Abstract
Simple SummaryIn the next decades, the incidence of patients with glioblastoma (GBM) will markedly increase due to the growth of the elderly population. Despite the increasing incidence of GBM, elderly patients are frequently excluded from clinical studies and thus, only few data are available specifically focusing on the elderly population. In the current study, we aimed to investigate the efficacy, outcome, and safety of surgically-treated GBM including resections and biopsies in the 5-ALA era in a large elderly cohort of altogether 272 patients. Our data of this large elderly cohort demonstrate for the first time the clinical utility and safety of 5-ALA fluorescence in GBM for improved tumor visualization in both resections as well as biopsies. Therefore, we recommend the use of 5-ALA not only in resections, but also in open/stereotactic biopsies to optimize the neurosurgical management of elderly GBM patients.Background: In the next decades, the incidence of patients with glioblastoma (GBM) will increase due to the growth of the elderly population. Fluorescence-guided resection using 5-aminolevulinic acid (5-ALA) is widely applied to achieve maximal safe resection of GBM and is identified as a novel intraoperative marker for diagnostic tissue during biopsies. However, detailed analyses of the use of 5-ALA in resections as well as biopsies in a large elderly cohort are still missing. The aim of this study was thus to investigate the efficacy, outcome, and safety of surgically- treated GBM in the 5-ALA era in a large elderly cohort. Methods: All GBM patients aged 65 years or older who underwent neurosurgical intervention between 2007 and 2019 were included. Data on 5-ALA application, intraoperative fluorescence status, and 5-ALA-related side effects were derived from our databank. In the case of resection, the tumor resectability and the extent of resection were determined. Potential prognostic parameters relevant for overall survival were analyzed. Results: 272 GBM patients with a median age of 71 years were included. Intraoperative 5-ALA fluorescence was applied in most neurosurgical procedures (n = 255/272, 88%) and visible fluorescence was detected in most cases (n = 252/255, 99%). In biopsies, 5-ALA was capable of visualizing tumor tissue by visible fluorescence in all but one case (n = 91/92, 99%). 5-ALA administration did not result in any severe side effects. Regarding patient outcome, smaller preoperative tumor volume (<22.75 cm3), gross total resection, single lesions, improved postoperative neurological status, and concomitant radio-chemotherapy showed a significantly longer overall survival. Conclusions: Our data of this large elderly cohort demonstrate the clinical utility and safety of 5-ALA fluorescence in GBM for improved tumor visualization in both resections as well as biopsies. Therefore, we recommend the use of 5-ALA not only in resections, but also in open/stereotactic biopsies to optimize the neurosurgical management of elderly GBM patients.
Highlights
Glioblastoma (GBM) is the most common primary malignant brain tumor with very poor prognosis and predominance in the elderly population [1]
We investigated if gross total resection (GTR) achieved mostly by 5-aminolevulinic acid (5-ALA) fluorescence-guided resection results in a higher rate of neurological deficits in our elderly cohort
Since we found a positive predictive value of 100% of strong fluorescence for diagnostic tumor tissue, we modified the biopsy strategy at our institution and we terminate the procedure in cases with strong 5-ALA
Summary
Glioblastoma (GBM) is the most common primary malignant brain tumor with very poor prognosis and predominance in the elderly population [1]. GBM patients aged ≥ 65 years is 2.6 times higher than in younger patients [2]. Approximately half of GBM patients are aged ≥ 65 years at the time of diagnosis [3,4]. The anticipated higher life expectancy over the decades represents a crucial factor for the increasing incidence of elderly GBM patients [5]. In 2030, the age group ≥ 65 years is expected to account for two thirds of all GBM patients according to epidemiological studies [3,4]. Despite the increasing incidence of GBM cases, elderly patients are frequently excluded from clinical studies or inadequately represented and only few data are available focusing on the elderly population [2]. In the case of resection, the tumor resectability and the extent of resection were determined
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