Obaid Ashraf, MD
Fellow Physician
Allegheny Health System, United States
Disclosure information not submitted.
Subbarao Elapavaluru, MD,
Medical Director of Allegheny General Hospital ECMO Program
Allegheny General Hospital, United States
Disclosure information not submitted.
Briana Disilvio, MD
Physician
Allegheny Health Network, United States
Disclosure information not submitted.
Title: Putting Time in Perspective: Extracorporeal Membrane Oxygenation for Complex Thoracic Resection
Case Report Body:
Introduction: Advances in extracorporeal membrane oxygenation(ECMO) have enabled the facilitation of surgical intervention in patients who may otherwise be considered inoperable and giving them a terminal life sentence. We describe the first of its kind utilization of venoarterial(VA) ECMO for metastatic sarcomatoid yolk sac tumor involving right hemithorax presenting with impending cardio-respiratory failure.
Description: A 31-year-old male with a history of stage IB non-seminomatous germ cell tumor of the left testis presented to Emergency Room with progressively worsening dyspnea on exertion. Workup revealed mass occupying whole right hemithorax with the left mediastinal shift. The mass effect on the heart displaces the heart to the left, compressing the left atrium and IVC. Transthoracic biopsy of the mass showed a metastatic sarcomatoid yolk sac tumor. Patient deteriorated with hypoxia, acute kidney injury, lactic acidosis, and transaminitis suggestive of obstructive shock. After a Multi-disciplinary discussion, the patient was cannulated for VA ECMO, followed by intubation and initiated on mechanical ventilation. He underwent urgent surgical debulking with uncomplicated operative course. Post-Operative Day(POD) 2, he was transitioned to Veno-venous ECMO, and ECMO support was discontinued on Day 7. He required tracheostomy on POD 12. Two weeks later, chemotherapy with Cisplatin and etoposide was initiated. Since that time, he has been decannulated. He is functionally independent and oncologic plans for restaging at the end of four cycles of his chemotherapy.
Discussion: Sarcomatoid transformation of the Germ Cell tumor is a poor prognostic marker with five-year survival in the range of 35-65%. Our patient presented with bulky disease resulting in obstructive shock from mass effect on IVC and Left atrium, along with respiratory failure from mediastinal shift and lung collapse. These were all deemed high risk for imminent cardiopulmonary arrest and considered inoperable in current condition. We demonstrate utilization of ECMO to stabilize impending cardiopulmonary arrest in a metastatic disease patient, allowing to rescue and provide support to undergo complex thoracic surgery with minimal complications. These efforts resulted in allowing this gentleman to undergo chemotherapy and maintain his functional status.