Severe reversible neurologic toxicity after apatinib for metastatic gastric cancer

What happened, in summary

A 56-year-old man had been living with Stage IV gastric cancer since April 2012. Over the following years he received multiple chemotherapy courses as the cancer progressed. Palliative radiation was used for a right scapular bone metastasis in 2016 and a right adrenal metastasis in 2017. His last documented chemotherapy before the featured event was paclitaxel liposome plus epirubicin in May 2018.

In July 2018, CT showed that a left adrenal metastasis had enlarged. He declined further chemotherapy and started apatinib. Twelve days later he developed marked hypertension, dizziness and weakness in both legs, followed by two seizures and loss of vision. Brain imaging showed changes consistent with reversible posterior leukoencephalopathy syndrome, a serious neurologic toxicity.

Apatinib was stopped immediately. Blood-pressure control and treatment for brain swelling and seizures led to rapid improvement. His vision and leg strength returned, and later MRI showed complete resolution of the brain abnormalities.

By phone follow-up on April 25, 2019, he was alive, had no obvious discomfort and could care for himself. He was therefore living with Stage IV gastric cancer about 7 years after the original diagnosis.