Seizure Prognosis in Brain Tumors: New Insights and Evidence‐Based Management

• Published in: The oncologist (Dayton, Ohio) Ohio), 2014-07, Vol.19 (7), p.751-759
• Main Authors: Vecht, Charles J., Kerkhof, Melissa, Duran‐Pena, Alberto
• Format: Article
• Language: English
• Subjects: Anticonvulsants - therapeutic use; Brain Neoplasms - drug therapy; Brain Neoplasms - physiopathology; Cancer; Epilepsy; Epilepsy - drug therapy; Epilepsy - etiology; Glioblastoma; Glioma; Glioma - drug therapy; Glioma - physiopathology; Guideline; Humans; Levetiracetam; Neuro-Oncology; Prognosis; Review; Seizures; Valproic acid
• ISSN: 1083-7159; 1549-490X
• DOI: 10.1634/theoncologist.2014-0060

Brain tumor‐related epilepsy (BTE) is common in low‐ and high‐grade gliomas. The risk of seizures varies between 60% and 100% among low‐grade gliomas and between 40% and 60% in glioblastomas. The presence of seizures in patients with brain tumors implies favorable and unfavorable factors. New‐onset seizures represent an early warning sign for the presence of a brain tumor and count as a good prognostic factor for survival. Recurrence or worsening of seizures during the course of disease may signal tumor progression. Each of the modalities for tumor control (i.e., surgery, radiotherapy, chemotherapy) contributes to seizure control. Nevertheless, one third of BTE shows pharmacoresistance to antiepileptic drugs (AEDs) and may severely impair the burden of living with a brain tumor. For symptomatic therapy of BTE, seizure type and individual patient factors determine the appropriate AED. Randomized controlled trials in partial epilepsy in adults to which type BTE belongs and additional studies in gliomas indicate that levetiracetam is the agent of choice, followed by valproic acid (VPA). In the case of recurring seizures, combining these two drugs (polytherapy) seems effective and possibly synergistic. If either one is not effective or not well tolerated, lacosamide, lamotrigine, or zonisamide are additional options. A new and exciting insight is the potential contribution of VPA to prolonged survival, particularly in glioblastomas. A practice guideline on symptomatic medical management including dose schedules of AEDs is supplied. The choice of an antiepileptic drug (AED) for treatment of brain tumor‐related epilepsy (BTE) depends on its proof of evidence in partial epilepsies in adults and individual patient features. Recent designation of a number of AEDs prompts the use of levetiracetam followed by valproic acid as the AED monotherapy of choice in BTE. In case either one is insufficiently active as a single agent or in combination, as in the case of untoward effects, alternative AEDs are lacosamide, lamotrigine, and zonisamide.