Gastric Cancer Treatment Interrupted by Capecitabine-Related Brain Toxicity

What happened, in summary

A woman in her 40s had been diagnosed 1 year earlier with stage IIB, non-metastatic gastric adenocarcinoma of the poorly differentiated diffuse signet ring cell type. She received 2 months of neoadjuvant FLOT chemotherapy, using fluorouracil, leucovorin, oxaliplatin, and docetaxel. She then underwent total gastrectomy with Roux-en-Y reconstruction. Because she could not tolerate the multiagent regimen, capecitabine was started 11 months later while abdominal radiation was being planned.

After only 1 week of capecitabine, she was hospitalized with severe nausea, vomiting, and upper abdominal pain. During the night, her blood pressure rose to 184/119 mm Hg. She became drowsy, could not follow commands, and had a witnessed seizure. Ativan and Keppra stopped the seizure, while hydralazine and labetalol controlled her blood pressure. Brain MRI showed symmetrical swelling in the posterior parietal, temporal, occipital, and superior frontal regions, supporting posterior reversible encephalopathy syndrome.

Capecitabine was stopped, and Keppra was gradually reduced as her cognition and vital signs improved over several days. At oncology follow-up 2 weeks later, chemotherapy and radiation remained suspended because of the seizure and MRI findings. She was advised to continue antihypertensive medication, aspirin, and Keppra and to establish neurological follow-up. Anxiety related to cancer and the new seizures also prompted a psychiatry referral. Her plan was later revised to radiation therapy alone.