Factors associated with survival for patients with glioblastoma with poor pre-operative functional status

Abstract

Patients with glioblastoma (GB) are known to have poor prognoses, and among these patients, those with poor neurological function have an even poorer prognosis. Consequently, aggressive surgeries and adjuvant therapies are often withheld because of this dismal outlook. The effects of aggressive therapies in this small subset of patients remain unknown. The goal of this study was to evaluate outcomes and factors associated with survival for poor functioning patients who underwent aggressive resection of their GB. Adult patients who underwent surgical resection of an intracranial primary GB at an academic tertiary-care institution between 1997 and 2007 were retrospectively reviewed. Patients with a Karnofsky Performance Scale (KPS) score of ≤60 were included. A total of 100 patients with primary GB met the inclusion criteria. The average age (± standard deviation) and KPS score of this cohort were 54 ± 15 years and 53 ± 12, respectively. No patient (0%) experienced perioperative mortality, and 0 (0%), 10 (10%), and 3 (3%) of patients incurred a new or increasing language, motor, and visual deficit, respectively. At last follow-up, 88 (88%) patients died with a median survival of 6.6 months. The factors associated with improved survival were age <65 year (p = 0.005), tumor size >2 cm (p = 0.01), radical tumor resection (p=0.01), and temozolomide (p = 0.001). This study identifies a subset of patients with poor functional status who may benefit from aggressive surgical resection.

Fig. 1

Percentage survival for patients with poor preoperative Karnofsky Performance Scale scores (KPS). Kaplan–Meier curve for patients with KPS ≤60 prior to glioblastoma resection. Median survival was 6.6 months, where the 3-, 6-, 12-, and 18-month survival rates were 73%, 52%, 32%, and 14%, respectively.

Fig. 2

Survival for patients with poor preoperative Karnofsky Performance Scale score (KPS) stratified by their preoperative KPS score. Median survival for patients with preoperative KPS score 60 was 6.6 months, where the 6-, 12-, and 18-month survival rates were 35%, 21%, and 9%, respectively. Median survival for patients with preoperative KPS score of 40–50 was 7.9 months, where the 6-, 12-, and 18-month survival rates were 11%, 8%, and 3%, respectively. Median survival for patients with preoperative KPS score of 20–30 was 3.7 months, where the 6-, 12-, and 18-month survival rates were 6%, 4%, and 4%, respectively. In Log-rank analysis, there was no statistical significance in survival between the cohorts (p > 0.05).

Fig. 3

Survival for patients with poor preoperative Karnofsky Performance Scale scores stratified by independent predictors of outcome. (A) Survival by age. Patients older than 65 years had a median survival of 3.9 months as compared to 7.6 months for patients younger than 65 years (p = 0.02). (B) Survival by extent of resection. Patients who underwent subtotal resection (STR) had a median survival of 4.3 months as compared to 7.3 months for patients who had radical resection (p = 0.05). (C) Survival by tumor size. Patients who had tumors <2 cm in size had a median survival of 3.1 months as compared to 7.6 months for patients with larger tumors (p = 0.006). (D) Survival by temozolomide therapy. Patients who did not receive temozolomide had a median survival of 5.1 months as compared to 12.9 months for patients who received adjuvant therapy (p = 0.002).