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Seidel S, Wehner T, Miller D, Wellmer J, Schlegel U, Grönheit W. Brain tumor related epilepsy: pathophysiological approaches and rational management of antiseizure medication. Neurol Res Pract 2022; 4:45. [PMID: 36059029 PMCID: PMC9442934 DOI: 10.1186/s42466-022-00205-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 07/13/2022] [Indexed: 11/10/2022] Open
Abstract
Background Brain tumor related epilepsy (BTRE) is a common complication of cerebral tumors and its incidence is highly dependent on the type of tumor, ranging from 10–15% in brain metastases to > 80% in low grade gliomas. Clinical management is challenging and has to take into account aspects beyond the treatment of non-tumoral epilepsy. Main body Increasing knowledge about the pathophysiology of BTRE, particularly on glutamatergic mechanisms of oncogenesis and epileptogenesis, might influence management of anti-tumor and BTRE treatment in the future. The first seizure implies the diagnosis of epilepsy in patients with brain tumors. Due to the lack of prospective randomized trials in BTRE, general recommendations for focal epilepsies currently apply concerning the initiation of antiseizure medication (ASM). Non-enzyme inducing ASM is preferable. Prospective trials are needed to evaluate, if AMPA inhibitors like perampanel possess anti-tumor effects. ASM withdrawal has to be weighed very carefully against the risk of seizure recurrence, but can be achievable in selected patients. Permission to drive is possible for some patients with BTRE under well-defined conditions, but requires thorough neurological, radiological, ophthalmological and neuropsychological examination.
Conclusion An evolving knowledge on pathophysiology of BTRE might influence future therapy. Randomized trials on ASM in BTRE with reliable endpoints are needed. Management of withdrawal of ASMs and permission to drive demands thorough diagnostic as well as neurooncological and epileptological expertise.
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Chan M, Ferguson D, Ni Mhurchu E, Yuan R, Gondara L, McKenzie M, Olson R, Thiessen B, Lalani N, Ma R, Nichol A. Patients with pretreatment leukoencephalopathy and older patients have more cognitive decline after whole brain radiotherapy. Radiat Oncol 2020; 15:271. [PMID: 33239056 PMCID: PMC7687765 DOI: 10.1186/s13014-020-01717-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/13/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose To investigate predictors of cognitive decline after whole brain radiotherapy (WBRT) for brain metastases. Methods A secondary analysis of a phase 2 clinical trial was conducted in patients who received stereotactic radiosurgery for 1–10 brain metastases and WBRT (NCT01046123). The Montreal Cognitive Assessment (MoCA) was performed at baseline and every 3 months after WBRT. Baseline T2-weighted fluid attenuation inversion recovery magnetic resonance imaging was independently assessed by two neuroradiologists for the presence of white matter hyperintensities (WMH) using the Fazekas visual rating scale. WMH were also manually segmented for volumetric analysis. Univariable and multivariable logistic regression were used to test the association between baseline variables and MoCA score decline.
Results Forty-six patients survived ≥ 3 months after treatment. Age (OR 1.12 (1.04–1.21), p < 0.01), baseline WMH volume (OR 1.20, 95% CI 1.06–1.52, p = 0.02) and baseline Fazekas score ≥ 3/6 (OR 6.4, 95% CI 1.7–24.7, p < 0.01) were predictive of MoCA score decline. In multivariable analysis, age was the only significant predictor of MoCA decline. However, all three patients with pre-treatment leukoencephalopathy (Fazekas score = 6/6) had notable adverse outcomes due to cognitive impairment: one required full-time home nursing support and two were institutionalized. Conclusion A greater decline in cognition after WBRT was observed in older patients and patients with a higher baseline WMH burden. Although this study is small and hypothesis-generating, we propose that radiation oncologists should exercise caution in prescribing WBRT if leukoencephalopathy is present on pre-treatment imaging. Trial Registration: clinicaltrials.gov identifier NCT01046123. First posted January 11, 2010. https://clinicaltrials.gov/ct2/show/NCT01046123
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Affiliation(s)
- Matthew Chan
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Vancouver, 600 West 10th Ave, Vancouver, BC, V5Z 4E6, Canada
| | - David Ferguson
- Department of Radiology, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Elaine Ni Mhurchu
- Department of Radiology, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Ren Yuan
- Department of Radiology, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Lovedeep Gondara
- Department of Population Oncology, BC Cancer - Vancouver Centre, Vancouver, BC, Canada
| | - Michael McKenzie
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Vancouver, 600 West 10th Ave, Vancouver, BC, V5Z 4E6, Canada
| | - Robert Olson
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Prince George, Prince George, BC, Canada
| | - Brian Thiessen
- Department of Medical Oncology, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Nafisha Lalani
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Vancouver, 600 West 10th Ave, Vancouver, BC, V5Z 4E6, Canada
| | - Roy Ma
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Vancouver, 600 West 10th Ave, Vancouver, BC, V5Z 4E6, Canada
| | - Alan Nichol
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada. .,Department of Radiation Oncology, BC Cancer - Vancouver, 600 West 10th Ave, Vancouver, BC, V5Z 4E6, Canada.
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