Best Practices for Seizure Treatment in Oncology Patients

The aim of the review is to examine the management of seizures for patients with primary brain tumors, brain metastases, and as a consequence of oncologic treatment. The review highlights the variability in seizure incidence based on tumor types and emphasizes the need for individualized treatment strategies, including antiseizure medications (ASMs) and tumor management. Seizure frequency response to oncologic treatments (e.g., radiation) is reviewed. The approach to treatment of seizures resulting from systemic therapies is addressed. Additionally, we acknowledge the limited evidence-based recommendations in the field due to the heterogeneous nature of the patient population and ongoing treatment changes. Overall, the review seeks to enhance understanding and improve seizure management for patients with a cancer diagnosis.

Current guidelines continue to recommend against initiating an ASM in patients with a newly diagnosed brain tumor unless they have experienced a seizure. While there remains insufficient evidence to prescribe any specific ASM as a first-line agent, considerations regarding side effects and drug-drug interactions are important. Recently, it has become evident that there is a bidirectional relationship between epileptogenicity and tumor growth through multiple mechanisms. Targeting these shared mechanisms with medical treatments (e.g., IDH mutant inhibitors) holds promise and represents a future direction for therapeutics.

Management of tumor related epilepsy requires a multifaceted approach that incorporates ASMs and oncologic treatments. Current guidelines dictate that prophylactic ASMs are not recommended for newly diagnosed brain tumors, yet ASMs are essential for those with a history of seizures. Levetiracetam is commonly prescribed as a first-line agent due to its favorable side-effect profile, although neuropsychiatric symptoms are notable among users. In cases of refractory seizures, other ASMs like lacosamide, lamotrigine, and clobazam may be considered.

Surgery is often indicated, particularly for primary tumors, with gross total resection yielding better seizure outcomes. Various oncologic therapies, including chemotherapy and radiation, can also provoke seizures, necessitating careful management of potential drug interactions and side effects. Common offending agents are reviewed and approach to treatment is discussed.