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Prognostic Implications of Extent of Resection in Glioblastoma: Analysis from a Large Database
Poster Viewing E113
Volume 99 Number 2S Supplement 2017 Purpose/Objective(s): Hemangiopericytomas are rare central nervous system (CNS) tumors. We sought to investigate existing clinical management strategies and overall survival (OS) among patients with hemangiopericytomas arising from the CNS. Materials/Methods: All patients diagnosed with CNS hemangiopericytoma from 2004-2014 in the National Cancer Database were included. Clinical and treatment-related characteristics were recorded and analyzed for an association with OS following diagnosis using univariable and multivariable analyses. Results: Nine-hundred and eighty-one patients were included (0.22% of all CNS tumors). At diagnosis, 22 patients had spinal tumors (2%), 21 patients had multifocal tumors (2%) and 28 had disseminated disease (3%). Patients either underwent surgical resection and radiation (48%), surgery alone (37%), radiation alone (6%), or biopsy alone (9%). Of patients with known extent of resection, 53% underwent gross total resection, and, of patients with known radiation modality, 15% received stereotactic radiosurgery. Among the total cohort, 3 and 10 year OS was 87% and 59%, respectively. On multivariable analysis, factors associated with inferior OS included age (HRZ1.05, p<0.001), WHO grade (p<0.001), multifocal disease (HRZ2.59, pZ0.04), disseminated disease (HRZ2.67, pZ0.01), and chemotherapy (HRZ2.66, pZ0.01). Patients receiving surgery alone or surgery and radiation demonstrated improved OS compared to biopsy alone (HRZ0.45, pZ0.01 and HRZ0.47, pZ0.02, respectively). However radiation utilization did not impact OS (pZ0.691). Conclusion: The present data provide large-scale prognostic information from a contemporary cohort of patients with hemangiopericytoma and support an initial attempt at surgical extirpation. The benefits of ionizing radiation are likely limited to improved local control and neurologic function. Author Disclosure: D.M. Trifiletti: ; ARRO. G.U. Mehta: None. S. Grover: None. J.P. Sheehan: None.
2269 Prognostic Implications of Extent of Resection in Glioblastoma: Analysis from a Large Database D.M. Trifiletti,1 C. Alonso,1 S. Grover,2 C.E. Fadul,3 J.P. Sheehan,4 and T.N. Showalter1; 1Department of Radiation Oncology, University of Virginia, Charlottesville, VA, 2Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, 3Department of Neurology, University of Virginia, Charlottesville, VA, 4Department of Neurosurgery, University of Virginia, Charlottesville, VA Purpose/Objective(s): To analyze the predictors for and clinical impact of gross total resection (GTR) in patients with glioblastoma (GBM). Materials/Methods: The National Cancer Database was queried for patients with GBM diagnosed from 2004-2013 with known survival and extent of resection. Patients were grouped based on extent of resection into biopsy alone, subtotal resection (STR), and GTR. Univariable and multivariable (MVA) analyses were performed to investigate factors associated with the likelihood of GTR and overall survival (OS) following diagnosis. Results: 27,865 patients met inclusion criteria. Factors associated with increased odds of GTR on MVA included later year of diagnosis, younger age, higher performance status, non-right sided tumors, multifocal tumors, and O6-methylguanine-methyltransferase (MGMT)gene promoter nonhypermethylated tumors (each p < 0.020). Factors associated with improved OS on MVA included younger patient age, female gender, race, lower comorbidity score, higher performance score, smaller tumor size, unifocality, MGMT hypermethylation, radiotherapy, chemotherapy, and facility volume (each p < 0.005). After adjusting for each of these factors, compared to biopsy alone, GTR was associated with improved OS (HR 0.768, p < 0.001), while STR was not (HR 0.995, p Z 0.930). Conclusion: While a prospective randomized trial on this topic is unlikely to be completed on this subject, this large retrospective analysis provides evidence to support the recommendation of GTR in patients with GBM. This study does not support a survival benefit of STR over biopsy alone, although there may be a subset of patients with near total resection who would benefit.
Author Disclosure: D.M. Trifiletti: ; ARRO. C. Alonso: None. S. Grover: None. C.E. Fadul: None. J.P. Sheehan: None. T.N. Showalter: Honoraria; Varian Medical Systems.
2270 Association between Increase in WBC Absolute Value and Survival Before, During, and After Concurrent Chemoradiation Therapy in Patients With Newly Diagnosed Glioblastoma A. Turkaj,1 L. Trombetta,1 J.K. Molitoris,1 S.N. Badiyan,1 S.M. Bentzen,2 M.V. Mishra,1 M.P. Mehta,3 Y. Kwok,4 and A. Kaiser1; 1University of Maryland Medical Center, Baltimore, MD, 2Greenebaum Comprehensive Cancer Center and Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, 3Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 4University of Maryland School of Medicine, Baltimore, MD Purpose/Objective(s): In Glioblastoma (GBM), lymphopenia has been shown to be a predictor of overall survival (OS). The primary aim of this study was to expand on this known observation and to determine whether this is retained in the context of adjusting for contemporary prognostic variables in a modern cohort of patients. Materials/Methods: In this retrospective study of consecutive newly diagnosed GBM patients from September 2008 to December 2015, we collected Complete Blood Count with differential (CBCd) during CRT at early (TP1, median 11days, range 2-33) and late (TP2, median 36 days, range 19 e 53) time points as well as after CRT (TP3, median 23 days post CRT, range 5-80). To determine whether changes in white blood cell (WBC) or absolute lymphocyte counts (ALC) were associated with OS, we evaluated “early” (during CRT, TP1 to TP2) and “sustained” (after CRT, TP1 to TP3) decreases. To account for independent prognostic factors we utilized a validated nomogram-predicted survival (NPS) that includes age, gender, extent of resection, Karnofsky Performance Status, and MGMT status. Kaplan-Meier (KM) analysis was used for OS, and univariate and multivariate (MVA) Cox Regression analyses for Hazard Ratio (HR) of OS. Results: Sixty-seven of 127 patients with newly diagnosed GBM had all necessary independent prognostic variables for evaluation. Median age was 61 (range 21-86 years). For evaluation of changes in WBC and ALC during CRT, 50/67 and 42/67 patients were evaluable, respectively. For sustained changes in ABC and ALC, (TP1 to TP3), 57/67 and 56/67 were evaluable. There was no significant association between “early” changes in WBC or ALC and OS. Any “sustained” decrease in ALC was associated with a worse OS (HR 2.095 95% [1.041 e 4.214] pZ0.018). On MVA using the one year NPS, a “sustained” ALC decrease continued to be correlated with worse OS (HR 2.095 95% [1.041 e 4.214] pZ0.038). KM estimates of survival were 25.5 vs 16.8 months (pZ0.040) for any “sustained” decrease in ALC. Conclusion: Our data suggest that it is actually the sustained drop in ALC from early in treatment initiation post-treatment that is associated with to survival decrement, rather than a specific ALC value. An intriguing hypothesis that emerges from this observation is that if an adequate reserve of functional lymphocytes is not maintained during and immediately after CRT, worse OS can be expected. Therefore, attempts to mitigate lymphopenia during CRT should be prospectively evaluated to determine if these can improve OS. Author Disclosure: A. Turkaj: None. L. Trombetta: None. J.K. Molitoris: None. S.N. Badiyan: None. S.M. Bentzen: Travel Expenses; University of Copenhagen. M.V. Mishra: Employee; Orthofix. Research Grant; ASTRO, Keep Punching. Advisory Board; Patient Centers Outcomes Research Institute (PCORI. Travel Expenses; Patient Centers Outcomes Research Institute (PCORI. M.P. Mehta: Stock options; Pharmacyclics. Consultant; Monteris, Varian. Travel Expenses; Pharmacyclics. Administrative and Scientific; PTCOG. Board responsibilities; PCG. CNS Committee Chair; NRG Oncology. Y. Kwok: None. A. Kaiser: None.
Volume 99 Number 2S Supplement 2017 Purpose/Objective(s): Hemangiopericytomas are rare central nervous system (CNS) tumors. We sought to investigate existing clinical management strategies and overall survival (OS) among patients with hemangiopericytomas arising from the CNS. Materials/Methods: All patients diagnosed with CNS hemangiopericytoma from 2004-2014 in the National Cancer Database were included. Clinical and treatment-related characteristics were recorded and analyzed for an association with OS following diagnosis using univariable and multivariable analyses. Results: Nine-hundred and eighty-one patients were included (0.22% of all CNS tumors). At diagnosis, 22 patients had spinal tumors (2%), 21 patients had multifocal tumors (2%) and 28 had disseminated disease (3%). Patients either underwent surgical resection and radiation (48%), surgery alone (37%), radiation alone (6%), or biopsy alone (9%). Of patients with known extent of resection, 53% underwent gross total resection, and, of patients with known radiation modality, 15% received stereotactic radiosurgery. Among the total cohort, 3 and 10 year OS was 87% and 59%, respectively. On multivariable analysis, factors associated with inferior OS included age (HRZ1.05, p<0.001), WHO grade (p<0.001), multifocal disease (HRZ2.59, pZ0.04), disseminated disease (HRZ2.67, pZ0.01), and chemotherapy (HRZ2.66, pZ0.01). Patients receiving surgery alone or surgery and radiation demonstrated improved OS compared to biopsy alone (HRZ0.45, pZ0.01 and HRZ0.47, pZ0.02, respectively). However radiation utilization did not impact OS (pZ0.691). Conclusion: The present data provide large-scale prognostic information from a contemporary cohort of patients with hemangiopericytoma and support an initial attempt at surgical extirpation. The benefits of ionizing radiation are likely limited to improved local control and neurologic function. Author Disclosure: D.M. Trifiletti: ; ARRO. G.U. Mehta: None. S. Grover: None. J.P. Sheehan: None.
2269 Prognostic Implications of Extent of Resection in Glioblastoma: Analysis from a Large Database D.M. Trifiletti,1 C. Alonso,1 S. Grover,2 C.E. Fadul,3 J.P. Sheehan,4 and T.N. Showalter1; 1Department of Radiation Oncology, University of Virginia, Charlottesville, VA, 2Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, 3Department of Neurology, University of Virginia, Charlottesville, VA, 4Department of Neurosurgery, University of Virginia, Charlottesville, VA Purpose/Objective(s): To analyze the predictors for and clinical impact of gross total resection (GTR) in patients with glioblastoma (GBM). Materials/Methods: The National Cancer Database was queried for patients with GBM diagnosed from 2004-2013 with known survival and extent of resection. Patients were grouped based on extent of resection into biopsy alone, subtotal resection (STR), and GTR. Univariable and multivariable (MVA) analyses were performed to investigate factors associated with the likelihood of GTR and overall survival (OS) following diagnosis. Results: 27,865 patients met inclusion criteria. Factors associated with increased odds of GTR on MVA included later year of diagnosis, younger age, higher performance status, non-right sided tumors, multifocal tumors, and O6-methylguanine-methyltransferase (MGMT)gene promoter nonhypermethylated tumors (each p < 0.020). Factors associated with improved OS on MVA included younger patient age, female gender, race, lower comorbidity score, higher performance score, smaller tumor size, unifocality, MGMT hypermethylation, radiotherapy, chemotherapy, and facility volume (each p < 0.005). After adjusting for each of these factors, compared to biopsy alone, GTR was associated with improved OS (HR 0.768, p < 0.001), while STR was not (HR 0.995, p Z 0.930). Conclusion: While a prospective randomized trial on this topic is unlikely to be completed on this subject, this large retrospective analysis provides evidence to support the recommendation of GTR in patients with GBM. This study does not support a survival benefit of STR over biopsy alone, although there may be a subset of patients with near total resection who would benefit.
Author Disclosure: D.M. Trifiletti: ; ARRO. C. Alonso: None. S. Grover: None. C.E. Fadul: None. J.P. Sheehan: None. T.N. Showalter: Honoraria; Varian Medical Systems.
2270 Association between Increase in WBC Absolute Value and Survival Before, During, and After Concurrent Chemoradiation Therapy in Patients With Newly Diagnosed Glioblastoma A. Turkaj,1 L. Trombetta,1 J.K. Molitoris,1 S.N. Badiyan,1 S.M. Bentzen,2 M.V. Mishra,1 M.P. Mehta,3 Y. Kwok,4 and A. Kaiser1; 1University of Maryland Medical Center, Baltimore, MD, 2Greenebaum Comprehensive Cancer Center and Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, 3Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 4University of Maryland School of Medicine, Baltimore, MD Purpose/Objective(s): In Glioblastoma (GBM), lymphopenia has been shown to be a predictor of overall survival (OS). The primary aim of this study was to expand on this known observation and to determine whether this is retained in the context of adjusting for contemporary prognostic variables in a modern cohort of patients. Materials/Methods: In this retrospective study of consecutive newly diagnosed GBM patients from September 2008 to December 2015, we collected Complete Blood Count with differential (CBCd) during CRT at early (TP1, median 11days, range 2-33) and late (TP2, median 36 days, range 19 e 53) time points as well as after CRT (TP3, median 23 days post CRT, range 5-80). To determine whether changes in white blood cell (WBC) or absolute lymphocyte counts (ALC) were associated with OS, we evaluated “early” (during CRT, TP1 to TP2) and “sustained” (after CRT, TP1 to TP3) decreases. To account for independent prognostic factors we utilized a validated nomogram-predicted survival (NPS) that includes age, gender, extent of resection, Karnofsky Performance Status, and MGMT status. Kaplan-Meier (KM) analysis was used for OS, and univariate and multivariate (MVA) Cox Regression analyses for Hazard Ratio (HR) of OS. Results: Sixty-seven of 127 patients with newly diagnosed GBM had all necessary independent prognostic variables for evaluation. Median age was 61 (range 21-86 years). For evaluation of changes in WBC and ALC during CRT, 50/67 and 42/67 patients were evaluable, respectively. For sustained changes in ABC and ALC, (TP1 to TP3), 57/67 and 56/67 were evaluable. There was no significant association between “early” changes in WBC or ALC and OS. Any “sustained” decrease in ALC was associated with a worse OS (HR 2.095 95% [1.041 e 4.214] pZ0.018). On MVA using the one year NPS, a “sustained” ALC decrease continued to be correlated with worse OS (HR 2.095 95% [1.041 e 4.214] pZ0.038). KM estimates of survival were 25.5 vs 16.8 months (pZ0.040) for any “sustained” decrease in ALC. Conclusion: Our data suggest that it is actually the sustained drop in ALC from early in treatment initiation post-treatment that is associated with to survival decrement, rather than a specific ALC value. An intriguing hypothesis that emerges from this observation is that if an adequate reserve of functional lymphocytes is not maintained during and immediately after CRT, worse OS can be expected. Therefore, attempts to mitigate lymphopenia during CRT should be prospectively evaluated to determine if these can improve OS. Author Disclosure: A. Turkaj: None. L. Trombetta: None. J.K. Molitoris: None. S.N. Badiyan: None. S.M. Bentzen: Travel Expenses; University of Copenhagen. M.V. Mishra: Employee; Orthofix. Research Grant; ASTRO, Keep Punching. Advisory Board; Patient Centers Outcomes Research Institute (PCORI. Travel Expenses; Patient Centers Outcomes Research Institute (PCORI. M.P. Mehta: Stock options; Pharmacyclics. Consultant; Monteris, Varian. Travel Expenses; Pharmacyclics. Administrative and Scientific; PTCOG. Board responsibilities; PCG. CNS Committee Chair; NRG Oncology. Y. Kwok: None. A. Kaiser: None.