EDEMA, NECROSIS, TUMOR SIZE, CONTRAST
ENHANCEMENT (Multivariate Studies)
A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of
resection, and survival. Michel Lacroix 2001
–
Also found that more resection, the better. More than 98% resection = 13 months vs 8.8
months.
–
Tumor necrosis measured by Hamoud et al method based on T1 images (grade I = less
than 20%, grade 2 = 25-50%, and grade 3 = more than 50%)
–
univeriate predictor of shorter survival time
–
tumor volume – area of increased signal on T1 images, and on T2 for nonenhancing.
–
Enhancement measured by in Hamoud et al's method too. 1 is low – intermediate signal,
2 is high intermediate signal intensity and 3 is signal intensity equal to that of fat
–
univeriate predictor of shorter survival time
–
Edema was also measured with Hamoud's method. 1 is edema less than tumor volume, 2
is approx equal to tumor volume and 3 is greater than tumor volume.
–
Univeriate, but NOT independent predictor in multivariate analysis, predictor of shorter
survival time
OBJECT:
The extent of tumor resection that should be undertaken in patients with glioblastoma
multiforme (GBM) remains controversial. The purpose of this study was to identify
significant independent predictors of survival in these patients and to determine whether
the extent of resection was associated with increased survival time.
METHODS:
The authors retrospectively analyzed 416 consecutive patients with histologically proven
GBM who underwent tumor resection at the authors' institution between June 1993 and
June 1999. Volumetric data and other tumor characteristics identified on magnetic
resonance (MR) imaging were collected prospectively.
CONCLUSIONS:
Five independent predictors of survival were identified: age, Karnofsky Performance Scale
(KPS) score, extent of resection, and the degree of necrosis and enhancement on
preoperative MR imaging studies. A significant survival advantage was associated with
resection of 98% or more of the tumor volume (median survival 13 months, 95%
confidence interval [CI] 11.4-14.6 months), compared with 8.8 months (95% CI 7.4-10.2
months; p < 0.0001) for resections of less than 98%. Using an outcome scale ranging from 0
to 5 based on age, KPS score, and tumor necrosis on MR imaging, we observed
significantly longer survival in patients with lower scores (1-3) who underwent aggressive
resections, and a trend toward slightly longer survival was found in patients with higher
scores (4-5). Gross-total tumor resection is associated with longer survival in patients with
GBM, especially when other predictive variables are favorable
Prognostic significance of preoperatives MRI scans in glioblastoma multiforme – Maarouf
A Hammoud 1996
–
Measured sex, tumor location and volume, necrosis, enhancement, edema, neurological
symptoms, preoperative Karnofsky score, type of radiotherapy as they related to survival
outcome.
–
Variables individually predictive of survival: Edema, Necrosis.
–
Variables predicting survival using multivariate cox model: Edema, enhancement. But not
volume or tumor location.
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but volume was measured pie*(axbxc)/6. In cm cubed.
Tumor necrosis, enhancement, and associated edema in patients with glioblastoma
multiforme (GBM) represent biological variables that can be quantitated on preoperative
MRI scans. We reviewed 48 highly selected patients, all of whom had supratentorial lesions,
had undergone gross total tumor resection, and had received adjuvant treatments (radioand chemotherapies). None of these patients had had surgery for recurrent tumor resection
and none had harbored multifocal tumors. The median age was 50 years. The median
Karnofsky performance score was 80. Multivariate analysis using the Cox regression model
revealed that the strongest prognostic variable was the amount of tumor necrosis on
preoperative scan (P < 0.001), with median survivals of 42, 24, 15, and 12 months for tumor
necrosis grades of 0 (7 'pts'), I (11 'pts'), II (9 'pts'), and III (21 'pts'), respectively. The
intensity of enhancement of the tumor nodule was another prognostic factor (P = 0.003),
with median survivals of 35, 18, and 13.5 months for enhancement grades of 0 (2 'pts'), I
(22 'pts'), and II (24 'pts'), respectively. The extent of peritumoral edema had a quadratic
effect (P = 0.001), with grades I (19 'pts'), II (22 'pts'), and III (7 'pts') surviving for 24, 12,
and 20 months respectively. Location and volume of tumors were not statistically
significant predictors of survival (P < 0.05). In conclusion, in this highly selected group,
GBM patients with little or no necrosis and with less tumor nodule enhancement on
preoperative MRI survive longer than patients with greater amounts of necrosis and
greater degrees of tumor enhancement. In addition, a moderate degree of peritumoral
edema is associated with worse prognosis.
Supratentorial glioblastoma: neuroradiological findings and survival after surgery and
radiotherapy.
Few studies have attempted to correlate neuroimaging with outcome in patients with
glioblastoma. Our aim was to evaluate the relationship between neuroradiological findings
and survival in these patients. We studied 18 consecutive patients with glioblastoma who
had undergone surgery and radiotherapy. We assessed the following features, using
preoperative CT and/or MRI: tumour size, extent of necrotic area within the mass, extent
of perifocal oedema and contrast enhancement. The mean survival was 14.2 +/- 5 months
(range 6-22). The extent of radiological evidence of necrosis within the mass correlated
significantly with survival time, whereas tumour size, perifocal oedema and contrast
enhancement did not.
Imaging features of invasion and preoperative and postoperative tumor burden in
previously untreated glioblastoma: Correlation with survival
Background:
A paucity of data exists concerning the prognostic usefulness of preoperative and postoperative imaging
after resection of glioblastoma multiforme (GBM). This study aimed to connect outcome with imaging
features of GBM.
Methods:
Retrospective computer-assisted volumetric calculations quantified central necrotic (T0), gadoliniumenhanced (T1) and increased T2-weighted signal volumes (T2) in 70 patients with untreated GBM.
Clinical and treatment data, including extent of resection (EOR), were obtained through chart review. T1
volume was used as a measure of solid tumor burden; and T2 volume, as an indicator of invasive isolated
tumor cell (ITC) burden. Indicators of invasiveness included T2:T1 ratios as a propensity for ITC
infiltration compared to solid tumor volumes and qualitative analysis of subependymal growth and
infiltration of the basal ganglia, corpus callosum or brainstem. Cox multivariate analysis (CMVA) was
used to identify significant associations between imaging features and survival.
Results:
In the 70 patients studied, significant associations with reduced survival existed for gadoliniumenhancing tumor crossing the corpus callosum (odds ratio, 3.14) and with increased survival with
gross total resection (GTR) (GTR median survival, 62 weeks versus 37 and 34 weeks for sub-total
resection and biopsy, respectively). For a selected “GTR-eligible” subgroup of 52 patients, prolonged
survival was associated with smaller preoperative gadolinium-enhancing volume (T1) and actual
GTR.
Conclusion:
Some magnetic resonance (MR) imaging indicators of tumor invasiveness (gadolinium-enhancing
tumor crossing the corpus callosum) and tumor burden (GTR and preoperative T1 volume in
GTR-eligible subgroup) correlate with survival. However, ITC-infiltrative tumor burden (T2 volume)
and “propensity” for ITC invasiveness (T2:T1 ratio) did not impact survival. These results indicate that
while the ITC component is the ultimate barrier to cure for GBM, the pattern of spread and volumes of
gadolinium-enhancing solid tumor are more robust indicators of prognosis.
Table 4
Multivariate statistical analysis
Variable
Age
(continuous)
Group/subgroup
Full
(n=70)Odds
GTR
(n=32)Odds
Ratio
P value
Ratio
P value
Ratio
P value
1.64*
.000
1.63*
.000
1.76*
.001
Sex (M vs. F)
KPS (<70
vs.≥70)
GTR-Eligible
(n=52)Odds
0.36
.403
.512
.007
.257
.944
Variable
Group/subgroup
Full
(n=70)Odds
Ratio
EOR
P value
GTR-Eligible
(n=52)Odds
Ratio
P value
4.52
.000
GTR
(n=32)Odds
Ratio
P value
.003
BX vs. GTR
4.01
.013
STR vs. GTR
3.12
.001
Other TX (#)
.533
.663
.858
Chemotherapy
(Y/N )
.814
.532
.745
Primary location
(Deep/mixed vs.
Lobar)
.764
.942
.424
Midline shift
(continuous)
.315
.015
.287
Basal ganglia
.748
.145
.507
.360
.068
.264
.177
.890
.374
.009
.723
0.25
Edema only vs.
None
Gad+ vs. None
Contralateral
corpus callosum
.015
Edema only vs.
None
0.58
.303
Gad+ vs. None
3.14
.008
Subependymal
C+ (Y/N)
.350
Brainstem
involvement
(Y/N)
.298
T0 volume
.067
T1 volume
.753
T2 volume
.374
.773
.804
T2/T1
.531
.877
.886
T2/T1 total
.699
.862
.889
PCFA
.972
.580
.139
1.02
Imaging features of invasion and preoperative and postoperative tumor burden in
previously untreated glioblastoma: Correlation with survival (Ramakrishna 2010)
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-
-
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invasive feature of gadolinium enhancement crossing the corpus callosum and the tumor
burden feature of greater t1 volume were associated with shorter survival
the lack of t1 enhancement post operatively predicted longer survival.
Nothing else associated with outcome.
Tumor burden does not equal tumor “size” as visualized on MRI. But t2 signal (edema) is
a good estimator.
o ITC (isolated tumor cells) can be in normal brain so MRI is also not good at
measuring ITC density.
High T2/T1 ratios (edema/contrast enhancement) associate with EGFR overexpression
which is associated with increased angiogenesis, edema, and brain invasion.
Also mentioned how rate (ie glioma cell motility) is not studied with MRI images and
probably deals with invasiveness
Background: A paucity of data exists concerning the prognostic usefulness of
preoperative and postoperative imaging after resection of glioblastoma multiforme
(GBM). This study aimed to connect outcome with imaging features of GBM.
Methods: Retrospective computer-assisted volumetric calculations quantified central
necrotic (T0), gadolinium-enhanced (T1) and increased T2-weighted signal volumes (T2)
in 70 patients with untreated GBM. Clinical and treatment data, including extent of
resection (EOR), were obtained through chart review. T1 volume was used as a measure
of solid tumor burden; and T2 volume, as an indicator of invasive isolated tumor cell
(ITC) burden. Indicators of invasiveness included T2:T1 ratios as a propensity for ITC
infiltration compared to solid tumor volumes and qualitative analysis of subependymal
growth and infiltration of the basal ganglia, corpus callosum or brainstem. Cox
multivariate analysis (CMVA) was used to identify significant associations between
imaging features and survival.
Results: In the 70 patients studied, significant associations with reduced survival existed
for gadolinium-enhancing tumor crossing the corpus callosum (odds ratio, 3.14) and with
increased survival with gross total resection (GTR) (GTR median survival, 62 weeks
versus 37 and 34 weeks for sub-total resection and biopsy, respectively). For a selected
"GTR-eligible" subgroup of 52 patients, prolonged survival was associated with smaller
preoperative gadolinium-enhancing volume (T1) and actual GTR.
Conclusion: Some magnetic resonance (MR) imaging indicators of tumor invasiveness
(gadolinium-enhancing tumor crossing the corpus callosum) and tumor burden (GTR and
preoperative T1 volume in GTR-eligible subgroup) correlate with survival. However,
ITC-infiltrative tumor burden (T2 volume) and "propensity" for ITC invasiveness (T2:T1
ratio) did not impact survival. These results indicate that while the ITC component is the
ultimate barrier to cure for GBM, the pattern of spread and volumes of gadoliniumenhancing solid tumor are more robust indicators of prognosis.
Keywords: Glioblastoma, invasion, MR imaging, resection, survival, tumor burden