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Cucchiara F, Ferraro S, Luci G, Bocci G. Relevant pharmacological interactions between alkylating agents and antiepileptic drugs: Preclinical and clinical data. Pharmacol Res 2021; 175:105976. [PMID: 34785318 DOI: 10.1016/j.phrs.2021.105976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 11/07/2021] [Accepted: 11/07/2021] [Indexed: 01/01/2023]
Abstract
Seizures are relatively common in cancer patients, and co-administration of chemotherapeutic and antiepileptic drugs (AEDs) is highly probable and necessary in many cases. Nonetheless, clinically relevant interactions between chemotherapeutic drugs and AEDs are rarely summarized and pharmacologically described. These interactions can cause insufficient tumor and seizure control or lead to unforeseen toxicity. This review focused on pharmacokinetic and pharmacodynamic interactions between alkylating agents and AEDs, helping readers to make a rational choice of treatment optimization, and thus improving patients' quality of life. As an example, phenobarbital, phenytoin, and carbamazepine, by increasing the hepatic metabolism of cyclophosphamide, ifosfamide and busulfan, yield smaller peak concentrations and a reduced area under the plasma concentration-time curve (AUC) of the prodrugs; alongside, the maximum concentration and AUC of their active products were increased with the possible onset of severe adverse drug reactions. On the other side, valproic acid, acting as histone deacetylase inhibitor, showed synergistic effects with temozolomide when tested in glioblastoma. The present review is aimed at providing evidence that may offer useful suggestions for rational pharmacological strategies in patients with seizures symptoms undertaking alkylating agents. Firstly, clinicians should avoid the use of enzyme-inducing AEDs in combination with alkylating agents and prefer the use of AEDs, such as levetiracetam, that have a low or no impact on hepatic metabolism. Secondly, a careful therapeutic drug monitoring of both alkylating agents and AEDs (and their active metabolites) is necessary to maintain therapeutic ranges and to avoid serious adverse reactions.
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Affiliation(s)
- Federico Cucchiara
- Unit of Pharmacology, Department of Clinical and Experimental, University of Pisa, Pisa, Italy
| | - Sara Ferraro
- Unit of Pharmacology and Pharmacovigilance, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giacomo Luci
- Unit of Pharmacology, Department of Clinical and Experimental, University of Pisa, Pisa, Italy
| | - Guido Bocci
- Unit of Pharmacology, Department of Clinical and Experimental, University of Pisa, Pisa, Italy.
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2
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Pallud J, Huberfeld G, Dezamis E, Peeters S, Moiraghi A, Gavaret M, Guinard E, Dhermain F, Varlet P, Oppenheim C, Chrétien F, Roux A, Zanello M. Effect of Levetiracetam Use Duration on Overall Survival of Isocitrate Dehydrogenase Wildtype Glioblastoma in Adults: An Observational Study. Neurology 2021; 98:e125-e140. [PMID: 34675100 DOI: 10.1212/wnl.0000000000013005] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 10/15/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES The association between Levetiracetam and survival of Isocitrate Dehydrogenase (IDH) wildtype glioblastomas is controversial. We investigated whether the duration of Levetiracetam use during the standard chemoradiation protocol impacts overall survival of IDH-wildtype glioblastoma patients. METHODS Observational single-institution cohort study (2010-2018). Inclusion criteria were: 1) patients ≥18 years old; 2) newly diagnosed supratentorial tumor; 3) histomolecular diagnosis of IDH-wildtype glioblastoma; 4) standard chemoradiation protocol. To assess the survival benefit of Levetiracetam use during the standard chemoradiation protocol (whole duration, part time, and never subgroups), a Cox proportional hazard model was constructed. We performed a case-matched analysis (1:1) between patients with Levetiracetam use during the whole duration of the standard chemoradiation protocol and patients with Levetiracetam use part time or never according to the following criteria: sex, age, epileptic seizures at diagnosis, RTOG-RPA class, tumor location, preoperative volume, extent of resection, and O6-Methylguanine-DNA methyltransferase promoter methylation status. Patients with unavailable O6-Methylguanine-DNA methyltransferase promoter methylation status (48.5%) were excluded. RESULTS 460 patients were included. The median overall survival was longer in the 116 patients with Levetiracetam use during the whole duration of the standard chemoradiation protocol (21.0 months; 95%CI, 17.2-24.0) than in the 126 patients with part time Levetiracetam use (16.8 months; 95%CI, 12.4-19.0], and in the 218 patients who never received Levetiracetam (16.0 months; 95%CI, 15.5-19.4; p=0.027). Levetiracetam use during the whole duration of the standard chemoradiation protocol (adjusted Hazard Ratio (aHR) 0.69; 95%CI, 0.52-0.93; p=0.014), O6-Methylguanine-DNA methyltransferase promoter methylation (aHR 0.53; 95%CI, 0.39-0.71; p<0.001), and gross total tumor resection (aHR 0.57; 95%CI, 0.44-0.74; p<0.001) were independent predictors of a longer overall survival. After case matching (n=54 per group), a longer overall survival was found for Levetiracetam use during the whole duration of the standard chemoradiation protocol (HR=0.63; 95%CI, 0.42-0.94, p=0.023). DISCUSSION Levetiracetam use during the whole standard chemoradiation protocol possibly improves overall survival of IDH-wildtype glioblastoma patients. It should be considered in the anti-tumor strategy of future multicentric trials. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that in individuals with IDH-wildtype glioblastoma, levetiracetam use throughout the duration of standard chemotherapy is associated with longer median overall survival.
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Affiliation(s)
- Johan Pallud
- Department of Neurosurgery, GHU Paris - Sainte-Anne Hospital, Paris, France .,Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France
| | - Gilles Huberfeld
- Neurology Department, Hopital Fondation Adolphe de Rothschild, 29 rue Main, 75019 Paris, France.,Neuroglial Interactions in Cerebral Physiopathology, Center for Interdisciplinary Research in Biology, Collège de France, CNRS UMR 7241, INSERM U1050, Université PSL Paris, France
| | - Edouard Dezamis
- Department of Neurosurgery, GHU Paris - Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France
| | - Sophie Peeters
- Department of Neurosurgery, University of California, Los Angeles - Los Angeles, CA, USA
| | - Alessandro Moiraghi
- Department of Neurosurgery, GHU Paris - Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France
| | - Martine Gavaret
- Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France.,Department of Neurophysiology, GHU Paris - Sainte-Anne Hospital, Paris, France
| | - Eléonore Guinard
- Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France.,Department of Neurophysiology, GHU Paris - Sainte-Anne Hospital, Paris, France
| | - Frédéric Dhermain
- Department of Radiotherapy, Gustave Roussy University Hospital, Villejuif, France
| | - Pascale Varlet
- Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France.,Department of Neuropathology, GHU Paris - Sainte-Anne Hospital, Paris, France
| | - Catherine Oppenheim
- Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France.,Department of Neuroradiology, GHU Paris - Sainte-Anne Hospital, Paris, France
| | - Fabrice Chrétien
- Université de Paris, Sorbonne Paris Cité, Paris, France.,Department of Neuropathology, GHU Paris - Sainte-Anne Hospital, Paris, France
| | - Alexandre Roux
- Department of Neurosurgery, GHU Paris - Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France
| | - Marc Zanello
- Department of Neurosurgery, GHU Paris - Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France
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3
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de Bruin ME, van der Meer PB, Dirven L, Taphoorn MJB, Koekkoek JAF. Efficacy of antiepileptic drugs in glioma patients with epilepsy: a systematic review. Neurooncol Pract 2021; 8:501-517. [PMID: 34589231 PMCID: PMC8475226 DOI: 10.1093/nop/npab030] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Comprehensive data on the efficacy and tolerability of antiepileptic drugs (AED) treatment in glioma patients with epilepsy are currently lacking. In this systematic review, we specifically assessed the efficacy of AEDs in patients with a grade II-IV glioma. Methods Electronic databases PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane Library were searched up to June 2020. Three different outcomes for both mono- and polytherapy were extracted from all eligible articles: (i) seizure freedom; (ii) ≥50% reduction in seizure frequency; and (iii) treatment failure. Weighted averages (WA) were calculated for outcomes at 6 and 12 months. Results A total of 66 studies were included. Regarding the individual outcomes on the efficacy of monotherapy, the highest seizure freedom rate at 6 months was with phenytoin (WA = 72%) while at 12-month pregabalin (WA = 75%) and levetiracetam (WA = 74%) showed highest efficacy. Concerning ≥50% seizure reduction rates, levetiracetam showed highest efficacy at 6 and 12 months (WAs of 82% and 97%, respectively). However, treatment failure rates at 12 months were highest for phenytoin (WA = 34%) and pregabalin (41%). When comparing the described polytherapy combinations with follow-up of ≥6 months, levetiracetam combined with phenytoin was most effective followed by levetiracetam combined with valproic acid. Conclusion Given the heterogeneous patient populations and the low scientific quality across the different studies, seizure rates need to be interpreted with caution. Based on the current limited evidence, with the ranking of AEDs being confined to the AEDs studied, levetiracetam, phenytoin, and pregabalin seem to be most effective as AED monotherapy in glioma patients with epilepsy, with levetiracetam showing the lowest treatment failure rate, compared to the other AEDs studied.
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Affiliation(s)
| | - Pim B van der Meer
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Linda Dirven
- Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands.,Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Martin J B Taphoorn
- Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands.,Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Johan A F Koekkoek
- Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands.,Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
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4
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Knudsen-Baas KM, Storstein AM, Zarabla A, Maialetti A, Giannarelli D, Beghi E, Maschio M. Antiseizure medication in patients with Glioblastoma- a collaborative cohort study. Seizure 2021; 87:107-113. [PMID: 33761391 DOI: 10.1016/j.seizure.2021.03.012] [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: 08/25/2020] [Revised: 03/12/2021] [Accepted: 03/13/2021] [Indexed: 02/07/2023] Open
Abstract
PURPOSE We investigated, whether epileptic seizures (ES) as presenting symptom in adult patients with GBM are associated with better Overall Survival (OS) compared to ES presenting later during the course of GBM, and efficacy and safety of different antiseizure medications (ASMs). METHODS Retrospective consecutive cohort study of adults with GBM: 50 from Norway and 50 from Italy. We compared the time to changing ASM treatments. OS was investigated with a Cox regression model adjusted for time dependency. RESULTS Median follow-up was 17 months from GBM diagnosis. ES were the presenting symptom in 49 patients. All patients received ASM treatment. LEV was the first ASM in the majority of patients and the most effective at one year from the first prescription, (p = 0.004). Occurrence of adverse events (AEs) was similar between LEV and other ASMs (p = 0.47). Poorer OS correlated with older age at GBM diagnosis, country and ASM therapy. A negative impact of ASMs on OS was observed for LEV in a univariate and multivariate analysis, and for VPA (only in multivariate analysis), even when adjusted for O6-methylguanine-DNA-methyltransferase (MGMT) methylation status. Patients with ES as the onset symptom of GBM and patients who had first ES later had similar OS (p = 0.87). CONCLUSION ES as the GBM debut symptom did not lead to a longer OS. LEV was a more effective ASM compared to other treatments with no differences regarding AEs between LEV and other ASMs. Surprisingly, in our patients LEV and VPA were associated with worse OS than other ASMs. This result should be interpreted with caution due to the retrospective nature of this study along with the many variables which may affect the outcome in this population.
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Affiliation(s)
- Kristin M Knudsen-Baas
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; The National Center for Epilepsy, Norway.
| | | | - Alessia Zarabla
- Center for Tumor-related Epilepsy, UOSD Neuroncology, Regina Elena National Cancer Institute IRCCS, Rome, Italy.
| | - Andrea Maialetti
- Center for Tumor-related Epilepsy, UOSD Neuroncology, Regina Elena National Cancer Institute IRCCS, Rome, Italy.
| | - Diana Giannarelli
- Biostatistic Unit, Regina Elena National Cancer Institute IRCCS, Rome, Italy.
| | - Ettore Beghi
- Laboratorio Malattie Neurologiche, IRCCS - Istituto "Mario Negri", Milano, Italy.
| | - Marta Maschio
- Center for Tumor-related Epilepsy, UOSD Neuroncology, Regina Elena National Cancer Institute IRCCS, Rome, Italy.
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5
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Ahmadipour Y, Rauschenbach L, Santos A, Darkwah Oppong M, Lazaridis L, Quesada CM, Junker A, Pierscianek D, Dammann P, Wrede KH, Scheffler B, Glas M, Stuschke M, Sure U, Jabbarli R. Preoperative and early postoperative seizures in patients with glioblastoma-two sides of the same coin? Neurooncol Adv 2020; 3:vdaa158. [PMID: 33506201 PMCID: PMC7813191 DOI: 10.1093/noajnl/vdaa158] [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] [Indexed: 01/01/2023] Open
Abstract
Background Symptomatic epilepsy is a common symptom of glioblastoma, which may occur in different stages of disease. There are discrepant reports on association between early seizures and glioblastoma survival, even less is known about the background of these seizures. We aimed at analyzing the risk factors and clinical impact of perioperative seizures in glioblastoma. Methods All consecutive cases with de-novo glioblastoma treated at our institution between 01/2006 and 12/2018 were eligible for this study. Perioperative seizures were stratified into seizures at onset (SAO) and early postoperative seizures (EPS, ≤21days after surgery). Associations between patients characteristics and overall survival (OS) with SAO and EPS were addressed. Results In the final cohort (n = 867), SAO and EPS occurred in 236 (27.2%) and 67 (7.7%) patients, respectively. SAO were independently predicted by younger age (P = .009), higher KPS score (P = .002), tumor location (parietal lobe, P = .001), GFAP expression (≥35%, P = .045), and serum chloride at admission (>102 mmol/L, P = .004). In turn, EPS were independently associated with tumor location (frontal or temporal lobe, P = .013) and pathologic laboratory values at admission (hemoglobin < 12 g/dL, [P = .044], CRP > 1.0 mg/dL [P = 0.036], and GGT > 55 U/L [P = 0.025]). Finally, SAO were associated with gross-total resection (P = .006) and longer OS (P = .030), whereas EPS were related to incomplete resection (P = .005) and poorer OS (P = .009). Conclusions In glioblastoma patients, SAO and EPS seem to have quite different triggers and contrary impact on treatment success and OS. The clinical characteristics of SAO and EPS patients might contribute to the observed survival differences.
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Affiliation(s)
- Yahya Ahmadipour
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany.,DKFZ-Division Translational Neurooncology at the WTZ, German Cancer Research Center (DKFZ) Heidelberg and German Cancer Consortium (DKTK) Partner Site University Hospital Essen, Essen, Germany
| | - Alejandro Santos
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Lazaros Lazaridis
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany.,Division of Clinical Neurooncology, Department of Neurology, University Hospital Essen, Essen, Germany.,Department for Neurology, University Hospital Essen, Essen, Germany
| | - Carlos M Quesada
- Department for Neurology, University Hospital Essen, Essen, Germany
| | - Andreas Junker
- Department of Neuropathology, University Hospital Essen, Essen, Germany
| | - Daniela Pierscianek
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Björn Scheffler
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany.,DKFZ-Division Translational Neurooncology at the WTZ, German Cancer Research Center (DKFZ) Heidelberg and German Cancer Consortium (DKTK) Partner Site University Hospital Essen, Essen, Germany
| | - Martin Glas
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany.,Division of Clinical Neurooncology, Department of Neurology, University Hospital Essen, Essen, Germany.,Department for Neurology, University Hospital Essen, Essen, Germany
| | - Martin Stuschke
- German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany.,Department of Radiotherapy, University Hospital Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.,German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
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Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight advances in the management of seizures in brain metastases from solid tumors. RECENT FINDINGS The highest risk for seizures is in patients with melanoma and lung cancer. There is lack of data on the efficacy of antiepileptic drugs (AEDs), but interactions between enzyme-inducing AEDs and anticancer agents must be avoided. Levetiracetam and valproic acid are the most appropriate drugs. Prophylaxis with AEDs for patients with brain metastases without a history of seizures is not recommended. Total resection of a brain metastasis allows complete seizure control. Seizures may represent an adverse effect of stereotactic radiosurgery or of high-dose chemotherapy. New preclinical and clinical studies should define the risk of brain metastasis in light of the new treatment options in the different tumor types. New clinical trials should be designed in patients with brain metastases in terms of treatment or prophylaxis of seizures.
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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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8
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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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Cacho-Diaz B, San-Juan D, Salmeron K, Boyzo C, Lorenzana-Mendoza N. Choice of antiepileptic drugs affects the outcome in cancer patients with seizures. Clin Transl Oncol 2018; 20:1571-1576. [PMID: 29869040 DOI: 10.1007/s12094-018-1892-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 05/09/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Seizures in cancer patients may occur as a result of CNS primary or metastatic tumor, brain surgery, vascular disease, pharmacologic treatment (including chemotherapy), radiation therapy, or metabolic disorders. The aims of the study were to a) determine whether seizures in cancer patients have prognostic implications and b) study patient outcome based on the antiepileptic drug used. METHOD This is a prospective comparative study that included adult cancer patients with and without seizures from May 2010 to November 2016 seen by the neuro-oncology unit at a cancer referral center. Variables included age, gender, oncologic characteristics, seizure features, treatment, and outcome. Parametric and non-parametric tests were used to compare groups, and Kaplan-Meier curves with the log-rank test were used to analyze survival. Cox multivariate regression tests were used to describe survival and compare groups. RESULTS A total of 823 patients were included; 419 (51%) patients had at least one seizure and were compared with 404 (49%) who did not experience seizures. Of the seizure group, 53% had brain metastases, 36% did not have a brain tumor, and 11% had a primary brain tumor. No survival differences were noted among patients with brain metastases or primary tumor with or without seizures. In the seizure group, 249 (59%) required only one antiepileptic drug, whereas 134 (32%) required 2 or more. A better overall survival was identified for patients prescribed carbamazepine (p = 0.02), lamotrigine (p = 0.015), levetiracetam (p = 0.03), and valproic acid (p = 0.009). CONCLUSIONS Patients with primary or metastatic brain tumors have the same overall survival with or without seizures. However, patients with seizures not treated with antiepileptics exhibit worse overall survival.
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Affiliation(s)
- B Cacho-Diaz
- Neuroscience Unit, Neuro-oncology Service, Instituto Nacional de Cancerología, Avenida San Fernando 22 Col, Sección XVI, Tlalpan, Mexico City, 14080, Mexico.
| | - D San-Juan
- Clinical Research Department, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - K Salmeron
- Neuroscience Unit, Neuro-oncology Service, Instituto Nacional de Cancerología, Avenida San Fernando 22 Col, Sección XVI, Tlalpan, Mexico City, 14080, Mexico
| | - C Boyzo
- Neuroscience Unit, Neuro-oncology Service, Instituto Nacional de Cancerología, Avenida San Fernando 22 Col, Sección XVI, Tlalpan, Mexico City, 14080, Mexico
| | - N Lorenzana-Mendoza
- Neuroscience Unit, Neuro-oncology Service, Instituto Nacional de Cancerología, Avenida San Fernando 22 Col, Sección XVI, Tlalpan, Mexico City, 14080, Mexico
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10
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Rigamonti A, Imbesi F, Silvani A, Gaviani P, Agostoni E, Porcu L, De Simone I, Torri V, Salmaggi A. Antiepileptic treatment and survival in newly diagnosed glioblastoma patients: Retrospective multicentre study in 285 Italian patients. J Neurol Sci 2018; 390:14-19. [PMID: 29801876 DOI: 10.1016/j.jns.2018.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 03/07/2018] [Accepted: 04/03/2018] [Indexed: 01/09/2023]
Abstract
Glioblastoma multiforme (GBM) has a dismal prognosis even with the best available treatment. Different studies have suggested a possible impact of antiepileptic drugs (AED) on survival in patients with GBM. A recent pooled analysis of prospective clinical trials in newly diagnosed GBM found no significant survival benefit in GBM patients treated with AED. We performed a retrospective study on adult patients with GBM in order to evaluate the impact of AED therapy on overall survival (OS), after adjusting for known prognostic factor (age, extent of surgery, Karnofsky performance status, radiochemotherapy). A total of 285 patients were analyzed. Of them 144 received a non-enzyme-inducing (NEIAED) and 95 an enzyme-inducing AED (EIAED). At univariate analysis the OS of patients receiving AED was not significantly different from that of patients not receiving an AED (HR 0.98, 95%CI 0.69-1.4, p = 0.925), moreover OS was not significantly different between patients receiving EIAED or NEIAED. At multivariate analysis a trend to more prolonged survival (HR 0.8, 95% CI 0.59-1.08, p = 0.15) was detected in patients treated with NEIAED. The question whether treatment with AED may increase OS in GBM patients remains unanswered and randomized extremely large controlled clinical trial would be necessary to elucidate the possible impact of AED on prognosis. In the meantime the use of AED in GBM patients, based on the presumed potential antitumour activity, is not recommended.
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Affiliation(s)
- Andrea Rigamonti
- Neurological Department, ASST Lecco, Via Dell' Eremo 9-11, 23900 Lecco, Italy.
| | - Francesca Imbesi
- Neurological Department, ASST, Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162 Milano, Italy
| | - Antonio Silvani
- Neuro Oncology Unit, Fondazione IRCSS Carlo Besta, Via Celoria 11, 20133 Milano, Italy
| | - Paola Gaviani
- Neuro Oncology Unit, Fondazione IRCSS Carlo Besta, Via Celoria 11, 20133 Milano, Italy
| | - Elio Agostoni
- Neurological Department, ASST, Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162 Milano, Italy
| | - Luca Porcu
- Pharmacological Research Institute, IRCSS Mario Negri, Via La Masa 19, 20156 Milano, Italy
| | - Irene De Simone
- Pharmacological Research Institute, IRCSS Mario Negri, Via La Masa 19, 20156 Milano, Italy
| | - Valter Torri
- Pharmacological Research Institute, IRCSS Mario Negri, Via La Masa 19, 20156 Milano, Italy
| | - Andrea Salmaggi
- Neurological Department, ASST Lecco, Via Dell' Eremo 9-11, 23900 Lecco, Italy
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11
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Cardona AF, Rojas L, Wills B, Bernal L, Ruiz-Patiño A, Arrieta O, Hakim EJ, Hakim F, Mejía JA, Useche N, Bermúdez S, Carranza H, Vargas C, Otero J, Mayor LC, Ortíz LD, Franco S, Ortíz C, Gil-Gil M, Balaña C, Zatarain-Barrón ZL. Efficacy and safety of Levetiracetam vs. other antiepileptic drugs in Hispanic patients with glioblastoma. J Neurooncol 2017; 136:363-371. [PMID: 29177594 DOI: 10.1007/s11060-017-2660-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 10/29/2017] [Indexed: 01/05/2023]
Abstract
Epilepsy is a common symptom in patients with glioblastoma (GB). 213 patients with GB from RedLANO follow-up registry were included. All patients underwent surgery, if feasible, followed by chemoradiation based on temozolomide (Stupp platform). Information was recorded regarding demographics, seizure timing, anti-epileptic drugs (AEDs), dosage, time to next seizure, total seizures in 6 months, and main side effects of AEDs. The relationship between epilepsy treatment and overall survival (OS) was evaluated. Mean age was 53 years old and 56.8% were male. Seventy-eight patients (37%) were treated with levetiracetam (LEV), 27% were given another AED and 36% did not require any AED. Choice of AED was not associated with age (p = 0.67), performance status (p = 0.24) or anatomic tumor site (p = 0.34). Seizures and AED requirement were greater in those having primary GB (p = 0.04). After starting an AED, the mean time until next crisis was 9.9 days (SD ± 6.3), which was shorter in those receiving LEV (p = 0.03); mean number of seizures during the first 3 and 6 months were 2.9 and 4, respectively. Most patients treated with LEV (n = 46) required less than two medication adjustments compared to those treated with other AEDs (p = 0.02). Likewise, less patients exposed to LEV required a coadjuvant drug (p = 0.04). Additionally, patients receiving LEV had significantly less adverse effects compared to patients treated with another AED. OS was significantly higher in the group treated with LEV compared to other AEDs (25.5 vs. 17.9 months; p = 0.047). Patients treated with LEV had better seizure control and longer OS compared to other AEDs.
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Affiliation(s)
- Andrés F Cardona
- Brain Tumors Unit, Clinical and Translational Oncology Group, Institute of Oncology, Clínica del Country, Bogotá, Colombia. .,Foundation for Clinical and Applied Cancer Research (FICMAC), Calle 116 No. 9 - 72, c. 318, Bogotá, Colombia. .,Latin American Neuro-Oncology Network (RedLANO), Bogotá, Colombia.
| | - Leonardo Rojas
- Clinical Oncology Department, Centro Javeriano de Oncología, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Beatriz Wills
- Foundation for Clinical and Applied Cancer Research (FICMAC), Calle 116 No. 9 - 72, c. 318, Bogotá, Colombia
| | - Laura Bernal
- Internal Medicine Department, Hospital Universitario San Ignacio, Bogotá, Colombia
| | | | - Oscar Arrieta
- Thoracic Oncology Unit and Laboratory of Personalized Medicine, Instituto Nacional de Cancerología (INCan), México City, Mexico
| | - Enrique Jiménez Hakim
- Neurosurgery Department, Fundación Santa Fe de Bogotá, Bogotá, Colombia.,Institute of Neuroscience, Universidad El Bosque, Bogotá, Colombia
| | - Fernando Hakim
- Neurosurgery Department, Fundación Santa Fe de Bogotá, Bogotá, Colombia.,Institute of Neuroscience, Universidad El Bosque, Bogotá, Colombia
| | - Juan Armando Mejía
- Neurosurgery Department, Fundación Santa Fe de Bogotá, Bogotá, Colombia.,Institute of Neuroscience, Universidad El Bosque, Bogotá, Colombia
| | - Nicolás Useche
- Institute of Neuroscience, Universidad El Bosque, Bogotá, Colombia.,Radiology Department, Neuro-radiology Section, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Sonia Bermúdez
- Institute of Neuroscience, Universidad El Bosque, Bogotá, Colombia.,Radiology Department, Neuro-radiology Section, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Hernán Carranza
- Brain Tumors Unit, Clinical and Translational Oncology Group, Institute of Oncology, Clínica del Country, Bogotá, Colombia.,Foundation for Clinical and Applied Cancer Research (FICMAC), Calle 116 No. 9 - 72, c. 318, Bogotá, Colombia
| | - Carlos Vargas
- Brain Tumors Unit, Clinical and Translational Oncology Group, Institute of Oncology, Clínica del Country, Bogotá, Colombia.,Foundation for Clinical and Applied Cancer Research (FICMAC), Calle 116 No. 9 - 72, c. 318, Bogotá, Colombia
| | - Jorge Otero
- Brain Tumors Unit, Clinical and Translational Oncology Group, Institute of Oncology, Clínica del Country, Bogotá, Colombia.,Foundation for Clinical and Applied Cancer Research (FICMAC), Calle 116 No. 9 - 72, c. 318, Bogotá, Colombia
| | - Luis Carlos Mayor
- Neurology Department, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - León Darío Ortíz
- Latin American Neuro-Oncology Network (RedLANO), Bogotá, Colombia.,Neuro-Oncology Unit, Clinical Oncology Department, Clínica de Las Américas, Medellín, Colombia
| | - Sandra Franco
- Brain Tumors Unit, Clinical and Translational Oncology Group, Institute of Oncology, Clínica del Country, Bogotá, Colombia
| | - Carlos Ortíz
- Brain Tumors Unit, Clinical and Translational Oncology Group, Institute of Oncology, Clínica del Country, Bogotá, Colombia
| | - Miguel Gil-Gil
- Medical Oncology Service, Catalan Institute of Oncology, Hospital Duran I Reynals - IDIBELL, Hospitalet de Llobregat, Spain
| | - Carmen Balaña
- Medical Oncology Service, Catalan Institute of Oncology, Hospital Universitari Germans Trias i Pujol, IGTP, Badalona, Spain
| | - Zyanya Lucia Zatarain-Barrón
- Thoracic Oncology Unit and Laboratory of Personalized Medicine, Instituto Nacional de Cancerología (INCan), México City, Mexico
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12
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Lacosamide in patients with gliomas and uncontrolled seizures: results from an observational study. J Neurooncol 2017; 136:105-114. [DOI: 10.1007/s11060-017-2628-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 10/01/2017] [Indexed: 01/05/2023]
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13
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Rizzo A, Donzelli S, Girgenti V, Sacconi A, Vasco C, Salmaggi A, Blandino G, Maschio M, Ciusani E. In vitro antineoplastic effects of brivaracetam and lacosamide on human glioma cells. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2017; 36:76. [PMID: 28587680 PMCID: PMC5460451 DOI: 10.1186/s13046-017-0546-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 05/29/2017] [Indexed: 01/16/2023]
Abstract
Background Epilepsy is a frequent symptom in patients with glioma. Although treatment with antiepileptic drugs is generally effective in controlling seizures, drug-resistant patients are not uncommon. Multidrug resistance proteins (MRPs) and P-gp are over-represented in brain tissue of patients with drug-resistant epilepsy, suggesting their involvement in the clearance of antiepileptic medications. In addition to their anticonvulsant action, some drugs have been documented for cytotoxic effects. Aim of this study was to evaluate possible in vitro cytotoxic effects of two new-generation antiepileptic drugs on a human glioma cell line U87MG. Methods Cytotoxicity of brivaracetam and lacosamide was tested on U87MG, SW1783 and T98G by MTS assay. Expression of chemoresistance molecules was evaluated using flow cytometry in U87MG and human umbilical vein endothelial cells (HUVECs). To investigate the putative anti-proliferative effect, apoptosis assay, microRNA expression profile and study of cell cycle were performed. Results Brivaracetam and lacosamide showed a dose-dependent cytotoxic and anti-migratory effects. Cytotoxicity was not related to apoptosis. The exposure of glioma cells to brivaracetam and lacosamide resulted in the modulation of several microRNAs; particularly, the effect of miR-195-5p modulation seemed to affect cell cycle, while miR-107 seemed to be implicated in the inhibition of cells migration. Moreover, brivaracetam and lacosamide treatment did not modulate the expression of chemoresistance-related molecules MRPs1-3-5, GSTπ, P-gp on U87MG and HUVECs. Conclusion Based on antineoplastic effect of brivaracetam and lacosamide on glioma cells, we assume that patients with glioma could benefit by the treatment with these two molecules, in addition to standard therapeutic options. Electronic supplementary material The online version of this article (doi:10.1186/s13046-017-0546-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ambra Rizzo
- Laboratory of Clinical Pathology and Medical Genetics, Foundation IRCCS Neurological Institute C. Besta, Via Celoria, 11, 20133, Milan, Italy
| | - Sara Donzelli
- Oncogenomic and Epigenetic Unit, Regina Elena National Cancer Institute, Via Elio Chianesi, 5300144, Rome, Italy
| | - Vita Girgenti
- Laboratory of Clinical Pathology and Medical Genetics, Foundation IRCCS Neurological Institute C. Besta, Via Celoria, 11, 20133, Milan, Italy
| | - Andrea Sacconi
- Oncogenomic and Epigenetic Unit, Regina Elena National Cancer Institute, Via Elio Chianesi, 5300144, Rome, Italy
| | - Chiara Vasco
- Laboratory of Clinical Pathology and Medical Genetics, Foundation IRCCS Neurological Institute C. Besta, Via Celoria, 11, 20133, Milan, Italy
| | - Andrea Salmaggi
- Neurologia- Stroke Unit, Manzoni Hospital, Via dell'Eremo 9/11, 23900, Lecco, Italy
| | - Giovanni Blandino
- Oncogenomic and Epigenetic Unit, Regina Elena National Cancer Institute, Via Elio Chianesi, 5300144, Rome, Italy
| | - Marta Maschio
- Center for tumor-related epilepsy, Area of Supporting Care, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy.
| | - Emilio Ciusani
- Laboratory of Clinical Pathology and Medical Genetics, Foundation IRCCS Neurological Institute C. Besta, Via Celoria, 11, 20133, Milan, Italy
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14
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Pattern of care and outcome in elderly patients with glioblastoma: Data in 151 patients from 3 Lombardia Hospitals. J Neurol Sci 2017; 378:3-8. [PMID: 28566172 DOI: 10.1016/j.jns.2017.04.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 03/30/2017] [Accepted: 04/17/2017] [Indexed: 01/15/2023]
Abstract
The appropriate treatment approach for elderly patients with glioblastoma multiforme (GBM) is unclear, although different studies suggest survival benefit in fit patients treated with radiotherapy and chemiotherapy after surgery. We performed a retrospective analysis of 151 patients older than 65years with GBM treated in 3 Lombardia Hospitals. In univariate regression analysis higher KPS (p=0.02), macroscopical total resection (p<0.003), radiotherapy (p<0.0001), chemotherapy (p<0.0001) and second line chemotheraphy (p=0.02) were of positive prognostic value. On the contrary older age (>70years), presence of seizure at onset and additional resection after tumor recurrence did not influence OS. Multivariate analysis revealed radiotherapy (HR 0.2 p<0.0001) and extent of surgery (HR 0.3, p=0,0063) as positive independent prognostic factors. Patients receiving radio-chemiotherapy displayed more treatment-related toxicities with a slightly prolonged OS versus those receiving hypofractionated radiotherapy. With the limits of a retrospective study, our data suggest that in elderly fit patients extensive surgery should be considered, moreover adjuvant treatments led to an increase in OS. Randomized controlled study are needed to develop treatment guidelines for elderly GBM patients and to assess whether the combination of post-surgical radio and chemiotherapy may be superior to hypofractionated radiotherapy and chemiotherapy in fit patients.
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15
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Marutani A, Nakamura M, Nishimura F, Nakazawa T, Matsuda R, Hironaka Y, Nakagawa I, Tamura K, Takeshima Y, Motoyama Y, Boku E, Ouji Y, Yoshikawa M, Nakase H. Tumor-inhibition effect of levetiracetam in combination with temozolomide in glioblastoma cells. NEUROCHEM J+ 2017. [DOI: 10.1134/s1819712416040073] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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16
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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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17
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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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18
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Shin JY, Kizilbash SH, Robinson S, Uhm JH, Jatoi A. Incidence, Characteristics, and Implications of Seizures in Patients With Glioblastoma. Am J Hosp Palliat Care 2016; 34:650-653. [PMID: 27151973 DOI: 10.1177/1049909116647405] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Seizures in patients with glioblastoma are associated with worse quality of life. However, their incidence, clinical characteristics, and prognostic implications are less well characterized. OBJECTIVE This study was undertaken to provide a contemporary experience along with benchmark data relevant to the above in patients with glioblastoma. It also sought to reexplore improved survival with seizures, as observed by others. METHODS In this single-institution study, patients with glioblastoma from 2010 through 2014 had their medical records reviewed in detail. RESULTS Among 122 patients, 58 (48%) had a seizure history. Of these, 67% had more than 1, 41% had generalized seizures, and most received antiseizure medication (most commonly levetiracetam). The median survival for patients with seizures was 1.66 years and 0.87 years for those without (hazard ratio for risk of death with seizures: 0.72; 95% confidence interval: 0.43, 1.21; P = .22 by the log-rank test). CONCLUSION Seizures are common in patients with glioblastoma and, in contrast to earlier reports, are not associated with a statistically significant improvement in survival.
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Affiliation(s)
- John Y Shin
- 1 Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Joon H Uhm
- 3 Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Aminah Jatoi
- 2 Department of Oncology, Mayo Clinic, Rochester, MN, USA
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19
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Rudà R, Pellerino A, Soffietti R. Does valproic acid affect tumor growth and improve survival in glioblastomas? CNS Oncol 2016; 5:51-3. [PMID: 26985579 DOI: 10.2217/cns-2016-0004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Roberta Rudà
- Department of Neuro-Oncology, University & City of Health and Science Hospital, Via Cherasco 15, 10126, Turin, Italy
| | - Alessia Pellerino
- Department of Neuro-Oncology, University & City of Health and Science Hospital, Via Cherasco 15, 10126, Turin, Italy
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University & City of Health and Science Hospital, Via Cherasco 15, 10126, Turin, Italy
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20
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Happold C, Gorlia T, Chinot O, Gilbert MR, Nabors LB, Wick W, Pugh SL, Hegi M, Cloughesy T, Roth P, Reardon DA, Perry JR, Mehta MP, Stupp R, Weller M. Does Valproic Acid or Levetiracetam Improve Survival in Glioblastoma? A Pooled Analysis of Prospective Clinical Trials in Newly Diagnosed Glioblastoma. J Clin Oncol 2016; 34:731-9. [PMID: 26786929 DOI: 10.1200/jco.2015.63.6563] [Citation(s) in RCA: 129] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Symptomatic epilepsy is a common complication of glioblastoma and requires pharmacotherapy. Several uncontrolled retrospective case series and a post hoc analysis of the registration trial for temozolomide indicated an association between valproic acid (VPA) use and improved survival outcomes in patients with newly diagnosed glioblastoma. PATIENTS AND METHODS To confirm the hypothesis suggested above, a combined analysis of survival association of antiepileptic drug use at the start of chemoradiotherapy with temozolomide was performed in the pooled patient cohort (n = 1,869) of four contemporary randomized clinical trials in newly diagnosed glioblastoma: AVAGlio (Avastin in Glioblastoma; NCT00943826), CENTRIC (Cilengitide, Temozolomide, and Radiation Therapy in Treating Patients With Newly Diagnosed Glioblastoma and Methylated Gene Promoter Status; NCT00689221), CORE (Cilengitide, Temozolomide, and Radiation Therapy in Treating Patients With Newly Diagnosed Glioblastoma and Unmethylated Gene Promoter Status; NCT00813943), and Radiation Therapy Oncology Group 0825 (NCT00884741). Progression-free survival (PFS) and overall survival (OS) were compared between: (1) any VPA use and no VPA use at baseline or (2) VPA use both at start of and still after chemoradiotherapy. Results of Cox regression models stratified by trial and adjusted for baseline prognostic factors were analyzed. The same analyses were performed with levetiracetam (LEV). RESULTS VPA use at start of chemoradiotherapy was not associated with improved PFS or OS compared with all other patients pooled (PFS: hazard ratio [HR], 0.91; 95% CI, 0.77 to 1.07; P = .241; OS: HR, 0.96; 95% CI, 0.80 to 1.15; P = .633). Furthermore, PFS and OS of patients taking VPA both at start of and still after chemoradiotherapy were not different from those without antiepileptic drug use at both time points (PFS: HR, 0.92; 95% CI, 0.74 to 1.15; P = .467; OS: HR, 1.10; 95% CI, 0.86 to 1.40; P = .440). Similarly, no association with improved outcomes was observed for LEV use. CONCLUSION The results of this analysis do not justify the use of VPA or LEV for reasons other than seizure control in patients with newly diagnosed glioblastoma outside clinical trials.
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Affiliation(s)
- Caroline Happold
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Thierry Gorlia
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Olivier Chinot
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Mark R Gilbert
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - L Burt Nabors
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Wolfgang Wick
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Stephanie L Pugh
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Monika Hegi
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Timothy Cloughesy
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Patrick Roth
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - David A Reardon
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - James R Perry
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Minesh P Mehta
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Roger Stupp
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD
| | - Michael Weller
- Caroline Happold, Patrick Roth, Roger Stupp, and Michael Weller, University Hospital Zurich; Monika Hegi, University Hospital Lausanne, Switzerland; Thierry Gorlia, EORTC Data Centre, Brussels, Belgium; Olivier Chinot, Aix-Marseille University, Marseille, France; Mark R. Gilbert, The University of Texas MD Anderson Cancer Center, Houston, TX; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; Wolfgang Wick, University of Heidelberg & German Cancer Research Center, Heidelberg, Germany; Stephanie L. Pugh, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Timothy Cloughesy, UCLA Neuro-Oncology Program, Los Angeles, CA; David A. Reardon, Dana-Farber Cancer Institute, Boston, MA; James R. Perry, University of Toronto, Toronto, Ontario, Canada; and Minesh P. Mehta, University of Maryland, Baltimore, MD.
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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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22
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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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23
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Rundle-Thiele D, Head R, Cosgrove L, Martin JH. Repurposing some older drugs that cross the blood-brain barrier and have potential anticancer activity to provide new treatment options for glioblastoma. Br J Clin Pharmacol 2015; 81:199-209. [PMID: 26374633 DOI: 10.1111/bcp.12785] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 09/09/2015] [Accepted: 09/10/2015] [Indexed: 12/16/2022] Open
Abstract
Glioblastoma is a brain neoplasm with limited 5-year survival rates. Developments of new treatment regimens that improve patient survival in patients with glioblastoma are needed. It is likely that a number of existing drugs used in other conditions have potential anticancer effects that offer significant survival benefit to glioblastoma patients. Identification of such drugs could provide a novel treatment paradigm.
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Affiliation(s)
| | - Richard Head
- Future Industries Institute, Research and Innovation Portfolio, University of South Australia, Adelaide, SA, Australia
| | - Leah Cosgrove
- CSIRO, Human and Nutrition Flagship, Adelaide, SA, Australia
| | - Jennifer H Martin
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
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24
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Reddy JP, Dawood S, Mitchell M, Debeb BG, Bloom E, Gonzalez-Angulo AM, Sulman EP, Buchholz TA, Woodward WA. Antiepileptic drug use improves overall survival in breast cancer patients with brain metastases in the setting of whole brain radiotherapy. Radiother Oncol 2015; 117:308-14. [PMID: 26482599 DOI: 10.1016/j.radonc.2015.10.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 10/08/2015] [Accepted: 10/09/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE There is mounting evidence that histone deacetylase (HDAC) inhibitors, e.g. valproic acid (VPA), synergize with radiation to improve outcomes in several cancers. This study was conducted to ascertain whether VPA affected outcomes in breast cancer patients with brain metastases treated with whole brain radiotherapy (WBRT). MATERIALS AND METHODS Records from 253 breast cancer patients with brain metastases treated with WBRT were reviewed. Data regarding use of all antiepileptic drugs (AEDs) were extracted. Kaplan-Meier survival times were calculated using the date of brain involvement as time zero. Cox proportional hazard models were used to determine the association between patient and tumor characteristics and overall survival (OS). RESULTS Median OS for the entire patient cohort was 6 months. Patients receiving VPA (n=20) had a median OS of 11 months versus 5 months for those not receiving VPA (p=0.028). Median OS was 9 months for patients taking any AED (n=101) versus 4 months for those not taking AEDs (p=0.0003). On multivariate analysis both VPA and AED use were associated with improved OS (HR 0.61, p=0.0419; HR 0.59, p=0.0002, respectively). CONCLUSIONS This study suggests the use of AEDs, including VPA, is associated with improved OS in breast cancer patients with brain metastases following WBRT.
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Affiliation(s)
- Jay P Reddy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Shaheenah Dawood
- Department of Medical Oncology, Dubai Hospital, United Arab Emirates
| | - Melissa Mitchell
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Bisrat G Debeb
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Elizabeth Bloom
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Ana M Gonzalez-Angulo
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Erik P Sulman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Thomas A Buchholz
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Wendy A Woodward
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States.
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25
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Berendsen S, Varkila M, Kroonen J, Seute T, Snijders TJ, Kauw F, Spliet WGM, Willems M, Poulet C, Broekman ML, Bours V, Robe PA. Prognostic relevance of epilepsy at presentation in glioblastoma patients. Neuro Oncol 2015; 18:700-6. [PMID: 26420896 DOI: 10.1093/neuonc/nov238] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 08/24/2015] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Epileptogenic glioblastomas are thought to convey a favorable prognosis, either due to early diagnosis or potential antitumor effects of antiepileptic drugs. We investigated the relationship between survival and epilepsy at presentation, early diagnosis, and antiepileptic drug therapy in glioblastoma patients. METHODS Multivariable Cox regression was applied to survival data of 647 consecutive patients diagnosed with de novo glioblastoma between 2005 and 2013 in order to investigate the association between epilepsy and survival in glioblastoma patients. In addition, we quantified the association between survival and valproic acid (VPA) treatment. RESULTS Epilepsy correlated positively with survival (HR: 0.75 (95% CI: 0.61-0.92), P < .01). This effect is independent of age, sex, performance status, type of surgery, adjuvant therapy, tumor location, and tumor volume, suggesting that this positive correlation cannot be attributed solely to early diagnosis. For patients who presented with epilepsy, the use of the antiepileptic drug VPA did not associate with survival when compared with patients who did not receive VPA treatment. CONCLUSION Epilepsy is an independent prognostic factor for longer survival in glioblastoma patients. This prognostic effect is not solely explained by early diagnosis, and survival is not associated with VPA treatment.
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Affiliation(s)
- Sharon Berendsen
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center, Utrecht, Netherlands (S.B., M.V., J.K., T.S., T.J.S., F.K., M.L.B., P.A.R.); Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands (W.G.M.S.); Department of Human Genetics, GIGA Research Center, University of Liège, Liège, Belgium (M.W., C.P., V.B., P.A.R.)
| | - Meri Varkila
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center, Utrecht, Netherlands (S.B., M.V., J.K., T.S., T.J.S., F.K., M.L.B., P.A.R.); Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands (W.G.M.S.); Department of Human Genetics, GIGA Research Center, University of Liège, Liège, Belgium (M.W., C.P., V.B., P.A.R.)
| | - Jérôme Kroonen
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center, Utrecht, Netherlands (S.B., M.V., J.K., T.S., T.J.S., F.K., M.L.B., P.A.R.); Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands (W.G.M.S.); Department of Human Genetics, GIGA Research Center, University of Liège, Liège, Belgium (M.W., C.P., V.B., P.A.R.)
| | - Tatjana Seute
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center, Utrecht, Netherlands (S.B., M.V., J.K., T.S., T.J.S., F.K., M.L.B., P.A.R.); Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands (W.G.M.S.); Department of Human Genetics, GIGA Research Center, University of Liège, Liège, Belgium (M.W., C.P., V.B., P.A.R.)
| | - Tom J Snijders
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center, Utrecht, Netherlands (S.B., M.V., J.K., T.S., T.J.S., F.K., M.L.B., P.A.R.); Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands (W.G.M.S.); Department of Human Genetics, GIGA Research Center, University of Liège, Liège, Belgium (M.W., C.P., V.B., P.A.R.)
| | - Frans Kauw
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center, Utrecht, Netherlands (S.B., M.V., J.K., T.S., T.J.S., F.K., M.L.B., P.A.R.); Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands (W.G.M.S.); Department of Human Genetics, GIGA Research Center, University of Liège, Liège, Belgium (M.W., C.P., V.B., P.A.R.)
| | - Wim G M Spliet
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center, Utrecht, Netherlands (S.B., M.V., J.K., T.S., T.J.S., F.K., M.L.B., P.A.R.); Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands (W.G.M.S.); Department of Human Genetics, GIGA Research Center, University of Liège, Liège, Belgium (M.W., C.P., V.B., P.A.R.)
| | - Marie Willems
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center, Utrecht, Netherlands (S.B., M.V., J.K., T.S., T.J.S., F.K., M.L.B., P.A.R.); Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands (W.G.M.S.); Department of Human Genetics, GIGA Research Center, University of Liège, Liège, Belgium (M.W., C.P., V.B., P.A.R.)
| | - Christophe Poulet
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center, Utrecht, Netherlands (S.B., M.V., J.K., T.S., T.J.S., F.K., M.L.B., P.A.R.); Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands (W.G.M.S.); Department of Human Genetics, GIGA Research Center, University of Liège, Liège, Belgium (M.W., C.P., V.B., P.A.R.)
| | - Marike L Broekman
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center, Utrecht, Netherlands (S.B., M.V., J.K., T.S., T.J.S., F.K., M.L.B., P.A.R.); Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands (W.G.M.S.); Department of Human Genetics, GIGA Research Center, University of Liège, Liège, Belgium (M.W., C.P., V.B., P.A.R.)
| | - Vincent Bours
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center, Utrecht, Netherlands (S.B., M.V., J.K., T.S., T.J.S., F.K., M.L.B., P.A.R.); Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands (W.G.M.S.); Department of Human Genetics, GIGA Research Center, University of Liège, Liège, Belgium (M.W., C.P., V.B., P.A.R.)
| | - Pierre A Robe
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center, Utrecht, Netherlands (S.B., M.V., J.K., T.S., T.J.S., F.K., M.L.B., P.A.R.); Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands (W.G.M.S.); Department of Human Genetics, GIGA Research Center, University of Liège, Liège, Belgium (M.W., C.P., V.B., P.A.R.)
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26
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Berg AK, Buckner JC, Galanis E, Jaeckle KA, Ames MM, Reid JM. Quantification of the impact of enzyme-inducing antiepileptic drugs on irinotecan pharmacokinetics and SN-38 exposure. J Clin Pharmacol 2015; 55:1303-12. [PMID: 25975718 DOI: 10.1002/jcph.543] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 05/11/2015] [Indexed: 01/25/2023]
Abstract
The population pharmacokinetic model reported here was developed using data from 2 phase 2 trials of irinotecan for treatment of malignant glioma to quantify the impact of concomitant therapy with enzyme-inducing antiepileptic drugs (EIAEDs) on irinotecan pharmacokinetics. Patients received weekly irinotecan doses of 100 to 400 mg/m(2) , and plasma samples were collected and analyzed for irinotecan and its APC, SN-38, and SN-38G metabolites. Nonlinear mixed-effects modeling was employed for population pharmacokinetic analysis. Concomitant therapy with phenytoin, phenobarbital, or carbamazepine increased the clearances of irinotecan, SN-38, and SN-38G but not APC. SN-38 clearance was 2-fold higher with concomitant EIAED use, resulting in 40% lower SN-38 exposure. Evaluation of additional covariates revealed no clinically relevant effects of sex or concomitant corticosteroid use. The population pharmacokinetic model suggests that a 1.7-fold increase in irinotecan dose may compensate for decreases in SN-38 exposure in the presence of concomitant EIAEDs. Although slightly more conservative, this dose adjustment is consistent with those recommended based on increases in the maximally tolerated dose for malignant glioma patients receiving EIAEDs and may be an appropriate starting point for further investigation when extrapolating to other cancer types or alternative regimens.
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Affiliation(s)
- Alexander K Berg
- Department of Clinical Pharmacology, Upsher-Smith Laboratories Inc., Maple Grove, MN, USA
| | - Jan C Buckner
- Department of Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Kurt A Jaeckle
- Department of Neurology, Mayo Clinic, Jacksonville, MN, USA
| | - Matthew M Ames
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - Joel M Reid
- Department of Oncology, Mayo Clinic, Rochester, MN, USA.,Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
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Kim YH, Kim T, Joo JD, Han JH, Kim YJ, Kim IA, Yun CH, Kim CY. Survival benefit of levetiracetam in patients treated with concomitant chemoradiotherapy and adjuvant chemotherapy with temozolomide for glioblastoma multiforme. Cancer 2015; 121:2926-32. [PMID: 25975354 DOI: 10.1002/cncr.29439] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 04/05/2015] [Accepted: 04/08/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND A chemosensitizing effect of levetiracetam (LEV) has been suggested because LEV inhibits O-6 methylguanine-DNA methyltransferase (MGMT). However, the survival benefit of LEV has not been clinically documented. The objective of this study was to assess the survival benefit of LEV compared with other antiepileptic drugs as a chemosensitizer to temozolomide for patients with glioblastoma. METHODS In total, 103 consecutive patients with primary glioblastoma who received concomitant chemoradiotherapy and adjuvant chemotherapy with temozolomide were retrospectively reviewed, and 58 patients (56%) received LEV during temozolomide chemotherapy for at least 3 months. A Cox regression survival analysis was performed to adjust for confounding factors, including age, extent of lesion, Karnofsky performance scale score, extent of removal, and MGMT promoter methylation status. RESULTS The median progression-free survival (PFS) and overall survival (OS) for patients who received LEV in combination with temozolomide (PFS: median, 9.4 months; 95% confidence interval [CI], 7.5-11.3 months; OS: median, 25.7 months; 95% CI, 21.7-29.7 months) were significantly longer than those for patients who did not receive LEV (PFS: median, 6.7 months; 95% CI, 5.8-7.6 months; OS: median, 16.7 months; 95% CI, 12.1-21.3 months; P = .010 and P = .027, respectively). In multivariate analysis, the variables that were identified as significant prognostic factors for OS were preoperative Karnofsky performance scale score (hazard ratio [HR], 0.37; P = .016), MGMT promoter methylation (HR, 0.30; P = .002), and receipt of LEV (HR, 0.31; P < .001. CONCLUSIONS LEV may provide a survival benefit in patients with glioblastoma who receive temozolomide-based chemotherapy. A prospective randomized study may be indicated.
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Affiliation(s)
- Young-Hoon Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Jin-Deok Joo
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Jung Ho Han
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Yu Jung Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - In Ah Kim
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Chang-Ho Yun
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Chae-Yong Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
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Woo PYM, Chan DTM, Chan KY, Wong WK, Po YC, Kwok JCK, Poon WS. Risk factors for seizures and antiepileptic drug-associated adverse effects in high-grade glioma patients: A multicentre, retrospective study in Hong Kong. SURGICAL PRACTICE 2015; 19:2-8. [PMID: 26097495 PMCID: PMC4467242 DOI: 10.1111/1744-1633.12102] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 09/15/2014] [Indexed: 11/30/2022]
Abstract
Aim The aim of this present study was to determine the frequency, as well as risk factors, for seizures and antiepileptic drug (AED)-associated adverse effects among high-grade glioma (HGG) patients. Patients and Methods A multicentre, retrospective study of adult Chinese Hong Kong patients from three neurosurgical centres diagnosed with supratentorial HGG between 1 January 2001 and 31 December 2010 was performed. Results A total of 198 patients, with a mean age of 55 years (range: 18–88) and a mean follow up of 15 months, was recruited. Most suffered from glioblastoma multiforme (GBM) (63 per cent) followed by anaplastic astrocytoma (25 per cent). Median overall survival for patients with GBM was 8 months, and 11 months for those with grade III gliomas. Prophylactic AED was prescribed in 165 patients (83 per cent), and 64 per cent of patients were continued until end of life or last follow up. A total of 112 patients (57 per cent) experienced seizures at a mean duration of 8 months postoperatively (range: 1 day–75 months). Independent predictors for seizures were a diagnosis of GBM [adjusted odds ratio (OR): 2.33, 95 per cent confidence interval (CI): 1.21–4.52] and adjuvant radiotherapy (adjusted OR: 2.97, 95 per cent CI: 1.49–6.62). One-fifth of patients (21 per cent) experienced AED adverse effects, with idiosyncratic cutaneous reactions and hepatotoxicity most frequently observed. An independent predictor for adverse effects was exposure to aromatic AED, such as phenytoin, carbamazepine and phenobarbital (adjusted OR: 3.32, 95 per cent CI: 1.32–8.40). Conclusions Antiepileptic drug prescription for primary seizure prophylaxis is both pervasive and prolonged for HGG patients. Seizures occur frequently, but most were delayed and none were life threatening. Judicious prescription of AED is required, especially when a significant proportion of patients experience adverse effects. Patients with a diagnosis of GBM and exposure to radiotherapy are at risk. We suggest, contrary to present practice, that primary seizure prophylaxis be given only during the perioperative period and resumed when they occur. We also recommend avoidance of aromatic AED due to their association with idiosyncratic adverse effects.
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Affiliation(s)
| | - Danny Tat-Ming Chan
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong Hong Kong
| | - Kwong-Yau Chan
- Department of Neurosurgery, Kwong Wah Hospital Hong Kong
| | - Wai-Kei Wong
- Department Neurosurgery, Princess Margaret Hospital Hong Kong
| | - Yin-Chung Po
- Department Neurosurgery, Princess Margaret Hospital Hong Kong
| | | | - Wai-Sang Poon
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong Hong Kong
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Abstract
The diagnosis of a brain tumor is a life-changing event for patients and families. High-grade gliomas are incurable and long-term survival remains limited. While low-grade glioma patients have better outcomes, their quality of life is often affected by a variety of symptoms as well. Helping glioma patients improve quality of life at all stages of illness is an important goal for the interdisciplinary care team. There is evidence from advanced lung cancer patients that early involvement of a palliative care team can improve patient's quality of life, symptom burden, and even survival and a similar approach benefits glioma patients as well. Patients with high-grade and low-grade glioma often suffer from significant symptom burden. We discuss how validated global symptom assessments and symptom-specific screening tools are useful to identify distressing symptoms. Seizures, fatigue, depression, and anxiety are some of the more common symptoms throughout the disease course and should be managed actively. Patients with glioma also have high symptom burden at the end of life and the majority lose decision-making capacity. Advance care planning conversations early in the disease course are essential to elicit the patient's wishes for end of life care and effective communication with surrogate decision makers during all stages of the disease helps ensure that those wishes are respected.
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Affiliation(s)
- Tobias Walbert
- Departments of Neurosurgery and Neurology, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI, 48202, USA,
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Vecht CJ, Kerkhof M, Duran-Pena A. Seizure prognosis in brain tumors: new insights and evidence-based management. Oncologist 2014; 19:751-9. [PMID: 24899645 DOI: 10.1634/theoncologist.2014-0060] [Citation(s) in RCA: 150] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Brain tumor-related epilepsy (BTE) is common in low- and high-grade gliomas. The risk of seizures varies between 60% and 100% among low-grade gliomas and between 40% and 60% in glioblastomas. The presence of seizures in patients with brain tumors implies favorable and unfavorable factors. New-onset seizures represent an early warning sign for the presence of a brain tumor and count as a good prognostic factor for survival. Recurrence or worsening of seizures during the course of disease may signal tumor progression. Each of the modalities for tumor control (i.e., surgery, radiotherapy, chemotherapy) contributes to seizure control. Nevertheless, one third of BTE shows pharmacoresistance to antiepileptic drugs (AEDs) and may severely impair the burden of living with a brain tumor. For symptomatic therapy of BTE, seizure type and individual patient factors determine the appropriate AED. Randomized controlled trials in partial epilepsy in adults to which type BTE belongs and additional studies in gliomas indicate that levetiracetam is the agent of choice, followed by valproic acid (VPA). In the case of recurring seizures, combining these two drugs (polytherapy) seems effective and possibly synergistic. If either one is not effective or not well tolerated, lacosamide, lamotrigine, or zonisamide are additional options. A new and exciting insight is the potential contribution of VPA to prolonged survival, particularly in glioblastomas. A practice guideline on symptomatic medical management including dose schedules of AEDs is supplied.
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Affiliation(s)
- Charles J Vecht
- Service Neurologie Mazarin, GH Pitié-Salpêtrière, Paris, France; Department of Neurology, Medical Center The Hague, The Netherlands
| | - Melissa Kerkhof
- Service Neurologie Mazarin, GH Pitié-Salpêtrière, Paris, France; Department of Neurology, Medical Center The Hague, The Netherlands
| | - Alberto Duran-Pena
- Service Neurologie Mazarin, GH Pitié-Salpêtrière, Paris, France; Department of Neurology, Medical Center The Hague, The Netherlands
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Addeo R, Zappavigna S, Parlato C, Caraglia M. Erlotinib: early clinical development in brain cancer. Expert Opin Investig Drugs 2014; 23:1027-37. [PMID: 24836441 DOI: 10.1517/13543784.2014.918950] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Glioblastoma (GBM) is the most common brain cancer in adults. It is also, unfortunately, the most aggressive type and the least responsive to therapy. Overexpression of EGFR and/or EGFRvIII is frequently found in GBM and is frequently associated with the more malignant phenotype of the disease and a poor clinical outcome. EGFR-targeted therapy represents a promising anti-GBM therapy. Two EGFR kinase inhibitors, gefitinib and erlotinib have been tested in clinical trials for malignant gliomas. However, the clinical efficacy of EGFR-targeted therapy has been only modest in GBM patients. AREAS COVERED The authors provide an evaluation of erlotinib as a potential therapy for GBM. The authors highlight experiences drawn from clinical trials and discuss the challenges, which include the insufficient penetration through the blood-brain barrier (BBB) and chemoresistance. EXPERT OPINION Malignant brain tumours have a very complex signalling network that is not only driven by EGFR. This complexity dictates tumour sensitivity to EGFR-targeted therapies. Alternative kinase signalling pathways may be involved in parallel with the inhibited target, so that a single target's inactivation is not sufficient to block downstream oncogenic signalling. The use of nanocarriers offers many opportunities, such as the release of the drug to specific cells or tissues, together with the ability to overcome different biological barriers, like the BBB.
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Bauer R, Ortler M, Seiz-Rosenhagen M, Maier R, Anton JV, Unterberger I. Treatment of epileptic seizures in brain tumors: a critical review. Neurosurg Rev 2014; 37:381-8; discussion 388. [PMID: 24760366 DOI: 10.1007/s10143-014-0538-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 10/24/2013] [Accepted: 01/26/2014] [Indexed: 01/28/2023]
Abstract
Epileptic seizures represent a common signal of intracranial tumors, frequently the presenting symptom and the main factor influencing quality of life. Treatment of tumors concentrates on survival; antiepileptic drug (AED) treatment frequently is prescribed in a stereotyped way. A differentiated approach according to epileptic syndromes can improve seizure control and minimize unwarranted AED effects. Prophylactic use of AEDs is to be discouraged in patients without seizures. Acutely provoked seizures do not need long-term medication except for patients with high recurrence risk indicated by distinct EEG patterns, auras, and several other parameters. With chronically repeated seizures (epilepsies), long-term AED treatment is indicated. Non-enzyme-inducing AEDs might be preferred. Valproic acid exerts effects against progression of gliomatous tumors. In low-grade astrocytomas with epilepsy, a comprehensive presurgical epilepsy work-up including EEG-video monitoring is advisable; in static non-progressive tumors, it is mandatory. In these cases, the neurosurgical approach has to include the removal of the seizure-onset zone frequently located outside the lesion.
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Affiliation(s)
- R Bauer
- Neurosurgery, Landeskrankenhaus Feldkirch, Feldkirch, Austria,
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Liubinas SV, O'Brien TJ, Moffat BM, Drummond KJ, Morokoff AP, Kaye AH. Tumour associated epilepsy and glutamate excitotoxicity in patients with gliomas. J Clin Neurosci 2014; 21:899-908. [PMID: 24746886 DOI: 10.1016/j.jocn.2014.02.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 02/22/2014] [Indexed: 02/04/2023]
Abstract
Tumour associated epilepsy (TAE) is common, debilitating and often not successfully controlled by surgical resection of the tumour and administration of multiple anti-epileptic drugs. It represents a cause of significant lost quality of life in an incurable disease and is therefore an important subject for ongoing research. The pathogenesis of TAE is likely to be multifactorial and involve, on the microscopic level, the interaction of genetic factors, changes in the peritumoural microenvironment, alterations in synaptic neurotransmitter release and re-uptake, and the excitotoxic effects of glutamate. On a macroscopic level, the occurrence of TAE is likely to be influenced by tumour size, location and interaction with environmental factors. The optimal treatment of TAE requires a multi-disciplinary approach with input from neurosurgeons, neurologists, radiologists, pathologists and basic scientists. This article reviews the current literature regarding the incidence, treatment, and aetiology of TAE.
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Affiliation(s)
- Simon V Liubinas
- Department of Neurosurgery, The Royal Melbourne Hospital, Grattan Street, Parkville, VIC 3050, Australia; Department of Surgery (RMH/WH), The University of Melbourne, Parkville, VIC, Australia.
| | - Terence J O'Brien
- Department of Medicine (RMH/WH), The University of Melbourne, Parkville, VIC, Australia
| | - Bradford M Moffat
- Department of Radiology (RMH/WH), The University of Melbourne, Parkville, VIC, Australia
| | - Katharine J Drummond
- Department of Neurosurgery, The Royal Melbourne Hospital, Grattan Street, Parkville, VIC 3050, Australia; Department of Surgery (RMH/WH), The University of Melbourne, Parkville, VIC, Australia
| | - Andrew P Morokoff
- Department of Neurosurgery, The Royal Melbourne Hospital, Grattan Street, Parkville, VIC 3050, Australia; Department of Surgery (RMH/WH), The University of Melbourne, Parkville, VIC, Australia
| | - Andrew H Kaye
- Department of Neurosurgery, The Royal Melbourne Hospital, Grattan Street, Parkville, VIC 3050, Australia; Department of Surgery (RMH/WH), The University of Melbourne, Parkville, VIC, Australia
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Lee JW, Norden AD, Ligon KL, Golby AJ, Beroukhim R, Quackenbush J, Wells W, Oelschlager K, Maetzold D, Wen PY. Tumor associated seizures in glioblastomas are influenced by survival gene expression in a region-specific manner: a gene expression imaging study. Epilepsy Res 2014; 108:843-52. [PMID: 24690158 DOI: 10.1016/j.eplepsyres.2014.02.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 01/31/2014] [Accepted: 02/28/2014] [Indexed: 11/15/2022]
Abstract
Tumor associated seizures (TAS) are common and cause significant morbidity. Both imaging and gene expression features play significant roles in determining TAS, with strong interactions between them. We describe gene expression imaging tools which allow mapping of brain regions where gene expression has significant influence on TAS, and apply these methods to study 77 patients who underwent surgical evaluation for supratentorial glioblastomas. Tumor size and location were measured from MRI scans. A 9-set gene expression profile predicting long-term survivors was obtained from RNA derived from formalin-fixed paraffin embedded tissue. A total of 32 patients (42%) experienced preoperative TAS. Tumor volume was smaller (31.1 vs. 58.8 cubic cm, p<0.001) and there was a trend toward median survival being higher (48.4 vs. 32.7 months, p=0.055) in patients with TAS. Although the expression of only OLIG2 was significantly lower in patients with TAS in a groupwise analysis, gene expression imaging analysis revealed regions with significantly lower expression of OLIG2 and RTN1 in patients with TAS. Gene expression imaging is a powerful technique that demonstrates that the influence of gene expression on TAS is highly region specific. Regional variability should be evaluated with any genomic or molecular markers of solid brain lesions.
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Affiliation(s)
- Jong Woo Lee
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States.
| | - Andrew D Norden
- Center for Neuro-oncology, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02115, United States
| | - Keith L Ligon
- Department of Pathology, Brigham and Women's Hospital, Boston Children's Hospital, and Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States; Department of Medical Oncology, Center for Molecular Oncologic Pathology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02115, United States
| | - Alexandra J Golby
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States
| | - Rameen Beroukhim
- Center for Neuro-oncology, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02115, United States
| | - John Quackenbush
- Department of Biostatistics, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02115, United States
| | - William Wells
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, United States
| | - Kristen Oelschlager
- Castle Biosciences Inc., 3330N 2nd Street, Suite 207, Phoenix, AZ 85012, United States
| | - Derek Maetzold
- Castle Biosciences Inc., 3330N 2nd Street, Suite 207, Phoenix, AZ 85012, United States
| | - Patrick Y Wen
- Center for Neuro-oncology, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02115, United States
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Abstract
Between 30% and 50% of patients with brain tumors first present with a seizure, and up to 30% more will develop seizures later. Therefore, optimal management of these patients requires a rational approach to the use of antiseizure medications. Based on current evidence, prophylactic prescription of long-term antiepileptic drugs (AEDs) in patients with brain tumors in patients who did not present with seizures is not justified. Because of the high risk of recurrence, however, AED treatment should be strongly considered after a single seizure considered to be due to a tumor. Because of the lack of well-controlled randomized trials, the decision on which AED provides the best risk-benefit ratio in the individual patient is based mostly on physician's judgment rather than sound scientific evidence. In patients who may require chemotherapy, a non-enzyme-inducing AED is preferred for initial treatment to minimize the risk of drug interactions that impact adversely on the outcome of anticancer chemotherapy. Several retrospective studies in seizure patients with glioblastoma treated with chemotherapy have provided evidence for a moderately improved survival with the use of valproic acid, possibly due to inhibition of histone deacetylase. However, valproic acid may also increase the hematologic toxicity of antineoplastic drugs, presumably by inhibiting their metabolism, and may independently impair hemostasis, which is of some concern for patients who require surgical intervention. Among newer generation AEDs, levetiracetam has a number of advantageous features, including availability of a parenteral formulation, but other agents such as gabapentin, lamotrigine, oxcarbazepine, topiramate, and zonisamide may also be considered. Potentially more effective treatments targeting specific mechanisms of epileptogenesis and ictogenesis are being investigated. Resection of the tumor, radiation therapy, or chemotherapy can bring refractory seizures under control or prolong the duration of seizure freedom, an effect that does not appear to be necessarily related to removal or shrinkage of the tumor mass. In patients with a successfully treated tumor and an overall good prognosis for long-term survival, gradual discontinuation of AEDs may be considered.
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Affiliation(s)
- Emilio Perucca
- Department of Internal Medicine and Therapeutics, University of Pavia and C Mondino National Neurological Institute, Pavia, Italy
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37
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Bruna J, Miró J, Velasco R. Epilepsy in glioblastoma patients: basic mechanisms and current problems in treatment. Expert Rev Clin Pharmacol 2013; 6:333-44. [PMID: 23656344 DOI: 10.1586/ecp.13.12] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Glioblastoma-related epilepsy requires paying careful attention to a combination of factors with an integrated approach. Major interrelated issues must be considered in the seizure care of glioblastoma patients. Seizure control frequently requires the administration of antiepileptic drugs simultaneously with other treatments, including surgery, radiotherapy and chemotherapy, with complete seizure relief often being difficult to achieve. The pharmacological interactions between antiepileptic drugs and antineoplastic agents can modify the activity of both treatments, compromising their efficacy and increasing the probability of developing adverse events related to both therapies. This review summarizes the new pathophysiological pathways involved in the epileptogenesis of glioblastoma-related seizures and the interactions between antiepileptic drugs and oncological treatment, paying special attention to its impact on survival and the current evidence of the antiepileptic treatment efficacy, including the potential usefulness of new third-generation compounds.
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Affiliation(s)
- Jordi Bruna
- Unit of Neuro-Oncology, Hospital Universitari de Bellvitge-ICO Duran i Reynals, Barcelona, Spain
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38
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Guthrie G, Eljamel S. Does the choice of antiepileptic drug have an impact on the survival of glioblastoma multiforme? Br J Neurosurg 2013; 27:270. [DOI: 10.3109/02688697.2013.772101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Guthrie GD, Eljamel S. Impact of particular antiepileptic drugs on the survival of patients with glioblastoma multiforme. J Neurosurg 2012; 118:859-65. [PMID: 23176328 DOI: 10.3171/2012.10.jns12169] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECT Glioblastoma multiforme (GBM) is the most common astrocytic brain tumor and carries a dire prognosis. Despite current therapeutic options--surgery, radiotherapy, and chemotherapy--survival varies from 11.3 to 14.6 months. A group of drugs known as histone deacetylase inhibitors (HDIs) has demonstrated a potentially beneficial role in cancer treatment, particularly in combination with other therapies. A drug that exhibits potential as an HDI is sodium valproate (VPA), which is frequently used to treat seizures in patients with cerebral neoplasms. The present study was undertaken to investigate the role of VPA as an antitumor agent in the management of patients with GBM. METHODS A review was conducted in terms of how HDIs work, the use of antiepileptic drugs (AEDs), and the effects of AEDs on survival in a local cohort of patients diagnosed with GBM. The local cohort of patients was determined by reviewing the electronic histopathology and AED informatics systems. A meta-analysis of papers on the use of AEDs in GBM was also performed. RESULTS The local cohort consisted of 236 patients with GBM, 210 of whom had complete data available for analysis, a median age of 62 years, and 1-year survival of 26%. Patients treated with AEDs had a significantly longer survival than those who were not (Mantel-Cox log-rank test 19.617, p < 0.001). Those treated with VPA had significantly longer survival than those who did not receive an AED (Mantel-Cox log-rank test 17.506, p < 0.001), and patients treated with VPA had a significantly longer survival than those who had received other AEDs (Mantel-Cox log-rank test 5.303, p < 0.02). CONCLUSIONS Authors of this study demonstrated evidence supporting the theory that VPA may benefit patients with GBM in terms of survival.
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Affiliation(s)
- Greg D Guthrie
- Centre for Neurosciences, Department of Surgical Neurology, Ninewells Hospital and Medical School, Dundee, Scotland, United Kingdom
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Abstract
The lifetime risk of having epileptic seizures is profoundly increased in patients with cancer: about 20% of all patients with systemic cancer may develop brain metastases. These patients and those with primary brain tumours have a lifetime risk of epilepsy of 20-80%. Moreover, exposure to chemotherapy or radiotherapy to the brain, cancer-related metabolic disturbances, stroke, and infection can provoke seizures. The management of epilepsy in patients with cancer includes diagnosis and treatment of the underlying cerebral pathological changes, secondary prophylaxis with antiepileptic drugs, and limiting of the effect of epilepsy and its treatment on the efficacy and tolerability of anticancer treatments, cognitive function, and quality of life. Because of the concern of drug-drug interactions, the pharmacological approach to epilepsy requires a multidisciplinary approach, specifically in a setting of rapidly increasing choices of agents both to treat cancer and cancer-associated epilepsy.
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Affiliation(s)
- Michael Weller
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland.
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Brodie MJ, Mintzer S, Pack AM, Gidal BE, Vecht CJ, Schmidt D. Enzyme induction with antiepileptic drugs: Cause for concern? Epilepsia 2012; 54:11-27. [DOI: 10.1111/j.1528-1167.2012.03671.x] [Citation(s) in RCA: 244] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Lian K, Engelsen B, Storstein A. [Glioma-associated epilepsy]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2012; 132:1752-6. [PMID: 22929942 DOI: 10.4045/tidsskr.11.0812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Epileptic seizures are a common symptom in patients with primary brain tumours of the glioma type. The paper presents a discussion of epileptogenesis, choice of medication and follow-up of these patients. METHOD The article is based on a search in PubMed and selection of articles based on the authors' discretionary judgement and clinical experience with this patient group. RESULTS Epileptic seizures are a common symptom of glioma, particularly the low-grade types. The background to glioma-associated epilepsy is multifactorial, and the molecular biological characteristics of the tumour probably play a central part in the epileptogenesis. Effective treatment of epileptic seizures is of great importance to the quality of life of the glioma patient. Seizure frequency and the effectiveness of anti-epileptic treatment vary, and some patients require treatment with several anti-epileptic drugs. Surgical and oncological treatment of the tumour will also often reduce the frequency of seizures. CONCLUSION As a general rule, antiepileptics without enzyme-inducing properties and with low protein-binding should be preferred for glioma patients. This will reduce the risk of interactions with chemotherapy or steroid therapy. Patients with brain tumours are particularly vulnerable to the effects on wakefulness, moods and cognition, and this should be borne in mind in the choice of medication and in follow-up. Haematological status should be monitored particularly closely when there is concomitant use of chemotherapy and antiepileptic drugs that may affect the bone marrow function.
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Affiliation(s)
- Kathrine Lian
- Nevrologisk avdeling, Haukeland universitetssykehus, Norway
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Englot DJ, Berger MS, Chang EF, Garcia PA. Characteristics and treatment of seizures in patients with high-grade glioma: a review. Neurosurg Clin N Am 2012; 23:227-35, vii-viii. [PMID: 22440866 DOI: 10.1016/j.nec.2012.01.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
High-grade gliomas (HGGs), including anaplastic astrocytoma and glioblastoma multiforme, are the most common primary brain tumors, and are often associated with seizures. Seizure control is a critical but often underappreciated goal in the treatment of patients harboring these malignant lesions. Patients with HGG who also have medically intractable seizures should be considered for a palliative resection guided by electrocorticography and functional mapping. Antiepileptic drugs remain the mainstay of seizure treatment in HGG, and antiepileptic medication should be started after a tumor-related seizure, but should not be used prophylactically in the absence of seizure activity.
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Affiliation(s)
- Dario J Englot
- UCSF Epilepsy Center, University of California, San Francisco, 505 Parnassus Avenue, Box 0138, San Francisco, CA 94143, USA.
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Maschio M. Brain tumor-related epilepsy. Curr Neuropharmacol 2012; 10:124-33. [PMID: 23204982 PMCID: PMC3386502 DOI: 10.2174/157015912800604470] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2011] [Revised: 11/19/2011] [Accepted: 12/21/2011] [Indexed: 01/12/2023] Open
Abstract
In patients with brain tumor (BT), seizures are the onset symptom in 20-40% of patients, while a further 20-45% of patients will present them during the course of the disease. These patients present a complex therapeutic profile and require a unique and multidisciplinary approach. The choice of antiepileptic drugs is challenging for this particular patient population because brain tumor-related epilepsy (BTRE) is often drug-resistant, has a strong impact on the quality of life and weighs heavily on public health expenditures.In BT patients, the presence of epilepsy is considered the most important risk factor for long-term disability. For this reason, the problem of the proper administration of medications and their potential side effects is of great importance, because good seizure control can significantly improve the patient's psychological and relational sphere. In these patients, new generation drugs such as gabapentin, lacosamide, levetiracetam, oxcarbazepine, pregabalin, topiramate, zonisamide are preferred because they have fewer drug interactions and cause fewer side effects. Among the recently marketed drugs, lacosamide has demonstrated promising results and should be considered a possible treatment option. Therefore, it is necessary to develop a customized treatment plan for each individual patient with BTRE. This requires a vision of patient management concerned not only with medical therapies (pharmacological, surgical, radiological, etc.) but also with emotional and psychological support for the individual as well as his or her family throughout all stages of the illness.
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Affiliation(s)
- Marta Maschio
- Center for Tumor-Related Epilepsy, Neurology Unit, Department of Neuroscience and Cervical-Facial Pathology, National Institute for Cancer “Regina Elena” Via Elio Chianesi, 53 00144 Roma, Italy
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Kast RE, Lefranc F, Karpel-Massler G, Halatsch ME. Why dapsone stops seizures and may stop neutrophils' delivery of VEGF to glioblastoma. Br J Neurosurg 2012; 26:813-7. [PMID: 22551309 DOI: 10.3109/02688697.2012.674577] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Lopez-Gomez et al. recently published remarkable but mechanistically unexplained empirical evidence that the old antibiotic dapsone has antiepileptic activity. We addressed the question "Why should a sulfone antibiotic reduce seizures?". We report here our conclusions based on data from past studies that seizures are associated with elevated interleukin-8 (IL-8) and that dapsone inhibits IL-8 release and function in several different clinical and experimental contexts. Diverse CNS insults cause an increase in CNS IL-8. Thus, the pro-inflammatory environment generated by increase IL-8 leads to a lower seizure threshold. Together this evidence indicates dapsone exerts anti-seizure activity by diminishing IL-8 signalling. Since IL-8 is clearly upregulated in glioblastoma and contributes to the florid angiogenesis of that disease, and since interference with IL-8 function has been shown to inhibit glioblastoma invasion and growth in several experimental models, and dapsone has been repeatedly been shown to clinically inhibit IL-8 function when used to treat human neutrophilic dermatoses, we believe that dapsone thereby reduces seizures by countering IL-8 function and may similarly retard glioblastoma growth by such anti-IL-8 function.
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Affiliation(s)
- R E Kast
- Department of Psychiatry, University of Vermont, Burlington, VT 05401, USA.
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47
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Patients with brain tumor-related epilepsy. J Neurooncol 2012; 109:1-6. [DOI: 10.1007/s11060-012-0867-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 03/29/2012] [Indexed: 10/28/2022]
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Chen Y, Tsai YH, Tseng SH. Valproic acid affected the survival and invasiveness of human glioma cells through diverse mechanisms. J Neurooncol 2012; 109:23-33. [PMID: 22528797 DOI: 10.1007/s11060-012-0871-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Accepted: 03/31/2012] [Indexed: 12/14/2022]
Abstract
The effects of valproic acid (VPA) on the viability, apoptosis, and invasiveness of two glioma cells (A172 and T98G) and the underlying mechanisms were studied. VPA induced cytotoxicity and apoptosis, and suppressed the invasiveness of both cells. VPA increased the activity of matrix metalloproteinase-2 (MMP-2) and MMP-9 in A172 cells, but decreased it in T98G cells. siRNA blockade of reversion-inducing cysteine-rich protein with Kazal motifs (RECK) expression partially reversed VPA-mediated effects in T98G cells, but had no effect on A172 cells. VPA increased the expression of phospho-JNK1 and phospho-ERK1/2 in A172 cells, but decreased it in T98G cells. Inhibition of JNK1 and/or ERK1/2 partially reversed the VPA effects in A172 cells. In conclusion, the effects of VPA (loss of viability, increased apoptosis, and decreased invasiveness) are, at least partly, mediated through the RECK-MMPs pathway in T98G cells and the mitogen-activated protein kinase pathways in A172 cells. The action of VPA seems to be cell type-specific in glioma cells.
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Affiliation(s)
- Yun Chen
- Department of Surgery, Far Eastern Memorial Hospital, Pan-Chiao, New Taipei, Taiwan.
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Lecture: profile of risks and benefits of new antiepileptic drugs in brain tumor-related epilepsy. Neurol Sci 2012; 32 Suppl 2:S259-62. [PMID: 22012629 DOI: 10.1007/s10072-011-0801-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
In patients with brain tumor, seizures are the onset symptom in 20-40% of the patients, while a further 20-45% of the patients will present them during the course of the disease. These data are important when considering the choice of antiepileptic drugs for this particular patient population, because brain tumor-related epilepsy (BTRE) is often drug resistant, has a strong impact on the quality of life and weighs heavily on public health expenditures. In brain tumor patients, the presence of epilepsy is considered as the most important risk factor for long-term disability. For this reason, the problem of the proper administration of medications and their potential side effects is of great importance, because good seizure control can significantly improve the patient's psychological and relational sphere. In these patients, new generation drugs such as gabapentin, lamotrigine, levetiracetam, oxcarbazepine, pregabalin, topiramate, and zonisamide are preferred, because they have fewer drug interactions and cause fewer side effects. Among the recently marketed drugs, lacosamide has demonstrated promising results and should be considered as a possible treatment option. Therefore, it is necessary to develop a customized treatment plan for each patient with BTRE, whose goals are complete seizure control, minimal or no side effects, and elimination of cognitive impairment and/or psychosocial problems.
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Simó M, Velasco R, Graus F, Verger E, Gil M, Pineda E, Blasco J, Bruna J. Impact of antiepileptic drugs on thrombocytopenia in glioblastoma patients treated with standard chemoradiotherapy. J Neurooncol 2012; 108:451-8. [PMID: 22407174 DOI: 10.1007/s11060-012-0836-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 02/15/2012] [Indexed: 01/01/2023]
Abstract
Epilepsy in glioblastoma multiforme (GBM) patients is common. Hematological toxicity is a potential side effect of antiepileptic drugs (AEDs) and a frequent limiting-dose effect of temozolomide (TMZ). The aim of the study was to investigate the impact of AEDs on thrombocytopenia in GBM patients treated with radiotherapy and TMZ. A cohort of 101 newly diagnosed GBM patients treated with radiotherapy and TMZ was reviewed. Clinical data, presence of seizures, AEDs use, platelet count, and accumulated TMZ dose were analyzed at each cycle. Thrombocytopenia was operationalized as a continuous platelet count and a dichotomic variable (cut-off <100.000/mm(3)). This cut-off represents the threshold beyond which TMZ treatment is modified. A linear and a probit pooled cross-sectional regression analysis were used to study the impact of age, gender, AEDs, and accumulated TMZ on thrombocytopenia. Impact of AEDs on survival was also analyzed. Thirty-five patients (35%) presented seizures at onset and 18 (27%) during follow-up. Seven (13%) needed two or more AEDs for seizure control. Grade 3-4 thrombocytopenia was found in 8%. Decrease in platelet count was related to accumulated TMZ (p < 0.001), age (p < 0.001), and valproate (p = 0.004). Platelet count <100.000/mm(3) was only associated with accumulated TMZ (p = 0.001). Recursive Partitioning Analysis prognostic class was the only variable with significant impact on survival. Valproate and age had an independent negative effect on total platelet count, although neither had an effect on critical thrombocytopenia (<100.000/mm(3)). Therefore, the systematic withhold of valproate in GBM patients might not be justified. Nevertheless, this negative effect may be taken into account especially in elderly patients.
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Affiliation(s)
- Marta Simó
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge and ICO Duran i Reynals, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), C/Feixa Llarga s/n, 08907, L'Hospitalet del Llobregat, Spain
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