratentorial glioblastoma multiforme: the role of surgical resection versus biopsy among older patients. Ann Surg Oncol. 2010; 18(1):239-45. PMC: 4612568. DOI: 10.1245/s10434-010-1242-6. View

Cohen-Inbar O . Geriatric brain tumor management part II: Glioblastoma multiforme. J Clin Neurosci. 2019; 67:1-4. DOI: 10.1016/j.jocn.2019.05.064. View

Malmstrom A, Gronberg B, Marosi C, Stupp R, Frappaz D, Schultz H . Temozolomide versus standard 6-week radiotherapy versus hypofractionated radiotherapy in patients older than 60 years with glioblastoma: the Nordic randomised, phase 3 trial. Lancet Oncol. 2012; 13(9):916-26. DOI: 10.1016/S1470-2045(12)70265-6. View

Barnholtz-Sloan J, Maldonado J, Williams V, Curry W, Rodkey E, Barker 2nd F . Racial/ethnic differences in survival among elderly patients with a primary glioblastoma. J Neurooncol. 2007; 85(2):171-80. DOI: 10.1007/s11060-007-9405-4. View

Schar R, Tashi S, Branca M, Soll N, Cipriani D, Schwarz C . How safe are elective craniotomies in elderly patients in neurosurgery today? A prospective cohort study of 1452 consecutive cases. J Neurosurg. 2020; 134(3):1113-1121. DOI: 10.3171/2020.2.JNS193460. View

Han Q, Liang H, Cheng P, Yang H, Zhao P . Gross Total vs. Subtotal Resection on Survival Outcomes in Elderly Patients With High-Grade Glioma: A Systematic Review and Meta-Analysis. Front Oncol. 2020; 10:151. PMC: 7093492. DOI: 10.3389/fonc.2020.00151. View

Watanabe T, Nobusawa S, Kleihues P, Ohgaki H . IDH1 mutations are early events in the development of astrocytomas and oligodendrogliomas. Am J Pathol. 2009; 174(4):1149-53. PMC: 2671348. DOI: 10.2353/ajpath.2009.080958. View

Wick W, Platten M, Meisner C, Felsberg J, Tabatabai G, Simon M . Temozolomide chemotherapy alone versus radiotherapy alone for malignant astrocytoma in the elderly: the NOA-08 randomised, phase 3 trial. Lancet Oncol. 2012; 13(7):707-15. DOI: 10.1016/S1470-2045(12)70164-X. View

10.

Sijben A, McIntyre J, Roldan G, Easaw J, Yan E, Forsyth P . Toxicity from chemoradiotherapy in older patients with glioblastoma multiforme. J Neurooncol. 2008; 89(1):97-103. DOI: 10.1007/s11060-008-9593-6. View

11.

Iwamoto F, Reiner A, Panageas K, Elkin E, Abrey L . Patterns of care in elderly glioblastoma patients. Ann Neurol. 2008; 64(6):628-34. DOI: 10.1002/ana.21521. View

12.

Krigers A, Demetz M, Thome C, Freyschlag C . Age is associated with unfavorable neuropathological and radiological features and poor outcome in patients with WHO grade 2 and 3 gliomas. Sci Rep. 2021; 11(1):17380. PMC: 8405625. DOI: 10.1038/s41598-021-96832-4. View

13.

Zorman M, Webb P, Nixon M, Sravanam S, Honeyman S, Nandhabalan M . Surgical and oncological score to estimate the survival benefit of resection and chemoradiotherapy in elderly (≥70 years) glioblastoma patients: A preliminary analysis. Neurooncol Adv. 2022; 4(1):vdac007. PMC: 8896333. DOI: 10.1093/noajnl/vdac007. View

14.

Ostrom Q, Gittleman H, Farah P, Ondracek A, Chen Y, Wolinsky Y . CBTRUS statistical report: Primary brain and central nervous system tumors diagnosed in the United States in 2006-2010. Neuro Oncol. 2013; 15 Suppl 2:ii1-56. PMC: 3798196. DOI: 10.1093/neuonc/not151. View

15.

Gerstner E, Yip S, Wang D, Louis D, Iafrate A, Batchelor T . Mgmt methylation is a prognostic biomarker in elderly patients with newly diagnosed glioblastoma. Neurology. 2009; 73(18):1509-10. PMC: 2779003. DOI: 10.1212/WNL.0b013e3181bf9907. View

16.

Conti Nibali M, Gay L, Sciortino T, Rossi M, Caroli M, Bello L . Surgery for Glioblastoma in Elderly Patients. Neurosurg Clin N Am. 2020; 32(1):137-148. DOI: 10.1016/j.nec.2020.08.008. View

17.

Schneider M, Potthoff A, Scharnbock E, Heimann M, Schafer N, Weller J . Newly diagnosed glioblastoma in geriatric (65 +) patients: impact of patients frailty, comorbidity burden and obesity on overall survival. J Neurooncol. 2020; 149(3):421-427. PMC: 7609438. DOI: 10.1007/s11060-020-03625-2. View

18.

Laigle-Donadey F, Greffard S . Management of glioblastomas in the elderly population. Rev Neurol (Paris). 2020; 176(9):724-732. DOI: 10.1016/j.neurol.2020.01.362. View

19.

Arvold N, Reardon D . Treatment options and outcomes for glioblastoma in the elderly patient. Clin Interv Aging. 2014; 9:357-67. PMC: 3937103. DOI: 10.2147/CIA.S44259. View

20.

Babu R, Komisarow J, Agarwal V, Rahimpour S, Iyer A, Britt D . Glioblastoma in the elderly: the effect of aggressive and modern therapies on survival. J Neurosurg. 2015; 124(4):998-1007. DOI: 10.3171/2015.4.JNS142200. View