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Resection and survival in glioblastoma multiforme: An RTOG recursive partitioning analysis of ALA study patients

Medac Gesellschaft für klinische Spezialpräparate mbH, Wedel (U.P.); Institute of Neuroradiology, University of Frankfurt, Frankfurt am Main (A.B.); Department of Neurosurgery, Carl Gustav Carus University, Dresden (G.S.); Department of Neurosurgery, University of Düsseldorf, (W.S.); Germany

Address correspondence to Walter Stummer, Department of Neurosurgery, University of Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf (stummer{at}uni-duesseldorf.de).

The benefit of cytoreductive surgery for glioblastoma multiforme (GBM) is unclear, and selection bias in past series has been observed. The 5-aminolevulinic acid (ALA) study investigated the influence of fluorescence-guided resections on outcome and generated an extensive database of GBM patients with optimized resections. We evaluated whether the Radiation Therapy Oncology Group recursive partitioning analysis (RTOG-RPA) would predict survival of these patients and whether there was any benefit from extensive resections depending on RPA class. A total of 243 per-protocol patients with newly diagnosed GBM were operated on with or without ALA and treated by radiotherapy. Postoperative MRI was obtained in all patients. Patients were allocated into RTOG-RPA classes III–V based on age, KPS, neurological condition, and mental status (as derived from the NIH Stroke Scale). Median overall survival among RPA classes III, IV, and V was 17.8, 14.7, and 10.7 months, respectively, with 2-year survival rates of 26%, 12%, and 7% (p = 0.0007). Stratified for degree of resection, survival of patients with complete resections was clearly longer in RPA classes IV and V (17.7 months vs. 12.9 months, p = 0.0015, and 13.7 months vs. 10.4 months, p = 0.0398; 2-year rates: 21.0% vs. 4.4% and 11.1% vs. 2.6%, respectively), but was not in the small subgroup of RPA class III patients (19.3 vs. 16.3 months, p = 0.14). Survival of patients from the ALA study is correctly predicted by the RTOG-RPA classes. Differences in survival depending on resection status, especially in RPA classes IV and V, support a causal influence of resection on survival.

Key Words: aminolevulinic acid • glioblastoma multiforme • recursive partitioning analysis • resection • survival