Possibility of venoarterial extracorporeal membranous oxygenator being a bridging therapy for hemodynamic deterioration of pulmonary tumor thrombotic microangiopathy prior to initiating chemotherapy

Abstract

Rationale:Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare but lethal complication of carcinoma, defined as non-occlusive pulmonary tumor embolism complicated by fibrocellular intimal proliferation of the small pulmonary arteries, with eventual occlusion of the pulmonary arteries. Hemodynamic deterioration caused by this condition leads to high mortality.Patient concerns:A 46-year-old woman who had undergone radiation therapy for anaplastic oligoastrocytoma and who was taking temozolomide presented with cough and palpitations.Diagnoses:A 12-lead electrocardiogram showed sinus tachycardia and SIQIII TIII, with negative T in V1–3. Ultrasound cardiography showed a distended right ventricle. Enhanced chest computed tomography showed no significant thrombus in the major pulmonary artery. The patient's condition deteriorated the next morning, with her blood pressure decreasing to 40 mmHg and her SpO2 unmeasurable. She suffered cardiac arrest.Interventions:We initiated venoarterial extracorporeal membranous oxygenation (VA-ECMO) and her blood pressure increased to 80 mmHg. Her hemodynamic status stabilized and she was weaned off VA-ECMO on intensive care unit (ICU) day 3.Outcomes:Gastroesophageal endoscopy on ICU day 4 revealed gastric cancer (Borrman type IV), and she arrested again and died on ICU day 5. Autopsy confirmed gastric cancer and PTTM.Lessons:VA-ECMO rapidly stabilized the hemodynamic status of this patient with PTTM, and may thus be a possible bridging therapy for deterioration of PTTM prior to initiating imatinib.

Crizotinib for ROS1‐rearranged lung cancer and pulmonary tumor thrombotic microangiopathy under venoarterial extracorporeal membrane oxygenation

“…The use of VA‐ECMO for PTTM has been controversial because PTTM characterizes rapid progression associated with malignancy, where it is almost impossible to wean a patient from support. There have been only two reports demonstrating the use of VA‐ECMO for PTTM 2,3 . Ogawa et al 2 reported about a 47‐year‐old female with gastric adenocarcinoma who was supported with VA‐ECMO, which bridged imatinib, a TKI against PDGF, followed by chemotherapy.…”

“…There have been only two reports demonstrating the use of VA‐ECMO for PTTM. 2 , 3 Ogawa et al 2 reported about a 47‐year‐old female with gastric adenocarcinoma who was supported with VA‐ECMO, which bridged imatinib, a TKI against PDGF, followed by chemotherapy. The patient died 9 months later.…”

“…The patient died 9 months later. Iwashita et al 3 reported about a 46‐year‐old female supported with VA‐ECMO who died 2 days after weaning. No other reports have described long‐term survival.…”

“…Therefore, very few cases have been diagnosed antemortem. Some reports have demonstrated the efficacy of imatinib, a tyrosine kinase inhibitor (TKI) against platelet‐derived growth factor (PDGF), in PTTM 2,3 . Recent advances in tailoring cancer treatment to the genetic profile could prolong survival in cancer.…”

“…Some reports have demonstrated the efficacy of imatinib, a tyrosine kinase inhibitor (TKI) against platelet‐derived growth factor (PDGF), in PTTM. 2 , 3 Recent advances in tailoring cancer treatment to the genetic profile could prolong survival in cancer. However, there have been no reports of PTTM with an antemortem diagnosis of genetically analyzed cancer and personalized treatment.…”