A 43-year-old married man was referred to Memorial Sloan-Kettering
Cancer Center in June, 1995, for further management of a malignant
brain tumor. He was asymptomatic until April, 1994, when he suffered
a generalized seizure and was admitted to a local hospital. An
MRI revealed a right parietal lobe lesion. The tumor was resected
and found to be a glioblastoma multiforme.
The patient received hyperfractionated radiation therapy to a
total of 7,124 cGy during May and June of 1994, which was followed
by chemotherapy (carmustine [BiCNU]) every 6 weeks until January,
1995. No active treatment was administered from January to June,
but in April the patient was hospitalized for a partial motor
seizure, which was associated with hyponatremia and confusion.
In June, after a fall, a second MRI revealed progression with
a large contrast-enhancing right parieto-occipital mass invading
the corpus callosum and the anterior horn of the lateral ventricle
with considerable edema. He was begun on dexamethasone, 4 mg qid,
which produced significant improvement.
On initial consultation at Memorial Hospital in June, 1995, the
patient had considerable left-sided weakness, which was associated
with sensory impairment and difficulty with left peripheral vision.
He was unable to walk and required assistance with dressing and
bathing. Although he had no recent seizures, he was experiencing
frequent headaches not associated with nausea or vomiting.
In addition to dexamethasone, his drug regimen included phenytoin,
200 mg twice a day; phenobarbital, 45 mg twice a day and 60 mg
at bedtime; and trimethoprim-sulfamethoxazole, three times a week.
Because of the headaches, his dexamethasone dosage was increased
to 8 mg four times a day.
The patient was considered an appropriate candidate for an experimental
protocol and proceeded with four inpatient treatments of chemotherapy
during July and August. During the fourth cycle of treatment,
a psychiatric evaluation was requested for the assessment and
management of depression.
1. Bukberg J et al: Depression in hospitalized cancer patients.
Psychosom Med 43:199-212, 1983.
2. Cunningham LA: Depression in the medically ill. J Clin Psychiatry
55(suppl A):90-97, 1994.