MANAGEMENT N OF PRIMARY BRAIN TUMOURS IN THE ELDERLY Meningioma, Glioma, Lymphoma Cornu Ph, Keime-Guibert F, Hoang-Xuan K, Pierga JY, Delattre JY Neuro-oncology Group of Pitie-Salpetriere hospital-paris-france MANAGEMENT OF PRIMARY BRAIN TUMOURS IN THE ELDERLY Meningioma 15 to % of brain tumours Elderly people ~ 5% (Kuru et al - 1997) BENIGN tumour surgical resection RISK : morbidity / mortality Page 1
Meningioma in Elderly Patients AGE SEXE KARNOFSKY ASA TUMOUR SIZE TUMOUR LOCATION OEDEMA Good outcome Karnofsky > 7 Poor outcome Death or Karnofsky < 7 Meningioma in Elderly Patients ASA Physical Status I Healthy patient II Mild systemic disease no functional limitation III Severe systemic disease definite functional limitation IV Severe systemic disease constant threat to life V Moribund patient Page 2
MANAGEMENT OF PRIMARY BRAIN TUMOURS IN THE ELDERLY The incidence of primary intracranial tumours has increased over the past two decades in elderly people age > 7 18.1 /1 / year age specific incidence /1 / year 23.2 7-74 18.1 75-79 15.1 8-84 7.6 > 85 Meningioma in Elderly Patients 3 34 96 patients 36 Males 6 Females 18 14 18 1 4 8 65-7 7-75 > 75 Cornu et al, Acta Neurochir (Wien), 12 : 98-12, 199 AGE Page 3
Meningioma in Elderly Patients Convexity n = 34 (35%) 96 Patients Parasagittal / Falx n = 24 (25 %) Base n = 38 ( %) Olfactory groove 4 Tuberculum sellae 9 Sphenoidal ridge 8 Orbito-cranial 3 Temporo-basal 5 Tentorial 3 Posterior Fossa 5 Foramen Magnum 1 Meningioma in Elderly Patients Operative mortality 15 / 96 16 % Haematoma 6 Cerebral infarction 4 Empyema 1 Status epilepticus 1 Pulmonary Embolism 2 Gastro-intestinal haemorrhage 1 Page 4
Meningioma in Elderly Patients Surgical complications Haematoma 15 (16 %) Cerebral infarction 12 (13 %) Cerebral oedema (stupor transient ± deficit) 16 (17 %) Infection 1 (1 %) Hydrocephaly 2 (2 %) Meningioma in Elderly Patients Medical Complications Pneumopathy 19 ( %) Meningitis 3 (3 %) Septicaemia 2 (2 %) Cardio respiratory failure 5 (5%) Pulmonary embolism 6 (6 %) Cardiac insufficiency 4 (4 %) Epilepsy (seizure) 4 (3 %) Gastro-intestinal haemorrhage 1 (1 %) Page 5
Meningioma in Elderly Patients 96 patients No Complication 55 / 96 (57 %) Complications Surgical Medical p <. 1 Meningioma in Elderly Patients AGE SEXE ASA KARNOFSKY TUMOUR LOCATION TUMOUR SIZE OEDEMA Good outcome Karnofsky > 7 Poor outcome Death or Karnofsky Š 7 Page 6
Meningioma in Elderly Patients Prognostic factors Outcome Good Poor p n = 6 n = 36 ------------------------------------------------------------------------------------- Age 7 ± 4 71 ± 4 NS Males % 37 39 NS ASA I (%) 27 14 ASA II 53 44 ASA III 42 p =.5 Karnofsky Š 7 33 72 p <.1 Location 32 53 p <.5 Size > 5 cm 48 58 NS oedema 38 5 NS Meningioma in Elderly Patients Prognostic value of ASA classification % of POOR outcome 8 6 57 48 75 ASA I ASA II ASA III 7 14 K>7 KŠ 7 Pre-operative Karnofsky's index Page 7
Meningioma in Elderly Patients Prognostic value of tumour location % of POOR outcome 8 6 48 6 44 56 Convexity Falcine / Parasgittal Skullbase 24 K > 7 K Š 7 Pre-operative Karnofsky's index Meningioma in Elderly Patients Conclusion Age is not a contraindication to the surgery of intracranial meningioma BUT Surgery must be considered in symptomatic elderly patients Because of the high mortality and morbidity associated with this type of surgery careful examination of risk factors for poor outcome is needed 1. Neurological conditions 2.General health conditions 3.Tumour location Page 8
9 Glioma in Elderly Patients Average annual age specific incidence rates by histologic types 8 7 % Low grade astrocytomas Oligodendrogliomas and mixte 6 Malignant gliomas 5 3 1 Age Fleury A et al, Cancer, 79, 6, 1195-12, 1997 1 Glioma in Elderly Patients Relation between age and the incidence of malignant gliomas % 9 8 7 6 5 3 comparison 1983-1984 1988-199 1 Age Fleury A et al, Cancer, 79, 6, 1195-12, 1997 Page 9
% 1 9 8 7 6 Glioma in Elderly Patients Relation between age and the incidence of malignant gliomas comparison 1983-1984 1988-199 5 3 1 Age Fleury A et al, Cancer, 79, 6, 1195-12, 1997 Malignant gliomas in Elderly Patients Overall survival % probability 1 9 8 7 6 3 patients Age > 7 years old 5 3 1 1 3 5 6 7 8 Weeks Pierga JY et al, Treatment of malignant gliomas in the elderly, submitted Page 1
Malignant gliomas in Elderly Patients Survival according to the performance status at the onset 1 % probability 9 8 7 6 IK > 7 IK < 7 5 3 Logrank test p <.5 1 1 3 5 6 7 8 Pierga JY et al, Treatment of malignant gliomas in the elderly, submitted Weeks Malignant gliomas in Elderly Patients TOLERATED? ELDERLY PEOPLE surgery radiotherapy chemotherapy USEFUL? Page 11
Malignant gliomas in Elderly Patients Surgery LONGER DURATION COMPLETE RESECTION QUALITY OF SURVIVAL MEAN SURVIVAL 128 patients > 65 y.o. kelly et al, 1994 BIOPSY + RT = 16.9 wk SURGERY + RT = 3. wk n = 62 n = 34 Malignant gliomas in Elderly Patients Radiotherapy Median survival 17.5 wk - 67 patients Meckling et al, 1996 36 wk - 3 patients Pierga et al, 1997 Modalities of treatment WBRT / limited field Total dose / dose per fraction Page 12
Malignant gliomas in Elderly Patients Favorable prognostic factors for radiotherapy age karnofsky tumour size LIMITED FIELD & REDUCED DOSES Longer survival Limited survival Malignant gliomas in Elderly Patients Chemotherapy Response rates are poor Myelosuppressive complications frequent Grant et al, Neurology 1995 Page 13
Malignant gliomas in Elderly Patients Conclusion Increasing incidence Prognosis for elderly patients is poor BUT in selected patients Surgical resection Radiotherapy (limited field - adapted doses) Chemotherapy Therapeutic trials Survival Quality of Life Lymphomas in Elderly Patients 1 Overall survival % probability 9 8 7 Age < 6 Age > 6 6 5 3 1 1 2 3 4 5 6 7 8 9 1 11 Years Corry J et al, Int J Radiation Oncology Biol. Phys.,, 3 : 615-6, 1998 Page 14
1 Lymphomas in Elderly Patients Proportion of patients developing neurotoxicity 8 Age > 6 Age < 6 6 p <.1 (Mantel - Cox method) 24 48 72 96 1 144 Months Abrey LE et al, Journal of Clinical Oncology, 16, 3 : 859-863, 1998 MANAGEMENT OF PRIMARY BRAIN TUMOURS IN THE ELDERLY Conclusion Functionnal and neurological integrity Good general health conditions - ASA classification Brain tolerance to treatments (physiopathology of Aging) Multicentric clinical trials - most appropriate therapeutic stategies - Quality of Life assessment Neuro-oncology Group of Pitie-Salpetriere hospital-paris-france Page 15