The Impact of Clinical Frailty on Overall Survival following Surgical Resection in Patients with High-Grade Meningiomas

Introduction: World Health Organization (WHO) grade II and III meningiomas, though relatively uncommon, represent an important subset of meningiomas that are characterized by increased recurrence and decreased survival. The standard treatment paradigm for these high-grade meningiomas generally consists of maximum safe resection, often in combination with adjuvant radiotherapy. As the general population ages, older patients are presenting with meningiomas more often, and the impact of patient frailty on postoperative outcomes emerges as an especially important question. “Patient frailty,” however, has been loosely defined, and prior studies on this topic have only examined patient populations with predominantly WHO I meningiomas. Thus, an adequate understanding of the impact of frailty on overall survival (OS) in patients undergoing surgical resection of high-grade meningiomas remains unclear. This study provides a comprehensive assessment of the impact of patient frailty on postsurgical survival in patients with high-grade meningiomas in the largest patient cohort of its kind to date.

Methods: A retrospective review was performed to identify all patients who underwent surgical resection for WHO grade II and III meningiomas at our institution between 1995 and 2019. Measures of frailty, including patient age, clinical frailty index (CFI), and Charlson’s comorbidity index (CCI) were recorded. Patients for whom adequate demographic or clinical information was unavailable were excluded from the study. Univariate and stepwise multivariate cox proportional hazards models were used to determine the best fit predictive model for overall survival based on a variety of patient- and tumor-specific variables. Correlations between frailty measures were controlled for via a collinearity analysis.

Results: A total of 253 patients were included in the final analysis. Mean follow-up was 5.5 years. A total of 141 patients (55.7%) were female, and 112 patients (44.3%) were male. The mean CFI and CCI were 3.68 ± 1.21, 4.52 ± 1.98, respectively. A total 144 patients (57.4%) received either adjuvant or salvage radiation therapy, and 7 patients (2.8%) received chemotherapy. Tumor location was as follows: skull base—75 (29.6%), convexity—63 (24.9%), parasagittal/falcine—92 (36.4%), and other—23 (9.1%). Univariate cox regression analysis revealed that higher values of age, CFI, and CCI were all significantly correlated with increased risk for mortality (adjusted hazard ratios of 1.82, 1.67, and 1.34, respectively; p-value <0.001 for all measures). The final cox proportional hazards model found CFI to be associated with increased risk for mortality (HR = 1.72, p < 0.001). Other, nonfrailty, parameters independently associated with increased risk for adverse OS included male gender (HR = 1.94, p = 0.029), WHO grade III (vs. grade II; HR = 4.45, p = 0.0055), and recurrent tumor (HR = 2.49, p = 0.012). Protective factors included bilaterality of tumor location (HR = 0.462, p = 0.027).

Conclusion: Higher degrees of patient frailty using the CFI was correlated with decreased OS in patients who underwent surgical resection for high-grade meningiomas. Frailty appears to be an important element in understanding overall survival in patients with high-grade meningiomas. Further study is needed to determine if functional optimization preoperatively in frailer patients may have a positive impact on OS in patients with high-grade meningiomas.

No conflict of interest has been declared by the author(s).