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Journal of Clinical Oncology, Vol 23, No 31 (November 1), 2005: pp. 8112-8113 © 2005 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.95.159
Variable Problems in LymphomasCASE 1. Burkitt's Lymphoma Presenting With Central Airway ObstructionNational Cancer Centre, Singapore, Singapore
Singapore General Hospital, Singapore, Singapore
National Cancer Centre, Singapore, Singapore
National Heart Centre, Singapore, Singapore A previously healthy, nonsmoking 21-year-old female student presented with cough, progressive dyspnea, and wheezing of 2 month's duration. The dyspnea and wheezing were most pronounced in the supine position, and she was thus unable to lie flat in bed. This was not associated with fever or weight loss. A chest x-ray revealed an anterior mediastinal mass further evaluated on a computed tomography scan of the chest. The mass occupied the anterior and superior mediastinum, encompassing the left brachiocephalic vein, and compressing the lower trachea, left main bronchus, left upper lobe, and pulmonary arteries (Fig 1). There was no other associated adenopathy. Her lactate dehydrogenase level was elevated at 535 U/L. Both alpha-feta protein (2.5 U/L) and beta-human chorionic gonadotrophin (< 2.0 U/L) levels were unremarkable. At initial presentation, she had an Eastern Cooperative Oncology Group performance status of 1, reduced air entry in both lungs with occasional wheezing, and she had neither any palpable lymphadenopathy nor organomegaly. Her blood pressure was normal at 110/70 mmHg, and pulse oximetry done with intranasal oxygen of 4 L/min in an upright posture was 98%. However, the oximetry promptly decreased to 84% when the patient assumed a supine posture. The patient underwent an open biopsy of the mediastinal mass under local anesthesia by a cardiothoracic surgeon (H.N.K.). On frozen section, the mass was confirmed to be a malignant lymphoma. However, midway through the procedure, the patient desaturated acutely, and was immediately intubated by an anesthetist with an endotracheal tube of 7.5 Fr. However, due to extensive airway compression by the tumor, adequate ventilation could not be achieved by conventional positive pressure ventilation. Examination of the airway by rigid bronchoscopy showed extensive compression of major airways from the distal 4 cm of the trachea, to the left main bronchus, with a residual patency of 20%. The right main bronchus was reduced to a slit-like orifice. A 12 x 40-mm silicone stent (Endoxane; Cometh Laboratoire, La Ciotat Cedex, France) was deployed into the left main bronchus. However, due to the severity of the obstruction, the stent remained compressed following deployment. As we were unable to overcome the airway obstruction, she remained difficult to ventilate, developing hypotension, respiratory acidosis, with a pCO2 of 80 mmHg, and hypoxemia. She was thus placed on venovenous extracorperal membrane oxygenation (ECMO) as a temporary measure to maintain her oxygenation and acid-base status. Despite her gas exchange being maintained by the ECMO circuit, she remained on the ventilator, with tidal volumes of 120 mL, positive end expiratory pressure of 15 cm water, with a respiratory rate of eight breaths per minute to prevent lung atelectasis. Her peak airway pressures were 30 cm water. Chemotherapy (intravenous dexamethasone 40 mg for 4 days, cyclophosphamide 750 mg, and vincristine 2 mg) was started immediately. Plans were made for radiotherapy if the patient did not respond adequately to the chemotherapy. She was also supported with low doses of intravenous dopamine infusion. Forty-eight hours later, the patient's peak airway pressures dropped from 65 mmHg to 35 mmHg, and tidal volumes improved from 120 to 500 mL. She was weaned off ECMO after 3 days and was successfully extubated 6 days following surgery. Her post-ECMO recovery period was complicated by pneumonia, which was treated with intravenous cefepime and metronidazole, while supported with subcutaneous filgastrim. A final histology report confirmed the diagnosis of Burkitt's lymphoma. Immunostains were strongly positive for CD20 and bcl-6. CD10 also stained positive, MIB-1 fraction was 95%, and fluorescent in situ hybridization was positive for 8:14 translocation. Further computed tomography staging and bone marrow studies were negative for disease elsewhere. The patient responded well to combination chemotherapy with "hyperCVAD" (hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone).
Recognition and diagnosis and of a compromised airway from a mediastinal tumor is vital, especially for chemosensitive tumors like lymphomas. The multidisciplinary approach to the management of our difficult case was crucial in ensuring a good outcome. Large mediastinal masses that compress the trachea, bronchi, and pulmonary arteries cause unpredictable variations in pulmonary mechanics,1 with flattened flow-volume loops on spirometry and ventilation/perfusion abnormalities.2-5 General anesthesia should be avoided. It causes collapse of the airway distal to the endotracheal tube because of muscle relaxation and loss of negative airway pressure associated with awake ventilation.6 Difficulties in intubation because of anatomic distortion of the airway, ventilation difficulties because of high airway pressures from trapped lung, and perfusion abnormalities because of compression of the pulmonary vasculature were all present in our patient. The use of portable cardiopulmonary bypass was crucial in management. Radiotherapy was not required because of the rapid response to chemotherapy. Portable cardiopulmonary bypass has been used as an emergency intervention in a variety of applications, including profound hypothermia,7 cardiopulmonary arrest due to coronary heart disease,8-10 pulmonary embolism,11 trauma,12 and upper-airway obstruction.13 A search of MEDLINE revealed one other case14 in which chemotherapy was administered while the patient was on portable cardiopulmonary bypass support. It is not known if cardiopulmonary bypass affects the plasma concentration levels of chemotherapy thus making it less effective. A small study15 on 10 patients showed that plasma vancomycin levels dropped by as much as 40%, when patients were on cardiopulmonary bypass, but not below the therapeutic levels for most pathogens. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
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9. Kurusz M, Zwischenberger JB: Percutaneous cardiopulmonary bypass for cardiac emergencies. Perfusion 17:269-277, 2002 10. Newsome LR, Ponganis P, Reichman R, et al: Portable percutaneous cardiopulmonary bypass: Use in supported coronary angioplasty, aortic valvuloplasty, and cardiac arrest. J Cardiothorac Vasc Anesth 6:328-331, 1992[CrossRef][Medline] 11. Mattox KL, Feldtman RW, Beall AC Jr, et al: Pulmonary embolectomy for acute massive pulmonary embolism. Ann Surg 195:726-731, 1982[Medline] 12. Hill JG, Bruhn PS, Cohen SE, et al:, Emergent applications of cardiopulmonary support: A multiinstitutional experience. Ann Thorac Surg 54:699-704, 1992[Abstract]
13. Rosa P Jr, Johnson EA, Barcia PJ: The impossible airway: A plan. Chest 109:1649-1650, 1996 14. Stewart AS, Smythe WR, Aukburg S, et al: Severe acute extrinsic airway compression by mediastinal tumor successfully managed with extracorporeal membrane oxygenation. Asaio J 44:219-221, 1998[Medline] 15. Miglioli PA, Merlo F, Grabocka E, et al: Effects of cardio-pulmonary bypass on vancomycin plasma concentration decay. Pharmacol Res 38:275-278, 1998[CrossRef][Medline]
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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