title: Biopsy versus partial versus gross total resection in older patients with high-grade glioma: a systematic review and meta-analysis.
abstract: BACKGROUND
  Optimal extent of surgical resection (EOR) of high-grade gliomas (HGGs) remains uncertain in the elderly given the unclear benefits and potentially higher rates of mortality and morbidity associated with more extensive degrees of resection.
  
  
  METHODS
  We undertook a meta-analysis according to a predefined protocol and systematically searched literature databases for reports about HGG EOR. Elderly patients (≥60 y) undergoing biopsy, subtotal resection (STR), and gross total resection (GTR) were compared for the outcome measures of overall survival (OS), postoperative karnofsky performance status (KPS), progression-free survival (PFS), mortality, and morbidity. Treatment effects as pooled estimates, mean differences (MDs), or risk ratios (RRs) with corresponding 95% confidence intervals (CIs) were determined using random effects modeling.
  
  
  RESULTS
  A total of 12 607 participants from 34 studies met eligibility criteria, including our current cohort of 211 patients. When comparing overall resection (of any extent) with biopsy, in favor of the resection group were OS (MD 3.88 mo, 95% CI: 2.14-5.62, P < .001), postoperative KPS (MD 10.4, 95% CI: 6.58-14.22, P < .001), PFS (MD 2.44 mo, 95% CI: 1.45-3.43, P < .001), mortality (RR = 0.27, 95% CI: 0.12-0.61, P = .002), and morbidity (RR = 0.82, 95% CI: 0.46-1.46, P = .514) . GTR was significantly superior to STR in terms of OS (MD 3.77 mo, 95% CI: 2.26-5.29, P < .001), postoperative KPS (MD 4.91, 95% CI: 0.91-8.92, P = .016), and PFS (MD 2.21 mo, 95% CI: 1.13-3.3, P < .001) with no difference in mortality (RR = 0.53, 95% CI: 0.05-5.71, P = .600) or morbidity (RR = 0.52, 95% CI: 0.18-1.49, P = .223).
  
  
  CONCLUSIONS
  Our findings suggest an upward improvement in survival time, functional recovery, and tumor recurrence rate associated with increasing extents of safe resection. These benefits did not result in higher rates of mortality or morbidity if considered in conjunction with known established safety measures when managing elderly patients harboring HGGs.
authors.affiliation: Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.).
authors.forename: Saleh A
authors.initials: SA
authors.lastname: Almenawer
authors.affiliation: Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.).
authors.forename: Jetan H
authors.initials: JH
authors.lastname: Badhiwala
authors.affiliation: Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.).
authors.forename: Waleed
authors.initials: W
authors.lastname: Alhazzani
authors.affiliation: Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.).
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Greenspoon
authors.affiliation: Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.).
authors.forename: Forough
authors.initials: F
authors.lastname: Farrokhyar
authors.affiliation: Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.).
authors.forename: Blake
authors.initials: B
authors.lastname: Yarascavitch
authors.affiliation: Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.).
authors.forename: Almunder
authors.initials: A
authors.lastname: Algird
authors.affiliation: Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.).
authors.forename: Edward
authors.initials: E
authors.lastname: Kachur
authors.affiliation: Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.).
authors.forename: Aleksa
authors.initials: A
authors.lastname: Cenic
authors.affiliation: Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.).
authors.forename: Waseem
authors.initials: W
authors.lastname: Sharieff
authors.affiliation: Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.).
authors.forename: Paula
authors.initials: P
authors.lastname: Klurfan
authors.affiliation: Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.).
authors.forename: Thorsteinn
authors.initials: T
authors.lastname: Gunnarsson
authors.affiliation: Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.).
authors.forename: Olufemi
authors.initials: O
authors.lastname: Ajani
authors.affiliation: Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.).
authors.forename: Kesava
authors.initials: K
authors.lastname: Reddy
authors.affiliation: Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.).
authors.forename: Sheila K
authors.initials: SK
authors.lastname: Singh
authors.affiliation: Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.).
authors.forename: Naresh K
authors.initials: NK
authors.lastname: Murty
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001706:Biopsy; D001932:Brain Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D018572:Disease-Free Survival; D005260:Female; D005910:Glioma / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D006801:Humans; D017567:Karnofsky Performance Status; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures; D016896:Treatment Outcome
keywords: elderly; extent of resection; malignant glioma; meta-analysis; systematic review