Elsevier

World Neurosurgery

Volume 86, February 2016, Pages 341-348.e3
World Neurosurgery

Original Article
Predictive Factors Determining the Overall Outcome of Primary Spinal Glioblastoma Multiforme: An Integrative Survival Analysis

https://doi.org/10.1016/j.wneu.2015.08.078Get rights and content

Objective

Primary glioblastoma multiforme of the spinal cord is a rare entity. The aim of this study was to perform an integrative analysis of patients whose cases were selected from the published studies, and to examine the influence of various factors on overall outcomes.

Methods

A PubMed search was performed for literature published from 1938 to 2015 to select the articles containing information about the demographics, tumor location, critical event (death), time to events, and treatment characteristics.

Results

One hundred twenty-eight cases of spinal glioblastoma were selected for analysis. Patients between 18 and 65 years of age had a better overall survival rate (14 months) compared with those of “extreme” age outside that range (<18 years, 10.5 months, and >65 years, 2 months; log-rank P = 0.0005). Univariate analysis showed age between 18 and 65 years (hazard ratio [HR] = 0.121; 95% confidence interval [CI] = 0.04–0.37; P = 0.0005) and surgery with radiotherapy (HR = 3.71; 95% CI = 1.36–10.13; P = 0.01) had a significant correlation with overall survival. In multivariate analysis, thoracic spine (odds ratio [OR] = 0.154; 95% CI = 0.033–0.717; P = 0.017) and conus (OR = 0.091; 95% CI = 0.010–0.798; P =0.030) tumor had a lesser chance for mortality at 6 months. Patients who received adjuvant therapy had a better median survival than those who had surgery (log-rank P = 0.0005).

Conclusion

In this systemic analysis of primary spinal glioblastoma multiforme, we found that surgery followed by adjuvant therapy (radiotherapy, chemotherapy, or both) was significantly associated with improved survival. The additional finding was that overall median survival was better in the age group of 18–65 years (68 cases) compared with the extremes (<18 years, 53 cases; >65 years, 4 cases).

Introduction

Intramedullary tumors are relatively uncommon among all central nervous system tumors, accounting for only 2–4% of the total. Ependymomas are the most common intramedullary tumors followed by astrocytoma. Spinal glioblastomas account for approximately 7.5% of all intramedullary gliomas, and barely 1.5% of all spinal tumors.1, 2 Patients within their first two decades of life3, 4, 5 tend to be more vulnerable to develop this type of tumor. The cervical spine is the most affected region—mainly the lower cervical spine—followed by the thoracic spine.4, 6, 7 Conus is a rare location for spinal glioblastoma multiforme (GBM). The treatment protocol for spinal cord glioblastoma is limited because of the scarcity of cases. The formal approach of spinal cord GBM consists of biopsy followed by radiotherapy (RT).8 Chemotherapy (CT) also plays a role in final outcomes as per various studies.9, 10 Because of the small number of cases in the literature featuring GBM and long-term survival, the assessment of the effects of prognostic factors on progression-free survival and overall survival is restricted. The aim of our study was to perform the integrative survival analysis by extracting individual patient data from the reported literature and elucidating more precisely the degree of association of the various factors with the survival outcome and to estimate the predictability of the overall survival (OS) by using Kaplan–Meier analysis.

Section snippets

Search Strategy

A systematic method was used to identify the relevant articles of English-language literature using the standard search string. The search was initiated inserting the key-term “spinal intramedullary malignant tumor” in PubMed, which generated 2108 articles published from 1938 to 2015. To conduct a comprehensive search, articles were further extracted by using key terms such “Primary spinal glioblastoma multiforme” and “Glioblastoma multiforme of spinal cord.” This second search generated 552

Results

The total number of cases published in the literature was 186 in 58 articles. Only 128 patients with primary spinal glioblastoma and complete information regarding the demographics, location of tumor, critical events (death), time to events, and treatment characteristics were selected for inclusion. Details about age, sex, and location were available in 126 (97.6%), 124 (96.1%), and 128 (100%) cases, respectively. The most common presenting symptom was limb weakness (50.4%), followed by sensory

Discussion

Intramedullary spinal cord tumors are rare and mainly composed of gliomas (80%), of which 60–70% are ependymomas and 30–40% are astrocytomas. Chamberlain et al.16 reported that 25% of spinal gliomas were high grade and associated with a poor survival rate. In general, the overall survival range for spinal GBM tends to be 12–24 months.22, 37, 63 Lam et al.64 found that the median survival for spinal GBM was 7 months in a population-based study. To our knowledge, the longest reported survival

Conclusions

The spinal cord is a rare site of GBM, which has a poor overall survival despite multimodality therapy. In this systemic analysis of spinal GBM, we found that surgery followed by RT and CT or surgery followed by RT alone had a significant effect on prolongation of life. The additional finding was improved OS in the adult group (18–65 years). This study did not find a statistically significant association between sex, tumor location, and extent of surgical resection on survival. For future

References (68)

  • K.J. Minehan et al.

    Prognosis and treatment of spinal cord astrocytoma

    Int J Radiat Oncol Biol Phys

    (2009)
  • A. Raco et al.

    Long-term follow-up of intramedullary spinal cord tumors: a series of 202 cases

    Neurosurgery

    (2005)
  • D.C. Miller

    Surgical pathology of intramedullary spinal cord neoplasms

    J Neurooncol

    (2000)
  • S. Constantini et al.

    Intramedullary spinal cord tumors in children under the age of 3 years

    J Neurosurg

    (1996)
  • F.J. Epstein et al.

    Adult intramedullary astrocytomas of the spinal cord

    J Neurosurg

    (1992)
  • G.I. Jallo et al.

    Intramedullary spinal cord tumors in children

    Childs Nerv Syst

    (2003)
  • B. Guidetti et al.

    Long-term results of the surgical treatment of 129 intramedullary spinal gliomas

    J Neurosurg

    (1981)
  • I.F. Pollack

    Intramedullary spinal cord astrocytomas in children

    Pediatr Blood Cancer

    (2004)
  • M.J. McGirt et al.

    Extent of surgical resection of malignant astrocytomas of the spinal cord: outcome analysis of 35 patients

    Neurosurgery

    (2008)
  • J.C. Allen et al.

    Treatment of high-grade spinal cord astrocytoma of childhood with “8-in-1” chemotherapy and radiotherapy: a pilot study of CCG-945. Children’s Cancer Group

    J Neurosurg

    (1998)
  • R. Sposto et al.

    The effectiveness of chemotherapy for treatment of high-grade astrocytoma in children: results of a randomized trial. A report from the Children’s Cancer Study Group

    J Neurooncol

    (1989)
  • A.A. Andrews et al.

    Spinal intramedullary glioblastoma with intracranial seeding. Report of a case

    Arch Neurol

    (1978)
  • N. Asano et al.

    Spinal cord glioblastoma multiforme with intracranial dissemination–case report

    Neurol Med Chir (Tokyo)

    (1990)
  • P. Banczerowski et al.

    Surgery of ventral intradural midline cervical spinal pathologies via anterior cervical approach: our experience

    Ideggyogy Sz

    (2003)
  • E. Caroli et al.

    Spinal glioblastoma with brain relapse in a child: clinical considerations

    Spinal Cord

    (2005)
  • M.C. Chamberlain et al.

    Adult primary intradural spinal cord tumors: a review

    Curr Neurol Neurosci Rep

    (2001)
  • P. Ciappetta et al.

    Spinal glioblastomas: report of seven cases and review of the literature

    Neurosurgery

    (1991)
  • A.R. Cohen et al.

    Malignant astrocytomas of the spinal cord

    J Neurosurg

    (1989)
  • S. Cursiefen et al.

    Intramedullary glioblastoma multiforme with intracranial spinal intracranial seeding

    J Neurol

    (1998)
  • K.C. Eden

    Dissemination of a glioma of the spinal cord in the leptomeninges

    Brain

    (1938)
  • T.S. Gee et al.

    Case report: a rare case of pediatric conus medularis glioblastoma multiforme

    Med J Malaysia

    (2012)
  • W. Grisold et al.

    Giant-cell glioblastoma of the thoracic cord

    Acta Neurochir (Wien)

    (1981)
  • M. Hely et al.

    Intramedullary spinal cord glioma with intracranial seeding

    J Neurol Neurosurg Psychiatry

    (1985)
  • K. Iwata et al.

    Significance of MIB-1, PCNA indices, and p53 protein over-expression in intramedullary tumors of the spinal cord

    Noshuyo Byori

    (1996)
  • Cited by (0)

    Supplementary digital content available online.

    View full text