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Bruno F, Pellerino A, Conti Nibali M, Pronello E, Cofano F, Rossi M, Levis M, Bertero L, Soffietti R, Cassoni P, Garbossa D, Bello L, Rudà R. Association of Clinical, Tumor, and Treatment Characteristics With Seizure Control in Patients With IDH1/2-Mutant Lower-Grade Glioma. Neurology 2024; 102:e209352. [PMID: 38684041 DOI: 10.1212/wnl.0000000000209352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with IDH1/2-mutant lower-grade glioma have a high frequency of seizures. We aimed to investigate the correlations between seizures and tumor/patient characteristics and the impact of surgery and adjuvant treatments (AT) on seizure control along the disease trajectory. METHODS We retrospectively included patients with IDH1/2-mutant lower-grade glioma who underwent surgery at the neurosurgery divisions of the University of Turin and Milan and were treated at the Division of Neuro-Oncology of Turin. Inclusion criteria were a diagnosis according to the 2021 WHO Classification and presentation with seizures; exclusion criteria were presence of CDKN2A/B homozygous deletion, intense/ring contrast enhancement on MRI at presentation, and small tissue biopsy. We evaluated seizure freedom for 2 months after surgery, 6 months from starting observation or AT, at recurrence, and for 6 months after treatments of recurrence. RESULTS We included 150 patients. There were 77 (51%) and 31 (21%) patients with IDH-mutant/1p19q-codeleted grade 2 and 3 oligodendroglioma and 30 (20%) and 12 (8%) with IDH-mutant grade 2 and 3 astrocytoma, respectively. Total resection was accomplished in 68 (45%). Seventy-five patients (50%) received AT while the remaining 75 were observed with MRI. After 6 months after AT, 28 of 29 patients (96.5%) displayed seizure reduction, 5 of 28 (18%) being seizure-free. 66 of 124 patients (53%) had seizures at recurrence. After 6 months after second-line treatments, 60 of 66 patients (91%) had seizure reduction, 11 (17%) being seizure-free. In multivariable analyses, grade 3 histology positively correlated with seizure freedom at 2 months after surgery (OR 3.5, 1.4-8.9, p = 0.008), 6 months after AT (OR 9.0, 1.5-54.9, p = 0.017), and 6 months after treatment of recurrence (OR 4.9, 1.5-16.5, p = 0.009). Adjuvant radiotherapy reduced seizures at recurrence in a univariate analysis (OR 0.14, 0.03-0.7, p = 0.020). Patients with seizure freedom after surgery and AT displayed longer progression-free survival (PFS) (65, 24.5-105, vs 48 months, 32-63.5, p = 0.037). DISCUSSION This study analyzed seizure control in patients with IDH1/2-mutant lower-grade glioma across multiple time points. Grade 3 correlated with better seizure control throughout the entire disease trajectory, and seizure freedom after surgery and AT correlated with a longer PFS regardless of tumor grade. These results could serve as an external control arm in clinical trials evaluating the efficacy on seizures of antitumor agents in patients with IDH-mutant lower-grade glioma.
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Affiliation(s)
- Francesco Bruno
- From the Division of Neuro-Oncology (F.B., A.P., R.S., R.R.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital, Turin; Neurosurgical Oncology Unit (M.C.N., M.R., L. Bello), "Galeazzi - Sant'Ambrogio" IRCCS, Milan; Departments of Oncology and Hemato-Oncology (L. Bello) and Medical Biotechnology and Translational Medicine (M.R.), University of Milan; Division of Neuro-Oncology (E.P.), Department of Neuroscience "Rita Levi di Montalcini", University and City of Health and Science Hospital, Turin; Neurology Unit (E.P.), Department of Translational Medicine, University of Eastern Piedmont, Novara; Division of Neurosurgery (F.C., D.G.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital; Division of Radiotherapy (M.L.), Department of Oncology; and Pathology Unit (L. Bertero, P.C.), Department of Medical Sciences, University of Turin, Italy
| | - Alessia Pellerino
- From the Division of Neuro-Oncology (F.B., A.P., R.S., R.R.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital, Turin; Neurosurgical Oncology Unit (M.C.N., M.R., L. Bello), "Galeazzi - Sant'Ambrogio" IRCCS, Milan; Departments of Oncology and Hemato-Oncology (L. Bello) and Medical Biotechnology and Translational Medicine (M.R.), University of Milan; Division of Neuro-Oncology (E.P.), Department of Neuroscience "Rita Levi di Montalcini", University and City of Health and Science Hospital, Turin; Neurology Unit (E.P.), Department of Translational Medicine, University of Eastern Piedmont, Novara; Division of Neurosurgery (F.C., D.G.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital; Division of Radiotherapy (M.L.), Department of Oncology; and Pathology Unit (L. Bertero, P.C.), Department of Medical Sciences, University of Turin, Italy
| | - Marco Conti Nibali
- From the Division of Neuro-Oncology (F.B., A.P., R.S., R.R.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital, Turin; Neurosurgical Oncology Unit (M.C.N., M.R., L. Bello), "Galeazzi - Sant'Ambrogio" IRCCS, Milan; Departments of Oncology and Hemato-Oncology (L. Bello) and Medical Biotechnology and Translational Medicine (M.R.), University of Milan; Division of Neuro-Oncology (E.P.), Department of Neuroscience "Rita Levi di Montalcini", University and City of Health and Science Hospital, Turin; Neurology Unit (E.P.), Department of Translational Medicine, University of Eastern Piedmont, Novara; Division of Neurosurgery (F.C., D.G.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital; Division of Radiotherapy (M.L.), Department of Oncology; and Pathology Unit (L. Bertero, P.C.), Department of Medical Sciences, University of Turin, Italy
| | - Edoardo Pronello
- From the Division of Neuro-Oncology (F.B., A.P., R.S., R.R.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital, Turin; Neurosurgical Oncology Unit (M.C.N., M.R., L. Bello), "Galeazzi - Sant'Ambrogio" IRCCS, Milan; Departments of Oncology and Hemato-Oncology (L. Bello) and Medical Biotechnology and Translational Medicine (M.R.), University of Milan; Division of Neuro-Oncology (E.P.), Department of Neuroscience "Rita Levi di Montalcini", University and City of Health and Science Hospital, Turin; Neurology Unit (E.P.), Department of Translational Medicine, University of Eastern Piedmont, Novara; Division of Neurosurgery (F.C., D.G.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital; Division of Radiotherapy (M.L.), Department of Oncology; and Pathology Unit (L. Bertero, P.C.), Department of Medical Sciences, University of Turin, Italy
| | - Fabio Cofano
- From the Division of Neuro-Oncology (F.B., A.P., R.S., R.R.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital, Turin; Neurosurgical Oncology Unit (M.C.N., M.R., L. Bello), "Galeazzi - Sant'Ambrogio" IRCCS, Milan; Departments of Oncology and Hemato-Oncology (L. Bello) and Medical Biotechnology and Translational Medicine (M.R.), University of Milan; Division of Neuro-Oncology (E.P.), Department of Neuroscience "Rita Levi di Montalcini", University and City of Health and Science Hospital, Turin; Neurology Unit (E.P.), Department of Translational Medicine, University of Eastern Piedmont, Novara; Division of Neurosurgery (F.C., D.G.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital; Division of Radiotherapy (M.L.), Department of Oncology; and Pathology Unit (L. Bertero, P.C.), Department of Medical Sciences, University of Turin, Italy
| | - Marco Rossi
- From the Division of Neuro-Oncology (F.B., A.P., R.S., R.R.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital, Turin; Neurosurgical Oncology Unit (M.C.N., M.R., L. Bello), "Galeazzi - Sant'Ambrogio" IRCCS, Milan; Departments of Oncology and Hemato-Oncology (L. Bello) and Medical Biotechnology and Translational Medicine (M.R.), University of Milan; Division of Neuro-Oncology (E.P.), Department of Neuroscience "Rita Levi di Montalcini", University and City of Health and Science Hospital, Turin; Neurology Unit (E.P.), Department of Translational Medicine, University of Eastern Piedmont, Novara; Division of Neurosurgery (F.C., D.G.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital; Division of Radiotherapy (M.L.), Department of Oncology; and Pathology Unit (L. Bertero, P.C.), Department of Medical Sciences, University of Turin, Italy
| | - Mario Levis
- From the Division of Neuro-Oncology (F.B., A.P., R.S., R.R.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital, Turin; Neurosurgical Oncology Unit (M.C.N., M.R., L. Bello), "Galeazzi - Sant'Ambrogio" IRCCS, Milan; Departments of Oncology and Hemato-Oncology (L. Bello) and Medical Biotechnology and Translational Medicine (M.R.), University of Milan; Division of Neuro-Oncology (E.P.), Department of Neuroscience "Rita Levi di Montalcini", University and City of Health and Science Hospital, Turin; Neurology Unit (E.P.), Department of Translational Medicine, University of Eastern Piedmont, Novara; Division of Neurosurgery (F.C., D.G.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital; Division of Radiotherapy (M.L.), Department of Oncology; and Pathology Unit (L. Bertero, P.C.), Department of Medical Sciences, University of Turin, Italy
| | - Luca Bertero
- From the Division of Neuro-Oncology (F.B., A.P., R.S., R.R.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital, Turin; Neurosurgical Oncology Unit (M.C.N., M.R., L. Bello), "Galeazzi - Sant'Ambrogio" IRCCS, Milan; Departments of Oncology and Hemato-Oncology (L. Bello) and Medical Biotechnology and Translational Medicine (M.R.), University of Milan; Division of Neuro-Oncology (E.P.), Department of Neuroscience "Rita Levi di Montalcini", University and City of Health and Science Hospital, Turin; Neurology Unit (E.P.), Department of Translational Medicine, University of Eastern Piedmont, Novara; Division of Neurosurgery (F.C., D.G.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital; Division of Radiotherapy (M.L.), Department of Oncology; and Pathology Unit (L. Bertero, P.C.), Department of Medical Sciences, University of Turin, Italy
| | - Riccardo Soffietti
- From the Division of Neuro-Oncology (F.B., A.P., R.S., R.R.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital, Turin; Neurosurgical Oncology Unit (M.C.N., M.R., L. Bello), "Galeazzi - Sant'Ambrogio" IRCCS, Milan; Departments of Oncology and Hemato-Oncology (L. Bello) and Medical Biotechnology and Translational Medicine (M.R.), University of Milan; Division of Neuro-Oncology (E.P.), Department of Neuroscience "Rita Levi di Montalcini", University and City of Health and Science Hospital, Turin; Neurology Unit (E.P.), Department of Translational Medicine, University of Eastern Piedmont, Novara; Division of Neurosurgery (F.C., D.G.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital; Division of Radiotherapy (M.L.), Department of Oncology; and Pathology Unit (L. Bertero, P.C.), Department of Medical Sciences, University of Turin, Italy
| | - Paola Cassoni
- From the Division of Neuro-Oncology (F.B., A.P., R.S., R.R.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital, Turin; Neurosurgical Oncology Unit (M.C.N., M.R., L. Bello), "Galeazzi - Sant'Ambrogio" IRCCS, Milan; Departments of Oncology and Hemato-Oncology (L. Bello) and Medical Biotechnology and Translational Medicine (M.R.), University of Milan; Division of Neuro-Oncology (E.P.), Department of Neuroscience "Rita Levi di Montalcini", University and City of Health and Science Hospital, Turin; Neurology Unit (E.P.), Department of Translational Medicine, University of Eastern Piedmont, Novara; Division of Neurosurgery (F.C., D.G.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital; Division of Radiotherapy (M.L.), Department of Oncology; and Pathology Unit (L. Bertero, P.C.), Department of Medical Sciences, University of Turin, Italy
| | - Diego Garbossa
- From the Division of Neuro-Oncology (F.B., A.P., R.S., R.R.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital, Turin; Neurosurgical Oncology Unit (M.C.N., M.R., L. Bello), "Galeazzi - Sant'Ambrogio" IRCCS, Milan; Departments of Oncology and Hemato-Oncology (L. Bello) and Medical Biotechnology and Translational Medicine (M.R.), University of Milan; Division of Neuro-Oncology (E.P.), Department of Neuroscience "Rita Levi di Montalcini", University and City of Health and Science Hospital, Turin; Neurology Unit (E.P.), Department of Translational Medicine, University of Eastern Piedmont, Novara; Division of Neurosurgery (F.C., D.G.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital; Division of Radiotherapy (M.L.), Department of Oncology; and Pathology Unit (L. Bertero, P.C.), Department of Medical Sciences, University of Turin, Italy
| | - Lorenzo Bello
- From the Division of Neuro-Oncology (F.B., A.P., R.S., R.R.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital, Turin; Neurosurgical Oncology Unit (M.C.N., M.R., L. Bello), "Galeazzi - Sant'Ambrogio" IRCCS, Milan; Departments of Oncology and Hemato-Oncology (L. Bello) and Medical Biotechnology and Translational Medicine (M.R.), University of Milan; Division of Neuro-Oncology (E.P.), Department of Neuroscience "Rita Levi di Montalcini", University and City of Health and Science Hospital, Turin; Neurology Unit (E.P.), Department of Translational Medicine, University of Eastern Piedmont, Novara; Division of Neurosurgery (F.C., D.G.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital; Division of Radiotherapy (M.L.), Department of Oncology; and Pathology Unit (L. Bertero, P.C.), Department of Medical Sciences, University of Turin, Italy
| | - Roberta Rudà
- From the Division of Neuro-Oncology (F.B., A.P., R.S., R.R.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital, Turin; Neurosurgical Oncology Unit (M.C.N., M.R., L. Bello), "Galeazzi - Sant'Ambrogio" IRCCS, Milan; Departments of Oncology and Hemato-Oncology (L. Bello) and Medical Biotechnology and Translational Medicine (M.R.), University of Milan; Division of Neuro-Oncology (E.P.), Department of Neuroscience "Rita Levi di Montalcini", University and City of Health and Science Hospital, Turin; Neurology Unit (E.P.), Department of Translational Medicine, University of Eastern Piedmont, Novara; Division of Neurosurgery (F.C., D.G.), Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science Hospital; Division of Radiotherapy (M.L.), Department of Oncology; and Pathology Unit (L. Bertero, P.C.), Department of Medical Sciences, University of Turin, Italy
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Avila EK, Tobochnik S, Inati SK, Koekkoek JAF, McKhann GM, Riviello JJ, Rudà R, Schiff D, Tatum WO, Templer JW, Weller M, Wen PY. Brain tumor-related epilepsy management: A Society for Neuro-oncology (SNO) consensus review on current management. Neuro Oncol 2024; 26:7-24. [PMID: 37699031 PMCID: PMC10768995 DOI: 10.1093/neuonc/noad154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Tumor-related epilepsy (TRE) is a frequent and major consequence of brain tumors. Management of TRE is required throughout the course of disease and a deep understanding of diagnosis and treatment is key to improving quality of life. Gross total resection is favored from both an oncologic and epilepsy perspective. Shared mechanisms of tumor growth and epilepsy exist, and emerging data will provide better targeted therapy options. Initial treatment with antiseizure medications (ASM) in conjunction with surgery and/or chemoradiotherapy is typical. The first choice of ASM is critical to optimize seizure control and tolerability considering the effects of the tumor itself. These agents carry a potential for drug-drug interactions and therefore knowledge of mechanisms of action and interactions is needed. A review of adverse effects is necessary to guide ASM adjustments and decision-making. This review highlights the essential aspects of diagnosis and treatment of TRE with ASMs, surgery, chemotherapy, and radiotherapy while indicating areas of uncertainty. Future studies should consider the use of a standardized method of seizure tracking and incorporating seizure outcomes as a primary endpoint of tumor treatment trials.
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Affiliation(s)
- Edward K Avila
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Steven Tobochnik
- Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Neurology, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Sara K Inati
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Johan A F Koekkoek
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Guy M McKhann
- Department of Neurosurgery, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York, USA
| | - James J Riviello
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas, USA
| | - Roberta Rudà
- Division of Neuro-Oncology, Department of Neuroscience “Rita Levi Montalcini,” University of Turin, Italy
| | - David Schiff
- Department of Neurology, Division of Neuro-Oncology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - William O Tatum
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | - Jessica W Templer
- Department of Neurology, Northwestern University, Chicago, Illinois, USA
| | - Michael Weller
- Department of Neurology, Clinical Neuroscience Centre, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber Cancer Center, and Division of Neuro-Oncology, Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Welch MR. Management of Complications in Neuro-oncology Patients. Continuum (Minneap Minn) 2023; 29:1844-1871. [PMID: 38085901 DOI: 10.1212/con.0000000000001359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
OBJECTIVE The purpose of this article is to familiarize the reader with the spectrum of neurologic and medical complications relevant to the care of patients with neurologic cancer while highlighting best practices to prevent morbidity and mortality. Topics include tumor-related epilepsy, vasogenic edema, complications of corticosteroid use, disruption of the hypothalamic-pituitary axis, venous thromboembolism, and opportunistic infection. LATEST DEVELOPMENTS In 2021, a joint guideline from the Society for Neuro-Oncology and the European Association of Neuro-Oncology reaffirmed recommendations first established in 2000 that patients with newly diagnosed brain tumors should not be prescribed an antiseizure medication prophylactically. For those with tumor-related epilepsy, monotherapy with a non-enzyme-inducing anticonvulsant is the preferred initial treatment, and levetiracetam remains the preferred first choice. Surveys of physician practice continue to demonstrate excessive use of glucocorticoids in the management of patients with both primary and metastatic central nervous system malignancy. This is particularly concerning among patients who require checkpoint inhibitors as the efficacy of these agents is blunted by concomitant glucocorticoid use, resulting in a reduction in overall survival. Finally, direct oral anticoagulants have been shown to be safe in patients with brain tumors and are now favored as first-line treatment among those who require treatment for venous thromboembolism. ESSENTIAL POINTS Medical care for patients impacted by primary and secondary central nervous system malignancy is complex and requires a committed team-based approach that routinely calls upon the expertise of physicians across multiple fields. Neurologists have an important role to play and should be familiar with the spectrum of complications impacting these patients as well as the latest recommendations for management.
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Joghataei MT, Bakhtiarzadeh F, Dehghan S, Ketabforoush AHME, Golab F, Zarbakhsh S, Ahmadirad N. The role of neurotransmitters in glioblastoma multiforme-associated seizures. Int J Dev Neurosci 2023; 83:677-690. [PMID: 37563091 DOI: 10.1002/jdn.10294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/20/2023] [Accepted: 07/26/2023] [Indexed: 08/12/2023] Open
Abstract
GBM, or glioblastoma multiforme, is a brain tumor that poses a great threat to both children and adults, being the primary cause of death related to brain tumors. GBM is often associated with epilepsy, which can be debilitating. Seizures and the development of epilepsy are the primary symptoms that have a severe impact on the quality of life for GBM patients. It is increasingly apparent that the nervous system plays an essential role in the tumor microenvironment for all cancer types, including GBM. In recent years, there has been a growing understanding of how neurotransmitters control the progression of gliomas. Evidence suggests that neurotransmitters and neuromodulators found in the tumor microenvironment play crucial roles in the excitability, proliferation, quiescence, and differentiation of neurons, glial cells, and neural stem cells. The involvement of neurotransmitters appears to play a significant role in various stages of GBM. In this review, the focus is on presenting updated knowledge and emerging ideas regarding the interplay between neurotransmitters and neuromodulators, such as glutamate, GABA, norepinephrine, dopamine, serotonin, adenosine, and their relationship with GBM and the seizures induced by this condition. The review aims to explore the current understanding and provide new insights into the complex interactions between these neurotransmitters and neuromodulators in the context of GBM-related seizures.
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Affiliation(s)
| | - Fatemeh Bakhtiarzadeh
- Department of Physiology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Samaneh Dehghan
- Eye Research Center, The Five Senses Institute, Rasool Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
- Stem Cell and Regenerative Medicine Research Center, Iran University of Medical Sciences, Tehran, Iran
| | | | - Fereshteh Golab
- Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Sam Zarbakhsh
- Nervous System Stem Cells Research Center, Semnan University of Medical Sciences, Semnan, Iran
| | - Nooshin Ahmadirad
- Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran, Iran
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Yuan N, Lv ZH, Tao TY, Qian D. Influencing Factors and Nomogram for the Development of Epilepsy in Advanced Lung Cancer Patients With Brain Metastases. Biol Res Nurs 2023; 25:606-614. [PMID: 37138370 DOI: 10.1177/10998004231173425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND Epilepsy is a prevalent comorbidity in patients with brain metastases (BM) and could result in sudden and accidental damage, as well as increased disease burden due to its rapid onset. Foreseeing the potential for the development of epilepsy may permit timely and efficient measures. This study aimed to analyze the influencing factors of epilepsy in advanced lung cancer (ALC) patients with BM and construct a nomogram model to predict the likelihood of developing epilepsy. METHODS Socio-demographic and clinical data of ALC patients with BM were retrospectively collected from the First Affiliated Hospital of Zhejiang University School of Medicine between September 2019 and June 2021. Univariate and multivariate logistic regression analyses were applied to determine the influencing factors for epilepsy in ALC patients with BM. Based on the results of the logistic regression analysis, a nomogram was built to represent the contribution of each influencing factor in predicting the probability of epilepsy development in ALC patients with BM. The Hosmer-Lemeshow test and receiver operating characteristic (ROC) curve were utilized to evaluate the goodness of fit and prediction performance of the model. RESULTS The incidence of epilepsy among 138 ALC patients with BM was 29.7%. On the multivariate analysis, having a higher number of supratentorial lesions (odds ratio [OR] = 1.727; p = 0.022), hemorrhagic foci (OR = 4.922; p = .021), and a high-grade of peritumoral edema (OR = 2.524; p < .001) were independent risk factors for developing epilepsy, while undergoing gamma knife radiosurgery (OR = .327; p = .019) was an independent protective factor. The p-value of the Hosmer-Lemeshow test was .535 and the area under the ROC curve (AUC) was .852 (95% CI: .807-.897), suggesting the model had a good fit and exhibited strong predictive accuracy. CONCLUSION The nomogram was constructed that can predict the probability of epilepsy development for ALC patients with BM, which is helpful for healthcare professionals to identify high-risk groups early and allows for individualized interventions.
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Affiliation(s)
- Niu Yuan
- Department of Nursing, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Department of Respiratory Medicine, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Zhang-Hong Lv
- Department of Nursing, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Department of Respiratory Medicine, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ting-Yu Tao
- Department of Nursing, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Department of Respiratory Medicine, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Dan Qian
- Department of Nursing, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Department of Respiratory Medicine, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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McKevitt FM. What neurologists can do for neuro-oncology patients. Pract Neurol 2023:pn-2022-003665. [PMID: 37019612 DOI: 10.1136/pn-2022-003665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2023] [Indexed: 04/07/2023]
Abstract
Neuro-oncology is a branch of medical science concerned with managing central nervous system tumours and neurological complications of cancer. Patients with brain tumours need a multidisciplinary approach to their care and neurologists can play a key part within that team. This review shows how neurologists can contribute to the care of patients with neuro-oncological disease at various points during the illness, including at initial diagnosis, during symptom management and at end of life assisting with palliative seizure management. The review focuses on brain tumour-related epilepsy, the complications of brain tumour treatments and the neurological complications of systemic cancer treatments including immunotherapies.
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Affiliation(s)
- Fiona M McKevitt
- Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Vacher E, Rodriguez Ruiz M, Rees JH. Management of brain tumour related epilepsy (BTRE): a narrative review and therapy recommendations. Br J Neurosurg 2023:1-8. [PMID: 36694327 DOI: 10.1080/02688697.2023.2170326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 12/21/2022] [Accepted: 01/16/2023] [Indexed: 01/26/2023]
Abstract
Brain Tumour Related Epilepsy (BTRE) has a significant impact on Quality of Life with implications for driving, employment, and social activities. Management of BTRE is complex due to the higher incidence of drug resistance and the potential for interaction between anti-cancer therapy and anti-seizure medications (ASMs). Neurologists, neurosurgeons, oncologists, palliative care physicians and clinical nurse specialists treating these patients would benefit from up-to-date clinical guidelines. We aim to review the current literature and to outline specific recommendations for the optimal treatment of BTRE, encompassing both Primary Brain Tumours (PBT) and Brain Metastases (BM). A comprehensive search of the literature since 1995 on BTRE was carried out in PubMed, MEDLINE and EMCARE. A broad search strategy was used, and the evidence evaluated and graded based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence. Seizure frequency varies between 10 and 40% in patients with Brain Metastases (BM) and from 30% (high-grade gliomas) to 90% (low-grade gliomas) in patients with PBT. In patients with BM, risk factors include number of BM and melanoma histology. In patients with PBT, BTRE is more common in patients with lower grade histology, frontal and temporal tumours, presence of an IDH mutation and cortical infiltration. All patients with BTRE should be treated with ASMs. Non-enzyme inducing ASMs are recommended as first line treatment for BTRE, but up to 50% of patients with BTRE due to PBT remain resistant. There is no proven benefit for the use of prophylactic ASMs, although there are no randomised trials testing newer agents. Surgical and oncological treatments i.e. radiotherapy and chemotherapy improve BTRE. Vagus Nerve Stimulation has been used with partial success. The review highlights the relative dearth of high-quality evidence for the management of BTRE and provides a framework for further studies aiming to improve seizure control, quality of life, and indications for ASMs.KEY POINTSOffer levetiracetam or lamotrigine to all patients with primary or metastatic brain tumours who have seizure(s), irrespective of whether these are partial or generalised.ASM withdrawal for patients in remission is not recommended due to high rates of seizure recurrence.ASM prophylaxis is not generally recommended in the management of seizure-naïve patients.Both levetiracetam and lamotrigine are safe in pregnancy and breastfeeding.
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Affiliation(s)
- Elizabeth Vacher
- UCL Medical School, London, UK
- UCL Queen Square Institute of Neurology, London, UK
| | | | - Jeremy H Rees
- UCL Queen Square Institute of Neurology, London, UK
- National Hospital for Neurology and Neurosurgery, London, UK
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8
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Hills KE, Kostarelos K, Wykes RC. Converging Mechanisms of Epileptogenesis and Their Insight in Glioblastoma. Front Mol Neurosci 2022; 15:903115. [PMID: 35832394 PMCID: PMC9271928 DOI: 10.3389/fnmol.2022.903115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/25/2022] [Indexed: 12/15/2022] Open
Abstract
Glioblastoma (GBM) is the most common and advanced form of primary malignant tumor occurring in the adult central nervous system, and it is frequently associated with epilepsy, a debilitating comorbidity. Seizures are observed both pre- and post-surgical resection, indicating that several pathophysiological mechanisms are shared but also prompting questions about how the process of epileptogenesis evolves throughout GBM progression. Molecular mutations commonly seen in primary GBM, i.e., in PTEN and p53, and their associated downstream effects are known to influence seizure likelihood. Similarly, various intratumoral mechanisms, such as GBM-induced blood-brain barrier breakdown and glioma-immune cell interactions within the tumor microenvironment are also cited as contributing to network hyperexcitability. Substantial alterations to peri-tumoral glutamate and chloride transporter expressions, as well as widespread dysregulation of GABAergic signaling are known to confer increased epileptogenicity and excitotoxicity. The abnormal characteristics of GBM alter neuronal network function to result in metabolically vulnerable and hyperexcitable peri-tumoral tissue, properties the tumor then exploits to favor its own growth even post-resection. It is evident that there is a complex, dynamic interplay between GBM and epilepsy that promotes the progression of both pathologies. This interaction is only more complicated by the concomitant presence of spreading depolarization (SD). The spontaneous, high-frequency nature of GBM-associated epileptiform activity and SD-associated direct current (DC) shifts require technologies capable of recording brain signals over a wide bandwidth, presenting major challenges for comprehensive electrophysiological investigations. This review will initially provide a detailed examination of the underlying mechanisms that promote network hyperexcitability in GBM. We will then discuss how an investigation of these pathologies from a network level, and utilization of novel electrophysiological tools, will yield a more-effective, clinically-relevant understanding of GBM-related epileptogenesis. Further to this, we will evaluate the clinical relevance of current preclinical research and consider how future therapeutic advancements may impact the bidirectional relationship between GBM, SDs, and seizures.
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Affiliation(s)
- Kate E. Hills
- Nanomedicine Lab, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Kostas Kostarelos
- Nanomedicine Lab, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Catalan Institute for Nanoscience and Nanotechnology (ICN2), Edifici ICN2, Campus UAB, Barcelona, Spain
| | - Robert C. Wykes
- Nanomedicine Lab, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom
- *Correspondence: Robert C. Wykes
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9
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Silva M, Vivancos C, Duffau H. The Concept of «Peritumoral Zone» in Diffuse Low-Grade Gliomas: Oncological and Functional Implications for a Connectome-Guided Therapeutic Attitude. Brain Sci 2022; 12:brainsci12040504. [PMID: 35448035 PMCID: PMC9032126 DOI: 10.3390/brainsci12040504] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/10/2022] [Accepted: 04/12/2022] [Indexed: 12/22/2022] Open
Abstract
Diffuse low-grade gliomas (DLGGs) are heterogeneous and poorly circumscribed neoplasms with isolated tumor cells that extend beyond the margins of the lesion depicted on MRI. Efforts to demarcate the glioma core from the surrounding healthy brain led us to define an intermediate region, the so-called peritumoral zone (PTZ). Although most studies about PTZ have been conducted on high-grade gliomas, the purpose here is to review the cellular, metabolic, and radiological characteristics of PTZ in the specific context of DLGG. A better delineation of PTZ, in which glioma cells and neural tissue strongly interact, may open new therapeutic avenues to optimize both functional and oncological results. First, a connectome-based “supratotal” surgical resection (i.e., with the removal of PTZ in addition to the tumor core) resulted in prolonged survival by limiting the risk of malignant transformation, while improving the quality of life, thanks to a better control of seizures. Second, the timing and order of (neo)adjuvant medical treatments can be modulated according to the pattern of peritumoral infiltration. Third, the development of new drugs specifically targeting the PTZ could be considered from an oncological (such as immunotherapy) and epileptological perspective. Further multimodal investigations of PTZ are needed to maximize long-term outcomes in DLGG patients.
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Affiliation(s)
- Melissa Silva
- Department of Neurosurgery, Hospital Garcia de Orta, 2805-267 Almada, Portugal;
| | - Catalina Vivancos
- Department of Neurosurgery, Hospital Universitario La Paz, 28046 Madrid, Spain;
| | - Hugues Duffau
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, 34295 Montpellier, France
- Team “Plasticity of Central Nervous System, Stem Cells and Glial Tumors”, Institute of Functional Genomics, National Institute for Health and Medical Research (INSERM) U1191, University of Montpellier, 34295 Montpellier, France
- Correspondence:
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10
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Qi J, Liu X, Xu N, Wang Q. The Clinical Characteristics of New-Onset Epilepsy in the Elderly and Risk Factors for Treatment Outcomes of Antiseizure Medications. Front Neurol 2022; 13:819889. [PMID: 35273558 PMCID: PMC8901571 DOI: 10.3389/fneur.2022.819889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/20/2022] [Indexed: 12/01/2022] Open
Abstract
Objective To describe the clinical characteristics of elderly patients with new-onset epilepsy in a Class A tertiary comprehensive hospital in north China and evaluate the treatment outcomes of antiseizure medications (ASMs). This study focuses on investigating the factors affecting the treatment outcomes, guiding the drug treatment, and judging the prognosis of elderly epilepsy patients. Methods We included patients aged 60 years or older at the time of their first seizure between January 2014 and August 2020. Demographic characteristics, effects of ASM, and the proportion of 1-year and long-term seizure freedom were reported. The univariate analysis and binary logistic regression were used to identify factors potentially influencing treatment outcomes. Results A total of 326 patients (median age 65 years, 67.2% men) were included. Moreover, 185 (56.7%) patients who received the first ASM monotherapy achieved 1 year of seizure freedom in the early stage. Compared with structural etiology, unknown etiology was associated with a higher likelihood of early seizure freedom (odds ratio [OR] = 0.545; p < 0.05). Conversely, comorbid intracranial malignant tumors, taking carbamazepine (CBZ), and sodium valproate (VPA) were associated with a lower likelihood of seizure freedom (OR = 3.527 vs. 6.550 vs. 8.829; p < 0.05). At long-term follow-up, 263 (80.6%) patients achieved seizure freedom, with 79.8% on monotherapy. Conclusions Elderly patients with new-onset epilepsy responded well to the initial ASMs treatment. Patients with intracranial malignant tumors and prescribed VPA and CBZ were less likely to achieve early seizure freedom, while those with unknown etiology had higher probabilities of achieving early seizure freedom than those with structural etiology.
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Affiliation(s)
- Jing Qi
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiao Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Na Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Clinical Medicine of Neurological Diseases, Beijing, China.,Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
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11
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Seizures in patients with IDH-mutated lower grade gliomas. J Neurooncol 2022; 160:403-411. [PMID: 36258151 PMCID: PMC9722876 DOI: 10.1007/s11060-022-04158-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/03/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE Most patients with Lower Grade Gliomas (LGG) present with epileptic seizures. Since the advent of molecular diagnostics, more homogenous sub-entities have emerged, including the isocitrate dehydrogenase-mutated (IDH-mutated) astrocytomas and 1p19q-codeleted oligodendrogliomas. We aimed to describe the occurrence of seizures in patients with molecularly defined LGG pre- and postoperatively and to analyze factors affecting seizure status postoperatively. METHODS A population-based cohort of 130 adult patients with IDH-mutated WHO grade 2 or 3 astrocytomas and oligodendrogliomas was assessed pertaining to seizure burden before and after surgery. RESULTS Fifty-four (79.4%) patients with astrocytoma and 45 (72.6%) patients with oligodendroglioma had a history of seizures before surgery. At 12 months postoperatively, 51/67 (76.1%) patients with astrocytoma and 47/62 (75.8%) patients with oligodendrogliomas were seizure free. In a multivariable logistic regression analysis, lower extent of resection (EOR) (OR 0.98; 95% CI 0.97-1.00, p = 0.01) and insular tumor location (OR 5.02; 95% CI 1.01-24.87, p = 0.048) were associated with presence of seizures within 1 year postoperatively in the entire LGG cohort. In sub-entities, EOR was in a similar manner associated with seizures postoperatively in astrocytomas (OR 0.98; 95% CI 0.96-0.99, p < 0.01) but not in oligodendrogliomas (p = 0.34). CONCLUSION Our results are well in line with data published for non-molecularly defined LGG with a large proportion of patients being seizure free at 1 year postoperative. Better seizure outcome was observed with increased EOR in astrocytomas, but this association was absent in oligodendrogliomas.
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12
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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: 13] [Impact Index Per Article: 4.3] [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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13
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Easwaran TP, Lancki N, Henriquez M, Vortmeyer AO, Barbaro NM, Scholtens DM, Ahmed AU, Dey M. Molecular Classification of Gliomas is Associated with Seizure Control: A Retrospective Analysis. Neuromolecular Med 2021; 23:315-326. [PMID: 33206320 PMCID: PMC8128931 DOI: 10.1007/s12017-020-08624-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/08/2020] [Indexed: 01/18/2023]
Abstract
Classically, histologic grading of gliomas has been used to predict seizure association, with low-grade gliomas associated with an increased incidence of seizures compared to high-grade gliomas. In 2016, WHO reclassified gliomas based on histology and molecular characteristics. We sought to determine whether molecular classification of gliomas is associated with preoperative seizure presentation and/or post-operative seizure control across multiple glioma subtypes. All gliomas operated at our institution from 2007 to 2017 were identified based on ICD 9 and 10 billing codes and were retrospectively assessed for molecular classification of the IDH1 mutation, and 1p/19q codeletion. Logistic regression models were performed to assess associations of seizures at presentation as well as post-operative seizures with IDH status and the new WHO integrated classification. Our study included 376 patients: 82 IDH mutant and 294 IDH wildtype. The presence of IDH mutation was associated with seizures at presentation [OR 3.135 (1.818-5.404), p < 0.001]. IDH-mutant glioblastomas presented with seizures less often than other IDH-mutant glioma subtypes grade II and III [OR 0.104 (0.032-0.340), p < 0.001]. IDH-mutant tumors were associated with worse post-operative seizure outcomes, demonstrated by Engel Class [OR 2.666 (1.592-4.464), p < 0.001]. IDH mutation in gliomas is associated with an increased risk of seizure development and worse post-operative seizure control, in all grades except for GBM.
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Affiliation(s)
- Teresa P Easwaran
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicola Lancki
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mario Henriquez
- Department of Neurosurgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue CSC K3/803, Madison, WI, 53792, USA
| | - Alexander O Vortmeyer
- Department of Pathology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicholas M Barbaro
- Department of Neurosurgery, Dell Medical School, The University of Texas, Austin, TX, USA
| | - Denise M Scholtens
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Atique U Ahmed
- Department of Neurosurgery and Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mahua Dey
- Department of Neurosurgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue CSC K3/803, Madison, WI, 53792, USA.
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14
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Rades D, Witteler J, Olbrich D, Trillenberg P, Schild SE, Tvilsted S, Kjaer TW. A prospective interventional study evaluating seizure activity during a radiotherapy course for high-grade gliomas (SURF-ROGG). BMC Cancer 2021; 21:386. [PMID: 33836671 PMCID: PMC8033669 DOI: 10.1186/s12885-021-08121-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 03/29/2021] [Indexed: 11/10/2022] Open
Abstract
Background Gliomas are often associated with symptoms including seizures. Most patients with high-grade gliomas are treated with radiotherapy or radio-chemotherapy. Since irradiation causes inflammation, it may initially aggravate symptoms. Studies focusing on seizure activity during radiotherapy for gliomas are not available. Such knowledge may improve patient monitoring and anti-epileptic treatment. This study evaluates seizure activity during radiotherapy for high-grade gliomas. Methods The primary objective this prospective interventional study is the evaluation of seizure activity during a course of radiotherapy for high-grade gliomas. Progression of seizure activity is defined as increased frequency of seizures by > 50%, increased severity of seizures, or initiation/increase by ≥25% of anti-epileptic medication. Seizure frequency up to 6 weeks following radiotherapy and electroencephalography activity typical for epilepsy will also be evaluated. Patients keep a seizure diary during and up to 6 weeks following radiotherapy. Every day, they will document number (and type) of seizures and anti-epileptic medication. Once a week, the findings of the diary are checked and discussed with a neurologist to initiate or adjust anti-epileptic medication, if necessary. Patients complete a questionnaire regarding their satisfaction with the seizure diary. If the dissatisfaction rate is > 40%, the seizure diary will be considered not suitable for the investigated indication. Thirty-five patients (32 patients plus drop-outs) should be enrolled. With this sample size, a one-sample binomial test with a one-sided significance level of 2.5% has a power of 80% to yield statistical significance, if the rate of patients with progression of seizure activity is 30% (rate under the alternative hypothesis), assuming a ‘natural’ background progression-rate of 10% without radiotherapy (null hypothesis). Discussion If an increase in seizure activity during a course of radiotherapy for high-grade glioma occurs, the findings of this study may pave the way for a larger prospective trial and will likely lead to closer patient monitoring and better anti-epileptic treatment. Trial registration clinicaltrials.gov (NCT04552756); registered on 16th of September, 2020.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany.
| | - Jaspar Witteler
- Department of Radiation Oncology, University of Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | | | | | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic Scottsdale, Scottsdale, AZ, USA
| | - Soeren Tvilsted
- Research Projects and Clinical Optimization, Zealand University Hospital, Koege, Denmark
| | - Troels W Kjaer
- Neurological Department, Zealand University Hospital, Roskilde, Denmark
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15
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Zoccarato M, Nardetto L, Basile AM, Giometto B, Zagonel V, Lombardi G. Seizures, Edema, Thrombosis, and Hemorrhages: An Update Review on the Medical Management of Gliomas. Front Oncol 2021; 11:617966. [PMID: 33828976 PMCID: PMC8019972 DOI: 10.3389/fonc.2021.617966] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/04/2021] [Indexed: 12/21/2022] Open
Abstract
Patients affected with gliomas develop a complex set of clinical manifestations that deeply impact on quality of life and overall survival. Brain tumor-related epilepsy is frequently the first manifestation of gliomas or may occur during the course of disease; the underlying mechanisms have not been fully explained and depend on both patient and tumor factors. Novel treatment options derive from the growing use of third-generation antiepileptic drugs. Vasogenic edema and elevated intracranial pressure cause a considerable burden of symptoms, especially in high-grade glioma, requiring an adequate use of corticosteroids. Patients with gliomas present with an elevated risk of tumor-associated venous thromboembolism whose prophylaxis and treatment are challenging, considering also the availability of new oral anticoagulant drugs. Moreover, intracerebral hemorrhages can complicate the course of the illness both due to tumor-specific characteristics, patient comorbidities, and side effects of antithrombotic and antitumoral therapies. This paper aims to review recent advances in these clinical issues, discussing the medical management of gliomas through an updated literature review.
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Affiliation(s)
- Marco Zoccarato
- Neurology Unit, O.S.A., Azienda Ospedale-Università, Padua, Italy
| | - Lucia Nardetto
- Neurology Unit, O.S.A., Azienda Ospedale-Università, Padua, Italy
| | | | - Bruno Giometto
- Neurology Unit, Trento Hospital, Azienda Provinciale per i Servizi Sanitari (APSS) di Trento, Trento, Italy
| | - Vittorina Zagonel
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCSS, Padua, Italy
| | - Giuseppe Lombardi
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCSS, Padua, Italy
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16
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Li Z, Cai S, Li H, Gu J, Tian Y, Cao J, Yu D, Tang Z. Developing a lncRNA Signature to Predict the Radiotherapy Response of Lower-Grade Gliomas Using Co-expression and ceRNA Network Analysis. Front Oncol 2021; 11:622880. [PMID: 33767991 PMCID: PMC7985253 DOI: 10.3389/fonc.2021.622880] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/15/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Lower-grade glioma (LGG) is a type of central nervous system tumor that includes WHO grade II and grade III gliomas. Despite developments in medical science and technology and the availability of several treatment options, the management of LGG warrants further research. Surgical treatment for LGG treatment poses a challenge owing to its often inaccessible locations in the brain. Although radiation therapy (RT) is the most important approach in this condition and offers more advantages compared to surgery and chemotherapy, it is associated with certain limitations. Responses can vary from individual to individual based on genetic differences. The relationship between non-coding RNA and the response to radiation therapy, especially at the molecular level, is still undefined. METHODS In this study, using The Cancer Genome Atlas dataset and bioinformatics, the gene co-expression network that is involved in the response to radiation therapy in lower-grade gliomas was determined, and the ceRNA network of radiotherapy response was constructed based on three databases of RNA interaction. Next, survival analysis was performed for hub genes in the co-expression network, and the high-efficiency biomarkers that could predict the prognosis of patients with LGG undergoing radiotherapy was identified. RESULTS We found that some modules in the co-expression network were related to the radiotherapy responses in patients with LGG. Based on the genes in those modules and the three databases, we constructed a ceRNA network for the regulation of radiotherapy responses in LGG. We identified the hub genes and found that the long non-coding RNA, DRAIC, is a potential molecular biomarker to predict the prognosis of radiotherapy in LGG.
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Affiliation(s)
- Zhongyang Li
- School of Radiation Medicine and Protection, Soochow University Medical College (SUMC), Suzhou, China
| | - Shang Cai
- Department of Radiotherapy and Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Radiotherapy and Oncology, Soochow University, Suzhou, China
| | - Huijun Li
- Department of Biostatistics, School of Public Health, Medical College of Soochow University, Suzhou, China
- Jiangsu Provincial Key Laboratory of Geriatrics Prevention and Translational Medicine, School of Public Health, Soochow University Medical College, Suzhou, China
| | - Jincheng Gu
- Department of Biostatistics, School of Public Health, Medical College of Soochow University, Suzhou, China
- Jiangsu Provincial Key Laboratory of Geriatrics Prevention and Translational Medicine, School of Public Health, Soochow University Medical College, Suzhou, China
| | - Ye Tian
- Department of Radiotherapy and Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Radiotherapy and Oncology, Soochow University, Suzhou, China
| | - Jianping Cao
- School of Radiation Medicine and Protection, Soochow University Medical College (SUMC), Suzhou, China
- School of Radiation Medicine and Protection and Collaborative Innovation Center of Radiation Medicine of Jiangsu Higher Education Institutions, Soochow University, Suzhou, China
| | - Dong Yu
- School of Radiation Medicine and Protection, Soochow University Medical College (SUMC), Suzhou, China
| | - Zaixiang Tang
- Department of Biostatistics, School of Public Health, Medical College of Soochow University, Suzhou, China
- Jiangsu Provincial Key Laboratory of Geriatrics Prevention and Translational Medicine, School of Public Health, Soochow University Medical College, Suzhou, China
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17
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Stocksdale B, Nagpal S, Hixson JD, Johnson DR, Rai P, Shivaprasad A, Tremont-Lukats IW. Neuro-Oncology Practice Clinical Debate: long-term antiepileptic drug prophylaxis in patients with glioma. Neurooncol Pract 2020; 7:583-588. [PMID: 33312673 DOI: 10.1093/nop/npaa026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Patients with primary brain tumors often experience seizures, which can be the presenting symptom or occur for the first time at any point along the illness trajectory. In addition to causing morbidity, seizures negatively affect independence and quality of life in other ways, for example, by leading to loss of driving privileges. Long-term therapy with antiepileptic drugs (AEDs) is the standard of care in brain tumor patients with seizures, but the role of prophylactic AEDs in seizure-naive patients remains controversial. In this article, experts in the field discuss the issues of AED efficacy and toxicity, and explain their differing recommendations for routine use of prophylactic AEDs.
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Affiliation(s)
- Brian Stocksdale
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Seema Nagpal
- Department of Neurology, Stanford University, California
| | - John D Hixson
- Department of Neurology, University of California San Francisco
| | | | - Prashant Rai
- Department of Neurology, The University of Texas Medical Branch at Galveston
| | - Akhil Shivaprasad
- Stanley H. Appel Department of Neurology, Houston Methodist Hospital, Texas
| | - Ivo W Tremont-Lukats
- Kenneth R. Peak Brain and Pituitary Tumor Center, Houston Methodist Hospital, Texas.,Department of Neurosurgery, Houston Methodist Hospital, Texas
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18
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Lange F, Hartung J, Liebelt C, Boisserée J, Resch T, Porath K, Hörnschemeyer MF, Reichart G, Sellmann T, Neubert V, Kriesen S, Hildebrandt G, Schültke E, Köhling R, Kirschstein T. Perampanel Add-on to Standard Radiochemotherapy in vivo Promotes Neuroprotection in a Rodent F98 Glioma Model. Front Neurosci 2020; 14:598266. [PMID: 33328869 PMCID: PMC7734300 DOI: 10.3389/fnins.2020.598266] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/10/2020] [Indexed: 01/02/2023] Open
Abstract
An abnormal glutamate signaling of glioblastoma may contribute to both tumor progression and the generation of glioma-associated epileptic seizures. We hypothesized that the AMPA receptor antagonist perampanel (PER) could attenuate tumor growth and epileptic events. F98 glioma cells, grown orthotopically in Fischer rats, were employed as a model of glioma to investigate the therapeutic efficiency of PER (15 mg/kg) as adjuvant to standard radiochemotherapy (RCT). The epileptiform phenotype was investigated by video-EEG analysis and field potential recordings. Effects on glioma progression were estimated by tumor size quantification, survival analysis and immunohistological staining. Our data revealed that orthotopically-growing F98 glioma promote an epileptiform phenotype in rats. RCT reduced the tumor size and prolonged the survival of the animals. The adjuvant administration of PER had no effect on tumor progression. The tumor-associated epileptic events were abolished by PER application or RCT respectively, to initial baseline levels. Remarkably, PER preserved the glutamatergic network activity on healthy peritumoral tissue in RCT-treated animals. F98 tumors are not only a robust model to investigate glioma progression, but also a viable model to simulate a glioma-associated epileptiform phenotype. Furthermore, our data indicate that PER acts as a potent anticonvulsant and may protect the tumor-surrounding tissue as adjuvant to RCT, but failed to attenuate tumor growth or promote animal survival.
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Affiliation(s)
- Falko Lange
- Oscar-Langendorff-Institute of Physiology, Rostock University Medical Center, Rostock, Germany
- Center for Transdisciplinary Neurosciences Rostock, University of Rostock, Rostock, Germany
| | - Jens Hartung
- Oscar-Langendorff-Institute of Physiology, Rostock University Medical Center, Rostock, Germany
| | - Clara Liebelt
- Oscar-Langendorff-Institute of Physiology, Rostock University Medical Center, Rostock, Germany
| | - Julius Boisserée
- Oscar-Langendorff-Institute of Physiology, Rostock University Medical Center, Rostock, Germany
| | - Tobias Resch
- Oscar-Langendorff-Institute of Physiology, Rostock University Medical Center, Rostock, Germany
| | - Katrin Porath
- Oscar-Langendorff-Institute of Physiology, Rostock University Medical Center, Rostock, Germany
| | | | - Gesine Reichart
- Oscar-Langendorff-Institute of Physiology, Rostock University Medical Center, Rostock, Germany
| | - Tina Sellmann
- Oscar-Langendorff-Institute of Physiology, Rostock University Medical Center, Rostock, Germany
| | - Valentin Neubert
- Oscar-Langendorff-Institute of Physiology, Rostock University Medical Center, Rostock, Germany
| | - Stephan Kriesen
- Department of Radiotherapy and Radiation Oncology, Rostock University Medical Center, Rostock, Germany
| | - Guido Hildebrandt
- Department of Radiotherapy and Radiation Oncology, Rostock University Medical Center, Rostock, Germany
| | - Elisabeth Schültke
- Department of Radiotherapy and Radiation Oncology, Rostock University Medical Center, Rostock, Germany
| | - Rüdiger Köhling
- Oscar-Langendorff-Institute of Physiology, Rostock University Medical Center, Rostock, Germany
- Center for Transdisciplinary Neurosciences Rostock, University of Rostock, Rostock, Germany
| | - Timo Kirschstein
- Oscar-Langendorff-Institute of Physiology, Rostock University Medical Center, Rostock, Germany
- Center for Transdisciplinary Neurosciences Rostock, University of Rostock, Rostock, Germany
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Thakkar JP, Prabhu VC, Rouse S, Lukas RV. Acute Neurological Complications of Brain Tumors and Immune Therapies, a Guideline for the Neuro-hospitalist. Curr Neurol Neurosci Rep 2020; 20:32. [PMID: 32596758 DOI: 10.1007/s11910-020-01056-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE OF REVIEW Patients with brain tumors presenting to the emergency room with acute neurologic complications may warrant urgent investigations and emergent management. As the neuro-hospitalist will likely encounter this complex patient population, an understanding of the acute neurologic issues will have value. RECENT FINDINGS We discuss updated information and management regarding various acute neurologic complications among neuro-oncology patients and neurologic complications of immunotherapy. Understanding of the acute neurologic complications associated with central nervous system tumors and with common contemporary cancer treatments will facilitate the neuro-hospitalist management of these patient populations. While there are aspects analogous to the diagnosis and management in the non-oncologic population, a number of unique features discussed in this review should be considered.
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Affiliation(s)
- Jigisha P Thakkar
- Department of Neurology, Stritch School of Medicine, Loyola University Medical Center, 2160 S. 1st Avenue, Bldg 105, Room 2700, Maywood, IL, 60153, USA. .,Department of Neurosurgery, Stritch School of Medicine, Loyola University Chicago, 2160 S. 1st Avenue, Bldg 105, Room 1900, Maywood, IL, 60153, USA.
| | - Vikram C Prabhu
- Department of Neurosurgery, Stritch School of Medicine, Loyola University Chicago, 2160 S. 1st Avenue, Bldg 105, Room 1900, Maywood, IL, 60153, USA
| | - Stasia Rouse
- Department of Neurology, Stritch School of Medicine, Loyola University Medical Center, 2160 S. 1st Avenue, Bldg 105, Room 2700, Maywood, IL, 60153, USA
| | - Rimas V Lukas
- Department of Neurology, Northwestern University Feinberg School of Medicine, 710 N. Lake Shore Drive, Abbott Hall 1114, Chicago, IL, 60611, USA.,Lou and Jean Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, 60611, USA
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20
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Rudà R, Angileri FF, Ius T, Silvani A, Sarubbo S, Solari A, Castellano A, Falini A, Pollo B, Del Basso De Caro M, Papagno C, Minniti G, De Paula U, Navarria P, Nicolato A, Salmaggi A, Pace A, Fabi A, Caffo M, Lombardi G, Carapella CM, Spena G, Iacoangeli M, Fontanella M, Germanò AF, Olivi A, Bello L, Esposito V, Skrap M, Soffietti R. Italian consensus and recommendations on diagnosis and treatment of low-grade gliomas. An intersociety (SINch/AINO/SIN) document. J Neurosurg Sci 2020; 64:313-334. [PMID: 32347684 DOI: 10.23736/s0390-5616.20.04982-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In 2018, the SINch (Italian Society of Neurosurgery) Neuro-Oncology Section, AINO (Italian Association of Neuro-Oncology) and SIN (Italian Association of Neurology) Neuro-Oncology Section formed a collaborative Task Force to look at the diagnosis and treatment of low-grade gliomas (LGGs). The Task Force included neurologists, neurosurgeons, neuro-oncologists, pathologists, radiologists, radiation oncologists, medical oncologists, a neuropsychologist and a methodologist. For operational purposes, the Task Force was divided into five Working Groups: diagnosis, surgical treatment, adjuvant treatments, supportive therapies, and follow-up. The resulting guidance document is based on the available evidence and provides recommendations on diagnosis and treatment of LGG patients, considering all aspects of patient care along their disease trajectory.
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Affiliation(s)
- Roberta Rudà
- Department of Neuro-Oncology, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Filippo F Angileri
- Section of Neurosurgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy -
| | - Tamara Ius
- Neurosurgery Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Antonio Silvani
- Department of Neuro-Oncology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Silvio Sarubbo
- Department of Neurosurgery, Structural and Functional Connectivity Lab Project, "S. Chiara" Hospital, Trento, Italy
| | - Alessandra Solari
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Antonella Castellano
- Neuroradiology Unit, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Falini
- Neuroradiology Unit, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy
| | - Bianca Pollo
- Section of Oncologic Neuropathology, Division of Neurology V - Neuropathology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | | | - Costanza Papagno
- Center of Neurocognitive Rehabilitation (CeRiN), Interdepartmental Center of Mind/Brain, University of Trento, Trento, Italy.,Department of Psychology, University of Milan-Bicocca, Milan, Italy
| | - Giuseppe Minniti
- Radiation Oncology Unit, Department of Medicine, Surgery and Neurosciences, Policlinico Le Scotte, University of Siena, Siena, Italy
| | - Ugo De Paula
- Unit of Radiotherapy, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Pierina Navarria
- Department of Radiotherapy and Radiosurgery, Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Antonio Nicolato
- Unit of Stereotaxic Neurosurgery, Department of Neurosciences, Hospital Trust of Verona, Verona, Italy
| | - Andrea Salmaggi
- Neurology Unit, Department of Neurosciences, A. Manzoni Hospital, Lecco, Italy
| | - Andrea Pace
- IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Alessandra Fabi
- Division of Medical Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Maria Caffo
- Section of Neurosurgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Giuseppe Lombardi
- Unit of Oncology 1, Department of Oncology, Veneto Institute of Oncology-IRCCS, Padua, Italy
| | | | - Giannantonio Spena
- Neurosurgery Unit, Department of Neurosciences, A. Manzoni Hospital, Lecco, Italy
| | - Maurizio Iacoangeli
- Department of Neurosurgery, Marche Polytechnic University, Umberto I General University Hospital, Ancona, Italy
| | - Marco Fontanella
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Antonino F Germanò
- Section of Neurosurgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Alessandro Olivi
- Neurosurgery Unit, Department of Neurosciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico "A. Gemelli", Rome, Italy
| | - Lorenzo Bello
- Unit of Oncologic Neurosurgery, Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Vincenzo Esposito
- Sapienza University, Rome, Italy.,Giampaolo Cantore Department of Neurosurgery, IRCCS Neuromed, Pozzilli, Isernia, Italy
| | - Miran Skrap
- Neurosurgery Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Riccardo Soffietti
- Department of Neuro-Oncology, Città della Salute e della Scienza, University of Turin, Turin, Italy
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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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22
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Monforte Monteiro SR, Rossmeisl JH, Russell J, Holmes MA, Wessmann A, Morris J, Dobson JM, Vanhaesebrouck AE. Effect of radiotherapy on freedom from seizures in dogs with brain tumors. J Vet Intern Med 2020; 34:821-827. [PMID: 32032456 PMCID: PMC7096644 DOI: 10.1111/jvim.15695] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 12/20/2019] [Indexed: 11/28/2022] Open
Abstract
Background Seizures are a common presenting sign in dogs with brain tumors. Hypothesis/Objectives To investigate the effect of radiotherapy on freedom from brain tumor‐associated seizures and survival time in dogs. Animals Thirty‐two client‐owned dogs with brain tumor‐associated seizures; 18 received medical treatment and radiotherapy, 14 received medical treatment alone. Methods Multicenter retrospective study. Baseline characteristics (seizure semiology, magnetic resonance imaging [MRI] characteristics, and treatment) and duration of seizure freedom were recorded for the 2 treatment groups. Duration of seizure freedom between groups was compared (log‐rank test) using Cox's proportional hazard analysis, with baseline characteristics entered as covariates. Results The duration of seizure freedom and survival time were significantly longer in the radiotherapy group (P < .001), with a mean of 24 months (95% confidence interval [CI], 14.3‐33.8) versus 1.7 months in the control group (95% CI, 0.5‐2.9) and a mean of 34.6 months (95% CI: 25.2‐44.1) versus 6.2 months in the control group (95% CI, 2.6‐9.7) respectively. Baseline characteristics were not associated with duration of seizure freedom after the start of treatment. In the radiotherapy group, 5 dogs were euthanized during the study period because of causes other than seizures. In the control group, recurrence of seizures was observed before death in all dogs. Conclusions and Clinical Importance A longer period of seizure freedom and longer survival time was observed in dogs with brain tumors after radiotherapy compared to medical treatment only. The pathophysiological mechanisms of epileptogenesis and the effect of radiation therapy on seizure control are unclear to date. Further prospective studies are needed.
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Affiliation(s)
| | - John H Rossmeisl
- The Department of Veterinary Sciences, Virginia Maryland College of Veterinary Medicine, Blacksburg, Virginia
| | - Jason Russell
- Department of Pharmacology, Vanderbilt University, Nashville, Tennessee
| | - Mark A Holmes
- The Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | | | - Jo Morris
- The School of Veterinary Medicine, University of Glasgow, Glasgow, UK
| | - Jane M Dobson
- The Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | - An E Vanhaesebrouck
- The Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
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23
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Suzuki H, Mikuni N, Sugita S, Aoyama T, Yokoyama R, Suzuki Y, Enatsu R, Akiyama Y, Mikami T, Wanibuchi M, Hasegawa T. Molecular Aberrations Associated with Seizure Control in Diffuse Astrocytic and Oligodendroglial Tumors. Neurol Med Chir (Tokyo) 2020; 60:147-155. [PMID: 32009124 PMCID: PMC7073702 DOI: 10.2176/nmc.oa.2019-0218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Diffuse astrocytic and oligodendroglial tumors are frequently associated with symptomatic epilepsy, and predictive seizure control is important for the improvement of patient quality of life. To elucidate the factors related to drug resistance of brain tumor-associated epilepsy from a pathological perspective. From January 2012 to October 2017, 36 patients diagnosed with diffuse astrocytic or oligodendroglial tumors were included. Assessment for seizure control was performed according to the Engel classification of seizures. Patient clinical, radiological, and pathological data were stratified based on the following 16 variables: age, sex, location of tumor, existence of the preoperative seizure, extent of resection, administration of temozolomide, radiation therapy, recurrence, Karnofsky performance scale, isocitrate dehydrogenase 1, 1p/19q co-deletion, Olig2, platelet-derived growth factor receptor alpha, p53, ATRX, and Ki67. These factors were compared between the well-controlled group and drug-resistant seizure group. Twenty-seven patients experienced seizures; of these, 14 cases were well-controlled, and 13 cases were drug-resistant. Neither clinical nor radiological characteristics were significantly different between these two groups, though p53 immunodetection levels were significantly higher, and the frequency of 1p/19q co-deletion was significantly lower in the group with drug-resistant seizures than in the well-controlled group. In the multivariate analysis, only one item was selected according to stepwise methods, and a significant difference was observed for p53 (OR, 21.600; 95% CI, 2.135–218.579; P = 0.009). Upregulation of p53 may be a molecular mechanism underlying drug resistant epilepsy associated with diffuse astrocytic and oligodendroglial tumors.
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Affiliation(s)
- Hime Suzuki
- Department of Neurosurgery, Sapporo Medical University
| | | | - Shintaro Sugita
- Department of Surgical Pathology, Sapporo Medical University
| | - Tomoyuki Aoyama
- Department of Surgical Pathology, Sapporo Medical University
| | | | - Yuto Suzuki
- Department of Neurosurgery, Sapporo Medical University
| | - Rei Enatsu
- Department of Neurosurgery, Sapporo Medical University
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Dhawan S, Patil CG, Chen C, Venteicher AS. Early versus delayed postoperative radiotherapy for treatment of low-grade gliomas. Cochrane Database Syst Rev 2020; 1:CD009229. [PMID: 31958162 PMCID: PMC6984627 DOI: 10.1002/14651858.cd009229.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND This is an update of the review originally published in 2011 and first updated in 2015. In most people with low-grade gliomas (LGG), the primary treatment regimen remains a combination of surgery followed by postoperative radiotherapy. However, the optimal timing of radiotherapy is controversial. It is unclear whether to use radiotherapy in the early postoperative period, or whether radiotherapy should be delayed until tumour progression occurs. OBJECTIVES To assess the effects of early postoperative radiotherapy versus radiotherapy delayed until tumour progression for low-grade intracranial gliomas in people who had initial biopsy or surgical resection. SEARCH METHODS Original searches were run up to September 2014. An updated literature search from September 2014 through November 2019 was performed on the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 11), MEDLINE via Ovid (September 2014 to November week 2 2019), and Embase via Ovid (September 2014 to 2019 week 46) to identify trials for inclusion in this Cochrane review update. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared early versus delayed radiotherapy following biopsy or surgical resection for the treatment of people with newly diagnosed intracranial LGG (astrocytoma, oligodendroglioma, mixed oligoastrocytoma, astroblastoma, xanthoastrocytoma, or ganglioglioma). Radiotherapy may include conformal external beam radiotherapy (EBRT) with linear accelerator or cobalt-60 sources, intensity-modulated radiotherapy (IMRT), or stereotactic radiosurgery (SRS). DATA COLLECTION AND ANALYSIS Three review authors independently assessed the trials for inclusion and risk of bias, and extracted study data. We resolved any differences between review authors by discussion. Adverse effects were also extracted from the study report. We performed meta-analyses using a random-effects model with inverse variance weighting. MAIN RESULTS We included one large, multi-institutional, prospective RCT, involving 311 participants; the risk of bias in this study was unclear. This study found that early postoperative radiotherapy was associated with an increase in time to progression compared to observation (and delayed radiotherapy upon disease progression) for people with LGG but did not significantly improve overall survival (OS). The median progression-free survival (PFS) was 5.3 years in the early radiotherapy group and 3.4 years in the delayed radiotherapy group (hazard ratio (HR) 0.59, 95% confidence interval (CI) 0.45 to 0.77; P < 0.0001; 311 participants; 1 trial; low-quality evidence). The median OS in the early radiotherapy group was 7.4 years, while the delayed radiotherapy group experienced a median overall survival of 7.2 years (HR 0.97, 95% CI 0.71 to 1.33; P = 0.872; 311 participants; 1 trial; low-quality evidence). The total dose of radiotherapy given was 54 Gy; five fractions of 1.8 Gy per week were given for six weeks. Adverse effects following radiotherapy consisted of skin reactions, otitis media, mild headache, nausea, and vomiting. Rescue therapy was provided to 65% of the participants randomised to delayed radiotherapy. People in both cohorts who were free from tumour progression showed no differences in cognitive deficit, focal deficit, performance status, and headache after one year. However, participants randomised to the early radiotherapy group experienced significantly fewer seizures than participants in the delayed postoperative radiotherapy group at one year (25% versus 41%, P = 0.0329, respectively). AUTHORS' CONCLUSIONS Given the high risk of bias in the included study, the results of this analysis must be interpreted with caution. Early radiation therapy was associated with the following adverse effects: skin reactions, otitis media, mild headache, nausea, and vomiting. People with LGG who underwent early radiotherapy showed an increase in time to progression compared with people who were observed and had radiotherapy at the time of progression. There was no significant difference in overall survival between people who had early versus delayed radiotherapy; however, this finding may be due to the effectiveness of rescue therapy with radiation in the control arm. People who underwent early radiation had better seizure control at one year than people who underwent delayed radiation. There were no cases of radiation-induced malignant transformation of LGG. However, it remained unclear whether there were differences in memory, executive function, cognitive function, or quality of life between the two groups since these measures were not evaluated.
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Affiliation(s)
- Sanjay Dhawan
- University of MinnesotaDepartment of Neurosurgery420 Delaware St. SE, D429 MayoMinneapolisMinnesotaUSA55455
| | - Chirag G Patil
- Maxine Dunitz Neurosurgical InstituteDepartment of NeurosurgeryCedars‐Sinai Medical Center8631 West Third Street, Suite 800ELos AngelesCAUSA90048
| | - Clark Chen
- University of MinnesotaDepartment of Neurosurgery420 Delaware St. SE, D429 MayoMinneapolisMinnesotaUSA55455
| | - Andrew S Venteicher
- University of MinnesotaDepartment of Neurosurgery420 Delaware St. SE, D429 MayoMinneapolisMinnesotaUSA55455
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25
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Efficacy of initial temozolomide for high-risk low grade gliomas in a phase II AINO (Italian Association for Neuro-Oncology) study: a post-hoc analysis within molecular subgroups of WHO 2016. J Neurooncol 2019; 145:115-123. [PMID: 31556015 DOI: 10.1007/s11060-019-03277-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 08/29/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION The optimal management of high risk WHO grade II gliomas after surgery is debated including the role of initial temozolomide to delay radiotherapy and risk of cognitive defects. METHODS A post-hoc analysis of a phase II multicenter study on high risk WHO grade II gliomas, receiving initial temozolomide alone, has re-evaluated the long-term results within the molecular subgroups of WHO 2016. The primary endpoint of the study was response according to RANO, being seizure response, PFS and OS secondary endpoints. RESULTS Response rate among oligodendrogliomas IDH-mutant and 1p/19q codeleted (76%) was significantly higher than that among diffuse astrocytomas either mutant (55%) or wild-type (36%). A reduction of seizure frequency > 50% was observed in 87% of patients and a seizure freedom in 72%. The probability of seizure reduction > 50% was significantly associated with the presence of an IDH mutation. Median PFS, PFS at 5 and 10 years, median OS and OS at 5 and 10 years were significantly longer in oligodendrogliomas IDH-mutant and 1p/19q codeleted. Sixty-seven percent of patients with oligodendroglioma IDH mutant and 1p/19q codeleted did not recur with a median follow up of 9.3 years, while 59% did not receive radiotherapy at recurrence with a median follow up of 8.2 years. CONCLUSIONS The beneficial effects of initial temozolomide prevail in oligodendrogliomas IDH-mutant and 1p/19q codeleted: thus, these tumors, when incompletely resected or progressive after surgery alone, or with intractable seizures, should receive temozolomide as initial treatment with salvage radiotherapy and/o reoperation and/or second-line chemotherapy at recurrence.
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26
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Samudra N, Zacharias T, Plitt A, Lega B, Pan E. Seizures in glioma patients: An overview of incidence, etiology, and therapies. J Neurol Sci 2019; 404:80-85. [PMID: 31352293 DOI: 10.1016/j.jns.2019.07.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 06/24/2019] [Accepted: 07/18/2019] [Indexed: 12/19/2022]
Abstract
Gliomas are fatal brain tumors, and even low-grade gliomas (LGGs) have an average survival of less than a decade. Seizures are a common presentation of gliomas, particularly LGGs, and substantially impact quality of life. Glioma-related seizures differ from other focal epilepsies in their pathogenesis and in the likelihood of refractory epilepsy. We review factors that predict seizure activity and response to treatment, optimal pharmacologic and surgical management of glioma-related epilepsy, and the benefit of using newer anti-seizure medications in patients with gliomas. As surgery is so often beneficial with seizure reduction, we discuss oncologic and epilepsy surgery perspectives. Treatment of gliomas has the potential to ameliorate seizures and increase rates of seizure freedom. Prospective, well-powered studies are needed to provide more definitive answers for practitioners taking care of glioma patients with seizures.
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Affiliation(s)
- Niyatee Samudra
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Tresa Zacharias
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Aaron Plitt
- Department of Neurosurgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Bradley Lega
- Department of Neurosurgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Edward Pan
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
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27
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Liang S, Fan X, Zhao M, Shan X, Li W, Ding P, You G, Hong Z, Yang X, Luan G, Ma W, Yang H, You Y, Yang T, Li L, Liao W, Wang L, Wu X, Yu X, Zhang J, Mao Q, Wang Y, Li W, Wang X, Jiang C, Liu X, Qi S, Liu X, Qu Y, Xu J, Wang W, Song Z, Wu J, Liu Z, Chen L, Lin Y, Zhou J, Liu X, Zhang W, Li S, Jiang T. Clinical practice guidelines for the diagnosis and treatment of adult diffuse glioma-related epilepsy. Cancer Med 2019; 8:4527-4535. [PMID: 31240876 PMCID: PMC6712518 DOI: 10.1002/cam4.2362] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 05/05/2019] [Accepted: 05/25/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Glioma-related epilepsy (GRE) is defined as symptomatic epileptic seizures secondary to gliomas, it brings both heavy financial and psychosocial burdens to patients with diffuse glioma and significantly decreases their quality of life. To date, there have been no clinical guidelines that provide recommendations for the optimal diagnostic and therapeutic procedures for GRE patients. METHODS In March 2017, the Joint Task Force for GRE of China Association Against Epilepsy and Society for Neuro-Oncology of China launched the guideline committee for the diagnosis and treatment of GRE. The guideline committee conducted a comprehensive review of relevant domestic and international literatures that were evaluated and graded based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence, and then held three consensus meetings to discuss relevant recommendations. The recommendations were eventually given according to those relevant literatures, together with the experiences in the diagnosis and treatment of over 3000 GRE cases from 24 tertiary level hospitals that specialize in clinical research of epilepsy, glioma, and GRE in China. RESULTS The manuscript presented the current standard recommendations for the diagnostic and therapeutic procedures of GRE. CONCLUSIONS The current work will provide a framework and assurance for the diagnosis and treatment strategy of GRE to reduce complications and costs caused by unnecessary treatment. Additionally, it can serve as a reference for all professionals involved in the management of patients with GRE.
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Affiliation(s)
- Shuli Liang
- Department of Neurosurgery, Chinese PLA General Hospital and PLA Medical College, Beijing, China.,Department of Functional Neurosurgery, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xing Fan
- Department of Neuroelectrophysiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Zhao
- Department of Neurosurgery, First Affiliated Hospital of PLA General Hospital, Beijing, China
| | - Xia Shan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Molecular Neuropathology, Beijing Neurosurgery Institute, Capital Medical University, Beijing, China
| | - Wenling Li
- Department of Neurosurgery, Second Affiliated Hospital, Hebei Medical University, Shijiazhuang, China
| | - Ping Ding
- Department of Neurosurgery, Chinese PLA General Hospital and PLA Medical College, Beijing, China
| | - Gan You
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhen Hong
- Department of Neurology, Shanghai Huashan Hospital, Fudan University, Shaihai, China
| | - Xuejun Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Guoming Luan
- Department of Neurosurgery, Beijing Sanbo Hospital, Capital Medical University, Beijing, China
| | - Wenbin Ma
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Yang
- Department of Neurosurgery, Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Yongpin You
- Department of Neurosurgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Tianming Yang
- Department of Neurosurgery, Zhongda Hospital, Southeast University, Nanjing, China
| | - Liang Li
- Department of Neurosurgery, First Affiliated Hospital, Beijing University, Beijing, China
| | - Weiping Liao
- Department of Neurology, Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Lei Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xun Wu
- Department of Neurology, First Affiliated Hospital, Beijing University, Beijing, China
| | - Xinguang Yu
- Department of Neurosurgery, Chinese PLA General Hospital and PLA Medical College, Beijing, China
| | - Jianguo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qing Mao
- Department of Neurosurgery, Huaxi Hospital, Sichuan University, Chengdu, China
| | - Yuping Wang
- Department of Neurology, Beijing Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenbin Li
- Department of Neurosurgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Xuefeng Wang
- Department of Neurology, First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Chuanlu Jiang
- Department of Neurosurgery, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xiaoyan Liu
- Pediatric Department, First Affiliated Hospital, Beijing University, Beijing, China
| | - Songtao Qi
- Department of Neurosurgery, Nanfang Hospital, Nanfang Medical University, Guangzhou, China
| | - Xingzhou Liu
- Epilepsy Center, Shanghai Deji Hospital, Shanghai, China
| | - Yan Qu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Jiwen Xu
- Department of Functional Neurosurgery, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Weimin Wang
- Department of Neurosurgery, Guangzhou Military General Hospital, Guangzhou, China
| | - Zhi Song
- Department of Neurology, Xiangya Third Hospital, Center South University, Changsha, China
| | - Jinsong Wu
- Department of Neurosurgery, Shanghai Huashan Hospital, Fudan University, Shanghai, China
| | - Zhixiong Liu
- Department of Neurosurgery, Xiangya Hospital, Center South University, Changsha, China
| | - Ling Chen
- Department of Neurosurgery, Chinese PLA General Hospital and PLA Medical College, Beijing, China
| | - Yuanxiang Lin
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jian Zhou
- Department of Neurosurgery, Beijing Sanbo Hospital, Capital Medical University, Beijing, China
| | - Xianzeng Liu
- Department of Neurology, Peking University International Hospital, Beijing, China
| | - Wei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Molecular Neuropathology, Beijing Neurosurgery Institute, Capital Medical University, Beijing, China
| | - Shichuo Li
- China Association Against Epilepsy (CAAE), Beijing, China
| | - Tao Jiang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Molecular Neuropathology, Beijing Neurosurgery Institute, Capital Medical University, Beijing, China
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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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29
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Haggiagi A, Avila EK. Seizure response to temozolomide chemotherapy in patients with WHO grade II oligodendroglioma: a single-institution descriptive study. Neurooncol Pract 2019; 6:203-208. [PMID: 31073410 DOI: 10.1093/nop/npy029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 06/25/2018] [Accepted: 07/17/2018] [Indexed: 11/12/2022] Open
Abstract
Background Tumor-related epilepsy (TRE) is common in patients with low-grade oligodendrogliomas. TRE is difficult to control despite multiple antiepileptic drugs (AEDs) in up to 30% of patients. Chemotherapy has been used for treatment to avoid potential radiotherapy-related neurotoxicity. This study evaluates the effect of temozolomide on seizure frequency in a homogeneous group with World Health Organization (WHO) grade II oligodendrogliomas. Methods A retrospective analysis was conducted of adult patients with WHO grade II oligodendrogliomas and TRE followed at Memorial Sloan Kettering between 2005 and 2015 who were treated with temozolomide alone either as initial treatment or for disease progression. All had seizures 3 months prior to starting temozolomide. Seizure frequency was reviewed every 2 cycles and at the end of temozolomide treatment. Seizure reduction of ≥50% compared to baseline was defined as improvement. Results Thirty-nine individuals met inclusion criteria. Median follow-up since starting temozolomide was 6 years (0.8-13 years). Reduction in seizure frequency occurred in 35 patients (89.7%). Improvement was independent of AED regimen adjustments or prior antitumor treatment in 16 (41%); of these, AED dosage was successfully reduced or completely eliminated in 10 (25.6%). Twenty-five patients (64.1%) remained on a stable AED regimen. The majority (n = 32, 82%) had radiographically stable disease, 5 (12.8%) had objective radiographic response, and 2 (5.2%) had disease progression. Conclusions Temozolomide may result in reduced seizure frequency, and permit discontinuation of AEDs in patients with WHO II oligodendroglioma. Improvement was observed irrespective of objective tumor response on MRI, emphasizing the importance of incorporating seizure control in assessing response to tumor-directed therapy.
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Affiliation(s)
- Aya Haggiagi
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Edward K Avila
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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30
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Kerkhof M, Koekkoek JAF, Vos MJ, van den Bent MJ, Taal W, Postma TJ, Bromberg JEC, Kouwenhoven MCM, Dirven L, Reijneveld JC, Taphoorn MJB. Withdrawal of antiepileptic drugs in patients with low grade and anaplastic glioma after long-term seizure freedom: a prospective observational study. J Neurooncol 2019; 142:463-470. [PMID: 30778733 PMCID: PMC6478626 DOI: 10.1007/s11060-019-03117-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 01/31/2019] [Indexed: 12/16/2022]
Abstract
Background When glioma patients experience long-term seizure freedom the question arises whether antiepileptic drugs (AEDs) should be continued. As no prospective studies exist on seizure recurrence in glioma patients after AED withdrawal, we evaluated the decision-making process to withdraw AEDs in glioma patients, and seizure outcome after withdrawal. Methods Patients with a histologically confirmed low grade or anaplastic glioma were included. Eligible patients were seizure free ≥ 1 year from the date of last antitumor treatment, or ≥ 2 years since the last seizure when seizures occurred after the end of the last antitumor treatment. Patients and neuro-oncologists made a shared decision on the preferred AED treatment (i.e. AED withdrawal or continuation). Primary outcomes were: (1) outcome of the shared decision-making process and (2) rate of seizure recurrence. Results Eighty-three patients fulfilled all eligibility criteria. However, in 12/83 (14%) patients, the neuro-oncologist had serious objections to AED withdrawal. Therefore, 71/83 (86%) patients were analyzed; In 46/71 (65%) patients it was decided to withdraw AED treatment. In the withdrawal group, 26% (12/46) had seizure recurrence during follow-up. Seven of these 12 patients (58%) had tumor progression, of which three within 3 months after seizure recurrence. In the AED continuation group, 8% (2/25) of patients had seizure recurrence of which one had tumor progression. Conclusion In 65% of patients a shared decision was made to withdraw AEDs, of which 26% had seizure recurrence. AED withdrawal should only be considered in carefully selected patients with a presumed low risk of tumor progression.
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Affiliation(s)
- M Kerkhof
- Department of Neurology, Haaglanden Medical Center, PO Box 2191, 2501 VC, The Hague, The Netherlands.
| | - J A F Koekkoek
- Department of Neurology, Haaglanden Medical Center, PO Box 2191, 2501 VC, The Hague, The Netherlands.,Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - M J Vos
- Department of Neurology, Haaglanden Medical Center, PO Box 2191, 2501 VC, The Hague, The Netherlands
| | - M J van den Bent
- Brain Tumor Center at Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - W Taal
- Brain Tumor Center at Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - T J Postma
- Brain Tumor Center Amsterdam at VU University Medical Center, Amsterdam, The Netherlands
| | - J E C Bromberg
- Brain Tumor Center at Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - M C M Kouwenhoven
- Brain Tumor Center Amsterdam at VU University Medical Center, Amsterdam, The Netherlands
| | - L Dirven
- Department of Neurology, Haaglanden Medical Center, PO Box 2191, 2501 VC, The Hague, The Netherlands.,Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - J C Reijneveld
- Brain Tumor Center Amsterdam at VU University Medical Center, Amsterdam, The Netherlands
| | - M J B Taphoorn
- Department of Neurology, Haaglanden Medical Center, PO Box 2191, 2501 VC, The Hague, The Netherlands.,Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
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Abstract
The World Health Organization classifies diffuse low-grade gliomas (DLGGs) are highly epileptogenic primary brain tumors; epileptic seizures occur in more than 90% of cases. Epileptic seizures and drug resistance progress during the course of DLGGs. The glioma-related epileptogenic mechanisms are multifactorial; epileptogenic foci lie within the infiltrated peritumoral neocortex. A short seizure duration before surgery and a large extent of resection are the main predictors of postoperative seizure control in DLGGs. A supratotal resection of a DLGG can improve postoperative seizure control. Epileptic seizure at diagnosis positively affects DLGGs malignant transformation and overall survival.
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Affiliation(s)
- Johan Pallud
- Department of Neurosurgery, Sainte-Anne Hospital, 1 rue Cabanis, Paris Cedex 14 75674, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France; French Glioma Study Group, Réseau d'Etude des Gliomes, REG, Groland, France; Inserm, U894, Centre Psychiatrie et Neurosciences, Paris, France.
| | - Guy M McKhann
- Department of Neurological Surgery, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
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Abstract
Patients with brain tumor encounter a wide spectrum of tumor and treatment-related complications during their disease course. Tumors may serve as seizure substrates, are associated with a hypercoagulable state that results in thromboembolic complications, and may influence mood and cognition. Antitumor and supportive therapies may also have deleterious effects. Herein, we discuss major aspects of supportive care for patients with brain tumors, with attention to benefit and complications derived from the management of seizures, brain edema, venous thromboembolism, fatigue, mood alterations, and cognitive dysfunction.
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Affiliation(s)
- Kester A Phillips
- Department of Neuroscience, Inova Health System, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Camilo E Fadul
- Division of Neuro-Oncology, University of Virginia Health System, 1300 Jefferson Park Avenue, West Complex, Room 6228, Charlottesville, VA 22903-0156, USA
| | - David Schiff
- Division of Neuro-Oncology, University of Virginia Health System, 1300 Jefferson Park Avenue, West Complex, Room 6225, Charlottesville, VA 22903-0156, USA.
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Berntsson SG, Merrell RT, Amirian ES, Armstrong GN, Lachance D, Smits A, Zhou R, Jacobs DI, Wrensch MR, Olson SH, Il'yasova D, Claus EB, Barnholtz-Sloan JS, Schildkraut J, Sadetzki S, Johansen C, Houlston RS, Jenkins RB, Bernstein JL, Lai R, Shete S, Amos CI, Bondy ML, Melin BS. Glioma-related seizures in relation to histopathological subtypes: a report from the glioma international case-control study. J Neurol 2018; 265:1432-1442. [PMID: 29687214 PMCID: PMC5990563 DOI: 10.1007/s00415-018-8857-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/31/2018] [Accepted: 04/02/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the distribution of glioma-related seizures and seizure control at the time of tumor diagnosis with respect to tumor histologic subtypes, tumor treatment and patient characteristics, and to compare seizure history preceding tumor diagnosis (or study enrollment) between glioma patients and healthy controls. METHODS The Glioma International Case Control study (GICC) risk factor questionnaire collected information on demographics, past medical/medication history, and occupational history. Cases from eight centers were also asked detailed questions on seizures in relation to glioma diagnosis; cases (n = 4533) and controls (n = 4171) were also asked about seizures less than 2 years from diagnosis and previous seizure history more than 2 years prior to tumor diagnosis, including childhood seizures. RESULTS Low-grade gliomas (LGGs), particularly oligodendrogliomas/oligoastrocytomas, had the highest proportion of glioma-related seizures. Patients with low-grade astrocytoma demonstrated the most medically refractory seizures. A total of 83% of patients were using only one antiepileptic drug (AED), which was levetiracetam in 71% of cases. Gross total resection was strongly associated with reduced seizure frequency (p < 0.009). No significant difference was found between glioma cases and controls in terms of seizure occurring more than 2 years before diagnosis or during childhood. CONCLUSIONS Our study showed that glioma-related seizures were most common in low-grade gliomas. Gross total resection was associated with lower seizure frequency. Additionally, having a history of childhood seizures is not a risk factor ***for developing glioma-related seizures or glioma.
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Affiliation(s)
- Shala G Berntsson
- Department of Neuroscience, Neurology, Uppsala University, 751 85, Uppsala, Sweden.
| | - Ryan T Merrell
- Department of Neurology, NorthShore University HealthSystem, Evanston, IL, USA
| | - E Susan Amirian
- Division of Medicine, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Georgina N Armstrong
- Division of Medicine, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Daniel Lachance
- Department of Neurology, Mayo Clinic Comprehensive Cancer Center, Mayo Clinic, Rochester, MN, USA
| | - Anja Smits
- Department of Neuroscience, Neurology, Uppsala University, 751 85, Uppsala, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Renke Zhou
- Division of Medicine, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA.,Department of Neurology, Mayo Clinic Comprehensive Cancer Center, Mayo Clinic, Rochester, MN, USA
| | - Daniel I Jacobs
- Division of Medicine, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Margaret R Wrensch
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Sara H Olson
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Dora Il'yasova
- Department of Epidemiology and Biostatistics, Georgia State University School of Public Health, Atlanta, Georgia
| | - Elizabeth B Claus
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT, USA
| | - Jill S Barnholtz-Sloan
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Joellen Schildkraut
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Siegal Sadetzki
- Cancer and Radiation Epidemiology Unit, Gertner Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Christoffer Johansen
- Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, Denmark.,Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Richard S Houlston
- Section of Cancer Genetics, Institute of Cancer Research, Sutton, London, Surrey, UK.,Department of Laboratory Medicine and Pathology, Mayo Clinic Comprehensive Cancer Center, Mayo Clinic, Rochester, MN, USA
| | - Robert B Jenkins
- Department of Laboratory Medicine and Pathology, Mayo Clinic Comprehensive Cancer Center, Mayo Clinic, Rochester, MN, USA
| | - Jonine L Bernstein
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Rose Lai
- Departments of Neurology, Neurosurgery, and Preventive Medicine, The University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Sanjay Shete
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher I Amos
- Division of Medicine, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Melissa L Bondy
- Division of Medicine, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Beatrice S Melin
- Department of Radiation Sciences Oncology, Umeå University, Umeå, Sweden
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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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Chassoux F, Landre E. Prevention and management of postoperative seizures in neuro-oncology. Neurochirurgie 2017; 63:197-203. [PMID: 28599984 DOI: 10.1016/j.neuchi.2016.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 10/02/2016] [Accepted: 10/14/2016] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Epilepsy related to brain tumors is often difficult to treat and may impact the quality of life. We performed a review of current recommendations for the prevention of postoperative seizures and optimizing the anti-epileptic treatment. MATERIAL AND METHODS Based on studies performed since 2000 we conducted the review by (1) analyzing the incidence of tumoral epilepsy and mechanisms of epileptogenicity; (2) describing the current medical and surgical strategy according to oncologic treatments; (3) discussing the management of postoperative seizures; (4) considering the drug withdrawal after oncologic therapy. RESULTS Epilepsy related to supra-tentorial brain tumors is frequent (40-60%) especially in low-grade gliomas, glioneuronal tumors, fronto-temporal and eloquent cortex locations. Seizures can occur as a presenting symptom or during the course of the tumor, including after surgery and oncological treatments. Maximal safe surgical resection is the more effective therapy, alone or combined with adjuvant therapy (chemotherapy, radiotherapy). Anti-epileptic drugs are not indicated for epilepsy prophylaxis in patients without seizures but only after the first seizure due to high risk of recurrence. As they may generate adverse effects and interfere with oncological treatments, the choice is based on efficacy, tolerability and potential interactions. New anti-epileptic non-enzyme-inducing drugs are recommended in first-line monotherapy in association with adjuvant oncological therapies. Enzyme-inhibiting drugs could have a favorable effect on survival. Late seizures are often related to tumor progression or recurrence. Discontinuation of anti-epileptic drugs could be considered after successful oncological treatment and a stable medical condition. CONCLUSION These guidelines are helpful for a rational therapy in tumoral epilepsy.
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Affiliation(s)
- F Chassoux
- Department of Neurosurgery, Sainte-Anne Hospital, 1, rue Cabanis, 75014 Paris, France; Paris-Descartes University, 75005 Paris, France.
| | - E Landre
- Department of Neurosurgery, Sainte-Anne Hospital, 1, rue Cabanis, 75014 Paris, France; Paris-Descartes University, 75005 Paris, France
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Vecht C, Duran-Peña A, Houillier C, Durand T, Capelle L, Huberfeld G. Seizure response to perampanel in drug-resistant epilepsy with gliomas: early observations. J Neurooncol 2017; 133:603-607. [PMID: 28492978 DOI: 10.1007/s11060-017-2473-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 05/07/2017] [Indexed: 11/27/2022]
Abstract
Drug-resistant epilepsy (DRE) occurs commonly in gliomas, possibly due to a shared mechanism of AMPA-activation involving both seizure activity and tumor growth. We tested the AMPA-receptor blocker perampanel (PER) in patients with DRE in low- and high-grade gliomas. Seizure response was defined as 50% drop in seizure frequency or as seizure-freedom. Cognitive function was examined by computerized test on cognitive speed (CTCS), which is sensitive to the type of cognitive dysfunction associated with epilepsy and use of anticonvulsants. Treatment policy included reduction of dose or discontinuation of one or more concurrent AEDs, once a seizure-free response was observed. Twelve patients were included patients, median age 41 years, 9 men versus 3 women and 6 months median duration of follow-up. An objective seizure response (75%) was observed in 9 (75%) out of 12 patients: 50%-seizure response in 3, seizure-freedom in 6, which is plainly more than seen with other types of DRE. Side-effects occurred in six patients. Cognitive function as examined by CTCS improved in six out of eight associated withlowering of concurrent AEDs. The final median dose of PER was 8 mg (varying between 2 and 12 mg). These results of an objective seizure response in 9 (75%) out of 12 patients treated by PER in DRE may be interpreted as a surrogate-marker of tumor response secondary to AMPA blockade, advancing confirmation by MR imaging. These results warrant further study of PER on tumor activity in gliomas.
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Affiliation(s)
- Charles Vecht
- Department of Neurology Mazarin, Université Pierre et Marie Curie, INSERM U1129, 75015, Paris, France. .,Service Neurologie Mazarin, CHU Pitié-Salpêtrière, Paris, 47 Bld. de l´Hopital, 75651, PARIS CEDEX 13, France.
| | - Alberto Duran-Peña
- Department of Neurology Mazarin, Université Pierre et Marie Curie, INSERM U1129, 75015, Paris, France
| | - Caroline Houillier
- Department of Neurology Mazarin, Université Pierre et Marie Curie, INSERM U1129, 75015, Paris, France
| | - Thomas Durand
- Department of Neurology Mazarin, Université Pierre et Marie Curie, INSERM U1129, 75015, Paris, France
| | - Laurent Capelle
- Neurosurgery Babinski, Université Pierre et Marie Curie, INSERM U1129, 75015, Paris, France
| | - Gilles Huberfeld
- Pitié-Salpêtrière Hospital, and Laboratory of Neurophysiology, Université Pierre et Marie Curie, INSERM U1129, 75015, Paris, France
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38
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Neal A, Morokoff A, O'Brien TJ, Kwan P. Postoperative seizure control in patients with tumor-associated epilepsy. Epilepsia 2016; 57:1779-1788. [PMID: 27666131 DOI: 10.1111/epi.13562] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2016] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The patterns of postoperative seizure control and response to antiepileptic drugs (AEDs) in tumor-associated epilepsy (TAE) are poorly understood. We aim to document these characteristics in patients with supratentorial gliomas. METHODS This was a retrospective analysis of 186 patients with supratentorial gliomas. Seizure patterns were classified into four groups: A, no postoperative seizure; B, early postoperative seizure control within 6 months; C, fluctuating seizure control; and D, never seizure-free. Rates and duration of seizure freedom, subsequent seizure relapse, and response to AED were analyzed. RESULTS Among patients included, 49 (26.3%) had grade II, 28 (15.1%) had grade III, and 109 (58.6%) had grade IV glioma. Outcome pattern A was observed in 95 (51.1%), B in 22 (11.8%), C in 45 (24.2%), and D in 24 (12.9%). One hundred nineteen patients had at least one seizure and were classified as having TAE. Compared to pattern A, pattern B was predicted by histologic progression; pattern C by tumor grade, preoperative seizure, and histologic progression, and pattern D by preoperative seizure and gross total resection. Among patients with TAE, 57.5% of grade II, 68.2% of grade III, and 26.3% of grade IV experienced a period of 12-month seizure freedom. After first 12-month seizure remission, 39.1%, 60.0%, and 13.3% of grade II, III, and IV gliomas, respectively, experienced subsequent seizure; 22.6% of those with TAE reached terminal seizure freedom of at least 12 months on their first postoperative AED regimen, 6.5% on their second regimen, and 5.4% on subsequent regimens. SIGNIFICANCE Distinct patterns of postoperative seizure control exist in gliomas; they have specific risk factor profiles, and we hypothesize these correspond to unique pathogenic mechanisms. Twelve-month seizure freedom with subsequent relapse is frequent in grade II-III gliomas. Response to AEDs is markedly poorer than with non-TAE, highlighting the complex epileptogenicity of gliomas.
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Affiliation(s)
- Andrew Neal
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Andrew Morokoff
- Department of Surgery, The University of Melbourne, Parkville, Victoria, Australia.,Department of Neurosurgery, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Terence John O'Brien
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Patrick Kwan
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
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Avila EK, Chamberlain M, Schiff D, Reijneveld JC, Armstrong TS, Ruda R, Wen PY, Weller M, Koekkoek JAF, Mittal S, Arakawa Y, Choucair A, Gonzalez-Martinez J, MacDonald DR, Nishikawa R, Shah A, Vecht CJ, Warren P, van den Bent MJ, DeAngelis LM. Seizure control as a new metric in assessing efficacy of tumor treatment in low-grade glioma trials. Neuro Oncol 2016; 19:12-21. [PMID: 27651472 DOI: 10.1093/neuonc/now190] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Patients with low-grade glioma frequently have brain tumor-related epilepsy, which is more common than in patients with high-grade glioma. Treatment for tumor-associated epilepsy usually comprises a combination of surgery, anti-epileptic drugs (AEDs), chemotherapy, and radiotherapy. Response to tumor-directed treatment is measured primarily by overall survival and progression-free survival. However, seizure frequency has been observed to respond to tumor-directed treatment with chemotherapy or radiotherapy. A review of the current literature regarding seizure assessment for low-grade glioma patients reveals a heterogeneous manner in which seizure response has been reported. There is a need for a systematic approach to seizure assessment and its influence on health-related quality-of-life outcomes in patients enrolled in low-grade glioma therapeutic trials. In view of the need to have an adjunctive metric of tumor response in these patients, a method of seizure assessment as a metric in brain tumor treatment trials is proposed.
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Affiliation(s)
- Edward K Avila
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.K.A., L.M.D.); Department of Neurology, University of Washington, Seattle, Washington (M.C.); Department of Neurology, University of Virginia, Charlottesville, Virginia (D.S.); Department of Neurology, VUmc Cancer Center, Amsterdam, Netherlands (J.C.R.); Department of Family Health, University of Texas Health Science Center, Houston, Texas (T.S.A.); Department of Neuro-Oncology, City of Health and Science Hospital, Torino, Italy (R.R.); Center for Neuro-Oncology, Dana-Farber Cancer Institute/ Brigham and Women's Center, Boston, Massachusetts (P.W.); Department of Neurology, University Hospital Zurich, Zurich, Switzerland (M.W.); Department of Neurology, Leiden University Medical Center, The Hague, Netherlands (J.A.F.K.); Department of Neurosurgery, Wayne State University, Detroit, Michigan (S.M.); Department of Neurosurgery, Kyoto University School of Graduate Medicine, Kyoto, Japan (Y.A.); Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois (A.C.); Department of Epilepsy and Surgery Center, Cleveland Clinic, Cleveland, Ohio (J.G.-M.); Department of Neurology, London Health Sciences Center, London, Ontario, Canada (D.R.M.); Department of Neurosurgery, Saitama Medical University, Saitama, Japan (R.N.); Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan (A.S.); Service Neurologie Mazarin, CHU Pitie-Salpetriere, Paris, France (C.J.V.); Department of Neurology, University of Alabama, Birmingham, Alabama (P.W.); Department of Neuro-Oncology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.)
| | - Marc Chamberlain
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.K.A., L.M.D.); Department of Neurology, University of Washington, Seattle, Washington (M.C.); Department of Neurology, University of Virginia, Charlottesville, Virginia (D.S.); Department of Neurology, VUmc Cancer Center, Amsterdam, Netherlands (J.C.R.); Department of Family Health, University of Texas Health Science Center, Houston, Texas (T.S.A.); Department of Neuro-Oncology, City of Health and Science Hospital, Torino, Italy (R.R.); Center for Neuro-Oncology, Dana-Farber Cancer Institute/ Brigham and Women's Center, Boston, Massachusetts (P.W.); Department of Neurology, University Hospital Zurich, Zurich, Switzerland (M.W.); Department of Neurology, Leiden University Medical Center, The Hague, Netherlands (J.A.F.K.); Department of Neurosurgery, Wayne State University, Detroit, Michigan (S.M.); Department of Neurosurgery, Kyoto University School of Graduate Medicine, Kyoto, Japan (Y.A.); Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois (A.C.); Department of Epilepsy and Surgery Center, Cleveland Clinic, Cleveland, Ohio (J.G.-M.); Department of Neurology, London Health Sciences Center, London, Ontario, Canada (D.R.M.); Department of Neurosurgery, Saitama Medical University, Saitama, Japan (R.N.); Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan (A.S.); Service Neurologie Mazarin, CHU Pitie-Salpetriere, Paris, France (C.J.V.); Department of Neurology, University of Alabama, Birmingham, Alabama (P.W.); Department of Neuro-Oncology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.)
| | - David Schiff
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.K.A., L.M.D.); Department of Neurology, University of Washington, Seattle, Washington (M.C.); Department of Neurology, University of Virginia, Charlottesville, Virginia (D.S.); Department of Neurology, VUmc Cancer Center, Amsterdam, Netherlands (J.C.R.); Department of Family Health, University of Texas Health Science Center, Houston, Texas (T.S.A.); Department of Neuro-Oncology, City of Health and Science Hospital, Torino, Italy (R.R.); Center for Neuro-Oncology, Dana-Farber Cancer Institute/ Brigham and Women's Center, Boston, Massachusetts (P.W.); Department of Neurology, University Hospital Zurich, Zurich, Switzerland (M.W.); Department of Neurology, Leiden University Medical Center, The Hague, Netherlands (J.A.F.K.); Department of Neurosurgery, Wayne State University, Detroit, Michigan (S.M.); Department of Neurosurgery, Kyoto University School of Graduate Medicine, Kyoto, Japan (Y.A.); Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois (A.C.); Department of Epilepsy and Surgery Center, Cleveland Clinic, Cleveland, Ohio (J.G.-M.); Department of Neurology, London Health Sciences Center, London, Ontario, Canada (D.R.M.); Department of Neurosurgery, Saitama Medical University, Saitama, Japan (R.N.); Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan (A.S.); Service Neurologie Mazarin, CHU Pitie-Salpetriere, Paris, France (C.J.V.); Department of Neurology, University of Alabama, Birmingham, Alabama (P.W.); Department of Neuro-Oncology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.)
| | - Jaap C Reijneveld
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.K.A., L.M.D.); Department of Neurology, University of Washington, Seattle, Washington (M.C.); Department of Neurology, University of Virginia, Charlottesville, Virginia (D.S.); Department of Neurology, VUmc Cancer Center, Amsterdam, Netherlands (J.C.R.); Department of Family Health, University of Texas Health Science Center, Houston, Texas (T.S.A.); Department of Neuro-Oncology, City of Health and Science Hospital, Torino, Italy (R.R.); Center for Neuro-Oncology, Dana-Farber Cancer Institute/ Brigham and Women's Center, Boston, Massachusetts (P.W.); Department of Neurology, University Hospital Zurich, Zurich, Switzerland (M.W.); Department of Neurology, Leiden University Medical Center, The Hague, Netherlands (J.A.F.K.); Department of Neurosurgery, Wayne State University, Detroit, Michigan (S.M.); Department of Neurosurgery, Kyoto University School of Graduate Medicine, Kyoto, Japan (Y.A.); Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois (A.C.); Department of Epilepsy and Surgery Center, Cleveland Clinic, Cleveland, Ohio (J.G.-M.); Department of Neurology, London Health Sciences Center, London, Ontario, Canada (D.R.M.); Department of Neurosurgery, Saitama Medical University, Saitama, Japan (R.N.); Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan (A.S.); Service Neurologie Mazarin, CHU Pitie-Salpetriere, Paris, France (C.J.V.); Department of Neurology, University of Alabama, Birmingham, Alabama (P.W.); Department of Neuro-Oncology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.)
| | - Terri S Armstrong
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.K.A., L.M.D.); Department of Neurology, University of Washington, Seattle, Washington (M.C.); Department of Neurology, University of Virginia, Charlottesville, Virginia (D.S.); Department of Neurology, VUmc Cancer Center, Amsterdam, Netherlands (J.C.R.); Department of Family Health, University of Texas Health Science Center, Houston, Texas (T.S.A.); Department of Neuro-Oncology, City of Health and Science Hospital, Torino, Italy (R.R.); Center for Neuro-Oncology, Dana-Farber Cancer Institute/ Brigham and Women's Center, Boston, Massachusetts (P.W.); Department of Neurology, University Hospital Zurich, Zurich, Switzerland (M.W.); Department of Neurology, Leiden University Medical Center, The Hague, Netherlands (J.A.F.K.); Department of Neurosurgery, Wayne State University, Detroit, Michigan (S.M.); Department of Neurosurgery, Kyoto University School of Graduate Medicine, Kyoto, Japan (Y.A.); Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois (A.C.); Department of Epilepsy and Surgery Center, Cleveland Clinic, Cleveland, Ohio (J.G.-M.); Department of Neurology, London Health Sciences Center, London, Ontario, Canada (D.R.M.); Department of Neurosurgery, Saitama Medical University, Saitama, Japan (R.N.); Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan (A.S.); Service Neurologie Mazarin, CHU Pitie-Salpetriere, Paris, France (C.J.V.); Department of Neurology, University of Alabama, Birmingham, Alabama (P.W.); Department of Neuro-Oncology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.)
| | - Roberta Ruda
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.K.A., L.M.D.); Department of Neurology, University of Washington, Seattle, Washington (M.C.); Department of Neurology, University of Virginia, Charlottesville, Virginia (D.S.); Department of Neurology, VUmc Cancer Center, Amsterdam, Netherlands (J.C.R.); Department of Family Health, University of Texas Health Science Center, Houston, Texas (T.S.A.); Department of Neuro-Oncology, City of Health and Science Hospital, Torino, Italy (R.R.); Center for Neuro-Oncology, Dana-Farber Cancer Institute/ Brigham and Women's Center, Boston, Massachusetts (P.W.); Department of Neurology, University Hospital Zurich, Zurich, Switzerland (M.W.); Department of Neurology, Leiden University Medical Center, The Hague, Netherlands (J.A.F.K.); Department of Neurosurgery, Wayne State University, Detroit, Michigan (S.M.); Department of Neurosurgery, Kyoto University School of Graduate Medicine, Kyoto, Japan (Y.A.); Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois (A.C.); Department of Epilepsy and Surgery Center, Cleveland Clinic, Cleveland, Ohio (J.G.-M.); Department of Neurology, London Health Sciences Center, London, Ontario, Canada (D.R.M.); Department of Neurosurgery, Saitama Medical University, Saitama, Japan (R.N.); Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan (A.S.); Service Neurologie Mazarin, CHU Pitie-Salpetriere, Paris, France (C.J.V.); Department of Neurology, University of Alabama, Birmingham, Alabama (P.W.); Department of Neuro-Oncology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.)
| | - Patrick Y Wen
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.K.A., L.M.D.); Department of Neurology, University of Washington, Seattle, Washington (M.C.); Department of Neurology, University of Virginia, Charlottesville, Virginia (D.S.); Department of Neurology, VUmc Cancer Center, Amsterdam, Netherlands (J.C.R.); Department of Family Health, University of Texas Health Science Center, Houston, Texas (T.S.A.); Department of Neuro-Oncology, City of Health and Science Hospital, Torino, Italy (R.R.); Center for Neuro-Oncology, Dana-Farber Cancer Institute/ Brigham and Women's Center, Boston, Massachusetts (P.W.); Department of Neurology, University Hospital Zurich, Zurich, Switzerland (M.W.); Department of Neurology, Leiden University Medical Center, The Hague, Netherlands (J.A.F.K.); Department of Neurosurgery, Wayne State University, Detroit, Michigan (S.M.); Department of Neurosurgery, Kyoto University School of Graduate Medicine, Kyoto, Japan (Y.A.); Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois (A.C.); Department of Epilepsy and Surgery Center, Cleveland Clinic, Cleveland, Ohio (J.G.-M.); Department of Neurology, London Health Sciences Center, London, Ontario, Canada (D.R.M.); Department of Neurosurgery, Saitama Medical University, Saitama, Japan (R.N.); Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan (A.S.); Service Neurologie Mazarin, CHU Pitie-Salpetriere, Paris, France (C.J.V.); Department of Neurology, University of Alabama, Birmingham, Alabama (P.W.); Department of Neuro-Oncology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.)
| | - Michael Weller
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.K.A., L.M.D.); Department of Neurology, University of Washington, Seattle, Washington (M.C.); Department of Neurology, University of Virginia, Charlottesville, Virginia (D.S.); Department of Neurology, VUmc Cancer Center, Amsterdam, Netherlands (J.C.R.); Department of Family Health, University of Texas Health Science Center, Houston, Texas (T.S.A.); Department of Neuro-Oncology, City of Health and Science Hospital, Torino, Italy (R.R.); Center for Neuro-Oncology, Dana-Farber Cancer Institute/ Brigham and Women's Center, Boston, Massachusetts (P.W.); Department of Neurology, University Hospital Zurich, Zurich, Switzerland (M.W.); Department of Neurology, Leiden University Medical Center, The Hague, Netherlands (J.A.F.K.); Department of Neurosurgery, Wayne State University, Detroit, Michigan (S.M.); Department of Neurosurgery, Kyoto University School of Graduate Medicine, Kyoto, Japan (Y.A.); Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois (A.C.); Department of Epilepsy and Surgery Center, Cleveland Clinic, Cleveland, Ohio (J.G.-M.); Department of Neurology, London Health Sciences Center, London, Ontario, Canada (D.R.M.); Department of Neurosurgery, Saitama Medical University, Saitama, Japan (R.N.); Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan (A.S.); Service Neurologie Mazarin, CHU Pitie-Salpetriere, Paris, France (C.J.V.); Department of Neurology, University of Alabama, Birmingham, Alabama (P.W.); Department of Neuro-Oncology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.)
| | - Johan A F Koekkoek
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.K.A., L.M.D.); Department of Neurology, University of Washington, Seattle, Washington (M.C.); Department of Neurology, University of Virginia, Charlottesville, Virginia (D.S.); Department of Neurology, VUmc Cancer Center, Amsterdam, Netherlands (J.C.R.); Department of Family Health, University of Texas Health Science Center, Houston, Texas (T.S.A.); Department of Neuro-Oncology, City of Health and Science Hospital, Torino, Italy (R.R.); Center for Neuro-Oncology, Dana-Farber Cancer Institute/ Brigham and Women's Center, Boston, Massachusetts (P.W.); Department of Neurology, University Hospital Zurich, Zurich, Switzerland (M.W.); Department of Neurology, Leiden University Medical Center, The Hague, Netherlands (J.A.F.K.); Department of Neurosurgery, Wayne State University, Detroit, Michigan (S.M.); Department of Neurosurgery, Kyoto University School of Graduate Medicine, Kyoto, Japan (Y.A.); Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois (A.C.); Department of Epilepsy and Surgery Center, Cleveland Clinic, Cleveland, Ohio (J.G.-M.); Department of Neurology, London Health Sciences Center, London, Ontario, Canada (D.R.M.); Department of Neurosurgery, Saitama Medical University, Saitama, Japan (R.N.); Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan (A.S.); Service Neurologie Mazarin, CHU Pitie-Salpetriere, Paris, France (C.J.V.); Department of Neurology, University of Alabama, Birmingham, Alabama (P.W.); Department of Neuro-Oncology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.)
| | - Sandeep Mittal
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.K.A., L.M.D.); Department of Neurology, University of Washington, Seattle, Washington (M.C.); Department of Neurology, University of Virginia, Charlottesville, Virginia (D.S.); Department of Neurology, VUmc Cancer Center, Amsterdam, Netherlands (J.C.R.); Department of Family Health, University of Texas Health Science Center, Houston, Texas (T.S.A.); Department of Neuro-Oncology, City of Health and Science Hospital, Torino, Italy (R.R.); Center for Neuro-Oncology, Dana-Farber Cancer Institute/ Brigham and Women's Center, Boston, Massachusetts (P.W.); Department of Neurology, University Hospital Zurich, Zurich, Switzerland (M.W.); Department of Neurology, Leiden University Medical Center, The Hague, Netherlands (J.A.F.K.); Department of Neurosurgery, Wayne State University, Detroit, Michigan (S.M.); Department of Neurosurgery, Kyoto University School of Graduate Medicine, Kyoto, Japan (Y.A.); Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois (A.C.); Department of Epilepsy and Surgery Center, Cleveland Clinic, Cleveland, Ohio (J.G.-M.); Department of Neurology, London Health Sciences Center, London, Ontario, Canada (D.R.M.); Department of Neurosurgery, Saitama Medical University, Saitama, Japan (R.N.); Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan (A.S.); Service Neurologie Mazarin, CHU Pitie-Salpetriere, Paris, France (C.J.V.); Department of Neurology, University of Alabama, Birmingham, Alabama (P.W.); Department of Neuro-Oncology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.)
| | - Yoshiki Arakawa
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.K.A., L.M.D.); Department of Neurology, University of Washington, Seattle, Washington (M.C.); Department of Neurology, University of Virginia, Charlottesville, Virginia (D.S.); Department of Neurology, VUmc Cancer Center, Amsterdam, Netherlands (J.C.R.); Department of Family Health, University of Texas Health Science Center, Houston, Texas (T.S.A.); Department of Neuro-Oncology, City of Health and Science Hospital, Torino, Italy (R.R.); Center for Neuro-Oncology, Dana-Farber Cancer Institute/ Brigham and Women's Center, Boston, Massachusetts (P.W.); Department of Neurology, University Hospital Zurich, Zurich, Switzerland (M.W.); Department of Neurology, Leiden University Medical Center, The Hague, Netherlands (J.A.F.K.); Department of Neurosurgery, Wayne State University, Detroit, Michigan (S.M.); Department of Neurosurgery, Kyoto University School of Graduate Medicine, Kyoto, Japan (Y.A.); Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois (A.C.); Department of Epilepsy and Surgery Center, Cleveland Clinic, Cleveland, Ohio (J.G.-M.); Department of Neurology, London Health Sciences Center, London, Ontario, Canada (D.R.M.); Department of Neurosurgery, Saitama Medical University, Saitama, Japan (R.N.); Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan (A.S.); Service Neurologie Mazarin, CHU Pitie-Salpetriere, Paris, France (C.J.V.); Department of Neurology, University of Alabama, Birmingham, Alabama (P.W.); Department of Neuro-Oncology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.)
| | - Ali Choucair
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.K.A., L.M.D.); Department of Neurology, University of Washington, Seattle, Washington (M.C.); Department of Neurology, University of Virginia, Charlottesville, Virginia (D.S.); Department of Neurology, VUmc Cancer Center, Amsterdam, Netherlands (J.C.R.); Department of Family Health, University of Texas Health Science Center, Houston, Texas (T.S.A.); Department of Neuro-Oncology, City of Health and Science Hospital, Torino, Italy (R.R.); Center for Neuro-Oncology, Dana-Farber Cancer Institute/ Brigham and Women's Center, Boston, Massachusetts (P.W.); Department of Neurology, University Hospital Zurich, Zurich, Switzerland (M.W.); Department of Neurology, Leiden University Medical Center, The Hague, Netherlands (J.A.F.K.); Department of Neurosurgery, Wayne State University, Detroit, Michigan (S.M.); Department of Neurosurgery, Kyoto University School of Graduate Medicine, Kyoto, Japan (Y.A.); Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois (A.C.); Department of Epilepsy and Surgery Center, Cleveland Clinic, Cleveland, Ohio (J.G.-M.); Department of Neurology, London Health Sciences Center, London, Ontario, Canada (D.R.M.); Department of Neurosurgery, Saitama Medical University, Saitama, Japan (R.N.); Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan (A.S.); Service Neurologie Mazarin, CHU Pitie-Salpetriere, Paris, France (C.J.V.); Department of Neurology, University of Alabama, Birmingham, Alabama (P.W.); Department of Neuro-Oncology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.)
| | - Jorge Gonzalez-Martinez
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.K.A., L.M.D.); Department of Neurology, University of Washington, Seattle, Washington (M.C.); Department of Neurology, University of Virginia, Charlottesville, Virginia (D.S.); Department of Neurology, VUmc Cancer Center, Amsterdam, Netherlands (J.C.R.); Department of Family Health, University of Texas Health Science Center, Houston, Texas (T.S.A.); Department of Neuro-Oncology, City of Health and Science Hospital, Torino, Italy (R.R.); Center for Neuro-Oncology, Dana-Farber Cancer Institute/ Brigham and Women's Center, Boston, Massachusetts (P.W.); Department of Neurology, University Hospital Zurich, Zurich, Switzerland (M.W.); Department of Neurology, Leiden University Medical Center, The Hague, Netherlands (J.A.F.K.); Department of Neurosurgery, Wayne State University, Detroit, Michigan (S.M.); Department of Neurosurgery, Kyoto University School of Graduate Medicine, Kyoto, Japan (Y.A.); Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois (A.C.); Department of Epilepsy and Surgery Center, Cleveland Clinic, Cleveland, Ohio (J.G.-M.); Department of Neurology, London Health Sciences Center, London, Ontario, Canada (D.R.M.); Department of Neurosurgery, Saitama Medical University, Saitama, Japan (R.N.); Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan (A.S.); Service Neurologie Mazarin, CHU Pitie-Salpetriere, Paris, France (C.J.V.); Department of Neurology, University of Alabama, Birmingham, Alabama (P.W.); Department of Neuro-Oncology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.)
| | - David R MacDonald
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.K.A., L.M.D.); Department of Neurology, University of Washington, Seattle, Washington (M.C.); Department of Neurology, University of Virginia, Charlottesville, Virginia (D.S.); Department of Neurology, VUmc Cancer Center, Amsterdam, Netherlands (J.C.R.); Department of Family Health, University of Texas Health Science Center, Houston, Texas (T.S.A.); Department of Neuro-Oncology, City of Health and Science Hospital, Torino, Italy (R.R.); Center for Neuro-Oncology, Dana-Farber Cancer Institute/ Brigham and Women's Center, Boston, Massachusetts (P.W.); Department of Neurology, University Hospital Zurich, Zurich, Switzerland (M.W.); Department of Neurology, Leiden University Medical Center, The Hague, Netherlands (J.A.F.K.); Department of Neurosurgery, Wayne State University, Detroit, Michigan (S.M.); Department of Neurosurgery, Kyoto University School of Graduate Medicine, Kyoto, Japan (Y.A.); Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois (A.C.); Department of Epilepsy and Surgery Center, Cleveland Clinic, Cleveland, Ohio (J.G.-M.); Department of Neurology, London Health Sciences Center, London, Ontario, Canada (D.R.M.); Department of Neurosurgery, Saitama Medical University, Saitama, Japan (R.N.); Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan (A.S.); Service Neurologie Mazarin, CHU Pitie-Salpetriere, Paris, France (C.J.V.); Department of Neurology, University of Alabama, Birmingham, Alabama (P.W.); Department of Neuro-Oncology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.)
| | - Ryo Nishikawa
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.K.A., L.M.D.); Department of Neurology, University of Washington, Seattle, Washington (M.C.); Department of Neurology, University of Virginia, Charlottesville, Virginia (D.S.); Department of Neurology, VUmc Cancer Center, Amsterdam, Netherlands (J.C.R.); Department of Family Health, University of Texas Health Science Center, Houston, Texas (T.S.A.); Department of Neuro-Oncology, City of Health and Science Hospital, Torino, Italy (R.R.); Center for Neuro-Oncology, Dana-Farber Cancer Institute/ Brigham and Women's Center, Boston, Massachusetts (P.W.); Department of Neurology, University Hospital Zurich, Zurich, Switzerland (M.W.); Department of Neurology, Leiden University Medical Center, The Hague, Netherlands (J.A.F.K.); Department of Neurosurgery, Wayne State University, Detroit, Michigan (S.M.); Department of Neurosurgery, Kyoto University School of Graduate Medicine, Kyoto, Japan (Y.A.); Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois (A.C.); Department of Epilepsy and Surgery Center, Cleveland Clinic, Cleveland, Ohio (J.G.-M.); Department of Neurology, London Health Sciences Center, London, Ontario, Canada (D.R.M.); Department of Neurosurgery, Saitama Medical University, Saitama, Japan (R.N.); Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan (A.S.); Service Neurologie Mazarin, CHU Pitie-Salpetriere, Paris, France (C.J.V.); Department of Neurology, University of Alabama, Birmingham, Alabama (P.W.); Department of Neuro-Oncology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.)
| | - Aashit Shah
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.K.A., L.M.D.); Department of Neurology, University of Washington, Seattle, Washington (M.C.); Department of Neurology, University of Virginia, Charlottesville, Virginia (D.S.); Department of Neurology, VUmc Cancer Center, Amsterdam, Netherlands (J.C.R.); Department of Family Health, University of Texas Health Science Center, Houston, Texas (T.S.A.); Department of Neuro-Oncology, City of Health and Science Hospital, Torino, Italy (R.R.); Center for Neuro-Oncology, Dana-Farber Cancer Institute/ Brigham and Women's Center, Boston, Massachusetts (P.W.); Department of Neurology, University Hospital Zurich, Zurich, Switzerland (M.W.); Department of Neurology, Leiden University Medical Center, The Hague, Netherlands (J.A.F.K.); Department of Neurosurgery, Wayne State University, Detroit, Michigan (S.M.); Department of Neurosurgery, Kyoto University School of Graduate Medicine, Kyoto, Japan (Y.A.); Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois (A.C.); Department of Epilepsy and Surgery Center, Cleveland Clinic, Cleveland, Ohio (J.G.-M.); Department of Neurology, London Health Sciences Center, London, Ontario, Canada (D.R.M.); Department of Neurosurgery, Saitama Medical University, Saitama, Japan (R.N.); Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan (A.S.); Service Neurologie Mazarin, CHU Pitie-Salpetriere, Paris, France (C.J.V.); Department of Neurology, University of Alabama, Birmingham, Alabama (P.W.); Department of Neuro-Oncology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.)
| | - Charles J Vecht
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.K.A., L.M.D.); Department of Neurology, University of Washington, Seattle, Washington (M.C.); Department of Neurology, University of Virginia, Charlottesville, Virginia (D.S.); Department of Neurology, VUmc Cancer Center, Amsterdam, Netherlands (J.C.R.); Department of Family Health, University of Texas Health Science Center, Houston, Texas (T.S.A.); Department of Neuro-Oncology, City of Health and Science Hospital, Torino, Italy (R.R.); Center for Neuro-Oncology, Dana-Farber Cancer Institute/ Brigham and Women's Center, Boston, Massachusetts (P.W.); Department of Neurology, University Hospital Zurich, Zurich, Switzerland (M.W.); Department of Neurology, Leiden University Medical Center, The Hague, Netherlands (J.A.F.K.); Department of Neurosurgery, Wayne State University, Detroit, Michigan (S.M.); Department of Neurosurgery, Kyoto University School of Graduate Medicine, Kyoto, Japan (Y.A.); Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois (A.C.); Department of Epilepsy and Surgery Center, Cleveland Clinic, Cleveland, Ohio (J.G.-M.); Department of Neurology, London Health Sciences Center, London, Ontario, Canada (D.R.M.); Department of Neurosurgery, Saitama Medical University, Saitama, Japan (R.N.); Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan (A.S.); Service Neurologie Mazarin, CHU Pitie-Salpetriere, Paris, France (C.J.V.); Department of Neurology, University of Alabama, Birmingham, Alabama (P.W.); Department of Neuro-Oncology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.)
| | - Paula Warren
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.K.A., L.M.D.); Department of Neurology, University of Washington, Seattle, Washington (M.C.); Department of Neurology, University of Virginia, Charlottesville, Virginia (D.S.); Department of Neurology, VUmc Cancer Center, Amsterdam, Netherlands (J.C.R.); Department of Family Health, University of Texas Health Science Center, Houston, Texas (T.S.A.); Department of Neuro-Oncology, City of Health and Science Hospital, Torino, Italy (R.R.); Center for Neuro-Oncology, Dana-Farber Cancer Institute/ Brigham and Women's Center, Boston, Massachusetts (P.W.); Department of Neurology, University Hospital Zurich, Zurich, Switzerland (M.W.); Department of Neurology, Leiden University Medical Center, The Hague, Netherlands (J.A.F.K.); Department of Neurosurgery, Wayne State University, Detroit, Michigan (S.M.); Department of Neurosurgery, Kyoto University School of Graduate Medicine, Kyoto, Japan (Y.A.); Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois (A.C.); Department of Epilepsy and Surgery Center, Cleveland Clinic, Cleveland, Ohio (J.G.-M.); Department of Neurology, London Health Sciences Center, London, Ontario, Canada (D.R.M.); Department of Neurosurgery, Saitama Medical University, Saitama, Japan (R.N.); Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan (A.S.); Service Neurologie Mazarin, CHU Pitie-Salpetriere, Paris, France (C.J.V.); Department of Neurology, University of Alabama, Birmingham, Alabama (P.W.); Department of Neuro-Oncology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.)
| | - Martin J van den Bent
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.K.A., L.M.D.); Department of Neurology, University of Washington, Seattle, Washington (M.C.); Department of Neurology, University of Virginia, Charlottesville, Virginia (D.S.); Department of Neurology, VUmc Cancer Center, Amsterdam, Netherlands (J.C.R.); Department of Family Health, University of Texas Health Science Center, Houston, Texas (T.S.A.); Department of Neuro-Oncology, City of Health and Science Hospital, Torino, Italy (R.R.); Center for Neuro-Oncology, Dana-Farber Cancer Institute/ Brigham and Women's Center, Boston, Massachusetts (P.W.); Department of Neurology, University Hospital Zurich, Zurich, Switzerland (M.W.); Department of Neurology, Leiden University Medical Center, The Hague, Netherlands (J.A.F.K.); Department of Neurosurgery, Wayne State University, Detroit, Michigan (S.M.); Department of Neurosurgery, Kyoto University School of Graduate Medicine, Kyoto, Japan (Y.A.); Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois (A.C.); Department of Epilepsy and Surgery Center, Cleveland Clinic, Cleveland, Ohio (J.G.-M.); Department of Neurology, London Health Sciences Center, London, Ontario, Canada (D.R.M.); Department of Neurosurgery, Saitama Medical University, Saitama, Japan (R.N.); Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan (A.S.); Service Neurologie Mazarin, CHU Pitie-Salpetriere, Paris, France (C.J.V.); Department of Neurology, University of Alabama, Birmingham, Alabama (P.W.); Department of Neuro-Oncology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.)
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.K.A., L.M.D.); Department of Neurology, University of Washington, Seattle, Washington (M.C.); Department of Neurology, University of Virginia, Charlottesville, Virginia (D.S.); Department of Neurology, VUmc Cancer Center, Amsterdam, Netherlands (J.C.R.); Department of Family Health, University of Texas Health Science Center, Houston, Texas (T.S.A.); Department of Neuro-Oncology, City of Health and Science Hospital, Torino, Italy (R.R.); Center for Neuro-Oncology, Dana-Farber Cancer Institute/ Brigham and Women's Center, Boston, Massachusetts (P.W.); Department of Neurology, University Hospital Zurich, Zurich, Switzerland (M.W.); Department of Neurology, Leiden University Medical Center, The Hague, Netherlands (J.A.F.K.); Department of Neurosurgery, Wayne State University, Detroit, Michigan (S.M.); Department of Neurosurgery, Kyoto University School of Graduate Medicine, Kyoto, Japan (Y.A.); Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois (A.C.); Department of Epilepsy and Surgery Center, Cleveland Clinic, Cleveland, Ohio (J.G.-M.); Department of Neurology, London Health Sciences Center, London, Ontario, Canada (D.R.M.); Department of Neurosurgery, Saitama Medical University, Saitama, Japan (R.N.); Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan (A.S.); Service Neurologie Mazarin, CHU Pitie-Salpetriere, Paris, France (C.J.V.); Department of Neurology, University of Alabama, Birmingham, Alabama (P.W.); Department of Neuro-Oncology, Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, Netherlands (M.J.v.d.B.)
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Koekkoek JAF, Dirven L, Taphoorn MJB. The withdrawal of antiepileptic drugs in patients with low-grade and anaplastic glioma. Expert Rev Neurother 2016; 17:193-202. [PMID: 27484737 DOI: 10.1080/14737175.2016.1219250] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION The withdrawal of antiepileptic drugs (AEDs) in World Health Organization (WHO) grade II-III glioma patients with epilepsy is controversial, as the presence of a symptomatic lesion is often related to an increased risk of seizure relapse. However, some glioma patients may achieve long-term seizure freedom after antitumor treatment, raising questions about the necessity to continue AEDs, particularly when patients experience serious drug side effects. Areas covered: In this review, we show the evidence in the literature from 1990-2016 for AED withdrawal in glioma patients. We put this issue into the context of risk factors for developing seizures in glioma, adverse effects of AEDs, seizure outcome after antitumor treatment, and outcome after AED withdrawal in patients with non-brain tumor related epilepsy. Expert commentary: There is currently scarce evidence of the feasibility of AED withdrawal in glioma patients. AED withdrawal could be considered in patients with grade II-III glioma with a favorable prognosis, who have achieved stable disease and long-term seizure freedom. The potential benefits of AED withdrawal need to be carefully weighed against the presumed risk of seizure recurrence in a shared decision-making process by both the clinical physician and the patient.
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Affiliation(s)
- Johan A F Koekkoek
- a Department of Neurology , Leiden University Medical Center , Leiden , The Netherlands.,b Department of Neurology , Medical Center Haaglanden , The Hague , The Netherlands
| | - Linda Dirven
- a Department of Neurology , Leiden University Medical Center , Leiden , The Netherlands
| | - Martin J B Taphoorn
- a Department of Neurology , Leiden University Medical Center , Leiden , The Netherlands.,b Department of Neurology , Medical Center Haaglanden , The Hague , The Netherlands
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Huberfeld G, Vecht CJ. Seizures and gliomas — towards a single therapeutic approach. Nat Rev Neurol 2016; 12:204-16. [DOI: 10.1038/nrneurol.2016.26] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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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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Roelcke U, Wyss MT, Nowosielski M, Rudà R, Roth P, Hofer S, Galldiks N, Crippa F, Weller M, Soffietti R. Amino acid positron emission tomography to monitor chemotherapy response and predict seizure control and progression-free survival in WHO grade II gliomas. Neuro Oncol 2015; 18:744-51. [PMID: 26578622 DOI: 10.1093/neuonc/nov282] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 10/12/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Patients with WHO grade II glioma may respond to chemotherapy that is currently not standardized regarding timing and treatment duration. Metabolic changes during chemotherapy may precede structural tumor volume reductions. We therefore compared time courses of amino acid PET and MRI responses to temozolomide (TMZ) and assessed whether responses correlated with seizure control and progression-free survival (PFS). METHODS PET and MRI were performed before and during TMZ chemotherapy. Tumor volumes were calculated using regions-of-interest analysis. Amino acid uptake was also quantified as metabolically active tumor volume and tumor-to-cerebellum uptake ratio. RESULTS One hundred twenty-five PET and 125 MRI scans from 33 patients were analyzed. Twenty-five patients showed metabolic responses that exhibited an exponential time course with a 25% reduction of the active volume on average after 2.3 months. MRI responses followed a linear course with a 25% reduction after 16.8 months. Reduction of metabolically active tumor volumes, but not reduction of PET uptake ratios or MRI tumor volumes, correlated with improved seizure control following chemotherapy (P = .012). Receiver-operating-characteristic curve analysis showed that a decrease of the active tumor volume of ≥80.5% predicts a PFS of ≥60 months (P = .018) and a decrease of ≥64.5% a PFS of ≥48 months (P = .037). CONCLUSIONS Amino acid PET is superior to MRI for evaluating TMZ responses in WHO grade II glioma patients. The response delay between both imaging modalities favors amino acid PET for individually tailoring the duration of chemotherapy. Additional studies should investigate whether this personalized approach is appropriate with regard to outcome.
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Affiliation(s)
- Ulrich Roelcke
- Department of Neurology and Brain Tumor Center, Cantonal Hospital, Aarau, Switzerland (U.R.); Institute for Pharmacology and Toxicology, ETH and University of Zürich, Zürich, Switzerland (M.T.W.); Neuroscience Center, ETH and University of Zürich, Zürich, Switzerland (M.T.W.); Department of Neurology, Medical University, Innsbruck, Austria (M.N.); Department of Neuro-Oncology, University Hospital, Torino, Italy (R.R., R.S.); Department of Neurology, University Hospital, Switzerland (P.R., M.W.); Department of Oncology, University Hospital, Zürich, Switzerland (S.H.); Department of Neurology, University Hospital, Cologne, Germany, and Research Center, Jülich, Germany (N.G.); Medicina Nucleare, Istituto Nazionale dei Tumori, Milano, Italy (F.C.)
| | - Matthias T Wyss
- Department of Neurology and Brain Tumor Center, Cantonal Hospital, Aarau, Switzerland (U.R.); Institute for Pharmacology and Toxicology, ETH and University of Zürich, Zürich, Switzerland (M.T.W.); Neuroscience Center, ETH and University of Zürich, Zürich, Switzerland (M.T.W.); Department of Neurology, Medical University, Innsbruck, Austria (M.N.); Department of Neuro-Oncology, University Hospital, Torino, Italy (R.R., R.S.); Department of Neurology, University Hospital, Switzerland (P.R., M.W.); Department of Oncology, University Hospital, Zürich, Switzerland (S.H.); Department of Neurology, University Hospital, Cologne, Germany, and Research Center, Jülich, Germany (N.G.); Medicina Nucleare, Istituto Nazionale dei Tumori, Milano, Italy (F.C.)
| | - Martha Nowosielski
- Department of Neurology and Brain Tumor Center, Cantonal Hospital, Aarau, Switzerland (U.R.); Institute for Pharmacology and Toxicology, ETH and University of Zürich, Zürich, Switzerland (M.T.W.); Neuroscience Center, ETH and University of Zürich, Zürich, Switzerland (M.T.W.); Department of Neurology, Medical University, Innsbruck, Austria (M.N.); Department of Neuro-Oncology, University Hospital, Torino, Italy (R.R., R.S.); Department of Neurology, University Hospital, Switzerland (P.R., M.W.); Department of Oncology, University Hospital, Zürich, Switzerland (S.H.); Department of Neurology, University Hospital, Cologne, Germany, and Research Center, Jülich, Germany (N.G.); Medicina Nucleare, Istituto Nazionale dei Tumori, Milano, Italy (F.C.)
| | - Roberta Rudà
- Department of Neurology and Brain Tumor Center, Cantonal Hospital, Aarau, Switzerland (U.R.); Institute for Pharmacology and Toxicology, ETH and University of Zürich, Zürich, Switzerland (M.T.W.); Neuroscience Center, ETH and University of Zürich, Zürich, Switzerland (M.T.W.); Department of Neurology, Medical University, Innsbruck, Austria (M.N.); Department of Neuro-Oncology, University Hospital, Torino, Italy (R.R., R.S.); Department of Neurology, University Hospital, Switzerland (P.R., M.W.); Department of Oncology, University Hospital, Zürich, Switzerland (S.H.); Department of Neurology, University Hospital, Cologne, Germany, and Research Center, Jülich, Germany (N.G.); Medicina Nucleare, Istituto Nazionale dei Tumori, Milano, Italy (F.C.)
| | - Patrick Roth
- Department of Neurology and Brain Tumor Center, Cantonal Hospital, Aarau, Switzerland (U.R.); Institute for Pharmacology and Toxicology, ETH and University of Zürich, Zürich, Switzerland (M.T.W.); Neuroscience Center, ETH and University of Zürich, Zürich, Switzerland (M.T.W.); Department of Neurology, Medical University, Innsbruck, Austria (M.N.); Department of Neuro-Oncology, University Hospital, Torino, Italy (R.R., R.S.); Department of Neurology, University Hospital, Switzerland (P.R., M.W.); Department of Oncology, University Hospital, Zürich, Switzerland (S.H.); Department of Neurology, University Hospital, Cologne, Germany, and Research Center, Jülich, Germany (N.G.); Medicina Nucleare, Istituto Nazionale dei Tumori, Milano, Italy (F.C.)
| | - Silvia Hofer
- Department of Neurology and Brain Tumor Center, Cantonal Hospital, Aarau, Switzerland (U.R.); Institute for Pharmacology and Toxicology, ETH and University of Zürich, Zürich, Switzerland (M.T.W.); Neuroscience Center, ETH and University of Zürich, Zürich, Switzerland (M.T.W.); Department of Neurology, Medical University, Innsbruck, Austria (M.N.); Department of Neuro-Oncology, University Hospital, Torino, Italy (R.R., R.S.); Department of Neurology, University Hospital, Switzerland (P.R., M.W.); Department of Oncology, University Hospital, Zürich, Switzerland (S.H.); Department of Neurology, University Hospital, Cologne, Germany, and Research Center, Jülich, Germany (N.G.); Medicina Nucleare, Istituto Nazionale dei Tumori, Milano, Italy (F.C.)
| | - Norbert Galldiks
- Department of Neurology and Brain Tumor Center, Cantonal Hospital, Aarau, Switzerland (U.R.); Institute for Pharmacology and Toxicology, ETH and University of Zürich, Zürich, Switzerland (M.T.W.); Neuroscience Center, ETH and University of Zürich, Zürich, Switzerland (M.T.W.); Department of Neurology, Medical University, Innsbruck, Austria (M.N.); Department of Neuro-Oncology, University Hospital, Torino, Italy (R.R., R.S.); Department of Neurology, University Hospital, Switzerland (P.R., M.W.); Department of Oncology, University Hospital, Zürich, Switzerland (S.H.); Department of Neurology, University Hospital, Cologne, Germany, and Research Center, Jülich, Germany (N.G.); Medicina Nucleare, Istituto Nazionale dei Tumori, Milano, Italy (F.C.)
| | - Flavio Crippa
- Department of Neurology and Brain Tumor Center, Cantonal Hospital, Aarau, Switzerland (U.R.); Institute for Pharmacology and Toxicology, ETH and University of Zürich, Zürich, Switzerland (M.T.W.); Neuroscience Center, ETH and University of Zürich, Zürich, Switzerland (M.T.W.); Department of Neurology, Medical University, Innsbruck, Austria (M.N.); Department of Neuro-Oncology, University Hospital, Torino, Italy (R.R., R.S.); Department of Neurology, University Hospital, Switzerland (P.R., M.W.); Department of Oncology, University Hospital, Zürich, Switzerland (S.H.); Department of Neurology, University Hospital, Cologne, Germany, and Research Center, Jülich, Germany (N.G.); Medicina Nucleare, Istituto Nazionale dei Tumori, Milano, Italy (F.C.)
| | - Michael Weller
- Department of Neurology and Brain Tumor Center, Cantonal Hospital, Aarau, Switzerland (U.R.); Institute for Pharmacology and Toxicology, ETH and University of Zürich, Zürich, Switzerland (M.T.W.); Neuroscience Center, ETH and University of Zürich, Zürich, Switzerland (M.T.W.); Department of Neurology, Medical University, Innsbruck, Austria (M.N.); Department of Neuro-Oncology, University Hospital, Torino, Italy (R.R., R.S.); Department of Neurology, University Hospital, Switzerland (P.R., M.W.); Department of Oncology, University Hospital, Zürich, Switzerland (S.H.); Department of Neurology, University Hospital, Cologne, Germany, and Research Center, Jülich, Germany (N.G.); Medicina Nucleare, Istituto Nazionale dei Tumori, Milano, Italy (F.C.)
| | - Riccardo Soffietti
- Department of Neurology and Brain Tumor Center, Cantonal Hospital, Aarau, Switzerland (U.R.); Institute for Pharmacology and Toxicology, ETH and University of Zürich, Zürich, Switzerland (M.T.W.); Neuroscience Center, ETH and University of Zürich, Zürich, Switzerland (M.T.W.); Department of Neurology, Medical University, Innsbruck, Austria (M.N.); Department of Neuro-Oncology, University Hospital, Torino, Italy (R.R., R.S.); Department of Neurology, University Hospital, Switzerland (P.R., M.W.); Department of Oncology, University Hospital, Zürich, Switzerland (S.H.); Department of Neurology, University Hospital, Cologne, Germany, and Research Center, Jülich, Germany (N.G.); Medicina Nucleare, Istituto Nazionale dei Tumori, Milano, Italy (F.C.)
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Koekkoek JAF, Dirven L, Heimans JJ, Postma TJ, Vos MJ, Reijneveld JC, Taphoorn MJB. Seizure reduction is a prognostic marker in low-grade glioma patients treated with temozolomide. J Neurooncol 2015; 126:347-54. [PMID: 26547911 PMCID: PMC4718947 DOI: 10.1007/s11060-015-1975-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 10/24/2015] [Indexed: 01/02/2023]
Abstract
We aimed to analyze the value of seizure reduction and radiological response as prognostic markers of survival in patients with low-grade glioma (LGG) treated with temozolomide (TMZ) chemotherapy. We retrospectively reviewed adult patients with a progressive LGG and uncontrolled epilepsy in two hospitals (VUmc Amsterdam; MCH The Hague), who received chemotherapy with TMZ between 2002 and 2014. End points were a ≥50 % seizure reduction and MRI response 6, 12 and 18 months (mo) after the start of TMZ, and their relation with progression-free survival (PFS) and overall survival (OS). We identified 53 patients who met the inclusion criteria. Seizure reduction was an independent prognostic factor for both PFS (HR 0.38; 95 % CI 0.19–0.73; p = 0.004) and OS (HR 0.39; 95 % CI 0.18–0.85; p = 0.018) after 6mo, adjusting for age and histopathological diagnosis, as well as after 12 and 18mo. Patients with an objective radiological response showed a better OS (median 87.5mo; 95 % CI 62.0–112.9) than patients without a response (median 34.4mo; 95 % CI 26.1–42.6; p = 0.046) after 12mo. However, after 6 and 18mo OS was similar in patients with and without a response on MRI. Seizure reduction is an early and consistent prognostic marker for survival after treatment with TMZ, that seems to precede the radiological response. Therefore, seizure reduction may serve as a surrogate marker for tumor response.
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Affiliation(s)
- Johan A F Koekkoek
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands.
- Department of Neurology, Medical Center Haaglanden, The Hague, The Netherlands.
- Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.
| | - Linda Dirven
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands
- Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Jan J Heimans
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands
| | - Tjeerd J Postma
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands
| | - Maaike J Vos
- Department of Neurology, Medical Center Haaglanden, The Hague, The Netherlands
| | - Jaap C Reijneveld
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands
| | - Martin J B Taphoorn
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands
- Department of Neurology, Medical Center Haaglanden, The Hague, The Netherlands
- Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
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Armstrong TS, Grant R, Gilbert MR, Lee JW, Norden AD. Epilepsy in glioma patients: mechanisms, management, and impact of anticonvulsant therapy. Neuro Oncol 2015; 18:779-89. [PMID: 26527735 DOI: 10.1093/neuonc/nov269] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Accepted: 10/01/2015] [Indexed: 12/16/2022] Open
Abstract
Seizures are a well-recognized symptom of primary brain tumors, and anticonvulsant use is common. This paper provides an overview of epilepsy and the use of anticonvulsants in glioma patients. Overall incidence and mechanisms of epileptogenesis are reviewed. Factors to consider with the use of antiepileptic drugs (AEDs) including incidence during the disease trajectory and prophylaxis along with considerations in the selection of anticonvulsant use (ie, potential side effects, drug interactions, adverse effects, and impact on survival) are also reviewed. Finally, areas for future research and exploring the pathophysiology and use of AEDs in this population are also discussed.
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Affiliation(s)
- Terri S Armstrong
- Department of Family Health, University of Texas Health Science Center at Houston, Houston, Texas (T.S.A.); Edinburgh Centre for Neuro-Oncology, Edinburgh, UK (R.G.); Neuro-Oncology Branch, National Cancer Institute and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland (M.R.G.); Division of EEG and Epilepsy, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts (J.W.L.); Center for Neuro-Oncology, Dana-Farber Cancer Institute; Division of Cancer Neurology, Department of Neurology, Brigham and Women's Hospital; and Harvard Medical School, Boston, Massachusetts (A.D.N.)
| | - Robin Grant
- Department of Family Health, University of Texas Health Science Center at Houston, Houston, Texas (T.S.A.); Edinburgh Centre for Neuro-Oncology, Edinburgh, UK (R.G.); Neuro-Oncology Branch, National Cancer Institute and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland (M.R.G.); Division of EEG and Epilepsy, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts (J.W.L.); Center for Neuro-Oncology, Dana-Farber Cancer Institute; Division of Cancer Neurology, Department of Neurology, Brigham and Women's Hospital; and Harvard Medical School, Boston, Massachusetts (A.D.N.)
| | - Mark R Gilbert
- Department of Family Health, University of Texas Health Science Center at Houston, Houston, Texas (T.S.A.); Edinburgh Centre for Neuro-Oncology, Edinburgh, UK (R.G.); Neuro-Oncology Branch, National Cancer Institute and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland (M.R.G.); Division of EEG and Epilepsy, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts (J.W.L.); Center for Neuro-Oncology, Dana-Farber Cancer Institute; Division of Cancer Neurology, Department of Neurology, Brigham and Women's Hospital; and Harvard Medical School, Boston, Massachusetts (A.D.N.)
| | - Jong Woo Lee
- Department of Family Health, University of Texas Health Science Center at Houston, Houston, Texas (T.S.A.); Edinburgh Centre for Neuro-Oncology, Edinburgh, UK (R.G.); Neuro-Oncology Branch, National Cancer Institute and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland (M.R.G.); Division of EEG and Epilepsy, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts (J.W.L.); Center for Neuro-Oncology, Dana-Farber Cancer Institute; Division of Cancer Neurology, Department of Neurology, Brigham and Women's Hospital; and Harvard Medical School, Boston, Massachusetts (A.D.N.)
| | - Andrew D Norden
- Department of Family Health, University of Texas Health Science Center at Houston, Houston, Texas (T.S.A.); Edinburgh Centre for Neuro-Oncology, Edinburgh, UK (R.G.); Neuro-Oncology Branch, National Cancer Institute and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland (M.R.G.); Division of EEG and Epilepsy, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts (J.W.L.); Center for Neuro-Oncology, Dana-Farber Cancer Institute; Division of Cancer Neurology, Department of Neurology, Brigham and Women's Hospital; and Harvard Medical School, Boston, Massachusetts (A.D.N.)
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Abstract
Epilepsy develops in more than 70-90% of oligodendroglial tumors and represents a favorable indicator for long-term survival if present as the first clinical sign. Presence of IDH1 mutation is frequently associated with seizures in oligodendrogliomas, next to alterations of glutamate and GABA metabolism in the origin of glioma-associated epilepsy. Treatment by surgery or radiotherapy results in seizure freedom in about two-thirds of patients, and chemotherapy to a seizure reduction in about 50%. Symptomatic anticonvulsive therapy with levetiracetam and valproic acid as monotherapy are both evidence-based drugs for the partial epilepsies, and their effective use in brain tumors is supported by a large amount of additional data. Pharmacoresistance against anticonvulsants is more prevalent among oligodendrogliomas, occurring in about 40% despite polytherapy with two anticonvulsants or more. Toxic signs of anticonvulsants in brain tumors involve cognition, bone marrow and skin. Previous neurosurgery, radiation therapy or chemotherapy add to the risks of cognitive dysfunction.
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Affiliation(s)
- Melissa Kerkhof
- Department of Neurology, Medical Center The Hague, The Netherlands
| | - Christa Benit
- Department of Neurology, Medical Center The Hague, The Netherlands
| | | | - Charles J Vecht
- Service Neurologie Mazarin, GH Pitié-Salpêtrière, Paris, France
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Sarmiento JM, Venteicher AS, Patil CG. Early versus delayed postoperative radiotherapy for treatment of low-grade gliomas. Cochrane Database Syst Rev 2015; 6:CD009229. [PMID: 26118544 PMCID: PMC4506130 DOI: 10.1002/14651858.cd009229.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND In most people with low-grade gliomas (LGG), the primary treatment regimen remains a combination of surgery followed by postoperative radiotherapy. However, the optimal timing of radiotherapy is controversial. It is unclear whether to use radiotherapy in the early postoperative period, or whether radiotherapy should be delayed until tumour progression occurs. OBJECTIVES To assess the effects of early postoperative radiotherapy versus radiotherapy delayed until tumour progression for low-grade intracranial gliomas in people who had initial biopsy or surgical resection. SEARCH METHODS We searched up to September 2014 the following electronic databases: the Cochrane Register of Controlled Trials (CENTRAL, Issue 8, 2014), MEDLINE (1948 to Aug week 3, 2014), and EMBASE (1980 to Aug week 3, 2014) to identify trials for inclusion in this Cochrane review. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared early versus delayed radiotherapy following biopsy or surgical resection for the treatment of people with newly diagnosed intracranial LGG (astrocytoma, oligodendroglioma, mixed oligoastrocytoma, astroblastoma, xanthoastrocytoma, or ganglioglioma). Radiotherapy may include conformal external beam radiotherapy (EBRT) with linear accelerator or cobalt-60 sources, intensity-modulated radiotherapy (IMRT), or stereotactic radiosurgery (SRS). DATA COLLECTION AND ANALYSIS Three review authors independently assessed the trials for inclusion and risk of bias, and extracted study data. We resolved any differences between review authors by discussion. Adverse effects were also extracted from the study report. We performed meta-analyses using a random-effects model with inverse variance weighting. MAIN RESULTS We included one large, multi-institutional, prospective RCT, involving 311 participants; the risk of bias in this study was unclear. This study found that early postoperative radiotherapy is associated with an increase in time to progression compared to observation (and delayed radiotherapy upon disease progression) for people with LGG but does not significantly improve overall survival (OS). The median progression-free survival (PFS) was 5.3 years in the early radiotherapy group and 3.4 years in the delayed radiotherapy group (hazard ratio (HR) 0.59, 95% confidence interval (CI) 0.45 to 0.77; P value < 0.0001; 311 participants; 1 trail; low quality evidence). The median OS in the early radiotherapy group was 7.4 years, while the delayed radiotherapy group experienced a median overall survival of 7.2 years (HR 0.97, 95% CI 0.71 to 1.33; P value = 0.872; 311 participants; 1 trail; low quality evidence). The total dose of radiotherapy given was 54 Gy; five fractions of 1.8 Gy per week were given for six weeks. Adverse effects following radiotherapy consisted of skin reactions, otitis media, mild headache, nausea, and vomiting. Rescue therapy was provided to 65% of the participants randomised to delayed radiotherapy. People in both cohorts who were free from tumour progression showed no differences in cognitive deficit, focal deficit, performance status, and headache after one year. However, participants randomised to the early radiotherapy group experienced significantly fewer seizures than participants in the delayed postoperative radiotherapy group at one year (25% versus 41%, P value = 0.0329, respectively). AUTHORS' CONCLUSIONS Given the high risk of bias in the included study, the results of this analysis must be interpreted with caution. Early radiation therapy was associated with the following adverse effects: skin reactions, otitis media, mild headache, nausea, and vomiting. People with LGG who undergo early radiotherapy showed an increase in time to progression compared with people who were observed and had radiotherapy at the time of progression. There was no significant difference in overall survival between people who had early versus delayed radiotherapy; however, this finding may be due to the effectiveness of rescue therapy with radiation in the control arm. People who underwent early radiation had better seizure control at one year than people who underwent delayed radiation. There were no cases of radiation-induced malignant transformation of LGG. However, it remains unclear whether there are differences in memory, executive function, cognitive function, or quality of life between the two groups since these measures were not evaluated.
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Affiliation(s)
- J Manuel Sarmiento
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Andrew S Venteicher
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Chirag G Patil
- Department of Neurosurgery, Maxine Dunitz Neurosurgical Institute, Los Angeles, CA, USA
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Abstract
OPINION STATEMENT Seizures represent a common symptom in low- and high-grade gliomas. Tumor location and histology influence the risk for epilepsy. Some molecular factors (BRAF V 600E mutations in glioneuronal tumors and IDH1/2 mutations in diffuse grade II and III gliomas) are molecular factors that are relevant for diagnosis and prognosis and have been associated with the risk of epilepsy as well. Glutamate plays a central role in epileptogenicity and growth of glial and glioneuronal tumors, based on the release of glutamate from tumor cells that enhances excitotoxicity, and a downregulation of the inhibitory GABAergic pathways. Several potential targets for therapy have been identified, and m-TOR inhibitors have already shown activity. Gross total resection is the strongest predictor of seizure freedom in addition to clinical factors, such as preoperative seizure duration, type, and control with antiepileptic drugs (AEDs). Radiotherapy and chemotherapy with alkylating agents (procarbazine, CCNU, vincristine, temozolomide) are effective in reducing the frequency of seizures in patients with pharmacoresistant epilepsy. Newer AEDs (in particular levetiracetam and lacosamide) seem to be better tolerated than the old AEDs (phenobarbital, phenytoin, carbamazepine), but randomized clinical trials are needed to prove their superiority in terms of efficacy.
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Affiliation(s)
- Roberta Rudà
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Via Cherasco 15, 10126, Torino, Italy,
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Koekkoek JAF, Dirven L, Heimans JJ, Postma TJ, Vos MJ, Reijneveld JC, Taphoorn MJB. Seizure reduction in a low-grade glioma: more than a beneficial side effect of temozolomide. J Neurol Neurosurg Psychiatry 2015; 86:366-73. [PMID: 25055819 DOI: 10.1136/jnnp-2014-308136] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Seizures are a common symptom in patients with low-grade glioma (LGG), negatively influencing quality of life, if uncontrolled. Besides antiepileptic drugs, antitumour treatment might contribute to a reduction in seizure frequency. The aim of this study was to determine the effect of temozolomide (TMZ) chemotherapy on seizure frequency, to identify factors associated with post-treatment seizure reduction and to analyse the prognostic value of seizure reduction for survival. METHODS We retrospectively reviewed adult patients with supratentorial LGG and epilepsy who received chemotherapy with TMZ as initial treatment or for progressive disease in two hospitals (VUmc Amsterdam; MCH The Hague) between 2002 and 2012. RESULTS We identified 104 patients with LGG with epilepsy who had received TMZ. Uncontrolled epilepsy in the 3 months preceding chemotherapy was present in 66 of 104 (63.5%) patients. A ≥ 50% reduction in seizure frequency after 6 months occurred in 29 of 66 (43.9%) patients. Focal symptoms at presentation (OR 6.55; 95% CI 1.45 to 32.77; p = 0.015) appeared to be positively associated with seizure reduction. Seizure reduction was an independent prognostic factor for progression-free survival (HR 0.32; 95% CI 0.15 to 0.66; p = 0.002) and overall survival (HR 0.33; 95% CI 0.14 to 0.79; p = 0.013), along with a histological diagnosis of oligodendroglioma (HR 0.38; 95% CI 0.17 to 0.86; p = 0.021). Objective responses on MRI were similar for patients with and without seizure reduction. CONCLUSIONS TMZ may contribute to an important reduction in seizure frequency in patients with LGG. Seizure reduction following TMZ treatment has prognostic significance and may serve as an important clinical outcome measure in patients with LGG.
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Affiliation(s)
- Johan A F Koekkoek
- Department of Neurology, VU University Medical Centre, Amsterdam, The Netherlands Department of Neurology, Medical Centre Haaglanden, The Hague, The Netherlands
| | - Linda Dirven
- Department of Neurology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Jan J Heimans
- Department of Neurology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Tjeerd J Postma
- Department of Neurology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Maaike J Vos
- Department of Neurology, Medical Centre Haaglanden, The Hague, The Netherlands
| | - Jaap C Reijneveld
- Department of Neurology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Martin J B Taphoorn
- Department of Neurology, VU University Medical Centre, Amsterdam, The Netherlands Department of Neurology, Medical Centre Haaglanden, The Hague, The Netherlands
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van Thuijl HF, Mazor T, Johnson BE, Fouse SD, Aihara K, Hong C, Malmström A, Hallbeck M, Heimans JJ, Kloezeman JJ, Stenmark-Askmalm M, Lamfers MLM, Saito N, Aburatani H, Mukasa A, Berger MS, Söderkvist P, Taylor BS, Molinaro AM, Wesseling P, Reijneveld JC, Chang SM, Ylstra B, Costello JF. Evolution of DNA repair defects during malignant progression of low-grade gliomas after temozolomide treatment. Acta Neuropathol 2015; 129:597-607. [PMID: 25724300 DOI: 10.1007/s00401-015-1403-6] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 02/21/2015] [Accepted: 02/21/2015] [Indexed: 01/25/2023]
Abstract
Temozolomide (TMZ) increases the overall survival of patients with glioblastoma (GBM), but its role in the clinical management of diffuse low-grade gliomas (LGG) is still being defined. DNA hypermethylation of the O (6) -methylguanine-DNA methyltransferase (MGMT) promoter is associated with an improved response to TMZ treatment, while inactivation of the DNA mismatch repair (MMR) pathway is associated with therapeutic resistance and TMZ-induced mutagenesis. We previously demonstrated that TMZ treatment of LGG induces driver mutations in the RB and AKT-mTOR pathways, which may drive malignant progression to secondary GBM. To better understand the mechanisms underlying TMZ-induced mutagenesis and malignant progression, we explored the evolution of MGMT methylation and genetic alterations affecting MMR genes in a cohort of 34 treatment-naïve LGGs and their recurrences. Recurrences with TMZ-associated hypermutation had increased MGMT methylation compared to their untreated initial tumors and higher overall MGMT methylation compared to TMZ-treated non-hypermutated recurrences. A TMZ-associated mutation in one or more MMR genes was observed in five out of six TMZ-treated hypermutated recurrences. In two cases, pre-existing heterozygous deletions encompassing MGMT, or an MMR gene, were followed by TMZ-associated mutations in one of the genes of interest. These results suggest that tumor cells with methylated MGMT may undergo positive selection during TMZ treatment in the context of MMR deficiency.
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