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Stereotaktische Niedrigdosis-Therapie fokaler Epilepsien

Erste Daten einer monozentrischen Machbarkeitsstudie

Low-dose stereotactic treatment for focal epilepsy

First data from a single-centre feasibility study

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Zusammenfassung

Hintergrund

Die Resektion epileptogener Läsionen ist ein etabliertes Behandlungsverfahren pharmakoresistenter fokaler Epilepsien. In eloquenten Arealen ist das Risiko eines dauerhaften neurologischen Defizits jedoch sehr hoch. In solchen Fällen könnte die neuromodulatorische Wirkung einer niedrig dosierten (nicht ablativen) hoch präzisen Bestrahlung umschriebener Läsionen eine Alternative darstellen.

Methodik

Sieben Patienten mit pharmakoresistenter fokaler Epilepsie infolge (vermuteter) fokaler kortikaler Dysplasie in eloquenten Arealen wurden in einem individuellen Therapieversuch risikoadaptiert mittels niedrig dosierter stereotaktischer Radiochirurgie (SRS) oder hypofraktionierter stereotaktischer Strahlentherapie (hfSRT) behandelt.

Ergebnisse

Zwei Patienten wurden mittels hfSRT (Randdosis 36 Gy), fünf mittels SRS (Randdosis 13 Gy) behandelt. Beim letzten Follow-up (im Mittel 21,3 ± 7,9 Monate) waren zwei Patienten seit mehr als zwölf Monaten anfallsfrei. Von den verbleibenden Patienten hat sich die Anfallskontrolle bei zwei Patienten gebessert und blieb bei drei Patienten unverändert. Bei keinem Patienten wurden Nebenwirkungen oder neurologische Defizite beobachtet.

Diskussion

In dieser Fallserie zeigte die Behandlung von eloquent lokalisierten epileptogenen Läsionen mittels SRS oder hfSRT keine negativen Effekte und ein akzeptables Anfallsoutcome. Ein längerer postinterventioneller Beobachtungszeitraum muss abgewartet werden, um den neuromodulatorischen Effekt der Bestrahlung endgültig bewerten zu können. Unsere vorläufigen Ergebnisse rechtfertigen jedoch die Initiierung einer größeren prospektiven Studie zur Beantwortung der Frage, ob eine niedrig dosierte hoch fokussierte stereotaktische Bestrahlung eine Therapieoption für Läsionen in eloquenten Hirnarealen darstellt.

Abstract

Background

The resection of epileptogenic lesions is an established treatment for pharmacoresistant focal epilepsy. In eloquent brain regions, however, the risk of permanent neurological deficit is very high. In such cases, low-dose, high-precision irradiation of circumscribed lesions may represent, via sustained neuromodulatory effects, an alternative therapeutic option.

Materials and methods

Seven patients with pharmacoresistant focal epilepsy due to (putative) focal cortical dysplasia located in eloquent brain regions were treated in an individual therapeutic approach with risk-adapted, low-dose stereotactic radiosurgery (SRS) or hypofractionated stereotactic radiotherapy (hfSRT).

Results

Two patients were treated with hfSRT (marginal dose 36 Gy), and 5 with SRS (marginal dose 13 Gy). At the last follow-up (an average of 21.3 ± 7.9 months) 2 patients had been seizure-free for more than 12 months. Of the remaining patients, the seizure frequency improved in 2 and remained unchanged in 3 patients. There were no side effects or neurological deficits in any of the patients.

Conclusion

In this small prospective case series, treatment of epileptogenic lesions located in the eloquent brain regions with SRS and hfSRT did not result in any adverse events and led to an acceptable seizure outcome. A longer follow-up is required to evaluate the neuromodulatory effects. Our preliminary results, however, justify the initiation of a larger prospective trial investigating whether focused low-dose stereotactic irradiation could be an option for lesions in eloquent brain areas.

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Authors and Affiliations

  1. Abteilung für Strahlentherapie und Radioonkologie, MediClin Robert Janker Klinik und MediClin MVZ Bonn, Villenstraße 8, 53129, Bonn, Deutschland

    Jan P. Boström

  2. Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Bonn, Sigmund-Freud-Straße 25, 53105, Bonn, Deutschland

    Jan P. Boström, Daniel Delev & Hartmut Vatter

  3. Klinik für Epileptologie, Universitätsklinikum Bonn, Sigmund-Freud-Straße 25, 53105, Bonn, Deutschland

    Carlos M. Quesada, Guido Widman, Christian E. Elger &  Rainer Surges

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  1. Jan P. Boström
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  2. Daniel Delev
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  3. Carlos M. Quesada
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  4. Guido Widman
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  6. Christian E. Elger
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  7. Rainer Surges
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Correspondence to Jan P. Boström or Rainer Surges.

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Interessenkonflikt

Jan Boström hat in den letzten drei Jahren Honorare für Vorträge von Brainlab erhalten. Christian E. Elger hat in den letzten drei Jahren für folgende Firmen bezahlte Vorträge gehalten: Cyberonics, Desitin, Eisai, Medtronics, Novartis und UCB Pharma. Rainer Surges hat in den letzten drei Jahren Honorare für Vorträge bzw. als Berater von Bial, Cyberonics, Desitin, Eisai, Novartis und UCB Pharma erhalten. Daniel Delev, Carlos Quesada, Hartmut Vatter und Guido Widman haben keine Interessenkonflikte angegeben.

Die Bestrahlung wurde als individueller Behandlungsversuch angeboten, alle Patienten unterzeichneten eine mit der Deklaration von Helsinki konforme schriftliche Einwilligung.

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Boström, J.P., Delev, D., Quesada, C.M. et al. Stereotaktische Niedrigdosis-Therapie fokaler Epilepsien. Z. Epileptol. 30, 162–169 (2017). https://doi.org/10.1007/s10309-016-0086-x

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