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Dorotan MKC, Tobochnik S. Patient-Centered Management of Brain Tumor-Related Epilepsy. Curr Neurol Neurosci Rep 2024:10.1007/s11910-024-01360-z. [PMID: 39017829 DOI: 10.1007/s11910-024-01360-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2024] [Indexed: 07/18/2024]
Abstract
PURPOSE OF REVIEW Brain tumor-related epilepsy is a heterogenous syndrome involving variability in incidence, timing, pathophysiology, and clinical risk factors for seizures across different brain tumor pathologies. Seizure risk and disability are dynamic over the course of disease and influenced by tumor-directed treatments, necessitating individualized patient-centered management strategies to optimize quality of life. RECENT FINDINGS Recent translational findings in diffuse gliomas indicate a dynamic bidirectional relationship between glioma growth and hyperexcitability. Certain non-invasive measures of hyperexcitability are correlated with survival outcomes, however it remains uncertain how to define and measure clinically relevant hyperexcitability serially over time. The extent of resection, timing of pre-operative and/or post-operative seizures, and the likelihood of tumor progression are critical factors impacting the risk of seizure recurrence. Newer anti-seizure medications are generally well-tolerated with similar efficacy in this population, and several rapid-onset seizure rescue agents are in development and available. Seizures in patients with brain tumors are strongly influenced by the underlying tumor biology and treatment. An improved understanding of the interactions between tumor cells and the spectrum of hyperexcitability will facilitate targeted therapies. Multidisciplinary management of seizures should occur with consideration of tumor-directed therapy and prognosis, and anti-seizure medication decision-making tailored to the individual priorities and quality of life of the patient.
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Affiliation(s)
| | - Steven Tobochnik
- Department of Neurology, Harvard Medical School, Boston, MA, USA.
- Department of Neurology, VA Boston Healthcare System, 150 S. Huntington Ave., 6th Floor, Neurology Service, Boston, MA, 02130, USA.
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Feng S, Pan Y, Lu P, Li N, Zhu W, Hao Z. From bench to bedside: the application of cannabidiol in glioma. J Transl Med 2024; 22:648. [PMID: 38987805 PMCID: PMC11238413 DOI: 10.1186/s12967-024-05477-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 07/03/2024] [Indexed: 07/12/2024] Open
Abstract
Glioma is the most common malignant tumor in central nervous system, with significant health burdens to patients. Due to the intrinsic characteristics of glioma and the lack of breakthroughs in treatment modalities, the prognosis for most patients remains poor. This results in a heavy psychological and financial load worldwide. In recent years, cannabidiol (CBD) has garnered widespread attention and research due to its anti-tumoral, anti-inflammatory, and neuroprotective properties. This review comprehensively summarizes the preclinical and clinical research on the use of CBD in glioma therapy, as well as the current status of nanomedicine formulations of CBD, and discusses the potential and challenges of CBD in glioma therapy in the future.
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Affiliation(s)
- Shiying Feng
- Department of Oncology, Baotou City Central Hospital, Baotou, 014040, China
- Central Clinical Medical School, Baotou Medical College, Baotou, 014040, China
| | - Yuanming Pan
- Cancer Research Center, Beijing Tuberculosis & Thoracic Tumor Research Institute, Beijing Chest Hospital, Capital Medical University, Beijing, 101149, China
| | - Pu Lu
- Department of Oncology, Baotou City Central Hospital, Baotou, 014040, China
| | - Na Li
- Department of Gynecology, Baotou City Central Hospital, Baotou, 014040, China.
| | - Wei Zhu
- Department of Oncology, Baotou City Central Hospital, Baotou, 014040, China.
| | - Zhiqiang Hao
- Department of Oncology, Baotou City Central Hospital, Baotou, 014040, China
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Newton HB, Wojkowski J. Antiepileptic Strategies for Patients with Primary and Metastatic Brain Tumors. Curr Treat Options Oncol 2024; 25:389-403. [PMID: 38353859 PMCID: PMC10894758 DOI: 10.1007/s11864-024-01182-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2024] [Indexed: 02/27/2024]
Abstract
OPINION STATEMENT Seizure activity is common in patients with primary and metastatic brain tumors, affecting more than 50% of cases over the course of their disease. Several mechanisms contribute to brain tumor-related epilepsy (BTRE), including a pro-inflammatory environment, excessive secretion of glutamate and an increase in neuronal excitatory tone, reduction of GABAergic inhibitory activity, and an increase in 2-hydroxygluturate production in isocitrate dehydrogenase mutant tumors. After a verified seizure in a brain tumor patient, the consensus is that BTRE has developed, and it is necessary to initiate an antiepileptic drug (AED). It is not recommended to initiate AED prophylaxis. Second- and third-generation AEDs are the preferred options for initiation, due to a lack of hepatic enzyme induction and reduced likelihood for drug-drug interactions, especially in regard to neoplastic treatment. The efficacy of appropriate AEDs for patients with BTRE is fairly equivalent, although some data suggests that levetiracetam may be slightly more active in suppressing seizures than other AEDs. The consensus among most Neuro-Oncology providers is to initiate levetiracetam monotherapy after a first seizure in a brain tumor patient, as long as the patient does not have any psychiatric co-morbidities. If levetiracetam is not tolerated well or is ineffective, other appropriate initial AED options for monotherapy or as an add-on anticonvulsant include lacosamide, valproic acid, briviracetam, lamotrigine, and perampanel.
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Affiliation(s)
- Herbert B Newton
- Neuro-Oncology Center and Brain Tumor Institute, University Hospitals of Cleveland Medical Center, Seidman Cancer Center, Hanna Hall 5th Floor, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
| | - Jenna Wojkowski
- Neuro-Oncology Center and Brain Tumor Institute, University Hospitals of Cleveland Medical Center, Seidman Cancer Center, Hanna Hall 5th Floor, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
- Department of Pharmacy, University Hospitals of Cleveland Medical Center, Seidman Cancer Center, Cleveland, OH, USA
- Department of Pharmacy, Duke University Medical Center, Durham, NC, USA
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Avila EK, Tobochnik S, Inati SK, Koekkoek JAF, McKhann GM, Riviello JJ, Rudà R, Schiff D, Tatum WO, Templer JW, Weller M, Wen PY. Brain tumor-related epilepsy management: A Society for Neuro-oncology (SNO) consensus review on current management. Neuro Oncol 2024; 26:7-24. [PMID: 37699031 PMCID: PMC10768995 DOI: 10.1093/neuonc/noad154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Tumor-related epilepsy (TRE) is a frequent and major consequence of brain tumors. Management of TRE is required throughout the course of disease and a deep understanding of diagnosis and treatment is key to improving quality of life. Gross total resection is favored from both an oncologic and epilepsy perspective. Shared mechanisms of tumor growth and epilepsy exist, and emerging data will provide better targeted therapy options. Initial treatment with antiseizure medications (ASM) in conjunction with surgery and/or chemoradiotherapy is typical. The first choice of ASM is critical to optimize seizure control and tolerability considering the effects of the tumor itself. These agents carry a potential for drug-drug interactions and therefore knowledge of mechanisms of action and interactions is needed. A review of adverse effects is necessary to guide ASM adjustments and decision-making. This review highlights the essential aspects of diagnosis and treatment of TRE with ASMs, surgery, chemotherapy, and radiotherapy while indicating areas of uncertainty. Future studies should consider the use of a standardized method of seizure tracking and incorporating seizure outcomes as a primary endpoint of tumor treatment trials.
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Affiliation(s)
- Edward K Avila
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Steven Tobochnik
- Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Neurology, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Sara K Inati
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Johan A F Koekkoek
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Guy M McKhann
- Department of Neurosurgery, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York, USA
| | - James J Riviello
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas, USA
| | - Roberta Rudà
- Division of Neuro-Oncology, Department of Neuroscience “Rita Levi Montalcini,” University of Turin, Italy
| | - David Schiff
- Department of Neurology, Division of Neuro-Oncology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - William O Tatum
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | - Jessica W Templer
- Department of Neurology, Northwestern University, Chicago, Illinois, USA
| | - Michael Weller
- Department of Neurology, Clinical Neuroscience Centre, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber Cancer Center, and Division of Neuro-Oncology, Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Aboubakr O, Houillier C, Choquet S, Dupont S, Hoang-Xuan K, Mathon B. Epileptic seizures in patients with primary central nervous system lymphoma: A systematic review. Rev Neurol (Paris) 2023:S0035-3787(23)01116-5. [PMID: 38042665 DOI: 10.1016/j.neurol.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Primary central nervous system lymphoma (PCNSL) accounts for less than 5% of primary brain tumors. Epileptic seizures are a common manifestation of brain tumors; however, literature on the prevalence, characteristics, and oncological implications of seizures in patients with PCNSL is limited, and the management of antiepileptic drugs (AEDs) is unclear. This review aimed to summarize the existing knowledge on seizures in PCNSL, their potential association with surgery, oncological treatment, survival rates, and management of AEDs. METHODS A systematic review was performed according to the PRISMA recommendations and included articles published between 1953 and 2023 describing seizures in patients with PCNSL. RESULTS The search identified 282 studies, of which 21 were included. Up to 33% of patients with PCNSL developed seizures, mostly at the initial presentation. Little information was found on changes in seizure incidence through the course of the disease, and no details were found on seizure frequency, the percentage of treatment-resistant patients, or the evolution of seizures at remission. Younger age, cortical location, and immunodeficiency have been identified as potential risk factors for seizures, but evidence is very limited. The growing use of vigorous treatments including intensive chemotherapy with autologous stem cell transplantation and immunotherapy with CAR-T cells is associated with a higher incidence of seizures. The association between seizure development and patient mortality in PCNSL remains unknown. There are no data on AED prophylaxis or the use of specific AEDs in PCNSL. CONCLUSIONS Further studies are needed to investigate seizures in larger cohorts of PCNSL, to clarify their prevalence, better characterize them, identify risk factors, analyze survival rates, and make recommendations on AED management. We recommend following general practice guidelines for seizures symptomatic of brain tumors and not to prescribe AED prophylaxis in PCNSL.
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Affiliation(s)
- O Aboubakr
- Sorbonne University, Department of Neurosurgery, la Pitié-Salpêtrière Hospital, AP-HP, 75013 Paris, France
| | - C Houillier
- Department of Neurology 2 Mazarin, la Pitié-Salpêtrière Hospital, IHU, ICM, AP-HP, Sorbonne University, 75013 Paris, France
| | - S Choquet
- Department of Hematology, la Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, 75013 Paris, France
| | - S Dupont
- Epileptology Unit, Department of Rehabilitation, AP-HP, La Pitié-Salpêtrière Hospital, Sorbonne University, 75013 Paris, France
| | - K Hoang-Xuan
- Department of Neurology 2 Mazarin, la Pitié-Salpêtrière Hospital, IHU, ICM, AP-HP, Sorbonne University, 75013 Paris, France
| | - B Mathon
- Sorbonne University, Department of Neurosurgery, la Pitié-Salpêtrière Hospital, AP-HP, 75013 Paris, France; Paris Brain Institute, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne University, UMRS 1127, 75013 Paris, France; GRC 23, Brain Machine Interface, la Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, 75013 Paris, France.
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Hauff NS, Storstein A. Seizure Management and Prophylaxis Considerations in Patients with Brain Tumors. Curr Oncol Rep 2023; 25:787-792. [PMID: 37071297 PMCID: PMC10256653 DOI: 10.1007/s11912-023-01410-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 04/19/2023]
Abstract
PURPOSE OF REVIEW The article gives an overview of the current knowledge in the management of tumor related epilepsy, including systematic reviews and consensus statements as well as recent insight into a potentially more individualized treatment approach. RECENT FINDINGS Tumor molecular markers as IDH1 mutation and MGMT methylation status may provide future treatment targets. Seizure control should be included as a metric in assessing efficacy of tumor treatment. Prophylactic treatment is recommended in all brain tumor patients after the first seizure. Epilepsy has a profound effect on the quality of life in this patient group. The clinician should tailor the choice of seizure prophylactic treatment to the individual patient, with the goal of limiting adverse effects, avoiding interactions and obtaining a high degree of seizure freedom. Status epilepticus is associated with inferior survival and must be treated promptly. A multidisciplinary team should treat patients with brain tumors and epilepsy.
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Affiliation(s)
- Nils Stenvågnes Hauff
- Department of Neurology, Haukeland University Hospital, Jonas Lies Vei 65, 5021, Bergen, Norway.
| | - Anette Storstein
- Department of Neurology, Haukeland University Hospital, Jonas Lies Vei 65, 5021, Bergen, Norway
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van der Meer PB, Maschio M, Dirven L, Taphoorn MJB, Koekkoek JAF, Coppola A, Maialetti A, Pietrella A, Rigamonti A, Zarabla A, Frigeni B, Salis B, Di. Bonaventura C, Marras CE, Palestini C, Ferlazzo E, Venturelli E, Dainese F, Martella F, Paladin F, Villani F, Capizzi G, Napoleoni L, Stanzani L, Stragapede L, Zummo L, Balducci M, Eoli M, Rizzi M, Vernaleone M, Messina R, Vittorini R, Gasparini S, Ius T, Cianci V, Manfioli V, Mariani V, Capovilla G. First-line levetiracetam versus enzyme-inducing antiseizure medication in glioma patients with epilepsy. Epilepsia 2023; 64:162-169. [PMID: 36380710 PMCID: PMC10100008 DOI: 10.1111/epi.17464] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/08/2022] [Accepted: 11/14/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study aimed to directly compare the effectiveness of first-line monotherapy levetiracetam (LEV) versus enzyme-inducing antiseizure medications (EIASMs) in glioma patients. METHODS In this nationwide retrospective observational cohort study, Grade 2-4 glioma patients were included, with a maximum duration of follow-up of 36 months. Primary outcome was antiseizure medication (ASM) treatment failure for any reason, and secondary outcomes were treatment failure due to uncontrolled seizures and due to adverse effects. For estimation of the association between ASM treatment and ASM treatment failure, multivariate cause-specific cox proportional hazard models were estimated, adjusting for potential confounders. RESULTS In the original cohort, a total of 808 brain tumor patients with epilepsy were included, of whom 109 glioma patients were prescribed first-line LEV and 183 glioma patients first-line EIASMs. The EIASM group had a significantly higher risk of treatment failure for any reason compared to LEV (adjusted hazard ratio [aHR] = 1.82, 95% confidence interval [CI] = 1.20-2.75, p = .005). Treatment failure due to uncontrolled seizures did not differ significantly between EIASMs and LEV (aHR = 1.32, 95% CI = .78-2.25, p = .300), but treatment failure due to adverse effects differed significantly (aHR = 4.87, 95% CI = 1.89-12.55, p = .001). SIGNIFICANCE In this study, it was demonstrated that LEV had a significantly better effectiveness (i.e., less ASM treatment failure for any reason or due to adverse effects) compared to EIASMs, supporting the current neuro-oncology guideline recommendations to avoid EIASMs in glioma patients.
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Affiliation(s)
- Pim B van der Meer
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marta Maschio
- Center for Tumor-Related Epilepsy, Unità Operativa Semplice Dipartimentale Neuro-oncology, Istituto di Ricovero e Cura a Carattere Scientifico Regina Elena National Cancer Institute, Rome, Italy
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Neurology, Haaglanden Medical Center, the Hague, the Netherlands
| | - Martin J B Taphoorn
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Johan A F Koekkoek
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Neurology, Haaglanden Medical Center, the Hague, the Netherlands
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Abstract
PURPOSE OF REVIEW A concise review of recent findings in brain tumor-related epilepsy (BTRE), with focus on the effect of antitumor treatment on seizure control and the management of antiepileptic drugs (AEDs). RECENT FINDINGS Isocitrate dehydrogenase mutation and its active metabolite d -2-hydroxyglutarate seem important contributing factors to epileptogenesis in BTRE. A beneficial effect of antitumor treatment (i.e. surgery, radiotherapy, and chemotherapy) on seizure control has mainly been demonstrated in low-grade glioma. AED prophylaxis in seizure-naïve BTRE patients is not recommended, but AED treatment should be initiated after a first seizure has occurred. Comparative efficacy randomized controlled trials (RCTs) are currently lacking, but second-generation AED levetiracetam seems the preferred choice in BTRE. Levetiracetam lacks significant drug-drug interactions, has shown favorable efficacy compared to valproic acid in BTRE, generally causes no hematological or neurocognitive functioning adverse effects, but caution should be exercised with regard to psychiatric adverse effects. Potential add-on AEDs in case of uncontrolled seizures include lacosamide, perampanel, and valproic acid. Ultimately, in the end-of-life phase when oral intake of medication is hampered, benzodiazepines via nonoral administration routes are potential alternatives. SUMMARY Management of seizures in BTRE is complex and with currently available evidence levetiracetam seems the preferred choice. Comparative efficacy RCTs in BTRE are warranted.
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Affiliation(s)
| | - Martin J.B. Taphoorn
- Department of Neurology, Leiden University Medical Center, Leiden
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Johan A.F. Koekkoek
- Department of Neurology, Leiden University Medical Center, Leiden
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
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Elbadry Ahmed R, Tang H, Asemota A, Huang L, Boling W, Bannout F. Meningioma Related Epilepsy- Pathophysiology, Pre/postoperative Seizures Predicators and Treatment. Front Oncol 2022; 12:905976. [PMID: 35860576 PMCID: PMC9289540 DOI: 10.3389/fonc.2022.905976] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 06/06/2022] [Indexed: 11/13/2022] Open
Abstract
Meningiomas are the most common primary brain tumors accounting for about 30% of all brain tumors. The vast majority of meningiomas are slow-growing and of benign histopathology rendering them curable by surgery alone. Symptomatic lesions depend on the location with signs of mass effect or neurological deficits. Seizures are the presenting symptoms in approximately 30% of cases, which negatively affect quality of life, limit independence, impair cognitive functioning, as well as increase the risk for psychiatric comorbidities including depression. Although surgical resection may offer seizure freedom in 60-90% of meningiomas, seizures persist after surgical resection in approximately 12-19% of patients. Anti-seizure medications (ASMs) are employed in management, however, are limited by adverse neurocognitive side-effects and inefficacy in some patients. The potential predictors of pre- and post-operative seizures in meningioma patients have been identified in the literature. Understanding various factors associated with seizure likelihood in meningioma patients can help guide more effective seizure control and allow for better determination of risk before and after surgery.
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Affiliation(s)
- Rasha Elbadry Ahmed
- Department of Neurosurgery, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Hailiang Tang
- Department of Neurosurgery, Huasha Hospital, Fudan University, Shanghai, China
| | - Anthony Asemota
- Department of Neurosurgery, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Lei Huang
- Department of Neurosurgery, Loma Linda University Medical Center, Loma Linda, CA, United States
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, United States
| | - Warren Boling
- Department of Neurosurgery, Loma Linda University Medical Center, Loma Linda, CA, United States
- *Correspondence: Warren Boling, ; Firas Bannout,
| | - Firas Bannout
- Department of Neurology, Loma Linda University Medical Center, Loma Linda, CA, United States
- *Correspondence: Warren Boling, ; Firas Bannout,
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