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(Drug information 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(Drug information on phenytoin), 200 mg twice a day; phenobarbital(Drug information on phenobarbital), 45 mg twice a day and 60 mg at bedtime; and trimethoprim(Drug information on 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.