Determining the Best Surgery for Drug Resistant Epilepsy

Patrick Landazuri, MD

A new multicenter study that investigated 1-year outcomes of minimally invasive surgical treatment with laser interstitial thermal therapy (LITT) found it to be a safe and effective treatment option for patients with drug resistant epilepsy (DRE), with 64% of patients free of seizures at the end of the study period.

Additionally, the study assessed quality of life with the Quality of Life in Epilepsy questionnaire (QOLIE-31). The median score increased by 14.1 points at 1-year follow up, driven by improvements in seizure worry and social functioning. Although this total score change was not statistically significant, it is still clinically meaningful, according to Patrick Landazuri, MD, associate professor of neurology, University of Kansas Medical Center, and colleagues. 

They examined these 1-year outcomes from patients enrolled in the multicenter, prospective LAANTERN registry (Laser Ablation of Abnormal Neurological Tissue Using Robotic NeuroBlate System; NCT02392078) specifically for epilepsy treatment. They looked at the 60 LITT procedures performed for DRE. Patients with mesial temporal lobe epilepsy/mesial temporal sclerosis (MTLE/MTS) made up the majority of procedures but other etiologies were assessed, too. 

NeurologyLive talked to Landazuri to learn more about the LITT procedure, future studies and outcomes, and deciding the best options for patients.

NeurologyLive: How do you think LITT could be further improved?

Patrick Landazuri, MD: It's still a relatively new technique in terms of epilepsy surgery. The story of LITT for epilepsy treatment began in 2013, or 2014. So it's only 6 or 7 years old, and LAANTERN is the first multicenter and prospective study. I think as we gather more and more data, we’ll be guided to different directions to pursue. Mesial temporal lobe epilepsy is easily the most studied epilepsy type for LITT therapies, and our paper contributes to that literature. The next steps will be understanding how effective it may be with extra temporal lobe epilepsy, which is also generally harder to surgically treat compared to MTLE. So far, our paper looks at our 1-year outcomes, but the study is slated to go for 5 years, and hopefully we will see that these outcomes are durable. Another important consideration is identifying different patient characteristics and epilepsy etiologies that may or may not make patient better candidates for LITT versus other therapies. I think as we expand our own cohort and LAANTERN, we’re trying to find trends to determine if, let’s say, cortical dysplasia patients would be better candidates or maybe people with cavernoma instead. There are other centers doing single center studies reporting their cohorts, and I think that's valuable as well.

What further research would you like to see conducted to investigate LITT?

In an ideal world, we would do randomized control trials, but I think that's going to be very difficult in epilepsy surgery. There was a study published several years ago that compared stereotactic radiosurgery to open craniotomy for mesial temporal lobe epilepsy, and when you read that paper you see there was a significant struggle in recruiting people. This was at least due in part to patients' decisions about what they wanted in the first place. You could tell in that manuscript that some patients really just wanted one surgery or the other. I'm not sure if that that kind of research will ever be truly feasible in epilepsy surgery. Some patients are going to gravitate towards an open surgery, which have so far been shown to be a bit more effective than more minimally invasive techniques. Other patients don’t want to do open craniotomy, even if it would be more effective, and may elect to do a more minimally invasive surgery – which is an equally valid decision. For these patients, there’s no one size that fits all epilepsy surgery, and I think it's appropriate to provide different options for patients to consider.

Is there anything else you want clinicians to know about laser ablation?

I'd like physicians and patients alike to know that it's a good option, but that doesn’t mean it's the only option. I know that I've had patients come to our clinic here and say, “Well, I really want to have a laser ablation.” And then they go through the presurgical evaluation and we identify that perhaps a different treatment option would be best for them, whether for medical or personal reasons. And so, I would encourage physicians and patients alike to be open to different options. I mean, the goal is to investigate individual patient characteristics and then make a decision that's appropriate for them because again, every patient has different priorities. Every patient has different epilepsy types, and I think it's making that individual decision between the physician and the patient that really makes the best care.

Transcript edited for clarity.

REFERENCE

Landazuri P, Shih J, Leuthardt E, et. al. A prospective multicenter study of laser ablation for drug resistant epilepsy – One year outcomes. Epilepsy Res. 2020; 167. doi: 10.1016/j.eplepsyres.2020.106473