P059: BRIDGE TO CHEMOTHERAPY FOR POST-PARTUM METASTATIC TROPHOBLASTIC NEOPLASIA COMPLICATED WITH ACUTE RESPIRATORY DISTRESS SYNDROME: THE ROLE OF EXTRACORPOREAL MEMBRANE OXYGENATION
Jose Navas, MD; Jack Louro, MD; Miguel A Cobas, MD; Alexander C Fort, MD; University of Miami
Introduction: Gestational trophoblastic disease (GTD) encompasses a spectrum of benign and malignant conditions that have the potential to metastasize. Metastatic GTN constitutes a rare condition with a mortality of 30%–40% when multisystemic involvement is encountered. Metastatic seeds from GTN most commonly affect the lungs (80%), where it commonly manifests as dyspnea and hemoptysis with the ability to progress to adult respiratory distress syndrome (ARDS) in severe cases. The role of veno-venous extracorporeal corporeal membrane oxygenation (VV-ECMO) in the management of ARDS secondary to metastatic GTN has not been previously described in the literature.
Case Report: 23-year-old G2P1011 woman presented to the emergency department (ED) on postpartum day (PPD) 42 with a two-day history of vaginal bleeding, uterine tenderness, chest pain, shortness of breath, and hemoptysis. She had elevated beta-human chorionic gonadotropin, in addition to hypotension and hypoxemia and transvaginal ultrasound revealing retained products of conception. The patient was orally intubated, placed on mechanical ventilation; central venous access obtained, blood products administered and started on vasopressors. The CT of the chest demonstrated multiple consolidative opacities throughout both lung fields involving all lobes. The CT of the abdomen and pelvis showed an abnormally enlarged uterus, large volume ascites and extensive lesions throughout the liver. Diagnosis of stage IV metastatic GTN was made and the patient was emergently transferred to the intensive care unit. The patient subsequently developed hemoperitoneum secondary to bleeding liver metastatic lesions, that were successfully embolized by interventional radiology. Although, next day she developed massive hemoptysis which was initially controlled with angio-embolization, but associated to severe acute respiratory distress (PaO2/FiO2 ratio: 88mmHg). The patient was placed on veno-venous ECMO to facilitate bridge to initiation of chemotherapy and controlled of her hypoxemia.
On HD 10 she was started on induction chemotherapy (cisplatin/etoposide), which she tolerated well. On HD 13 full dose chemotherapy consisting of etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine (EMA/CO) was administered. Two more chemotherapy sessions were subsequently given over the course of the following three weeks and β-hCG levels decreased satisfactorily. During this time, her hemodynamic status remained stable and her respiratory status slowly improved without further hemoptysis. On HD 31 she was successfully decannulated from VV-ECMO and shortly after a tracheostomy was performed in preparation for transfer to a long-term acute care facility. Unfortunately, on HD 35 she developed acute mental status changes and was found to have a new metastatic cerebellar lesion with catastrophic cerebral hemorrhage. Ultimately, comfort care was initiated and the patient expired within a few days.
Conclusion: The case presented exemplifies a novel application for VV-ECMO in patients with metastatic GTN and ARDS. The patient was stabilized after the initiation of ECMO, which allowed for the initiation of chemotherapy. Therapy was deemed successful given an adequate decrease in the β-hCG levels. For either cardiovascular or respiratory support, ECMO techniques should be considered in the armamentarium of therapies for patients with metastatic GTN to facilitate initiation of chemotherapy and maximize the chances of survival in these patients.