Stage IV NSCLC with brain metastasis and organic psychosis: improvement with blonanserin patch

What happened, in summary

This man in his 80s had Stage IV non-small cell lung cancer, classified as cT3N2M1b. He first received 3 courses of pembrolizumab plus carboplatin and nab-paclitaxel, followed by 14 courses of maintenance pembrolizumab. About 2 years later, bone and brain metastases were detected, and CyberKnife radiation was given to brain metastases. At the next major presentation, he was urgently transported to the hospital because of disturbed consciousness and weakness in the left lower limb. Brain MRI showed new metastases in the right occipital lobe, right parietal lobe, and cerebellum. Doctors suspected seizure and impaired consciousness related to brain metastasis, and levetiracetam 1000 mg/day intravenously was started. He also had aspiration pneumonia, treated with antibiotics. On the night of admission, he became severely agitated, restless, sleepless, hallucinating, delusional, aggressive, and impulsive. Haloperidol and hydroxyzine did not control the symptoms, and the psychiatric liaison team diagnosed organic psychosis and delirium due to brain metastasis. Because he had difficulty swallowing and refused medication, the team started a blonanserin transdermal patch at 40 mg/day on hospital day 2. As he became calmer, intravenous haloperidol was stopped by day 9. A dose reduction to 20 mg/day was followed by worsening agitation and insomnia, so the patch was increased to 60 mg/day and then 80 mg/day. His mental state stabilized without oversedation or skin side effects, and he was discharged on hospital day 53. The lung cancer itself remained metastatic, so the outcome is ongoing life with cancer rather than remission.