Rapid-onset acute respiratory distress syndrome after mastectomy in a breast cancer patient

Abstract

Rationale: Postoperative acute respiratory distress syndrome (ARDS) often results in severe morbidity and mortality in surgical patients. The etiology of this condition is complex, especially in cancer patients. Patient concerns: We encountered a 53-year-old woman with left breast cancer, cT1cN2M0, stage IIIA with left axillary lymph node metastasis. She had received chemotherapy with 4 cycles of doxorubicin plus cyclophosphamide, and 4 cycles of trastuzumab plus docetaxel within a span of 6 months. Subsequently, she underwent left simple mastectomy and axillary lymph node dissection, shortly after which she developed respiratory distress with progressive desaturation and hemoptysis. Diagnosis: ARDS was diagnosed using the Berlin criteria. Her arterial blood gas analysis revealed profound hypoxemia and her chest imaging was suggestive of pulmonary edema. She developed diffuse alveolar hemorrhage (DAH) that was confirmed with bronchoscopy and hemorrhagic samples on bronchoalveolar lavage. Interventions: She was mechanically ventilated with lung protective measures for management of ARDS. In addition to antibiotic cover with amoxicillin sodium-potassium clavulanate for occult infections during her stay in the intensive care unit, we administered epinephrine inhalations, intravenous treatment with tranexamic acid, and methylprednisolone for DAH. Outcomes: Her clinical course improved; she was extubated successfully on day 7 and discharged home on day 11. Lessons subsections: Chemotherapeutic agents may cause pulmonary toxicity through a direct cytotoxic effect or immune-mediated reactions and result in an increased risk of development of ARDS. Furthermore, surgery may trigger a systemic inflammatory response syndrome that can also induce ARDS. In our patient, the development of ARDS was attributed to the combined effects of surgery and chemotherapeutic agents (trastuzumab or docetaxel). When patients undergo major surgery after receiving chemotherapeutic agents, careful consideration is necessary to prevent the development of ARDS.

Cancer Immunotherapies: What the Perioperative Physician Needs to Know

“…Perioperative pulmonary complications may be increased in patients treated with these agents. Acute respiratory distress syndrome after mastectomy was reported in a patient who received neoadjuvant therapy that included trastuzumab [ 67 ]. The perioperative physician should review the past medical history (PMH) for ILD or treatment with targeted antibodies associated with pulmonary toxicity, elicit signs and symptoms of such, and consider chest imaging and pulmonary function testing, to help guide intraoperative management (i.e., lung protective ventilation) and postoperative monitoring (i.e., continuous pulse oximetry) and care.…”