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Clinical Investigations |
Unit of Neuroepidemiology (Gr.F., C.F., R.F., M.F.), Department of Neurosurgery (G.B., D.C., L.F., S.G., C.L.S.), Unit of Clinical Neuro-oncology (A.B.), Unit of Neuroradiology (M.G.B., M.S.), Unit of Neuropathology (B.P.), and Unit of Experimental Neuro-oncology (Ga.F.), Fondazione I.R.C.C.S. Istituto Neurologico "Carlo Besta," Milan; and Department of Clinical Medicine, Prevention and Biotechnologies, Section of Medical Statistics, University of Milano-Bicocca, Monza (M.G.V.); Italy
Address correspondence to Graziella Filippini, Unit of Neuroepidemiology, Fondazione I.R.C.C.S. Istituto Neurologico "Carlo Besta," Via Celoria 11, 20133 Milan, Italy (gfilippini{at}istituto-besta.it).
Reliable data on large cohorts of patients with glioblastoma are needed because such studies differ importantly from trials that have a strong bias toward the recruitment of younger patients with a higher performance status. We analyzed the outcome of 676 patients with histologically confirmed newly diagnosed glioblastoma who were treated consecutively at a single institution over a 7-year period (1997-2003) with follow-up to April 30, 2006. Survival probabilities were 57% at 1 year, 16% at 2 years, and 7% at 3 years. Progression-free survival was 15% at 1 year. Prolongation of survival was significantly associated with surgery in patients with a good performance status, whatever the patient's age, with an adjusted hazard ratio of 0.55 (p < 0.001) or a 45% relative decrease in the risk of death. Radiotherapy and chemotherapy improved survival, with adjusted hazard ratios of 0.61 (p = 0.001) and 0.89 (p = 0.04), respectively, regardless of age, performance status, or residual tumor volume. Recurrence occurred in 99% of patients throughout the follow-up. Reoperation was performed in one-fourth of these patients but was not effective, whether performed within 9 months (hazard ratio, 0.86; p = 0.256) or after 9 months (hazard ratio, 0.98; p = 0.860) of initial surgery, whereas second-line chemotherapy with procarbazine, lomustine, and vincristine (PCV) or with temozolomide improved survival (hazard ratio, 0.77; p = 0.008). Surgery followed by radiotherapy and chemotherapy should be considered in all patients with glioblastoma, and these treatments should not be withheld because of increasing age alone. The benefit of second surgery at recurrence is uncertain, and new trials are needed to assess its effectiveness. Chemotherapy with PCV or temozolomide seems to be a reasonable option at tumor recurrence.
Key Words: chemotherapy • elderly • glioblastoma • radiotherapy • surgery • survival analysis
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