Critical Care Intensivist Cooper University Health Care
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Introduction: Metastatic melanoma, specifically with the BRAF V600E mutation, has seen remarkable therapeutic advances over the past decade. Targeted therapies such as dabrafenib and trametinib, selective inhibitors of BRAF and MEK, have demonstrated high response rates and rapid clinical improvement in patients with this mutation genotype. Despite these advancements, initiating treatment in critically ill patients with life-threatening organ failure remains a clinical dilemma when encountered in the ICU. Our case highlights a unique use of VV-ECMO to stabilize a patient with profound hypoxemic respiratory failure secondary to diffuse pulmonary metastases which enabled the use of targeted therapy.
Description: A 49 year old male with a recent diagnosis of BRAF V600E variant melanoma with hemorrhagic brain metastases and innumerable pulmonary and hepatic metastases developed rapidly progressive hypoxemic respiratory failure several days into his hospital stay. The primary etiology of his sudden respiratory deterioration was thought secondary to complete bilateral atelectasis due to metastatic tumor burden. Due to his melanoma variant, there was an expected robust response to targeted therapies with dabrafenib and trametinib. Thus, salvage VV-ECMO as a bridge to definitive targeted therapy was employed to stabilize his refractory hypoxemia. Once initiated on targeted melanoma treatment, he had rapid improvement in his hypoxia and imaging showed pronounced resolution of his tumor burden. He was ultimately successfully decannulated, extubated, and discharged from the hospital several weeks following ECMO support and antineoplastic therapy.
Discussion: To our knowledge, this is the first documented use of VV-ECMO as a bridge to targeted therapy with dabrafenib and trametinib in BRAF-mutant melanoma. Despite the historically poor outcomes in critically ill cancer patients, our experience in this case demonstrated that VV-ECMO can be a life-saving intervention in carefully selected individuals with a clear, actionable therapeutic target. As therapies for genotype-specific melanoma evolves, integrating advanced life support strategies may offer new opportunities to extend survival and improve outcomes in patients once considered too sick or unstable to treat.
