Mediastinal Lymphoma Presenting in Cardiogenic Shock with Superior Vena Cava Syndrome in a Primigravida at Full Term: Salvage Resection after Prolonged Extracorporeal Life Support

Abstract

Primary mediastinal large B-cell lymphoma (PMBCL) is a rare type of non-Hodgkin lymphoma that typically has a good response rate to first line chemotherapy regimens. There have been reports of successful chemotherapy, but with a residual mass from fibrosis. Here, we report the case of a 19-year-old primigravida presenting with cardiogenic shock and superior vena cava (SVC) syndrome at full term who was found to have a PMBCL. Following delivery via urgent cesarean section, she was put on veno-arterial extra corporeal membrane oxygenation (VA-ECMO) and once hemodynamically stable was started on chemotherapy. In view of limited change in tumor size on consecutive CT scans and questionable response to chemotherapy, there were multidisciplinary meetings wherein withdrawing support was discussed and put forward to the family. At that point, surgical debulking was offered on compassionate grounds to be able to wean her off the VA-ECMO. This case report highlights the role of salvage resection when there are no other options.

Extracorporeal Membrane Oxygenation to Facilitate Chemotherapy—Moving the Goalposts!

“…Despite this, both guidelines acknowledge that ECMO, in select patient populations, may be a beneficial life-sustaining therapy despite the provided contraindications. As previously stated, there are multiple reports on the successful use of ECMO in a variety of different patient populations with hematologic and solid tumor cancers [3][4][5][6][7][9][10][11][12][13]. As such, we believe that the use of ECMO was justified in our patient given a supportive, multidisciplinary team of surgical and medical experts who agreed upon the treatment plan, as well as patient-specific factors such as age and chemo-sensitive nature of primary tumor.…”

“…Both VA-ECMO and veno-venous ECMO have been successfully described as a bridge to chemotherapy. The use of ECMO as a bridge to chemotherapy has been reported in children with hematologic malignancies [11], both children and adults with other chemotherapy-sensitive mediastinal malignancies [3][4][5][6][7]12], and even a pregnant woman at full term with mediastinal lymphoma, cardiogenic shock, and superior vena cava (SVC) syndrome [13].…”

Veno-arterial extracorporeal membrane oxygenationas a bridge to cytolytic therapy

“…The need for emergency ECMO for cardiorespiratory compromise in mediastinal malignancy is uncommon. There are few case reports in the literature which describe airway and vena caval compression by mediastinal mass requiring ECMO [1][2][3]. Our case report is a unique combination of large mediastinal mass with pulmonary artery and RV outflow tract compression complicated by acute sub-massive pulmonary embolism causing cardiorespiratory collapse.…”

Safe management of acute respiratory failure by mediastinal lymphoma: Transient endotracheal stent placement with short-term extracorporeal membrane oxygenation

“…These reports suggest that prolonged ECMO may reduce life expectancy in patients with hematological malignancies in the long run. We summarized previous reports of mediastinal hematological malignancies in patients under respiratory management with ECMO, mainly focusing on the methods of airway management, patient age, and duration of ECMO (Table 1) [4][5][6][7][8][9][10][11][12][13][14] . As a result, conventional tracheal intubation was performed in 5 cases, and ES placement was performed in 3 cases, including our own.…”