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van den Bent MJ, Geurts M, French PJ, Smits M, Capper D, Bromberg JEC, Chang SM. Primary brain tumours in adults. Lancet 2023; 402:1564-1579. [PMID: 37738997 DOI: 10.1016/s0140-6736(23)01054-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 05/06/2023] [Accepted: 05/16/2023] [Indexed: 09/24/2023]
Abstract
The most frequent adult-type primary CNS tumours are diffuse gliomas, but a large variety of rarer CNS tumour types exists. The classification of these tumours is increasingly based on molecular diagnostics, which is reflected in the extensive molecular foundation of the recent WHO 2021 classification of CNS tumours. Resection as extensive as is safely possible is the cornerstone of treatment in most gliomas, and is now also recommended early in the treatment of patients with radiological evidence of histologically low-grade tumours. For the adult-type diffuse glioma, standard of care is a combination of radiotherapy and chemotherapy. Although treatment with curative intent is not available, combined modality treatment has resulted in long-term survival (>10-20 years) for some patients with isocitrate dehydrogenase (IDH) mutant tumours. Other rarer tumours require tailored approaches, best delivered in specialised centres. Targeted treatments based on molecular alterations still only play a minor role in the treatment landscape of adult-type diffuse glioma, and today are mainly limited to patients with tumours with BRAFV600E (ie, Val600Glu) mutations. Immunotherapy for CNS tumours is still in its infancy, and so far, trials with checkpoint inhibitors and vaccination studies have not shown improvement in patient outcomes in glioblastoma. Current research is focused on improving our understanding of the immunosuppressive tumour environment, the molecular heterogeneity of tumours, and the role of tumour microtube network connections between cells in the tumour microenvironment. These factors all appear to play a role in treatment resistance, and indicate that novel approaches are needed to further improve outcomes of patients with CNS tumours.
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Affiliation(s)
- Martin J van den Bent
- Department of Neurology, Brain Tumor Center, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Netherlands.
| | - Marjolein Geurts
- Department of Neurology, Brain Tumor Center, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Netherlands
| | - Pim J French
- Department of Neurology, Brain Tumor Center, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Netherlands
| | - Marion Smits
- Department of Radiology & Nuclear Medicine, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Netherlands; Medical Delta, Delft, Netherlands
| | - David Capper
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Berlin, Germany; German Cancer Consortium, Berlin, Germany; German Cancer Research Center, Heidelberg, Germany
| | - Jacoline E C Bromberg
- Department of Neurology, Brain Tumor Center, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Netherlands
| | - Susan M Chang
- Brain Tumor Center, University of California San Francisco, San Francisco, CA, USA
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Sahrizan NSA, Manan HA, Abdul Hamid H, Abdullah JM, Yahya N. Functional Alteration in the Brain Due to Tumour Invasion in Paediatric Patients: A Systematic Review. Cancers (Basel) 2023; 15:cancers15072168. [PMID: 37046828 PMCID: PMC10093754 DOI: 10.3390/cancers15072168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/29/2023] [Accepted: 03/29/2023] [Indexed: 04/14/2023] Open
Abstract
Working memory, language and speech abilities, motor skills, and visual abilities are often impaired in children with brain tumours. This is because tumours can invade the brain's functional areas and cause alterations to the neuronal networks. However, it is unclear what the mechanism of tumour invasion is and how various treatments can cause cognitive impairment. Therefore, this study aims to systematically evaluate the effects of tumour invasion on the cognitive, language, motor, and visual abilities of paediatric patients, as well as discuss the alterations and modifications in neuronal networks and anatomy. The electronic database, PubMed, was used to find relevant studies. The studies were systematically reviewed based on the type and location of brain tumours, cognitive assessment, and pre- and post-operative deficits experienced by patients. Sixteen studies were selected based on the inclusion and exclusion criteria following the guidelines from PRISMA. Most studies agree that tumour invasion in the brain causes cognitive dysfunction and alteration in patients. The effects of a tumour on cognition, language, motor, and visual abilities depend on the type of tumour and its location in the brain. The alteration to the neuronal networks is also dependent on the type and location of the tumour. However, the default mode network (DMN) is the most affected network, regardless of the tumour type and location.Furthermore, our findings suggest that different treatment types can also contribute to patients' cognitive function to improve or deteriorate. Deficits that persisted or were acquired after surgery could result from surgical manipulation or the progression of the tumour's growth. Meanwhile, recovery from the deficits indicated that the brain has the ability to recover and reorganise itself.
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Affiliation(s)
- Nur Shaheera Aidilla Sahrizan
- Department of Radiology, Makmal Pemprosesan Imej Kefungsian (Functional Image Processing Laboratory), University Kebangsaan Malaysia Medical Centre, Kuala Lumpur 56000, Malaysia
- Department of Radiology and Intervency, Hospital Pakar Kanak-Kanak (Children Specialist Hospital), Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Hanani Abdul Manan
- Department of Radiology, Makmal Pemprosesan Imej Kefungsian (Functional Image Processing Laboratory), University Kebangsaan Malaysia Medical Centre, Kuala Lumpur 56000, Malaysia
- Department of Radiology and Intervency, Hospital Pakar Kanak-Kanak (Children Specialist Hospital), Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Hamzaini Abdul Hamid
- Department of Radiology, Makmal Pemprosesan Imej Kefungsian (Functional Image Processing Laboratory), University Kebangsaan Malaysia Medical Centre, Kuala Lumpur 56000, Malaysia
- Department of Radiology and Intervency, Hospital Pakar Kanak-Kanak (Children Specialist Hospital), Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Jafri Malin Abdullah
- Jabatan Neurosains, Pusat Pengajian Sains Perubatan, Jalan Hospital USM, Kampus Kesihatan, Universiti Sains Malaysia, Kota Bharu 16150, Malaysia
- Brain and Behaviour Cluster, Pusat Pengajian Sains Perubatan, Kampus Kesihatan, Universiti Sains Malaysia, Kota Bharu 16150, Malaysia
- Department of Neurosciences & Brain Behaviour Cluster, Hospital Universiti Sains Malaysia, Kampus Kesihatan, Universiti Sains Malaysia, Kota Bharu 16150, Malaysia
| | - Noorazrul Yahya
- Diagnostic Imaging & Radiotherapy Program, School of Diagnostic & Applied Health Sciences, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur 50300, Malaysia
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Tyagunova EE, Zakharov AS, Glukhov AI, Dobrokhotova VZ, Shlapakov TI, Kozlov VV, Korotkova NV, Tyagunova TE. Features of epileptiform activity in patients with diagnosed glioblastoma: from genetic and biochemical mechanisms to clinical aspects. HEAD AND NECK TUMORS (HNT) 2022. [DOI: 10.17650/2222-1468-2022-12-3-102-113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction. glioblastomas multiforme (grade Iv gliomas) are common and the most aggressive primary tumors of the brain with very unfavorable prognosis. In all previously published papers on epileptiform activity in glioblastomas, not enough information on encephalogram results is presented.Aim. To study the features of epileptiform activity in patients with glioblastomas and development of a plan for further study of these patients.Materials and methods. An analysis of articles from Elsevier, Embase, Scopus, The Cochrane Library, global Health, Russian Science Citation Index (RSCI) databases, Scholar, google, web of Science, pubmed search engines and scientific electronic library CyberLeninka was performed. materials were selected considering journal indexing system and citations, scientific novelty of the studies, statistical significance of the results. publications repeating data from previous articles or describing animal experiments were excluded from analysis.Results. During the study, data on mechanisms of epileptiform activity pathogenesis, predisposing factors (tumor location in the temporal, frontal or parietal lobes, IDH-1 and / or IDH-2 gene mutations), treatment options in patients with glioblastomas were systemized. Additionally, and original plan of data accumulation for clinical studied taking into account limitations of the previous studies was developed to increase quality of results interpretation.Conclusion. Epileptiform symptoms in glioblastomas negatively affect patients’ quality of life and lifespan. Currently, researchers actively search for an effective method of treatment of epileptic seizures in patients with glioblastomas. The most effective is combination of temozolomide with valproate and levetiracetam due to good control of seizure frequency, low toxicity, and pharmacological synergy between the drugs.
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Affiliation(s)
- E. E. Tyagunova
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia
| | - A. S. Zakharov
- Pavlov Ryazan State Medical University, Ministry of Health of Russia
| | - A. I. Glukhov
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia; M.V. Lomonosov Moscow State University
| | - V. Z. Dobrokhotova
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia; N. N. Blokhin National Research Institute of Oncology, Ministry of Health of Russia
| | - T. I. Shlapakov
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia
| | - V. V. Kozlov
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia
| | - N. V. Korotkova
- Pavlov Ryazan State Medical University, Ministry of Health of Russia
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Hills KE, Kostarelos K, Wykes RC. Converging Mechanisms of Epileptogenesis and Their Insight in Glioblastoma. Front Mol Neurosci 2022; 15:903115. [PMID: 35832394 PMCID: PMC9271928 DOI: 10.3389/fnmol.2022.903115] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/25/2022] [Indexed: 12/15/2022] Open
Abstract
Glioblastoma (GBM) is the most common and advanced form of primary malignant tumor occurring in the adult central nervous system, and it is frequently associated with epilepsy, a debilitating comorbidity. Seizures are observed both pre- and post-surgical resection, indicating that several pathophysiological mechanisms are shared but also prompting questions about how the process of epileptogenesis evolves throughout GBM progression. Molecular mutations commonly seen in primary GBM, i.e., in PTEN and p53, and their associated downstream effects are known to influence seizure likelihood. Similarly, various intratumoral mechanisms, such as GBM-induced blood-brain barrier breakdown and glioma-immune cell interactions within the tumor microenvironment are also cited as contributing to network hyperexcitability. Substantial alterations to peri-tumoral glutamate and chloride transporter expressions, as well as widespread dysregulation of GABAergic signaling are known to confer increased epileptogenicity and excitotoxicity. The abnormal characteristics of GBM alter neuronal network function to result in metabolically vulnerable and hyperexcitable peri-tumoral tissue, properties the tumor then exploits to favor its own growth even post-resection. It is evident that there is a complex, dynamic interplay between GBM and epilepsy that promotes the progression of both pathologies. This interaction is only more complicated by the concomitant presence of spreading depolarization (SD). The spontaneous, high-frequency nature of GBM-associated epileptiform activity and SD-associated direct current (DC) shifts require technologies capable of recording brain signals over a wide bandwidth, presenting major challenges for comprehensive electrophysiological investigations. This review will initially provide a detailed examination of the underlying mechanisms that promote network hyperexcitability in GBM. We will then discuss how an investigation of these pathologies from a network level, and utilization of novel electrophysiological tools, will yield a more-effective, clinically-relevant understanding of GBM-related epileptogenesis. Further to this, we will evaluate the clinical relevance of current preclinical research and consider how future therapeutic advancements may impact the bidirectional relationship between GBM, SDs, and seizures.
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Affiliation(s)
- Kate E. Hills
- Nanomedicine Lab, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Kostas Kostarelos
- Nanomedicine Lab, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Catalan Institute for Nanoscience and Nanotechnology (ICN2), Edifici ICN2, Campus UAB, Barcelona, Spain
| | - Robert C. Wykes
- Nanomedicine Lab, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom
- *Correspondence: Robert C. Wykes
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5
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Brauchitsch SV, Strzelczyk A, Rosenow F, Neuhaus E, Dubinski D, Steinbach JP, Voss M. High end-of-life incidence of seizures and status epilepticus in patients with primary and secondary brain tumors. J Neurooncol 2022; 160:277-284. [PMID: 36329367 PMCID: PMC9722831 DOI: 10.1007/s11060-022-04133-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/08/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Seizures pose a significant burden in patients with primary and secondary brain tumors during the end-of-life period. A wide range of 6 to 56% of clinically observed epileptic seizures at the end of life has been reported. We aimed to analyse the incidence of epileptic seizures at the end of life in brain tumor patients more accurately using not only clinical but also electrophysiological findings. METHODS This retrospective, single center study included brain tumor patients who died during the stay on the ward or within 7 days after discharge between 01/2015 and 08/2020. Clinical observation of seizures derived from the original medical records and EEG findings (within 45 days prior to death) were analyzed to determine the incidence of seizures in that period. RESULTS Of the 68 eligible patients, 50 patients (73.5%) suffered from seizures within 45 days prior to death, of which n = 24 had a status epilepticus. The diagnosis of seizures/ status epilepticus was determined either by the presentation of clinical signs in 45 patients and if not, by the detection of a (possible) non-convulsive status epilepticus in the EEG of five patients. CONCLUSION In the presence of neurologically trained staff and with the frequent use of routine EEG, we were able to identify seizures and to distinguish status epilepticus from encephalopathy/ hypoactive delirium. We detected a higher incidence of seizures and status epilepticus at the end of life in neurooncological patients than previously reported.
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Affiliation(s)
- Sophie von Brauchitsch
- grid.7839.50000 0004 1936 9721Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital/ Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- grid.7839.50000 0004 1936 9721Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital/ Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- grid.7839.50000 0004 1936 9721Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital/ Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Elisabeth Neuhaus
- grid.7839.50000 0004 1936 9721Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital/ Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721Institute of Neuroradiology, University Hospital/ Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Daniel Dubinski
- grid.10493.3f0000000121858338Department of Neurosurgery, Faculty of Medicine, University of Rostock, Rostock, Germany
| | - Joachim P. Steinbach
- grid.7839.50000 0004 1936 9721Dr. Senckenberg Institute of Neurooncology, University Hospital/ Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721University Cancer Center Frankfurt (UCT), University Hospital/Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7497.d0000 0004 0492 0584German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Martin Voss
- grid.7839.50000 0004 1936 9721Dr. Senckenberg Institute of Neurooncology, University Hospital/ Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721University Cancer Center Frankfurt (UCT), University Hospital/Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7497.d0000 0004 0492 0584German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, and German Cancer Research Center (DKFZ), Heidelberg, Germany
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6
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Bounajem M, Cole KL, Menacho ST. Rapid Diffuse Leptomeningeal Dissemination of an Anaplastic Pleomorphic Xanthoastrocytoma in an Adult Patient. Cureus 2021; 13:e19186. [PMID: 34873526 PMCID: PMC8636185 DOI: 10.7759/cureus.19186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2021] [Indexed: 11/05/2022] Open
Abstract
Although pleomorphic xanthoastrocytomas generally carry a fair prognosis, anaplastic transformation has been identified in a subset of cases.We present the case of a patient with primary anaplastic pleomorphic xanthoastrocytoma (APXA) that demonstrated rapid recurrence and diffuse leptomeningeal spread of disease three months postoperatively, causing severe visual impairment and acute ischemic strokes leading to death.We believe this is the fastest reported time to leptomeningeal dissemination and death from the initial diagnosis. Through this case, we show how anaplastic features can have a highly variable biological effect on disease progression. We believe earlier craniospinal imaging at the time of APXA diagnosis should be pursued to manage disease progression more aggressively with currently recommended adjuvant therapies.
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Affiliation(s)
| | - Kyril L Cole
- Neurosurgery, University of Utah, Salt Lake City, USA
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7
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Westphal S, Hertler C, Blum D, Schettle M. Subcutaneous Levetiracetam Application Sustains Therapeutic Drug Levels. Palliat Med Rep 2021; 2:157-159. [PMID: 34223515 PMCID: PMC8241392 DOI: 10.1089/pmr.2020.0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 11/12/2022] Open
Abstract
We report on a patient suffering from seizures caused by cerebral metastases of adenocarcinoma of the lung. Initially, the patient was treated effectively with oral levetiracetam. As the disease progressed, oral intake was no longer possible. Since levetiracetam had controlled the patient's seizures well, the medication delivery mode was switched first to intravenous application, followed by a return to oral administration. After further deterioration, subcutaneous levetiracetam application was used to control epileptic symptoms while avoiding the sedating effects of subcutaneous midazolam. Subcutaneous levetiracetam allowed for stable seizure control in the end-of-life situation. Serum levels of levetiracetam were assessed for all application conditions and demonstrate that therapeutic drug levels can be reached by subcutaneous application. This report from a tertiary care center in Switzerland adds to the sparse but growing evidence base for the use of subcutaneous levetiracetam to manage seizures in palliative and end-of-life care.
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Affiliation(s)
- Sophia Westphal
- Competence Center Palliative Care, Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Caroline Hertler
- Competence Center Palliative Care, Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - David Blum
- Competence Center Palliative Care, Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Markus Schettle
- Competence Center Palliative Care, Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
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8
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Połczyńska MM. Organizing Variables Affecting fMRI Estimates of Language Dominance in Patients with Brain Tumors. Brain Sci 2021; 11:brainsci11060694. [PMID: 34070413 PMCID: PMC8226970 DOI: 10.3390/brainsci11060694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/21/2021] [Accepted: 05/22/2021] [Indexed: 11/16/2022] Open
Abstract
Numerous variables can affect the assessment of language dominance using presurgical functional magnetic resonance (fMRI) in patients with brain tumors. This work organizes the variables into confounding and modulating factors. Confounding factors give the appearance of changed language dominance. Most confounding factors are fMRI-specific and they can substantially disrupt the evaluation of language dominance. Confounding factors can be divided into two categories: tumor-related and fMRI analysis. The tumor-related confounds further subdivide into tumor characteristics (e.g., tumor grade) and tumor-induced conditions (aphasia). The fMRI analysis confounds represent technical aspects of fMRI methods (e.g., a fixed versus an individual threshold). Modulating factors can modify language dominance without confounding it. They are not fMRI-specific, and they can impact language dominance both in healthy individuals and neurosurgical patients. The effect of most modulating factors on fMRI language dominance is smaller than that of confounding factors. Modulating factors include demographics (e.g., age) and linguistic variables (e.g., early bilingualism). Three cases of brain tumors in the left hemisphere are presented to illustrate how modulating confounding and modulating factors can impact fMRI estimates of language dominance. Distinguishing between confounding and modulating factors can help interpret the results of presurgical language mapping with fMRI.
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Affiliation(s)
- Monika M Połczyńska
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA 90025, USA
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Sharma A, Mrugala MM. Supportive care for patients with brain metastases from lung cancer. J Thorac Dis 2021; 13:3258-3268. [PMID: 34164218 PMCID: PMC8182494 DOI: 10.21037/jtd-2019-rbmlc-11] [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] [Indexed: 12/02/2022]
Abstract
Lung cancer is the most common cause of intracranial metastases (ICM). Metastases in the brain can result in a broad range of uncomfortable symptoms and significant morbidity secondary to neurological disability. Treatment options can range from surgical resection of solitary metastases to radiotherapy and more recently systemic targeted therapies and immunotherapy. Patient survival continues to improve with innovations made in treatments for this condition, but each of these treatments carry their own adverse effects that must be appropriately managed. These patients can benefit greatly from multidisciplinary care throughout the course of their disease. Clinicians involved in their care must be equipped with the ability to communicate skillfully and compassionately and set expectations for the road ahead, including symptoms, treatment plans, and prognosis. Involvement of a palliative care team can be very helpful, especially for patients who are nearing the terminal stages of the disease. Palliative care skills may be invaluable in the management of symptoms and can ease suffering for patients and their caregivers, thus allowing for maximum quality of life for as long as possible. End of life may bring its own complications and challenges; and opinion of an experienced and knowledgeable clinician can alleviate the pain and distress of the patient and also bring peace to the caregivers and loved ones.
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Affiliation(s)
- Akanksha Sharma
- Department of Translational Neurosciences and Neurotherapeutics; John Wayne Cancer Institute and Pacific Neuroscience Institute, Santa Monica, CA, USA
| | - Maciej M Mrugala
- Department of Neurology, Comprehensive Neuro-Oncology Program, Mayo Clinic Cancer Center, Phoenix, AZ, USA
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Mendlik MT, McFarlin J, Kluger BM, Vaughan CL, Phillips JN, Jones CA. Top Ten Tips Palliative Care Clinicians Should Know About Caring for Patients with Neurologic Illnesses. J Palliat Med 2020; 22:193-198. [PMID: 30707071 DOI: 10.1089/jpm.2018.0617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Patients with neurologic illnesses are commonly encountered by palliative care (PC) clinicians though many clinicians feel uncomfortable caring for these patients. Understanding how to diagnose, treat, communicate with, and prognosticate for neurology patients will improve the confidence and competence of PC providers in the neurology setting. This article offers PC providers 10 useful tips that neurologists with PC training think all PC providers should know to improve care for patients with neurologic illness.
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Affiliation(s)
- Matthew T Mendlik
- 1 Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jessica McFarlin
- 2 Department of Neurology, University of Kentucky, Lexington, Kentucky
| | - Benzi M Kluger
- 3 Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado
| | - Christina L Vaughan
- 3 Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado
| | - Joel N Phillips
- 4 Mercy Health Hauenstein Neurosciences, Grand Rapids, Michigan
| | - Christopher A Jones
- 5 Perelman School of Medicine and Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
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11
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Gonzalez Castro LN, Milligan TA. Seizures in patients with cancer. Cancer 2020; 126:1379-1389. [PMID: 31967671 DOI: 10.1002/cncr.32708] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/21/2019] [Accepted: 12/18/2019] [Indexed: 12/12/2022]
Abstract
Seizures are common in patients with cancer and either result from brain lesions, paraneoplastic syndromes, and complications of cancer treatment or are provoked by systemic illness (metabolic derangements, infections). Evaluation should include a tailored history, neurologic examination, laboratory studies, neuroimaging, and electroencephalogram. In unprovoked seizures, antiepileptic drug (AED) treatment is required, and a nonenzyme-inducing AED is preferred. Treatment of the underlying cancer with surgery, chemotherapy, and radiation therapy also can help reduce seizures. Benzodiazepines are useful in the treatment of both provoked seizures and breakthrough epileptic seizures and as first-line treatment for status epilepticus. Counseling for safety is an important component in the care of a patient with cancer who has seizures. Good seizure management can be challenging but significantly improves the quality of life during all phases of care, including end-of-life care.
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Affiliation(s)
- L Nicolas Gonzalez Castro
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tracey A Milligan
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
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12
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Pace A, Dirven L, Koekkoek JAF, Golla H, Fleming J, Rudà R, Marosi C, Rhun EL, Grant R, Oliver K, Oberg I, Bulbeck HJ, Rooney AG, Henriksson R, Pasman HRW, Oberndorfer S, Weller M, Taphoorn MJB. European Association for Neuro-Oncology (EANO) guidelines for palliative care in adults with glioma. Lancet Oncol 2017; 18:e330-e340. [DOI: 10.1016/s1470-2045(17)30345-5] [Citation(s) in RCA: 147] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 03/08/2017] [Accepted: 03/09/2017] [Indexed: 12/14/2022]
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Fritz L, Dirven L, Reijneveld JC, Koekkoek JAF, Stiggelbout AM, Pasman HRW, Taphoorn MJB. Advance Care Planning in Glioblastoma Patients. Cancers (Basel) 2016; 8:E102. [PMID: 27834803 PMCID: PMC5126762 DOI: 10.3390/cancers8110102] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 10/20/2016] [Accepted: 11/02/2016] [Indexed: 12/27/2022] Open
Abstract
Despite multimodal treatment with surgery, radiotherapy and chemotherapy, glioblastoma is an incurable disease with a poor prognosis. During the disease course, glioblastoma patients may experience progressive neurological deficits, symptoms of increased intracranial pressure such as drowsiness and headache, incontinence, seizures and progressive cognitive dysfunction. These patients not only have cancer, but also a progressive brain disease. This may seriously interfere with their ability to make their own decisions regarding treatment. It is therefore warranted to involve glioblastoma patients early in the disease trajectory in treatment decision-making on their future care, including the end of life (EOL) care, which can be achieved with Advance Care Planning (ACP). Although ACP, by definition, aims at timely involvement of patients and proxies in decision-making on future care, the optimal moment to initiate ACP discussions in the disease trajectory of glioblastoma patients remains controversial. Moreover, the disease-specific content of these ACP discussions needs to be established. In this article, we will first describe the history of patient participation in treatment decision-making, including the shift towards ACP. Secondly, we will describe the possible role of ACP for glioblastoma patients, with the specific aim of treatment of disease-specific symptoms such as somnolence and dysphagia, epileptic seizures, headache, and personality changes, agitation and delirium in the EOL phase, and the importance of timing of ACP discussions in this patient population.
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Affiliation(s)
- Lara Fritz
- Department of Neurology, Haaglanden Medical Center, P.O. BOX 432, 2501 CK The Hague, The Netherlands.
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, P.O. BOX 9600, 2300 RC Leiden, The Netherlands.
| | - Jaap C Reijneveld
- Department of Neurology, VU University Medical Center, P.O. BOX 7057, 1007 MB Amsterdam, The Netherlands.
- Department of Neurology, Academic Medical Center, P.O. BOX 22660, 1100 DD Amsterdam, The Netherlands.
| | - Johan A F Koekkoek
- Department of Neurology, Haaglanden Medical Center, P.O. BOX 432, 2501 CK The Hague, The Netherlands.
- Department of Neurology, Leiden University Medical Center, P.O. BOX 9600, 2300 RC Leiden, The Netherlands.
| | - Anne M Stiggelbout
- Department of Medical Decision Making/Quality of Care, Leiden University Medical Center, P.O. BOX 9600, 2300 RC Leiden, The Netherlands.
| | - H Roeline W Pasman
- Department of Public and Occupational Health, VU University Medical Center, P.O. BOX 7057, 1007 MB Amsterdam, The Netherlands.
| | - Martin J B Taphoorn
- Department of Neurology, Haaglanden Medical Center, P.O. BOX 432, 2501 CK The Hague, The Netherlands.
- Department of Neurology, Leiden University Medical Center, P.O. BOX 9600, 2300 RC Leiden, The Netherlands.
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Koekkoek JAF, Postma TJ, Heimans JJ, Reijneveld JC, Taphoorn MJB. Antiepileptic drug treatment in the end-of-life phase of glioma patients: a feasibility study. Support Care Cancer 2016; 24:1633-8. [PMID: 26404860 PMCID: PMC4766209 DOI: 10.1007/s00520-015-2930-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 08/31/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND During the end-of-life (EOL) phase of glioma patients, a rapid deterioration in neurological functioning may interfere with the oral intake of antiepileptic drugs (AEDs). We aimed to assess the feasibility of non-oral AED treatment in an out-of-hospital setting according to an expert-based guideline. METHODS Glioma patients with a history of epilepsy, in whom further antitumor therapy was considered to be no longer meaningful, were recruited at two Dutch hospitals. As soon as swallowing difficulties developed, the patient's caregiver administered prophylactic treatment with buccal clonazepam. Acute seizures were treated with intranasal midazolam. We evaluated the adherence to the study medication, seizure prevalence, and caregiver's satisfaction. RESULTS Of the 34 patients who were approached, 25 gave consent to participate and 23 had died at the end of the study. Thirteen of 19 patients (68.4 %) who had developed swallowing difficulties showed adherence to the study protocol. Thirteen patients used prophylactic buccal clonazepam, of which eight patients remained seizure-free until death. Six patients received treatment with intranasal midazolam at least once. In all patients, seizure control was reached. None of the patients needed to be transferred to the hospital due to recurrent seizures. All caregivers were to some degree satisfied with the use of the study medication. CONCLUSIONS Our results demonstrate that it is feasible to treat seizures with a combination of non-oral benzodiazepines in the EOL phase of glioma patients, as it seems to provide an important level of comfort among caregivers to be able to manage seizures at home.
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Affiliation(s)
- Johan A F Koekkoek
- Department of Neurology, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands.
- Department of Neurology, Medical Center Haaglanden, PO Box 432, 2501 CK, The Hague, The Netherlands.
- Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.
| | - Tjeerd J Postma
- Department of Neurology, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Jan J Heimans
- Department of Neurology, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Jaap C Reijneveld
- Department of Neurology, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Martin J B Taphoorn
- Department of Neurology, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
- Department of Neurology, Medical Center Haaglanden, PO Box 432, 2501 CK, The Hague, The Netherlands
- Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
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Wells GH, Mason LD, Foreman E, Chambers J. Continuous subcutaneous levetiracetam in the management of seizures at the end of life: a case report. Age Ageing 2016; 45:321-2. [PMID: 26744359 DOI: 10.1093/ageing/afv195] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 11/11/2015] [Indexed: 11/13/2022] Open
Abstract
We report the case of a man who developed seizures on a background of recurrent metastatic squamous cell carcinoma with intracranial involvement. Initial seizure control with enteral levetiracetam was achieved, and when enteral and intravenous (i.v.) access was no longer available, a continuous subcutaneous infusion (CSCI) of levetiracetam successfully controlled his seizures without the need for sedating anticonvulsants. As a result, end-of-life care was able to be given with the patient retaining the ability to communicate with his family and healthcare staff. This report adds to the sparse but growing evidence base for the use of subcutaneous levetiracetam to manage seizures in palliative and end-of-life care.
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Affiliation(s)
- Geoffrey Howard Wells
- Department of Palliative Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Louise D Mason
- Department of Palliative Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Emma Foreman
- Pharmacy Department, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - John Chambers
- Academic Department of Elderly Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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Abstract
The end-of-life (EOL) phase of patients with a glioma starts when symptom prevalence increases and antitumor treatment is no longer effective. During the EOL phase, care is primarily aimed at reducing symptom burden while maintaining quality of life as long as possible without inappropriate prolongation of life. Palliative care during the EOL phase also involves complex medical decisions for the prevention and relief of suffering. We discuss the prevalence and treatment of the most common EOL symptoms, decision making in the EOL phase, the organization of EOL care, and the role of the patient's caregiver. Treating disease-specific symptoms, such as impaired consciousness, seizures, focal neurologic deficits and cognitive disturbances, is a major concern during the EOL phase, as these symptoms may interfere with EOL decision making. Advance care planning is aimed at reaching consensus about possible EOL decisions between all participants, respecting the values of patients and their informal caregivers. In order to prevent the possibility that the patient becomes incompetent to make informed decisions, we recommend initiating EOL conversations at a relatively early stage in the disease course.
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Thier K, Calabek B, Tinchon A, Grisold W, Oberndorfer S. The Last 10 Days of Patients With Glioblastoma: Assessment of Clinical Signs and Symptoms as well as Treatment. Am J Hosp Palliat Care 2015; 33:985-988. [PMID: 26472939 DOI: 10.1177/1049909115609295] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND High-grade gliomas are the most frequent primary brain tumors. Despite improvement in diagnostics and treatment, survival is still poor and quality-of-life issues are of major importance. Little is known regarding the clinical signs and symptoms of dying patients with glioblastoma. OBJECTIVE The aim of this study was to investigate signs and symptoms as well as therapeutic strategies in patients with glioblastoma in the end-of-life phase in order to improve end-of-life care. METHODS In this prospective single-center study, clinical data were obtained using a standardized protocol. We descriptively analyzed signs, symptoms, and therapeutic strategies on a daily basis. RESULTS A total of 57 patients, who died due to glioblastoma in a hospital setting, were included. The most frequent signs and symptoms in the last 10 days before death were decrease in level of consciousness (95%), fever (88%), dysphagia (65%), seizures (65%), and headache (33%). Concerning medication, 95% received opioids. There was a high need for nonsteroidal anti-inflammatory drugs (77%) and anticonvulsants (75%). Steroids were given to 56%. CONCLUSION Due to a decrease in level of consciousness and cognitive impairment, assessment of clinical signs and symptoms such as headache at the end of life is difficult. Based on the signs and symptoms in the last days before death in patients with glioblastoma, supportive drug treatment remains challenging. Our study emphasizes the importance of standardized guidelines for end-of-life care in patients with glioblastoma.
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Affiliation(s)
- Katrin Thier
- Department of Neurology, University Clinic St Pölten, KLPU and Karl Landsteiner Institute for Clinical Neurology and Neuropsychology, St Pölten, Austria
| | - Bernadette Calabek
- Department of Neurology, University Clinic St Pölten, KLPU and Karl Landsteiner Institute for Clinical Neurology and Neuropsychology, St Pölten, Austria
| | - Alexander Tinchon
- Department of Neurology, University Clinic St Pölten, KLPU and Karl Landsteiner Institute for Clinical Neurology and Neuropsychology, St Pölten, Austria
| | - Wolfgang Grisold
- Department of Neurology, Kaiser-Franz-Josef-Hospital, Vienna, Austria
| | - Stefan Oberndorfer
- Department of Neurology, University Clinic St Pölten, KLPU and Karl Landsteiner Institute for Clinical Neurology and Neuropsychology, St Pölten, Austria
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