Prognostic Factors and Treatment of Spinal Astrocytomas

A Multi-institutional Cohort Analysis

Yingjie Zou, MD; James Sun, BA; Yangying Zhou, BS; Harrison Xiao Bai, MD; Xiangyan Huang, MD; Ranjith Babu, MD; Alessandro Landi, MD; Kap Sum Foong, MD; Zishu Zhang, MD; John H. Woo, MD; Yongguang Tao, PhD; Xuejun Li, MD, PhD; Xiangqi Tang, MD, PhD; Bo Xiao, MD, PhD; Paul J. Zhang, MD; Li Yang, MD, PhD

Disclosures

Spine. 2018;43(10):E565-E573.

Limitations

We would like to acknowledge several limitations of our study. First, the multi-institutional cohort meant variation in patient demographics and treatment protocols. However, all four institutions included were large referral centers. Second, in the literature cohort, there was a higher proportion of high-grade tumors than low-grade tumors which may reflect publication bias. Third, there was unavoidable selection bias by including such a heterogeneous population from the literature, since treatments such as RT and chemotherapy may not have been given randomly. Fourth, some of the reports in our analysis come from the pre-magnetic resonance imaging era, where there was no central review of the extent of resection. Finally, attention has recently been paid to the molecular status of astrocytoma, such as the status of isocitrate dehydrogenase mutation. Because of the lack of molecular information for patients collected from the four institutions and the vast majority of the published articles, our analysis did not include this information.

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Table 1. Comparison of Baseline Characteristics Between Multi-institutional Cohort and Literature Data
Factor	Categories	Multi-institutional Cohort (n = 94)	Literature Cohort (n = 339)	Fisher Exact P Value
Age	Pediatric (<18 yr)	33	160	0.046*
	Adult (≥18 yr)	61	179
Sex	Male	64	172	0.024*
	Female	30	142
Weakness	No	29	55	1.000
	Yes	50	91
Paresthesia	No	42	92	0.018*
	Yes	37	40
Pain	No	42	79	0.474
	Yes	37	55
Bowel/bladder incontinence	No	66	116	1.000
	Yes	13	22
WHO grade	I	20	47	0.035*
	II	22	61
	III	23	60
	IV	25	134
Location	Cervical	44	160	0.108
	Thoracic	48	143
	Lumbar	2	8
	Holocord	0	15
Extent of resection	STR	50	150	0.287
	GRT	21	98
	No surgery	23	91
Radiotherapy	No	39	96	0.134
	Yes	54	194
Chemotherapy	No	40	151	0.072
	Yes	53	27
Complication	No	71	313	<0.001*
	Yes	22	26
Recurrence/progression	No	30	90	0.377
	Yes	64	151
Metastasis	No	70	291	0.487
	Yes	14	46

GTR indicates gross total resection; STR, subtotal resection.
*P < 0.05.

Table 2. Univariate Analysis of the Multi-institutional Cohort (n = 94)
Factor	Categories	n	PFS		OS
Factor	Categories	n	Median Length (mo)	Log Rank P Value	Median Length (mo)	Log Rank P Value
Age	Pediatric (<18 yr)	33	22	0.067*	56	<0.001*
	Adult (≥ 18 yr)	61	12		25
Sex	Male	64	12	0.647	25	0.634
	Female	30	19		32
Weakness	No	29	31	0.029*	93	0.074*
	Yes	50	11		24
Paresthesia	No	42	18	0.288	29	0.012*
	Yes	37	11		28
Pain	No	42	18	0.645	38	0.473
	Yes	37	12		26
Bowel/bladder incontinence	No	66	19	0.191	38	0.105
	Yes	13	12		23
WHO grade	I	20	87	<0.001*	110	<0.001*
	II	22	47		71
	III	23	10		23
	IV	25	6		20
Preoperative McCormic k Score	I	17	26	0.012*	110	0.487
	II	52	18		27
	III	23	6		22
	IV	2	2		25
Location	Cervical	44	12	0.096*	24	0.074*
	Thoracic	48	20		36
	Lumbar	2	5		—
Extent of resection	STR	50	11	<0.001*	23	0.007*
	GTR	21	24		93
	Biopsy	23	48		71
Radiotherapy	No	39	22	0.004*	32	0.059*
	Yes	54	12		25
Chemotherapy	No	40	67	0.001*	60	0.418
	Yes	53	12		26
Complication	No	71	18	0.380	26	0.562
	Yes	22	10		28
Change in McCormic k Score (Post-Pre)	−1	2	4	0.494	222	0.401
	0	69	18		28
	+1	22	12		25
	+3	1	—		—
Recurrence/progression	No	30			60	0.234
	Yes	64			26
Metastasis	No	70			36	0.134
	Yes	14			25

GTR indicates gross total resection; PFS, progression free survival; OS, overall survival; STR, subtotal resection.
*P < 0.10.

Table 3. Multivariate Cox Regression of Progression-Free Survival for Multi-institutional Cohort (n = 75)
Factor	Categories	PFS
Factor	Categories	HR (95% CI)	P
Age	Pediatric (<18 yr)
	Adult (≥ 18 yr)	1.19 (0.59–2.42)	0.626
Weakness	No
	Yes	1.16 (0.51–2.62)	0.728
WHO grade	I
	II	1.01 (0.36–2.86)	0.984
	III	2.61 (0.78–8.67)	0.118
	IV	3.92 (1.27–12.08)	0.017*
McCormick Score (Preoperative)	I
	II	1.02 (0.39–2.72)	0.962
	III	1.54 (0.54–4.36)	0.419
	IV	5.18 (0.45–58.93)	0.185
Location	Cervical
	Thoracic	0.68 (0.36–1.29)	0.242
	Lumbar	—	—
Extent of resection	STR
	GTR	0.41 (0.14–1.27)	0.124
	Biopsy	0.69 (0.29–1.68)	0.417
Radiotherapy	No
	Yes	1.06 (0.48–2.32)	0.890
Chemotherapy	No
	Yes	1.40 (0.69–2.83)	0.358

GTR indicates gross total resection; HR, hazard ratio; PFS, progression-free survival; STR, subtotal resection.
*P <0.05.

Table 4. Multivariate Cox Regression of Overall Survival for Multi-institutional Cohort (n = 75)
Factor	Categories	OS
Factor	Categories	HR (95% CI)	P
Age	Pediatric (<18 yr)
	Adult (≥ 18 yr)	2.69 (1.36–5.32)	0.004*
Weakness	No
	Yes	1.31 (0.67–2.57)	0.431
Paresthesia	No
	Yes	2.43 (1.26–4.67)	0.008*
WHO grade	I
	II	0.72 (0.29–1.75)	0.464
	III	2.61 (1.03–6.63)	0.043*
	IV	3.53 (1.42–8.78)	0.007*
Location	Cervical
	Thoracic	0.43 (0.24–0.78)	0.006*
	Lumbar	—	—
Extent of resection	STR
	GTR	0.47 (0.17–1.30)	0.143
	Biopsy	0.43 (0.20–0.91)	0.028*
Radiotherapy	No
	Yes	0.42 (0.20–0.88)	0.022*

CI indicates confidence interval; GTR, gross total resection; HR, hazard ratio; OS, overall survival; STR, subtotal resection.
*P <0.05.

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