Abstract
PurposeThe role of surgical resection in the treatment of brainstem glioma (BSG) is poorly understood. For pediatric low-grade (LGBSG) group, several monocentric small-scale retrospective studies reported contradictory conclusions. And there was no clinical study focused on surgical resection for adult or pediatric high-grade (HG) patient groups. This study aims to illustrate whether surgical resection and adjuvant therapy provide survival benefits for patients with histologically confirmed BSG.Patients and MethodsThis retrospective cohort study included 529 patients with histologically confirmed BSG in Surveillance Epidemiology and End Results (SEER) database from 2006-2015. Patients were divided into four groups by age and World Health Organization (WHO) grade. Kaplan-Meier curves of CSS were plotted by different treatment options to compare the survival probability. Univariate and multivariable analyses were then conducted to determine the prognosis effects of surgical resection and adjuvant therapy on cancer specific survival (CSS). All analyses were done in four different groups separately.ResultsThe final sample included 529 patients. The entire study population was divided into groups of pediatric LG (n=236, 44.6%), pediatric HG (n=37, 7.0%), adult LG (n=204, 38.6%) and adult HG (n=52, 9.8%). 52.7% (n=144) of pediatric patients had pilocytic astrocytoma and 45.3% (n=116) of adult patients had ependymoma. Pediatric LGBSG group had the highest gross total resection (GTR) rate (61.4%) and 5-year CSS rate (88.6%). Kaplan-Meier curves of pediatric LGBSG group revealed that patients treated with GTR had significantly better survival probability (P=0.033). Multivariable analysis identified GTR as independently significant predictor for prolonged CSS in pediatric LGBSG group (HR0.29, 95%CI 0.11-0.78, P=0.015); Surgical resection showed no relation to CSS in other patient groups. Kaplan-Meier curves of adult HGBSG group showed that patients treated with both RT and CT in adult HGBSG group had the best survival probability (P=0.02). However, multivariable analysis showed the combination of radiotherapy (RT) and chemotherapy (CT) was not significantly related to better CSS in adult HGBSG group (HR0.35, 95%CI 0.11-1.09, P=0.070). Adjuvant therapy didn’t associate with better CSS in other patient groups.ConclusionPediatric LGBSG group had the highest GTR rate and the most favorable clinical outcome. GTR can provide significant survival benefits for pediatric LGBSG group.
Highlights
Brainstem glioma (BSG) constitutes 10.9% of pediatric brain tumor and about 2.5% of adult brain tumor according to the most recent Central Brain Tumor Registry of the United States (CBTRUS) report [1]
The entire study population was divided into groups of pediatric LGBSG (n=236, 44.6%), pediatric HGBSG (n=37, 7.0%), adult LGBSG (n=204, 38.6%) and adult HGBSG (n=52, 9.8%)
In adult HGBSG group, the survival curve showed no difference between GTR and non-GTR group (P=0.67) (Figure 2) Consistently, univariate and multivariable analyses in four different patient groups revealed that GTR is an independently significant predictor for prolonged caner specific survival (CSS) in pediatric LGBSG group (HR0.29, 95%confidence intervals (CIs) 0.11-0.78, P=0.015); In pediatric HGBSG group, the univariate analysis showed that GTR is significantly related to better CSS (HR0.39, 95%CI 0.16-0.99, P=0.048) but lost its significance after the adjustment of multivariable analysis (HR0.60, 95%CI 0.20-1.76, P=0.350)
Summary
Brainstem glioma (BSG) constitutes 10.9% of pediatric brain tumor and about 2.5% of adult brain tumor according to the most recent Central Brain Tumor Registry of the United States (CBTRUS) report [1]. Pediatric patients with diffuse brainstem pontine glioma (DIPG) were reported to have dismal prognosis and primarily treated with radiotherapy (RT), which was highly infiltrative and less amenable to surgery [3, 4]. Several cohorts reported that pediatric patients with LGBSG treated with surgical resection had favorable clinical outcomes, but most of them were monocentric small-scale studies with selective patients [18,19,20]. A prospective cohort with 116 pediatric patients with LGBSG reported that higher extent of surgery was related to better progression free survival but not to overall survival [15]. As a result of relatively low prevalence and percentage of surgical resection, clinical study focused on surgery still lacks in pediatric patients with high grade BSG (HGBSG) and adult patients with BSG. The percentage of surgical resection was too low to determine its effects on survival
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