Management of elderly patients with aneurysmal subarachnoid hemorrhage]

Clinical features of 61 elderly patients aged over 70 years with ruptured intracranial aneurysms were compared with those of 328 younger patients aged under 70 years. According to a policy of early operation, elderly patients with Hunt and Kosnik's grade I, II and younger patients with grade I, II, III were operated on in the acute stage. In elderly patients with grade III, IV and younger patients with grade IV, the indication for surgery was determined case by case. Surgery was performed on 29 patients (48%) in the elderly group and 277 patients (86%) in the younger group. Our conclusions are as follows: 1. Regarding cases of grade I, II and III of Hunt and Kosnik's classification, the rate of good outcome in the elderly group was similar to that in the younger group, following early surgery and meticulous post-operative care. 2. In the elderly group, no patient in cases of grade IV obtained good surgical outcome. 3. Symptomatic vasospasm was less frequent in elderly patients (18.8%) than in younger cases (37%). 4. Delayed operation was planned for some patients in the elderly group, but none of them underwent surgery because of rerupture of aneurysms and deterioration of general condition.     

Arthroscopic debridement for grade III and IV chondromalacia of the knee in patients older than 60 years

Arthroscopic debridement has been used to treat patients with degenerative knee osteoarthritis, although there is sometimes conflicting evidence documenting its efficacy. This study evaluates the success of arthroscopic debridement in elderly patients with grade III and IV chondromalacia of the knee as measured by patient satisfaction and the need for additional surgery. From December 1998 to August 2001, a total of 102 consecutive cases of knee arthroscopy in 99 patients > 60 years were performed. Average follow-up was 34 months (range: 7-104 months). Patients were asked about their satisfaction using a visual analog scale, and the presence of meniscal lesions during arthroscopy and the treatment for these lesions were evaluated. Knees also were assessed for articular surface degeneration using Outerbridge's classification for chondromalacia. The need for and type of additional surgery was evaluated. During arthroscopy, meniscal lesions requiring a partial meniscectomy were found in 95 knees. Chondromalacia was found in 92 knees; 53 knees had grade I or II chondromalacia and 39 knees had grade III or IV chondromalacia. Additional surgery was performed in 17 knees. Mean patient satisfaction score was 73 (range: 50-100) in the 39 knees with grade III or IV chondromalacia after arthroscopic debridement was performed. These findings suggest arthroscopic debridement in elderly patients has a place in the treatment algorithm for grade III or IV chondromalacia of the knee.     

Incidence and prognosis in early onset breast cancer

The aim of this study was to assess the incidence and prognosis in early onset breast cancer. Age-adjusted incidence and death rate for the 5394 Swedish women diagnosed with breast cancer under the age of 40 between 1960 and 1996 was studied using data from the Swedish Cancer Registry and Swedish Death Cause Registry. A total of 107 consecutive young patients with invasive breast cancer undergoing surgery during 1980-1993 in the Southeast Swedish health care region were retrospectively followed up and their cancers reviewed and graded blindly. The median follow-up time was 11.2 years. The applicability of the Nottingham Prognostic Index (NPI) as a prognostic tool was investigated. Grade, age, node status, tumour size, S-phase fraction and steroid receptor content were related to survival univariately and multivariately in a Cox proportional hazard analysis. The incidence of early onset breast cancer has increased moderately and the survival rate has not improved during the last 35 years. When young women are diagnosed with breast cancer their tumours are larger, their lymph nodes more often involved, and the median grade higher than in older with 64% having grade 3 tumours. Lymph node status was the strongest sole prognostic indicator but the use of NPI gave more accurate prognostic information than node status alone.     

Midterm results of surgical treatment of displaced proximal humeral fractures in children

Purpose

To analyse the clinical outcomes of 26 children treated surgically for displaced proximal humerus fracture.

Materials and methods

From January 2008 to December 2012, 26 children/adolescents (14 boys, 12 girls) were treated surgically for displaced fractures at the proximal extremity of the humerus. Ten were grade III and 16 were grade IV according to the Neer–Horowitz classification with a mean age of 12.8 ± 4.2 years. Twenty young patients were surgically treated with a closed reduction and direct percutaneous pinning; six required an open approach. To obtain a proper analysis, we compared the Costant scores with the contralateral shoulder (Δ Costant).

Results

The mean follow-up period was 34 months (range 10–55). Two grade IV patients showed a loss in the reduction after percutaneous treatment. This required open surgery with a plate and screws. On average, the treated fractures healed at 40 days. The mean Δ Costant score was 8.43 (range 2–22). There was a statistically significant improvement in the mean Δ Costant score in grade III patients. In grade IV patients, there was a significant improvement in the mean Δ Costant score in those treated with open surgery versus mini-invasive surgery.

Conclusions

Our study shows excellent results with percutaneous k-wires. This closed surgery had success in these patients, and the excellent outcomes noted here lead us to prefer the mini-invasive surgical approach in NH grade III fractures. In grade IV, the best results were noted in patients treated with open surgery. We suggest an open approach for these patients.

Level of evidence

III.

     

Non-Hodgkin's lymphomas of the stomach. Therapy from the surgical viewpoint]

About 2-5% of all gastric tumours are Non-Hodgkin Lymphomas (NHL). In the last years we treated 15 patients with NHL of the stomach. Six of these patients were classified to group IE according to Ann Arbor classification, four to group II (three II 1 E and one II 2 E). In group III E were two patients (one III S and one III E) and one patient was classified to group IV. Ten patients displayed low grade and five high grade malignancies with respect to the Kiel classification. We performed in group I three gastrectomies and three BI resections. In four patients of group II two gastrectomies and two BI resections were carried out and in group III two BI resection. Our treatment policy consisted of operation and radiation in IE, to operation and chemotherapy in high grade lymphomas of group II, and operation plus radiation in low grade malignancies of group II. In group III we treated radiation, chemotherapy and operation and in group IV radiation and chemotherapy. In group I five patients survived, in group II two out of four and in group III one of two. The patient of group IV died within two years after diagnosis.     

Distant recurrences limit the survival of patients with thalamic high-grade gliomas after successful resection

The indications of surgery for thalamic high-grade gliomas are not well established. The present study investigated the outcome of 21 patients treated by surgery and reports the high incidence of distant recurrences including disseminations after successful removal. Twenty-one patients with thalamic high-grade gliomas not invading the pyramidal tract or midbrain underwent cytoreductive surgery at our institute from June 1997 to August 2015. Surgery was performed with the aid of a neuronavigation system, electrophysiological monitoring, and fluorescence navigation. Tumor histology included 12 cases of the World Health Organization grade III and nine cases of grade IV. Gross total resection was achieved in six cases, subtotal in 13, and partial in two. Motor weakness accompanied by sensory disturbance deteriorated immediately after surgery in 13 patients. However, five patients were determined to show deterioration at 2 months after surgery. Postoperative radiation and chemotherapy were given to every patient, and median progression-free survival of patients with grade III and IV tumors was 12.1 and 7.0 months, respectively. Median overall survival of patients with grade III and IV tumors was 25.6 and 12.6 months, respectively. High incidence of distant recurrences was found, with distant lesions at recurrence in 13 of 19 patients with recurrence, suggesting the life-restricting factor in these patients. Thalamic high-grade glioma without invasion into the pyramidal tract and brainstem can be considered as a candidate for surgical resection. Distant lesion limits the survival of patients after successful resection.     

Surgical treatment of oral cavity carcinoma

Ninety-four squamous cell carcinomas of the oral cavity, treated on the author's service between 1969 and 1981, were evaluated. The series included squamous cell carcinomas of various intraoral sites excluding the lips and hard palate. Survival of 60 mo was 70% for stage I, 65% for stage II, 45% for stage III, and 27% for stage IV carcinoma. Twenty-four of 34 patients with "early" cancer (stages I and II) were treated by operation alone. Too few patients with "early" cancer were treated by combined irradiation and surgery to draw conclusions regarding relative efficacy of combination therapy. Sixty patients had "advanced" cancer (stages III and IV). Five-year survival was 37% for patients treated by operation alone, 18% after salvage surgery after failed irradiation, and 60% for patients treated by operation combined with planned perioperative irradiation. Combination therapy appeared to improve control of locoregional disease as well as survival in patients with "advanced" cancer.     

Left atrioventricular valve regurgitation after repair of incomplete atrioventricular septal defect

BACKGROUND: Excellent surgical results have been reported for repair of incomplete atrioventricular septal defect; however, left atrioventricular valve regurgitation (ltAVVR) is a major cause of late morbidity. We reviewed our entire experience with incomplete atrioventricular septal defect in order to investigate long-term results of ltAVVR after repair and determine the factors influencing the progression of ltAVVR in late follow-up. METHODS: Between 1983 and 2002, 61 patients underwent surgical repair of incomplete atrioventricular septal defect, including 7 patients with intermediate forms. The age of operation ranged from 1 month to 62 years old (median 5.3 years old). Thirteen patients were less than 2 years old, including 7 infants, while there were 15 adult patients. All patients underwent patch closure of the ostium primum defect. Before 1995, the cleft was left open in 7 patients and partial closure of the cleft was done in 41 patients, whereas complete closure of the cleft was performed in 9 patients since 1996. Preoperative and postoperative ltAVVR at hospital discharge and late follow-up were graded 0-IV by echographic evaluation. RESULTS: There was 1 early death and 4 late deaths with a 91% 10-year actuarial survival rate. Preoperative ltAVVR grade was I in 25 patients, II in 31 patients, III in 4 patients, and IV in 1 patient. Postoperatively, ltAVVR deteriorated in 3 patients. Left AVVR decreased in 21 patients, whereas in 37 patients it remained the same at hospital discharge. Consequently, ltAVVR remained grade II in 18 patients, grade III in 2, and there was no patient with grade IV. During the long-term follow-up, 24 patients were noted to have increased ltAVVR, including grade III in 8 patients and grade IV in 4. Reoperations for ltAVVR were required in 5 patients (8.3% of hospital survivors); valve replacement in 3 patients and valve repair in 2. Actuarial freedom from reoperation for ltAVVR was 91% at 10 years, whereas actuarial freedom from postoperative ltAVVR grade III or more was 89% at 5 years and 78% at 10 years. Multivariate analysis indicated that postoperative ltAVVR grade II or more at hospital discharge (p = 0.0032, odds ratio = 7.41, 95%CI: 1.95-28.10) was the only independent variable related to late ltAVVR, whereas age at operation, preoperative grade of ltAVVR, and the method of cleft repair were not significant risk factors. CONCLUSIONS: Left AVVR is still a significant risk in long-term follow-up. Because the postoperative grade of ltAVVR is the only independent risk factor for late ltAVVR, more efforts should be focused on left atrioventricular valve repair so as to minimize residual regurgitation, even mild regurgitation.     

Bipolar revision arthroplasty for failed threaded acetabular components: radiographic evaluation of cup migration

 We studied the radiographic results of bipolar revision hip arthroplasty in 25 patients (25 hips). These patients had suffered from osteoarthrosis of the hip due to acetabular dysplasia and had undergone total hip replacement using smooth threaded acetabular components. In the revision surgery, these components were replaced by bipolar cups; autografts were implanted in 23 patients and hydroxyapatite grains were added in 7. At the time of follow-up, the severity of migration was radiographically graded from I to IV: grade I, 5 mm or less; grade II, 6 to 10 mm; grade III, 11 to 15 mm; and grade IV, 16 mm or more. Five to 11 years (average, 7.0 years) after surgery, 9 patients were classified as grade I, 6 as grade II, 4 as grade III, and 6 as grade IV. Among the 6 individuals with grade IV migration, hydroxyapatite grains had been used in 5. There was a significant negative correlation between the distance of migration and the increase in size of the threaded acetabular components used in the primary total hip replacement and the bipolar cups in the revision surgery. Because of the tendency to migrate, we concluded that this procedure has a limited role in revision surgery. Received: November 9, 2001 / Accepted: March 15, 2002     

High-dose superselective intra-arterial cisplatin and concomitant radiation (RADPLAT) for advanced head and neck cancer

BACKGROUND: The purpose of this study was to study the effect of intensive targeted chemoradiation in a group of patients with head and neck cancer with stage IV inoperable disease. METHODS: We examined 79 patients with inoperable stage IV head and neck cancer receiving intra-arterial infusion of high-dose cisplatin (150 mg/m(2)) on days 2, 9, 16, and 23 concomitant with delivery of external beam radiotherapy (total dose, 70 Gy; 2 Gy, 35 fractions; 1 fraction/day for 7 weeks). Sodium thiosulfate was administered intravenously to provide effective cisplatin neutralization. RESULTS: Four patients were not assessable. Complete local tumor response was achieved in 72 patients (91%) and a partial response in three patients. The complete response rate of neck node metastases was 90%. The 1- and 2-year locoregional control rates were 82% and 69%, respectively. The median overall survival time was 2.2 years, with a 3-year overall survival probability of 43%. Acute toxicities were as follows: grade III/IV hematologic toxicity (22%/16%), grade III/IV nephrotoxicity (0%), grade III mucositis (43%), grade III skin reactions (24%), grade III toxicity of the upper gastrointestinal tract (57%), grade III nausea (20%), and grade III subjective hearing loss (10%). Grade V toxicity (treatment-related deaths) was 3.8%. Six (18%) of 33 patients with complete remission needed tube feeding 2 years after treatment without intercurrent salvage surgery. CONCLUSIONS: Supradose superselective intra-arterial cisplatin and concomitant radiation is an effective organ-preserving therapy in an unfavorable group of patients. Our series confirms encouraging results reported previously. This regimen is justified in unresectable patients despite the substantial toxicity.     

Morbidity and Mortality Assessment of Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for Diffuse Malignant Peritoneal Mesothelioma—A Prospective Study of 70 Consecutive Cases

Background Although many reports regarding morbidity and mortality of cytoreductive surgery plus perioperative intraperitoneal chemotherapy are available, there are no prospective data on morbidity and mortality limited to patients with diffuse malignant peritoneal mesothelioma (DMPM). Methods This prospective morbidity and mortality assessment was performed on 70 consecutive cytoreductive procedures with perioperative intraperitoneal chemotherapy for DMPM. Forty-seven adverse events by eight categories were rated from grades I to IV with increasing severity. Grade I morbidity was self-limiting; grade II required medical treatments; grade III required an invasive intervention; grade IV required returning to the operating room or intensive care management. Risk factors for grades III and IV morbidity were determined. Results The perioperative mortality rate was 3%. The grades III and IV morbidity rates were 27 and 14%, respectively. Primary colonic anastomosis (P = 0.028), more than four peritonectomy procedures (P = 0.015), duration of the operation of more than 7 h (P = 0.027) were the risk factors for grade IV morbidity. Survival analysis of these 70 patients was provided. Conclusions The morbidity and mortality results for cytoreductive surgery and perioperative intraperitoneal chemotherapy for patients with DMPM were within the acceptable range for major gastrointestinal surgery. Grade IV morbidity was associated with more extensive cytoreduction.     

Early diagnostic and endoscopic dilatation for the treatment of acquired upper airway stenosis after intubation in children

Background

Upper airway stenosis (UAS) after endotracheal intubation is a common problem in children. Most literature refers to a surgical treatment for these lesions. Laryngotracheal reconstruction and cricotracheal resection are used for low- and high-grade stenosis, but decannulation is not always possible immediately after surgery.

Purpose

The aim of this study was to verify the feasibility and results of endoscopic dilatations for treatment of subglottic stenosis.

Method

The study encompassed a 12-year retrospective analysis of patients treated for UAS in a tertiary center. All children were symptomatic at the time of the endoscopic diagnosis. The stenosis was graded according to the Myer-Cotton criteria. Endoscopic dilatation was initiated immediately after the diagnosis. Children with grade IV stenosis underwent surgery.

Results

Children with tracheal stenosis and no involvement of the subglottic area did not respond to endoscopic dilatations and underwent surgery. There were 45 children with grade I stenosis, 12 with grade II, 7 with grade III, and 4 with grade IV lesions. Patients with grade I, II, and III stenosis were all treated by endoscopic dilatations alone and were decannulated when asymptomatic. The average time for decannulation was 18.90 ± 26.07 months for grade I, 32.5 ± 27.08 months for grade II, and 27.57 ± 20.60 months for grade III stenosis (P < .01, for grade II vs grade III).

Conclusion

Grade I, II, and III subglottic stenoses can be safely managed by early endoscopic dilatations with a high rate of success and low rate of morbidity but require a significantly long period of treatment.     

Shunt surgery for hydrocephalus in tuberculous meningitis: a long-term follow-up study

Hydrocephalus is a common complication of tuberculous meningitis. Case studies of 114 patients with tuberculous meningitis and hydrocephalus, who underwent shunt surgery between July, 1975, and June, 1986, were reviewed to evaluate the long-term outcome and to outline a management protocol for these patients based on the results. Seven factors were studied in each case: 1) age at admission; 2) grade on admission (I to IV, classified by the authors; Grade I being the best and Grade IV being the worst); 3) duration of alteration of sensorium; 4) cerebrospinal fluid (CSF) cell content at initial examination; 5) CSF protein levels at initial examination; 6) number of shunt revisions required; and 7) the necessity for bilateral shunts. During a long-term follow-up period ranging from 6 months to 13 years (mean 45.6 months), the mortality rate was 20% for patients in Grade I; 34.7% for patients in Grade II; 51.9% for patients in Grade III; and 100% for patients in Grade IV. Only the grade at the time of admission was found to be statistically significant in determining final outcome (p less than 0.001). Based on these results, the authors advocate early shunt surgery for Grade I and II patients. For patients in Grade III, surgery may be performed either if external ventricular drainage causes an improvement in sensorium or without selection. All patients in Grade IV should undergo external ventricular drainage and only those who show a significant change in their neurological status within 24 to 48 hours of drainage, should have shunt surgery.     

Intertrochanteric osteotomy for osteonecrosis of the femoral head

We studied 32 hips (in 27 patients) treated by intertrochanteric osteotomy for osteonecrosis of the femoral head. Average follow-up was 17 (range 9-26) years. There were 22 men and 5 women with an average age of 39 (range 25-55) years. Eleven hips were classified as Ficat stage II, 19 as stage III and two as early stage IV. Nine hips showed collapse of the femoral head within 3 years after operation and in six hips collapse occurred after 3-8 years. In 13 hips slow progression with incipient signs of arthrosis was noted 8 years after surgery. Four hips with a moderate degree of necrosis at the time of surgery showed no radiological progression 9-26 years after operation. We recommend intertrochanteric osteotomy for patients with Ficat stage II and early stage III, provided that they still have a good range of motion in the hip.     

Endoscopic treatment of vesicoureteral reflux in children with posterior urethral valves

Purpose

We reviewed the clinical outcome of endoscopic injection therapy in children with vesicoureteral reflux persisting after posterior urethral valve ablation.

Methods

We retrospectively reviewed the charts of 16 patients with posterior urethral valves who have undergone endoscopic injection to correct persistent reflux after successful relief of urethral obstruction. Breakthrough urinary tract infections, persistent high-grade reflux and failed ureteroneocystostomy were the indications of endoscopic antireflux surgery.

Results

Reflux was grade I in 1, grade II in 3, grade III in 11 and grade IV in 4 ureters. Mean age at injection was 6.9?±?3.8?years and the mean interval from initial intervention to injection was 4.3?±?2.4?years. Injected material was dextranomer/hyaluronic acid in the majority (87.5?%) of cases. Reflux was resolved or downgraded in 12 ureters (63.1?%) after a single injection. All failed cases had urodynamically documented bladder dysfunction.

Conclusion

More than half of the patients with vesicoureteral reflux, persisting after initial valve ablation, showed complete resolution or significant downgrading in their reflux grade after endoscopic injection. Given the technical difficulties and potential complications of open surgical reimplantation in valve patients, endoscopic subureteral injection can be considered as an effective alternative to cure persistent vesicoureteral reflux.     

Long-term results of aortic valve regurgitation after repair of ruptured sinus of valsalva aneurysm

BACKGROUND: We reviewed our 35-year-experience to investigate the determinants of long-term results of aortic valve regurgitation (AR) after surgical repair of ruptured sinus of Valsalva aneurysms (RSVA). METHODS: Between 1963 and 1998, a total of 35 patients aged 7 to 64 years underwent surgery for RSVA. The aneurysms ruptured into the right ventricle (n = 24), right atrium (n = 10), and left atrium (n = 1). In all, 19 patients had VSD and 9 patients had AR. A combined approach through aortotomy and the involved chamber was used for 24 patients. Either direct (n = 19) or patch (n = 16) closure was used to close the rupture hole. The AR was graded on a scale of 0 to IV by angiographic or echographic evaluation. RESULTS: There were no early deaths. Late death occurred in 1 patient, whose AR deteriorated to grade III 20 years later. Two patients (5.7%) required reoperations on the aortic valve, because grade III AR was noted 8 and 26 years after operation, respectively. Freedom from postoperative grade III AR or higher was 93% at 10 years and was 87% at 20 years. Late AR was associated with preoperative and early postoperative AR (p < 0.05) but not with the presence of VSD, location of the fistula, surgical approach, or type of repair (direct vs patch). Multivariate analysis indicated that early postoperative AR was the only independent variable. CONCLUSIONS: Late AR necessitating reoperation still confers significant risk in the long-term follow-up after repair of RSVA. No particular risk factor of preoperative conditions and surgical methods was elucidated in this study, and postoperative AR at discharge from the hospital was the only factor determining the long-term results of AR.     

Vagotomy and gastroenterostomy for stenosing duodenal ulcer

Vagotomy and gastroenterostomy (V-GE) was performed in 41 patients with chronic stenosing duodenal ulcer and gastric retention in the years 1965-84. There was no mortality and no severe complication occurred. One patient was reoperated for dysfunction of an antecolic stoma. After a follow-up of 1-16 (mean 8) years 30 patients were interviewed and gastroscopy was performed in 21. One recurrence of ulcer was found at endoscopy. Visick classification gave the following overall results: grade I 40%, grade II 13%, grade III 30% and grade IV 17%. One case of gastric carcinoma was found five years after operation. It was concluded that V-GE is a simple and safe method and will give satisfactory early and long-term results.     

Midterm outcome of mitral valve repair for congenital mitral regurgitation in infants and children

We analyzed the midterm results of children undergoing mitral valve repair without the use of prosthetic materials focusing on mitral annulus growth. From 1991 to 2004, 17 children (median age: 11 months) underwent mitral valve repair (grade III=9, IV=8). Regurgitation was due to prolapsed leaflet in 8 patients, annular dilatation in 4, and restrictive leaflet motion in 5. Preoperative indexed mitral valve diameter and Z-value were compared with those obtained at follow-up. There were no early or late deaths. All patients had an improved regurgitation grade after surgery. MV repair resulted in reduction in the indexed mitral valve diameter (58.2+/-22.9 vs. 47.3+/-18.9 mm/m2, P<0.05) and Z-value (3.3+/-2.3 vs. 0.79+/-2.2, P<0.05). One patient underwent re-repair, but no patients required mitral valve replacement during the median follow-up period of 95 months. The latest regurgitation grade was absent or I in 4 patients, II in 10 patients, and III in 3 patients. Mitral valve annulus increased by 23% at 3 years and by 49% at 5 years compared with that at surgery. Mitral valve repair without the use of prosthetic materials is feasible for the majority of patients and carries an appropriate growth pattern of the mitral valve annulus after surgery.     

Medical therapy of oligoasthenospermia associated with left varicocele

OBJECTIVE: To ascertain whether a nonsteroidal anti-inflammatory drug (cinnoxicam) or surgical varicocelectomy are suitable therapies for oligoasthenospermia associated with varicocele. PATIENTS AND METHODS: Patients who were oligoasthenospermic and had a varicocele were blindly randomized into three groups and the varicocele graded using echo-colour Doppler ultrasonography. In group 1, seven men had grade V, four grade IV and 30 grade III varicoceles; in group 2 eight had grade V, 10 grade IV and 43 grade III; in group 3 six had grade V, eight grade IV and 40 grade III. Group 1 underwent surgery, group 2 received cinnoxicam (one 30 mg suppository every 4 days for 12 months) and group 3 received a placebo (one glycerine suppository every 4 days for 12 months). Sperm was analysed at intervals to follow the response in the three groups, and any side-effects considered. RESULTS: Surgery significantly increased sperm values in men with grade III-V varicocele within 4 months, the highest values being obtained at 8 and 12 months. Cinnoxicam significantly improved sperm quality after 2 months in men with grade III varicocele, but the results were best at 4 months and stable at 12 months; stopping therapy caused a decline to the baseline values. Cinnoxicam did not change the sperm quality of men with grade IV or V varicocele. The placebo was inactive, and there were no side-effects of active treatment. CONCLUSIONS: Cinnoxicam is a safe and reliable therapeutic option for men with oligoasthenospermia associated with a grade III varicocele, but surgery is better for those with grade II, IV and V.     

Survival following surgery and prognostic factors for recently diagnosed malignant glioma: data from the Glioma Outcomes Project

OBJECT: The Glioma Outcomes Project represents a contemporary analysis of the management of malignant (Grade III and Grade IV/GBM) gliomas in North America. This observational database was used to evaluate the influence of resection, as opposed to biopsy, on patient outcome as measured by the length of survival. Attempts were made to reduce the impact of selection bias by repeating the data analysis after omitting patients with major negative prognostic factors. METHODS: Outcome data from 788 patients accrued from multiple sites over a 4-year period (1997-2001) were analyzed with the primary outcome measure being length of survival. Of these, 565 patients with recent diagnoses formed the basis of the present analysis. Patients were systematically followed up until death or up to 24 months after enrollment in the study, and survival data were correlated with the histopathological grade and location of the tumor, the extent of surgery, the patient's performance status, and demographic factors. The median length of survival was 40.9 weeks for patients with recently diagnosed GBMs. The true median length of survival for patients with Grade III gliomas was not reached, although there was a 58% survival rate at 104 weeks. In multivariate analysis, resection rather than biopsy (p < 0.0001), age 60 years or younger (p < 0.0001), and a Karnofsky Performance Scale (KPS) score of 70 or greater (p = 0.0004) were associated with a prolonged survival time for patients with Grade III or IV gliomas. The prognostic value of resection compared with biopsy was maintained (p < 0.0001), even after eliminating patients considered to be "poor risk" (those with age > 60 years, KPS score < 70, or presence of multifocal tumors), who may have been overrepresented in the biopsy group. Survival "tails" at 24 months were 58% for Grade III gliomas and 11% for GBMs. CONCLUSIONS: These data provide Class II evidence to support tumor grade, patient's age, and patient's functional status as prognostic factors for survival in individuals with recently diagnosed malignant gliomas. Resection (compared with biopsy) is also a strong prognostic factor; however, no quantitative attempt was made to assess the true extent of the resection.