Thoracoscopic Lung Biopsy During Venovenous Extracorporeal Membrane Oxygenation in Childhood

Clinical Summary

We report on the case of a 3-year-old child with a medulloblastoma grade IV WHO in the fourth ventricle, diagnosed 8 months prior to admission, and spinal metastases. The patient had already undergone resection of the cerebral mass and high-dose chemotherapy (HIT 2000 MET-BIS4; clinicaltrials.gov: NCT00303810) without radiation. Autologous stem cell therapy 6 months after diagnosis did not lead to clinical remission and the patient was intubated because of the development of acute respiratory distress syndrome (ARDS). Bronchoalveolar lavages showed persistent granulocytic inflammation, but no pathogens were detected. The suspicion of a chemotherapy-related lung insufficiency was raised as the patient could not be weaned from ventilation. High-frequency oscillation ventilation and high-dose steroid therapy were not clinically beneficial. After recurrent pneumothoraces, mediastinal emphysema, recurrent respiratory failure with resuscitation and hypercapnia, the patient was finally transferred to our hospital for further treatment.

We escalated the therapy to venovenous extracorporeal membrane oxygenation (ECMO, MEDOS DELTASTREAM; MEDOS Medizintechnik AG, Stolberg, Germany; Avalon ELITE Bi-Caval Dual Lumen, Avalon Laboratories LLC, Rancho Dominguez, CA, USA). The patient then stabilized clinically with normocapnia. No adequate lung recovery was seen under regular ventilation. There were radiological signs of a white lung without pathogens in subsequent lavages. Persistent elevation of inflammatory parameters and atypical cells in the lavage fluid raised the suspicion of malignancy ([Fig. 1]).

Fig. 1 Chest X-ray after initiation of extracorporeal membrane oxygenation establishing the presence of white lung sign.

Therefore, a lung biopsy was required to define the degree and origin of the lung damage. The platelet count was 113×10⁹/l, fibrinogen was 2.3 g/l and activated clotting time was 42 s. The biopsy was taken using a video-assisted thoracoscopic approach with a 5-mm optic trocar and two 3.5-mm working ports (KARL STORZ Instruments, Tuttlingen, Germany,) according to the technique recently published by us [1]. The procedure was well tolerated by the patient. We did not encounter any bleeding or clotting problems. Malignancy was ruled out by pathologic workup and the suspicious cells were accepted as a reactive alteration due to chemotherapy. Therefore, lung failure was due to chemotherapy and long-term ventilation. As a result of the histopathology, the therapy was ceased and the patient passed away 3 days after the operation.

References

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