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Sullivan JK, Fahey PP, Agho KE, Hurley SP, Feng Z, Day RO, Lim D. Valproic acid as a radio-sensitizer in glioma: A systematic review and meta-analysis. Neurooncol Pract 2023; 10:13-23. [PMID: 36659976 PMCID: PMC9837785 DOI: 10.1093/nop/npac078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background Histone deacetylase inhibitors (HDACi) including valproic acid (VPA) have the potential to improve radiotherapy (RT) efficacy and reduce treatment adverse events (AE) via epigenetic modification and radio-sensitization of neoplastic cells. This systematic review and meta-analysis aimed to assess the efficacy and AE associated with HDACi used as radio-sensitizers in adult solid organ malignancy patients. Methods A systematic review utilized electronic searches of MEDLINE(Ovid), Embase(Ovid), The Cochrane Library, and the International Clinical Trials Registry Platform to identify studies examining the efficacy and AEs associated with HDACi treatment in solid organ malignancy patients undergoing RT. Meta-analysis was performed with overall survival (OS) reported as hazard ratios (HR) as the primary outcome measure. OS reported as median survival difference, and AEs were secondary outcome measures. Results Ten studies reporting on the efficacy and/or AEs of HDACi in RT-treated solid organ malignancy patients met inclusion criteria. All included studies focused on HDACi valproic acid (VPA) in high-grade glioma patients, of which 9 studies (n = 6138) evaluated OS and 5 studies (n = 1055) examined AEs. The addition of VPA to RT treatment protocols resulted in improved OS (HR = 0.80, 95% CI 0.67-0.96). No studies focusing on non-glioma solid organ malignancy patients, or non-VPA HDACi met the inclusion criteria for this review. Conclusions This review suggests that glioma patients undergoing RT may experience prolonged survival due to HDACi VPA administration. Further randomized controlled trials are required to validate these findings. Additionally, more research into the use of HDACi radio-adjuvant treatment in non-glioma solid organ malignancies is warranted.
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Affiliation(s)
| | - Paul P Fahey
- School of Health Sciences, Western Sydney University, New South Wales, Australia
| | - Kinglsey E Agho
- School of Health Sciences, Western Sydney University, New South Wales, Australia
| | - Simon P Hurley
- School of Medicine, Flinders University, South Australia, Australia
| | - Zhihui Feng
- School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Richard O Day
- St Vincent’s Clinical Campus, University of New South Wales, New South Wales, Australia
| | - David Lim
- School of Medicine, Flinders University, South Australia, Australia
- School of Health Sciences, Western Sydney University, New South Wales, Australia
- Centre for Remote Health: A JBI Affiliated Centre, Alice Springs, Australia
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2
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Konrath E, Marhold F, Kindler W, Scheichel F, Popadic B, Blauensteiner K, Calabek B, Freydl E, Weber M, Ristl R, Hainz K, Sherif C, Oberndorfer S. Perioperative levetiracetam for seizure prophylaxis in seizure-naive brain tumor patients with focus on neurocognitive functioning. BMC Neurol 2022; 22:250. [PMID: 35804291 PMCID: PMC9264633 DOI: 10.1186/s12883-022-02762-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 06/13/2022] [Indexed: 11/14/2022] Open
Abstract
Introduction In seizure-naive brain tumor patients, the efficacy of perioperative prophylactic antiepileptic drug treatment remains controversial. In case of administration, the common preferred drug is levetiracetam (LEV) because of its favorable pharmacological profile. Research to date has not sufficiently determined how LEV affects cognition in the short term, as is the case in the perioperative period. The objective of this prospective study was to examine the neurocognitive functioning of seizure-naive brain tumor patients after receiving LEV perioperatively. Methods Fortythree patients with supratentorial brain tumor scheduled for surgery received LEV three days before until six days after surgery as seizure prophylaxis. Cognitive functioning (NeuroCogFX), LEV plasma-levels, hematotoxicity, side-effects, as well as health-related quality of life (HRQoL, Qolie31), were recorded preoperatively before (Baseline) and after onset of LEV (Pre-Op), 4–6 days postoperatively (Post-Op) and 21 days postoperatively (Follow-Up). Results No significant changes in cognitive functioning and HRQoL were seen after onset of preoperative LEV. There was a significant improvement of NeuroCogFX total-score at Follow-Up (p = 0.004) compared to Baseline. The overall-score Qolie31 showed simultaneous improvement patterns as cognitive functioning (p < 0.001). The most frequent side effect related to study drug was somnolence (in 28.6% of patients). Conclusions A significant improvement of cognitive functioning, as well as an improvement in HRQoL, were detected postoperatively. This is presumably due to the debulking effect of the surgery. Nevertheless, LEV has no detrimental effect on cognitive functioning in the perioperative phase in seizure-naive brain tumor patients. Trial registration This study was registered prospectively (Date: 25/11/2015; EudraCT: 2015–003,916-19). Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02762-7.
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Affiliation(s)
- Elias Konrath
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Austria. .,Department of Neurology, University Hospital St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Austria.
| | - Franz Marhold
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Austria.,Department of Neurosurgery, University Hospital St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Austria
| | - Wolfgang Kindler
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Austria.,Department of Neurology, University Hospital St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Austria
| | - Florian Scheichel
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Austria.,Department of Neurosurgery, University Hospital St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Austria
| | - Branko Popadic
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Austria.,Department of Neurosurgery, University Hospital St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Austria
| | - Katrin Blauensteiner
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Austria.,Department of Neurology, University Hospital St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Austria
| | - Bernadette Calabek
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Austria.,Department of Neurology, University Hospital St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Austria
| | - Elisabeth Freydl
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Austria.,Department of Neurology, University Hospital St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Austria
| | - Michael Weber
- Department of General Health Studies, Division Biostatistics and Data Science, Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Austria
| | - Robin Ristl
- Section for Medical Statistics, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Katharina Hainz
- Department of Neurology, University Hospital St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Austria
| | - Camillo Sherif
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Austria.,Department of Neurosurgery, University Hospital St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Austria
| | - Stefan Oberndorfer
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Austria.,Department of Neurology, University Hospital St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Austria.,Karl Landsteiner Institute for Clinical Neurology and Neuropsychology, c/o Department Neurology, 3100, St. Pölten, Austria
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3
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Villani V, Anghileri E, Prosperini L, Lombardi G, Rudà R, Gaviani P, Rizzato S, Lanzetta G, Fabi A, Scaringi C, Pronello E, Simonetti G, Targato G, Pace A. Adjuvant chemotherapy after severe myelotoxicity during chemoradiation phase in malignant gliomas. Is it feasibile? Results from AINO study (Italian Association for Neuro-Oncology). J Neurol 2021; 268:2866-2875. [PMID: 33609154 DOI: 10.1007/s00415-021-10438-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/29/2021] [Accepted: 01/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Malignant gliomas (MG) are aggressive brain tumours in adults. The standard of care is concurrent radiation plus temozolomide (TMZ) [chemo-radiotherapy (CRT)] followed by TMZ maintenance up to 6 months. TMZ is considered to have a low toxicity profile, but several studies reported occurrence of severe myelosuppression, especially during the concomitant phase. Toxicity may be prolonged, thus treatment should be discontinued. PURPOSE To evaluate the risk of recurrente myelotoxicity during adjuvant chemotherapy (CT) in patients who recovered from severe myelotoxicity during CRT. METHODS We retrospectively collected data on patients with MG who developed and recovered from severe myelotoxicity during CRT from eight Italian neuro-oncology centers. RESULTS We included 87 patients. Histology was Glioblastoma (GBM) in 78 patients (89.7%); 60% of patients were female. After myelotoxicity recovery, 54 (62%) received treatment. The majority of them (82%, n = 44) received adjuvant TMZ and 18% (n = 10) others treatments. Out of 44 patients who received adjuvant TMZ, 34% experienced the re-occurrence of grade 3-4 myelotoxicity which required permanent CT discontinuation in 6 (13%) cases. Patients who received TMZ or other treatments had longer overall (OS) (adjusted HR 0.46, p = 0.008) and progression free survival (PFS) (adjusted HR 0.57, p = 0.034) than those who remained untreated. CONCLUSION Our study suggests that after severe myelotoxicity the majority of patients received treatment, particularly with TMZ. Only a fraction of patients experienced toxicity recurrence, suggesting that TMZ is well tolerated and had an impact on PFS and OS.
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Affiliation(s)
- Veronica Villani
- Neuro-Oncology Unit, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy.
| | - Elena Anghileri
- Molecular Neuroncology Unit Fondazione IRCSS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Luca Prosperini
- Department of Neurosciences, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Giuseppe Lombardi
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Roberta Rudà
- Department of Neuro-Oncology, City of Health and Science Hospital, Turin, Italy
| | - Paola Gaviani
- Neuro-Oncology Unit Fondazione IRCSS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Simona Rizzato
- Department of Oncology, Department of Oncology, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Gaetano Lanzetta
- Oncology Department, Istituto Neurotraumatologico Italiano, Grottaferrata, RM, Italy.,Scientific Institute for Research, Hospitalization and Health Care (IRCCS) Neuromed, Pozzilli, Italy
| | - Alessandra Fabi
- Phase 1 Unit and Precision Medicine-IRCSS Regina Elena National Cancer Institute, Rome, Italy
| | - Claudia Scaringi
- Radiation Oncology Unit, UPMC Hillman Cancer Center, San Pietro Hospital FBF, Rome, Italy
| | - Edoardo Pronello
- Department of Neuro-Oncology, City of Health and Science Hospital, Turin, Italy
| | - Giorgia Simonetti
- Neuro-Oncology Unit Fondazione IRCSS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Giada Targato
- Department of Oncology, Department of Oncology, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Andrea Pace
- Neuro-Oncology Unit, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
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4
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Stepanović A, Nikitović M, Bogdanović A, Grujičić D. Long-lasting Thrombocytopenia after Transient Pancytopenia Induced by Short-Term Concomitant Radiotherapy and Temozolomide. Eur J Case Rep Intern Med 2020; 7:001785. [PMID: 33083356 DOI: 10.12890/2020_001785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 06/13/2020] [Indexed: 11/05/2022] Open
Abstract
We describe long-lasting and incompletely resolved thrombocytopenia after transient profound pancytopenia in a 62-year-old female patient with glioblastoma after short-term radiotherapy with temozolomide. Pancytopenia was present for more than 4 weeks and thrombocytopenia for more than 6 months, without platelet recovery to normal levels. LEARNING POINTS Some patients may experience severe haematological manifestations after even short-term radiotherapy with temozolomide.In everyday practice, clinical models precisely predicting the haematological toxicity of concomitant treatment with temozolomide and radiotherapy is necessary, especially in countries where genetic tests are not available.Incomplete recovery of the cells of a particular bloodline over a long period may necessitate permanent discontinuation of chemotherapy or radiotherapy.
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Affiliation(s)
| | - Marina Nikitović
- Institute for Oncology and Radiology of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Andrija Bogdanović
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Hematology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Danica Grujičić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Neurosurgery Clinic, Clinical Center of Serbia, Belgrade, Serbia
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5
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Jovčevska I. Next Generation Sequencing and Machine Learning Technologies Are Painting the Epigenetic Portrait of Glioblastoma. Front Oncol 2020; 10:798. [PMID: 32500035 PMCID: PMC7243123 DOI: 10.3389/fonc.2020.00798] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 04/23/2020] [Indexed: 12/31/2022] Open
Abstract
Even with a rare occurrence of only 1.35% of cancer cases in the United States of America, brain tumors are considered as one of the most lethal malignancies. The most aggressive and invasive type of brain tumor, glioblastoma, accounts for 60–70% of all gliomas and presents with life expectancy of only 12–18 months. Despite trimodal treatment and advances in diagnostic and therapeutic methods, there are no significant changes in patient outcome. Our understanding of glioblastoma was significantly improved with the introduction of next generation sequencing technologies. This led to the identification of different genetic and molecular subtypes, which greatly improve glioblastoma diagnosis. Still, because of the poor life expectancy, novel diagnostic, and treatment methods are broadly explored. Epigenetic modifications like methylation and changes in histone acetylation are such examples. Recently, in addition to genetic and molecular characteristics, epigenetic profiling of glioblastomas is also used for sample classification. Further advancement of next generation sequencing technologies is expected to identify in detail the epigenetic signature of glioblastoma that can open up new therapeutic opportunities for glioblastoma patients. This should be complemented with the use of computational power i.e., machine and deep learning algorithms for objective diagnostics and design of individualized therapies. Using a combination of phenotypic, genotypic, and epigenetic parameters in glioblastoma diagnostics will bring us closer to precision medicine where therapies will be tailored to suit the genetic profile and epigenetic signature of the tumor, which will grant longer life expectancy and better quality of life. Still, a number of obstacles including potential bias, availability of data for minorities in heterogeneous populations, data protection, and validation and independent testing of the learning algorithms have to be overcome on the way.
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Affiliation(s)
- Ivana Jovčevska
- Medical Centre for Molecular Biology, Institute of Biochemistry, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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6
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Abstract
PURPOSE OF REVIEW The concept of palliative care is becoming increasingly important in the management of glioma patients. However, the right time for implementation, as well as the individual degree of integration of palliative care aspects, are still a matter of debate. This review updates recent evidence of palliative care in glioma and raises questions for future developments. RECENT FINDINGS According to the disease-specific aspects of palliative care in glioma management, there is an increasing need for a specialized 'neurooncological' palliative care approach.The implementation of palliative care for glioma patients and caregivers avoids unnecessary hospitalization and reduces health-related costs. Moreover, palliative care may be offered in different settings (inpatient/outpatient) according to local health structures, but definitely improves the QOL of glioma patients and their caregivers. SUMMARY There are considerable differences between countries with respect to palliative care in glioma. Major aspects of good-quality care throughout the countries are optimized symptom control, support for patients and proxies by an interdisciplinary team and to provide realistic information to patients and caregivers. The availability of neurooncological palliative teams and multidisciplinary support programs increases well being of glioma patients and caregivers as well as releases pressure on healthcare systems.
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7
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Maschio M, Aguglia U, Avanzini G, Banfi P, Buttinelli C, Capovilla G, Casazza MML, Colicchio G, Coppola A, Costa C, Dainese F, Daniele O, De Simone R, Eoli M, Gasparini S, Giallonardo AT, La Neve A, Maialetti A, Mecarelli O, Melis M, Michelucci R, Paladin F, Pauletto G, Piccioli M, Quadri S, Ranzato F, Rossi R, Salmaggi A, Terenzi R, Tisei P, Villani F, Vitali P, Vivalda LC, Zaccara G, Zarabla A, Beghi E. Management of epilepsy in brain tumors. Neurol Sci 2019; 40:2217-2234. [PMID: 31392641 DOI: 10.1007/s10072-019-04025-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 07/20/2019] [Indexed: 12/15/2022]
Abstract
Epilepsy in brain tumors (BTE) may require medical attention for a variety of unique concerns: epileptic seizures, possible serious adverse effects of antineoplastic and antiepileptic drugs (AEDs), physical disability, and/or neurocognitive disturbances correlated to tumor site. Guidelines for the management of tumor-related epilepsies are lacking. Treatment is not standardized, and overall management might differ according to different specialists. The aim of this document was to provide directives on the procedures to be adopted for a correct diagnostic-therapeutic path of the patient with BTE, evaluating indications, risks, and benefits. A board comprising neurologists, epileptologists, neurophysiologists, neuroradiologists, neurosurgeons, neuro-oncologists, neuropsychologists, and patients' representatives was formed. The board converted diagnostic and therapeutic problems into seventeen questions. A literature search was performed in September-October 2017, and a total of 7827 unique records were retrieved, of which 148 constituted the core literature. There is no evidence that histological type or localization of the brain tumor affects the response to an AED. The board recommended to avoid enzyme-inducing antiepileptic drugs because of their interference with antitumoral drugs and consider as first-choice newer generation drugs (among them, levetiracetam, lamotrigine, and topiramate). Valproic acid should also be considered. Both short-term and long-term prophylaxes are not recommended in primary and metastatic brain tumors. Management of seizures in patients with BTE should be multidisciplinary. The panel evidenced conflicting or lacking data regarding the role of EEG, the choice of therapeutic strategy, and timing to withdraw AEDs and recommended high-quality long-term studies to standardize BTE care.
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Affiliation(s)
- Marta Maschio
- Center for Brain Tumor-Related Epilepsy, UOSD Neuro-Oncology, I.R.C.C.S. Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy.
| | - Umberto Aguglia
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Giuliano Avanzini
- Department of Neurophysiology and Experimental Epileptology, Carlo Besta Neurological Institute, Milan, Italy
| | - Paola Banfi
- Neurology Unit, Department of Emergency, Medicine Epilepsy Center, Circolo Hospital, Varese, Italy
| | - Carla Buttinelli
- Department of Neuroscience, Mental Health and Sensory Organs, University of Rome "La Sapienza", Rome, Italy
| | - Giuseppe Capovilla
- Department of Mental Health, Epilepsy Center, C. Poma Hospital, Mantua, Italy
| | | | - Gabriella Colicchio
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Rome, Italy
| | - Antonietta Coppola
- Department of Neuroscience, Reproductive and Odontostomatological Sciences, Epilepsy Centre, University of Naples Federico II, Naples, Italy
| | - Cinzia Costa
- Neurological Clinic, Department of Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Filippo Dainese
- Epilepsy Centre, UOC Neurology, SS. Giovanni e Paolo Hospital, Venice, Italy
| | - Ornella Daniele
- Epilepsy Center-U.O.C. Neurology, Policlinico Paolo Giaccone, Experimental Biomedicine and Clinical Neuroscience Department (BioNeC), University of Palermo, Palermo, Italy
| | - Roberto De Simone
- Neurology and Stroke Unit, Epilepsy and Sleep Disorders Center, St. Eugenio Hospital, Rome, Italy
| | - Marica Eoli
- Molecular Neuro-Oncology Unit, IRCCS-Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
| | - Sara Gasparini
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | | | - Angela La Neve
- Department of Neurological and Psychiatric Sciences, Centre for Epilepsy, University of Bari, Bari, Italy
| | - Andrea Maialetti
- Center for Brain Tumor-Related Epilepsy, UOSD Neuro-Oncology, I.R.C.C.S. Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Oriano Mecarelli
- Neurology Unit, Human Neurosciences Department, Sapienza University, Umberto 1 Hospital, Rome, Italy
| | - Marta Melis
- Department of Medical Sciences and Public Health, Institute of Neurology, University of Cagliari, Monserrato, Cagliari, Italy
| | - Roberto Michelucci
- Unit of Neurology, Bellaria Hospital, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Francesco Paladin
- Epilepsy Center, UOC Neurology, Ospedale Santi Giovanni e Paolo, Venice, Italy
| | - Giada Pauletto
- Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Marta Piccioli
- UOC Neurology, PO San Filippo Neri, ASL Roma 1, Rome, Italy
| | - Stefano Quadri
- USC Neurology, Epilepsy Center, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Federica Ranzato
- Epilepsy Centre, Neuroscience Department, S. Bortolo Hospital, Vicenza, Italy
| | - Rosario Rossi
- Neurology and Stroke Unit, San Francesco Hospital, 08100, Nuoro, Italy
| | | | - Riccardo Terenzi
- Epilepsy Consultation Room, Neurology Unit, S. Pietro Fatebenefratelli Hospital, Rome, Italy
| | - Paolo Tisei
- Neurophysiology Unit, Department of Neurology-University "La Sapienza", S. Andrea Hospital, Rome, Italy
| | - Flavio Villani
- Clinical Epileptology and Experimental Neurophysiology Unit, Fondazione IRCCS, Istituto Neurologico C. Besta, Milan, Italy
| | - Paolo Vitali
- Neuroradiology and Brain MRI 3T Mondino Research Center, IRCCS Mondino Foundation, Pavia, Italy
| | | | - Gaetano Zaccara
- Regional Health Agency of Tuscany, Via P Dazzi 1, 50141, Florence, Italy
| | - Alessia Zarabla
- Center for Brain Tumor-Related Epilepsy, UOSD Neuro-Oncology, I.R.C.C.S. Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Ettore Beghi
- Department of Neurosciences, IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
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Julie DAR, Ahmed Z, Karceski SC, Pannullo SC, Schwartz TH, Parashar B, Wernicke AG. An overview of anti-epileptic therapy management of patients with malignant tumors of the brain undergoing radiation therapy. Seizure 2019; 70:30-37. [PMID: 31247400 DOI: 10.1016/j.seizure.2019.06.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/28/2019] [Accepted: 06/12/2019] [Indexed: 01/01/2023] Open
Abstract
As our surgical, radiation, chemotherapeutic and supportive therapies for brain malignancies improve, and overall survival is prolonged, appropriate symptom management in this patient population becomes increasingly important. This review summarizes the published literature and current practice patterns regarding prophylactic and perioperative anti-epileptic drug use. As a wide range of anti-epileptic drugs is now available to providers, evidence guiding appropriate anticonvulsant choice is reviewed. A particular focus of this article is radiation therapy for brain malignancies. Toxicities and seizure risk associated with cranial irradiation will be discussed. Epilepsy management in patients undergoing radiation for gliomas, glioblastoma multiforme, and brain metastases will be addressed. An emerging but inconsistent body of evidence, reviewed here, indicates that anti-epileptic medications may increase radiosensitivity, and therefore improve clinical outcomes, specifically in glioblastoma multiforme patients.
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Affiliation(s)
- Diana A R Julie
- Department of Radiation Oncology, Weill Medical College of Cornell University, New York, NY, United States
| | | | - Stephen C Karceski
- Department of Neurology, Weill Medical College of Cornell University, New York, NY, United States
| | - Susan C Pannullo
- Department of Neurosurgery, Weill Medical College of Cornell University, New York, NY, United States
| | - Theodore H Schwartz
- Department of Neurosurgery, Weill Medical College of Cornell University, New York, NY, United States
| | - Bhupesh Parashar
- Department of Radiation Oncology, Northwell Health, New Hyde Park, NY, United States
| | - A Gabriella Wernicke
- Department of Radiation Oncology, Weill Medical College of Cornell University, New York, NY, United States; Department of Neurosurgery, Weill Medical College of Cornell University, New York, NY, United States.
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9
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Yi ZM, -, Wen C, Cai T, Xu L, Zhong XL, Zhan SY, Zhai SD. Levetiracetam for epilepsy: an evidence map of efficacy, safety and economic profiles. Neuropsychiatr Dis Treat 2018; 15:1-19. [PMID: 30587993 PMCID: PMC6301299 DOI: 10.2147/ndt.s181886] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy, safety and economics of levetiracetam (LEV) for epilepsy. MATERIALS AND METHODS PubMed, Scopus, the Cochrane Library, OpenGrey.eu and ClinicalTrials.gov were searched for systematic reviews (SRs), meta-analyses, randomized controlled trials (RCTs), observational studies, case reports and economic studies published from January 2007 to April 2018. We used a bubble plot to graphically display information of included studies and conducted meta-analyses to quantitatively synthesize the evidence. RESULTS A total of 14,803 records were obtained. We included 30 SRs/meta-analyses, 34 RCTs, 18 observational studies, 58 case reports and 2 economic studies after the screening process. The included SRs enrolled patients with pediatric epilepsy, epilepsy in pregnancy, focal epilepsy, generalized epilepsy and refractory focal epilepsy. Meta-analysis of the included RCTs indicated that LEV was as effective as carbamazepine (CBZ; treatment for 6 months: 58.9% vs 64.8%, OR=0.76, 95% CI: 0.50-1.16; 12 months: 54.9% vs 55.5%, OR=1.24, 95% CI: 0.79-1.93), oxcarbazepine (57.7% vs 59.8%, OR=1.34, 95% CI: 0.34-5.23), phenobarbital (50.0% vs 50.9%, OR=1.20, 95% CI: 0.51-2.82) and lamotrigine (LTG; 61.5% vs 57.7%, OR=1.22, 95% CI: 0.90-1.66). SRs and observational studies indicated a low malformation rate and intrauterine death rate for pregnant women, as well as low risk of cognitive side effects. But psychiatric and behavioral side effects could not be ruled out. LEV decreased discontinuation due to adverse events compared with CBZ (OR=0.52, 95% CI: 0.41-0.65), while no difference was found when LEV was compared with placebo and LTG. Two cost-effectiveness evaluations for refractory epilepsy with decision-tree model showed US$ 76.18 per seizure-free day gained in Canada and US$ 44 per seizure-free day gained in Korea. CONCLUSION LEV is as effective as CBZ, oxcarbazepine, phenobarbital and LTG and has an advantage for pregnant women and in cognitive functions. Limited evidence supports its cost-effectiveness. REGISTERED NUMBER PROSPERO (No CRD 42017069367).
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Affiliation(s)
- Zhan-Miao Yi
- Department of Pharmacy, Peking University Third Hospital, Beijing, China,
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- Department of Pharmacy, Peking University Third Hospital, Beijing, China,
| | - Cheng Wen
- Department of Pharmacy, Peking University Third Hospital, Beijing, China,
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University Health Science Center, Beijing, China
| | - Ting Cai
- Department of Epidemiology and Bio-statistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Lu Xu
- Department of Epidemiology and Bio-statistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Xu-Li Zhong
- Department of Pharmacy, Children's Hospital Affiliated to Capital Institute of Pediatrics, Beijing, China
| | - Si-Yan Zhan
- Department of Epidemiology and Bio-statistics, School of Public Health, Peking University Health Science Center, Beijing, China
- Center for Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Suo-Di Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China,
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China,
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10
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Knudsen-Baas KM, Engeland A, Gilhus NE, Storstein AM, Owe JF. Does the choice of antiepileptic drug affect survival in glioblastoma patients? J Neurooncol 2016; 129:461-469. [DOI: 10.1007/s11060-016-2191-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 06/24/2016] [Indexed: 12/27/2022]
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11
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Fröscher W, Kirschstein T, Rösche J. Anticonvulsant therapy in brain-tumor related epilepsy. JOURNAL OF EPILEPTOLOGY 2016. [DOI: 10.1515/joepi-2016-0004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
SummaryBackground. The lifetime risk of patients with brain tumors to have focal epileptic seizures is 10-100%; the risk depends on different histology. Specific guidelines for drug treatment of brain tumor-related seizures have not yet been established.Aim. This review addresses the special aspects of antiepileptic drug (AED) therapy in brain tumor-related epilepsy.Methods. We analyzed the literature up to December 2015.Results. Based on current evidence the management of tumor-related seizures does not differ substantially from that applied to epilepsies from other etiologies. Therefore, the choice of an AED is based, above all, on tolerability and pharmacokinetic interactions with chemotherapeutic drugs. Levetiracetam is recommended by many authors as first-line therapy in brain tumor-related epilepsy. Due to the possibility of interactions, the combination of enzyme-inducing AEDs and chemotherapeutic drugs, is usually not recommended as a first choice. Currently there is no evidence that prophylactic prescription of long-term AEDs in brain tumor-patients who did not present with seizures is justified. Because of the high risk of recurrence, however, AED treatment should be strongly considered after a single brain tumor-related seizure. The decision to withdraw AEDs must carefully consider the risk of seizure recurrence.Conclusion. At present levetiracetam is the preferred drug in brain tumor-related epilepsy, especially when drug interactions need to be avoided. In the future we hope to acquire more targeted drugs against this disorder by uncovering its pathogenesis.
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12
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Huberfeld G, Vecht CJ. Seizures and gliomas — towards a single therapeutic approach. Nat Rev Neurol 2016; 12:204-16. [DOI: 10.1038/nrneurol.2016.26] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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13
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Abstract
Seizures are common in patients with brain tumors, and epilepsy can significantly impact patient quality of life. Therefore, a thorough understanding of rates and predictors of seizures, and the likelihood of seizure freedom after resection, is critical in the treatment of brain tumors. Among all tumor types, seizures are most common with glioneuronal tumors (70-80%), particularly in patients with frontotemporal or insular lesions. Seizures are also common in individuals with glioma, with the highest rates of epilepsy (60-75%) observed in patients with low-grade gliomas located in superficial cortical or insular regions. Approximately 20-50% of patients with meningioma and 20-35% of those with brain metastases also suffer from seizures. After tumor resection, approximately 60-90% are rendered seizure-free, with most favorable seizure outcomes seen in individuals with glioneuronal tumors. Gross total resection, earlier surgical therapy, and a lack of generalized seizures are common predictors of a favorable seizure outcome. With regard to anticonvulsant medication selection, evidence-based guidelines for the treatment of focal epilepsy should be followed, and individual patient factors should also be considered, including patient age, sex, organ dysfunction, comorbidity, or cotherapy. As concomitant chemotherapy commonly forms an essential part of glioma treatment, enzyme-inducing anticonvulsants should be avoided when possible. Seizure freedom is the ultimate goal in the treatment of brain tumor patients with epilepsy, given the adverse effects of seizures on quality of life.
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Affiliation(s)
- Dario J Englot
- UCSF Comprehensive Epilepsy Center, University of California San Francisco, San Francisco, California, USA; Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Edward F Chang
- UCSF Comprehensive Epilepsy Center, University of California San Francisco, San Francisco, California, USA; Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Charles J Vecht
- Service Neurologie Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
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14
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Gefroh-Grimes HA, Gidal BE. Antiepileptic drugs in patients with malignant brain tumor: beyond seizures and pharmacokinetics. Acta Neurol Scand 2016; 133:4-16. [PMID: 25996875 DOI: 10.1111/ane.12437] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2015] [Indexed: 02/06/2023]
Abstract
In neurological malignancies, antiepileptic drugs (AEDs) are frequently used to control the seizure activity that accompanies the disorder. There is a growing body of evidence on the importance of AED selection for reasons other than pharmacokinetics (PK) properties. Epigenetic modifications may occur in glioblastomas, such as changes in gene methylation and histone acetylation states. Secondary mechanisms of AED drug action which impact these epigenetic modifications could play a significant role in patient survival outcomes. Both valproic acid (VPA) and carbamazepine have histone deacetylase (HDAC) inhibitory activities, and levetiracetam and VPA reduce the activity of O6-methylguanine-DNA methyltransferase (MGMT), a DNA-repair molecule implicated in resistance to alkylating agents used for chemotherapy. The use of AEDs for purposes other than seizure prophylaxis and their selection based on non-PK properties present a potential paradigm shift in the field of neuro-oncology.
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Affiliation(s)
- H. A. Gefroh-Grimes
- Pharmacy Practice Division; School of Pharmacy; University of Wisconsin-Madison; Madison WI USA
| | - B. E. Gidal
- School of Pharmacy & Department of Neurology; University of Wisconsin-Madison; Madison WI USA
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15
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Abstract
Epilepsy develops in more than 70-90% of oligodendroglial tumors and represents a favorable indicator for long-term survival if present as the first clinical sign. Presence of IDH1 mutation is frequently associated with seizures in oligodendrogliomas, next to alterations of glutamate and GABA metabolism in the origin of glioma-associated epilepsy. Treatment by surgery or radiotherapy results in seizure freedom in about two-thirds of patients, and chemotherapy to a seizure reduction in about 50%. Symptomatic anticonvulsive therapy with levetiracetam and valproic acid as monotherapy are both evidence-based drugs for the partial epilepsies, and their effective use in brain tumors is supported by a large amount of additional data. Pharmacoresistance against anticonvulsants is more prevalent among oligodendrogliomas, occurring in about 40% despite polytherapy with two anticonvulsants or more. Toxic signs of anticonvulsants in brain tumors involve cognition, bone marrow and skin. Previous neurosurgery, radiation therapy or chemotherapy add to the risks of cognitive dysfunction.
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Affiliation(s)
- Melissa Kerkhof
- Department of Neurology, Medical Center The Hague, The Netherlands
| | - Christa Benit
- Department of Neurology, Medical Center The Hague, The Netherlands
| | | | - Charles J Vecht
- Service Neurologie Mazarin, GH Pitié-Salpêtrière, Paris, France
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16
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Bénit CP, Vecht CJ. Seizures and cancer: drug interactions of anticonvulsants with chemotherapeutic agents, tyrosine kinase inhibitors and glucocorticoids. Neurooncol Pract 2015; 3:245-260. [PMID: 31385988 DOI: 10.1093/nop/npv038] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Indexed: 01/13/2023] Open
Abstract
Patients with cancer commonly experience seizures. Combined therapy with anticonvulsant drugs (AEDs) and chemotherapeutic drugs or tyrosine kinase inhibitors carries inherent risks on drug-drug interactions (DDIs). In this review, pharmacokinetic studies of AEDs with chemotherapeutic drugs, tyrosine kinase inhibitors, and glucocorticoids are discussed, including data on maximum tolerated dose, drug clearance, elimination half-life, and organ exposure. Enzyme-inducing AEDs (EIAEDs) cause about a 2-fold to 3-fold faster clearance of concurrent chemotherapeutic drugs metabolized along the same pathway, including cyclophosphamide, irinotecan, paclitaxel, and teniposide, and up to 4-fold faster clearance with the tyrosine kinase inhibitors crizotinib, dasatinib, imatinib, and lapatinib. The use of tyrosine kinase inhibitors, particularly imatinib and crizotinib, may lead to enzyme inhibition of concurrent therapy. Many of the newer generation AEDs do not induce or inhibit drug metabolism, but they can alter enzyme activity by other drugs including AEDs, chemotherapeutics and tyrosine kinase inhibitors. Glucocorticoids can both induce and undergo metabolic change. Quantitative data on changes in drug metabolism help to apply the appropriate dose regimens. Because the large individual variability in metabolic activity increases the risks for undertreatment and/or toxicity, we advocate routine plasma drug monitoring. There are insufficient data available on the effects of tyrosine kinase inhibitors on AED metabolism.
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Affiliation(s)
- Christa P Bénit
- Department of Neurology, Medical Center Haaglanden, The Hague, Netherlands (C.B.); Service Neurologie Mazarin, GH Pitié-Salpêtrière, Paris, France (C.J.V.)
| | - Charles J Vecht
- Department of Neurology, Medical Center Haaglanden, The Hague, Netherlands (C.B.); Service Neurologie Mazarin, GH Pitié-Salpêtrière, Paris, France (C.J.V.)
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17
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Abstract
OPINION STATEMENT Seizures represent a common symptom in low- and high-grade gliomas. Tumor location and histology influence the risk for epilepsy. Some molecular factors (BRAF V 600E mutations in glioneuronal tumors and IDH1/2 mutations in diffuse grade II and III gliomas) are molecular factors that are relevant for diagnosis and prognosis and have been associated with the risk of epilepsy as well. Glutamate plays a central role in epileptogenicity and growth of glial and glioneuronal tumors, based on the release of glutamate from tumor cells that enhances excitotoxicity, and a downregulation of the inhibitory GABAergic pathways. Several potential targets for therapy have been identified, and m-TOR inhibitors have already shown activity. Gross total resection is the strongest predictor of seizure freedom in addition to clinical factors, such as preoperative seizure duration, type, and control with antiepileptic drugs (AEDs). Radiotherapy and chemotherapy with alkylating agents (procarbazine, CCNU, vincristine, temozolomide) are effective in reducing the frequency of seizures in patients with pharmacoresistant epilepsy. Newer AEDs (in particular levetiracetam and lacosamide) seem to be better tolerated than the old AEDs (phenobarbital, phenytoin, carbamazepine), but randomized clinical trials are needed to prove their superiority in terms of efficacy.
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Affiliation(s)
- Roberta Rudà
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Via Cherasco 15, 10126, Torino, Italy,
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