Lung Cancer: Student/Resident Case Report Poster - Lung Cancer II |

Metastatic Choriocarcinoma to the Lung: Changing Dogma FREE TO VIEW

Darius Seidler, MD; Mark Franklin, MD
Author and Funding Information

Dartmouth-Hitchcock Medical Center, Lebanon, NH

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):765A. doi:10.1016/j.chest.2016.08.860
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SESSION TITLE: Student/Resident Case Report Poster - Lung Cancer II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Choriocarcinoma is a rare malignant germ cell tumor with a 80-85% rate of lung metastasis (1). Chemotherapy is highly effective, resulting in cure rates of approximately 90% (3). However, mortality rates have historically been close to 100% in patients requiring mechanical ventilation (MV) due to the tumor’s hypervascularity and propensity to bleed, resulting in catastrophic hemoptysis, barotrauma and ARDS (2). With such poor outcomes with MV and the absence of recent data, physicians are forced to rely on older studies which traditionally have argued against MV instead supporting the use of ECMO for management of hypoxia.

CASE PRESENTATION: A 29 year old female presented with respiratory distress and hypoxmia after an emergent c-section at 29 weeks of gestation. Work-up was pertinent for a beta-HCG level >1.9 million miU/mL, placental biopsy demonstrating choriocarcinoma, chest CT with multiple new pulmonary nodules and therefore the patient was diagnosed with metastatic choriocarcinoma. Standard chemotherapy with methotrexate, leucovorin, cisplatin and etoposide was started. Over the next 2 days the patient’s condition worsened and she required intubation for acute respiratory failure, with initial settings of volume control at a tidal volume of 380mL (0.6mL/kg), RR 20, PEEP 10cmH2O, FiO2 100%, plateau pressure 29cmH2O, resulting in oxygen saturations of 91%. Although initially maintaining stable plateau pressures her condition subsequently worsened. Veno-venous ECMO was started as per current initiation guidelines. After 5 days on ECMO, the patient’s oxygenation and CXR dramatically improved, allowing for decannulation. She was extubated 2 days later and 25 days after initial presentation the patient was discharged home without supplemental oxygen requirements

DISCUSSION: This is the second reported case of a patient with pulmonary choriocarcinoma metastases and respiratory failure requiring MV who has survived. Previous studies were done prior to the widespread use low tidal volume ventilation practices. Due to the rarity of choriocarcinoma and the relative paucity of data in terms of either ECMO or low tidal volume ventilation strategies, treatment modalities have not been firmly established. Treatment with ECMO vs. conventional ventilation should be made on a case-by-case assessment.

CONCLUSIONS: Our case suggests that ventilation strategies with low tidal volume ventilation may be a feasible option in patients with choriocarcinoma and respiratory failure. When converntional ventilation fails these patients can be supported with ECMO.

Reference #1: Nabers J et al. Choriocarcinoma with lung metastases during pregnancy and successful delivery and outcome after chemotherapy.Thorax1990;45:416-418.

Reference #2: Kelly MP et al. Respiratory failure due to choriocarcinoma:a study of 103 dyspneic patients. Gyn Onc 1990.28:149-154.

Reference #3: Vaccarello L, et al. Respiratory Failure from Metastatic Choriocarcinoma:A Survivor of Mechanical Ventilation. Gyn Onc 1997.67,111-114.

DISCLOSURE: The following authors have nothing to disclose: Darius Seidler, Mark Franklin

We describe the second case of choriocarcinoma metastatic to the lung who received mechanical ventilation and survived. Furthermore ECMO is a novel therapy and to our knowledge has not been described with choriocarcinoma metastatic to the lung.




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