Extracorporeal Membrane Oxygenation for Adult Patients With Neoplasms: Outcomes and Trend Over the Last 2 Decades

Metastatic Gestational Trophoblastic Neoplasia Leading to Acute Respiratory Failure and Death: A Case Report - About a Particularly Challenging Management in the Intensive Care Unit, and Exploring the Potential of Pembrolizumab in Treating Frail, Pretreated Gestational Trophoblastic Neoplasia

Introduction

Gestational trophoblastic disease (GTD) includes rare tumors from abnormal fertilization, ranging from benign hydatidiform moles to malignant choriocarcinomas (CCs) and rare placental-site trophoblastic tumors. Management of GTD depends on FIGO scoring, with low-risk cases treated conservatively and high-risk or ultra-high-risk cases requiring multi-agent chemotherapy, often EMA-CO, with induction therapy recommended for patients at very high risk of early death.

Case Presentation

We present the case of a 37-year-old female patient who developed an acute respiratory failure, requiring mechanical ventilation, 2 months after term delivery by cesarean section. The diagnosis of gestational trophoblastic neoplasia (GTN) was suspected due to high level of HCG in postpartum period and thoracic imaging suggesting multiple pulmonary metastases. No biopsy was available. She subsequently developed ventilator-associated pneumonia with severe acute respiratory distress syndrome (ARDS), requiring veno-venous extracorporeal membrane oxygenation support alongside concurrent polychemotherapy. After spending 61 days in the intensive care unit, and achieving biological complete remission based on HCG monitoring, the patient was transferred to the oncology ward. Due to prolonged hypoperfusion and hypoxemia, the patient developed ischemic cholangiopathy, severely constraining further therapeutic options. After 4 months of biological remission, the patient experienced a recurrence based on HCG rising and reappearing of pulmonary lesions on thoracic imaging in the lungs. In second line, the patient was treated with carboplatin, with no significant response. In third line, pembrolizumab was used, and the patient experienced a significant decrease in HCG. However, due to hematologic toxicity, we discontinued the treatment. Subsequently, the HCG level raised and the patient rapidly developed hemorrhagic cerebral metastasis and succumbed shortly thereafter.

Conclusion

This case underscores the importance of prompt recognition and timely intervention in the management of patients with ARDS during the early postpartum period. GTN with lung involvement should be considered after excluding the other more frequent causes of ARDS. It also highlights how ECMO support enables the continuation of chemotherapy and the achievement of remission in CC. Furthermore, due to the inability to initiate the desired chemotherapy, immunotherapy was introduced as a possible treatment modality. Therefore, this case underscores the importance of adaptability in treatment plans based on patient-specific clinical conditions and collaborative decision-making with specialized centers. Finally, it emphasizes the efficacy of pembrolizumab, even as a monotherapy, in pretreated CC cases.

Successful management of hemodynamic instability secondary to saddle pulmonary embolism-induced cardiac arrest using VA-ECMO in advanced malignancy with brain metastases

BACKGROUND

Saddle pulmonary embolism (SPE) represents a rare type of venous thromboembolism that frequently causes circulation collapse and sudden death. While venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been well established as a salvage treatment for SPE-induced circulatory shock, it is infrequently administered in patients with advanced malignancy, especially those with brain metastases, given the potential bleeding complications and an uncertain prognosis. As far, there are rare case reports regarding the successful management of hemodynamic instability secondary to SPE-induced cardiac arrest using VA-ECMO in advanced malignancy patients with brain metastases.

CASE PRESENTATION

A 65-year-old woman presenting with cough and waist discomfort who had a history of lung cancer with brain metastases was admitted to the hospital to receive chemoradiotherapy. She suffered sudden cardiac arrest during hospitalization and returned to spontaneous circulation after receiving a 10-min high-quality cardiopulmonary resuscitation. Pulmonary embolism was suspected due to the collapsed hemodynamics and a distended right ventricle identified by echocardiography. Subsequent computed tomographic pulmonary angiography revealed a massive saddle thrombus straddling the bifurcation of the pulmonary trunk. VA-ECMO with adjusted-dose systemic heparinization was initiated to rescue the unstable hemodynamics despite receiving thrombolytic therapy with alteplase. Immediately afterward, the hemodynamic status of the patient stabilized rapidly. VA-ECMO was successfully discontinued within 72 h of initiation without any clotting or bleeding complications. She was weaned off invasive mechanical ventilation on the 6th day of intensive care unit (ICU) admission and discharged from the ICU 3 days later with good neurological function.

CONCLUSION

VA-ECMO may be a 'bridging' therapy to circulation recovery during reperfusion therapy for SPE-induced hemodynamic collapse in malignancy patients with brain metastases.