Olanzapine and Betamethasone Are Effective for the Treatment of Nausea and Vomiting due to Metastatic Brain Tumors of Rectal Cancer
A 78-year-old male presented with nausea, vomiting, anorexia and slight right hemiplegia. He was diagnosed with rectal cancer in August 2007, and laparoscopic low anterior resection was performed. Pathological examination confirmed the diagnosis of rectal adenocarcinoma pSE,N2,M0, stage IIIb. He received adjuvant chemotherapy consisting of oral uracil and tegafur plus leucovorin for 1 year. In November 2008, lung metastases were detected, and the chemotherapy was switched to fluorouracil, levoleucovorin and irinotecan-based chemotherapy (FOLFIRI). In May 2009, lung metastases developed, and the chemotherapy was combined with bevacizumab. However, bevacizumab was discontinued due to angina in February 2011. The lung metastases worsened in January 2012, and the chemotherapy was changed from FOLFIRI to fluorouracil, levoleucovorin and oxaliplatin-based chemotherapy (FOLFOX4). In September 2012, brain imaging using magnetic resonance imaging (MRI) showed multiple brain metastases (maximum size 10 mm) in the left lobe with surrounding cerebral edema (fig. ).\nOn October 11, 2012 the patient was admitted for nausea, vomiting, anorexia and vertigo during body movement. Right hemiplegia appeared on hospital day 6, and he underwent whole brain radiation therapy with 30 Gy in 10 fractions starting on hospital day 7 in addition to therapy with glycerol 400 ml daily and the antiemetics metoclopramide and granisetron hydrochloride. The treatment failed to relieve his nausea and vomiting, and he was referred to the department of palliative care on hospital day 34. Treatment with olanzapine was initiated at a dose of 1.25 mg every night. The constant nausea disappeared the next day. The vomiting during body movement decreased from 2–3 times a day to 0–1 times a day, and the patient's appetite increased. However, 6 days after the administration of olanzapine, he developed a sudden intense headache in addition to nausea and vomiting, and right hemiplegia and anarthria rapidly progressed (on hospital day 39). On MRI, the size of the main brain metastatic lesion had increased to 20 mm and the surrounding cerebral edema had worsened (fig. ). The patient received betamethasone 4 mg per day in addition to olanzapine 1.25 mg. For approximately 3 weeks until death (on hospital day 64), the nausea and vomiting were relieved, without anorexia. However, the sudden periodic intense headaches and paralysis did not improve.