Introduction: The Intersection of Malignancy and Respiratory Failure
Acute respiratory failure (ARF) remains the primary driver for Intensive Care Unit (ICU) admission among patients with underlying malignancies. Within this cohort, Acute Respiratory Distress Syndrome (ARDS) represents a particularly lethal complication, characterized by non-cardiogenic pulmonary edema and profound hypoxemia. Historically, the prognosis for cancer patients requiring mechanical ventilation was considered dismal. While outcomes have improved over the last two decades due to advancements in both oncological therapies and critical care management, mortality rates remain significantly higher than those in the general population.
One of the most pressing questions in modern critical care is the role of advanced life support, specifically venovenous extracorporeal membrane oxygenation (ECMO), in patients with cancer. While ECMO has become a standard of care for refractory ARDS in many centers, its efficacy in the immunocompromised and oncological population remains a subject of intense debate. The YELENNA study (Acute respiratory distress syndrome in patients with cancer: the YELENNA prospective multinational observational cohort study) provides much-needed prospective data to clarify these clinical uncertainties.
Highlights
- The 90-day mortality rate for patients with cancer and ARDS reached 73.2%, rising to over 82% in those with severe disease.
- Venovenous ECMO did not demonstrate a survival benefit in patients with severe ARDS, even after rigorous propensity-score matching and adjustment.
- Independent predictors of mortality included advanced age, peripheral vascular disease, acute kidney injury, and severe ARDS at inclusion.
- A time-limited trial approach to ICU admission was associated with higher mortality compared to ‘full code’ status, reflecting the impact of pre-admission clinical status and goals-of-care.
Study Design and Methodology
The YELENNA study was a multinational, prospective, observational cohort study conducted across 13 countries in Europe and North America. The study aimed to describe the clinical characteristics, risk factors, and outcomes of cancer patients with ARDS and to specifically evaluate the association between ECMO and survival in the subgroup with severe ARDS.
Fig. Patient flowchart. ARDS acute respiratory distress syndrome, ECMO extracorporeal membrane oxygenation. Descriptive analyses are performed in 715 patients after exclusion of 61 patients due to missing 90-day survival status; the whole population cohort analysis is performed in 709 patients after exclusion of a further six patients due to missing time to event status
Patient Population
The researchers included 715 patients. The cohort was diverse but predominantly comprised of patients with hematologic malignancies (73.4%), while solid tumors accounted for 26.6%. Notably, 31.2% of the patients had undergone hematopoietic stem-cell transplantation (HSCT), with 168 of those being allogeneic—a group traditionally associated with the highest risk of infectious and non-infectious pulmonary complications.
Endpoints and Statistical Analysis
The primary endpoint was 90-day mortality. To address the inherent bias in observational data regarding ECMO use, the investigators employed a double-adjusted overlap- and propensity-weighted Cox mixed-effects model. This methodology allows for a more robust comparison between patients who received ECMO and those who did not by balancing baseline characteristics and severity of illness.
Key Findings and Results
The results of the YELENNA study underscore the gravity of ARDS in the oncological setting. The mortality rates across different stages of care were consistently high:
- ICU Mortality: 55.3%
- Hospital Mortality: 70.9%
- 90-Day Mortality: 73.2%
Predictors of Mortality
Through multivariate analysis, several factors were identified as independent predictors of higher 90-day mortality. These included older age, the presence of peripheral vascular disease, and the development of acute kidney injury (AKI). Furthermore, patients admitted to the ICU under a ‘time-limited trial’ (TLT) framework—where intensive care is provided for a set period to assess reversibility—had higher mortality compared to those admitted with ‘full code’ status. Interestingly, a diagnosis of lymphoma was associated with lower 90-day mortality, potentially reflecting the high chemosensitivity of certain lymphoma subtypes even in the setting of critical illness.
Table 2. Cox model assessing day-90 mortality in the overall population
| Adjusted hazard ratio (95% CI) | Adjusted P value | |
|---|---|---|
| Age tercile: ref. = [19–56] years | ||
| [56–66] | 1.3 (1.04–1.62) | 0.02 |
| [66–87] | 1.63 (1.3–2.06) | < 0.001 |
| Hematologic malignancy: ref. = leukemia | ||
| Lymphoma | 0.75 (0.57–0.97) | 0.03 |
| Myeloma | 0.7 (0.47–1.02) | 0.06 |
| Other | 0.87 (0.7–1.07) | 0.18 |
| Peripheral vascular comorbidity | 1.83 (1.21–2.77) | 0.004 |
| Goals of care: ICU trial (ref. = full code) | 1.41 (1.07–1.85) | 0.01 |
| ARDS severity (ref. = mild) | ||
| Moderate | 1.14 (0.86–1.51) | 0.36 |
| Severe | 1.76 (1.33–2.32) | < 0.001 |
| Acute kidney injury (ref. = no AKI) | 1.38 (1.13–1.69) | 0.002 |
Table 3. Doubly adjusted Cox model in patients with severe acute respiratory distress syndrome
| Adjusted hazard ratio (95% CI) | Adjusted P value | |
|---|---|---|
| SOFA score quartile: reference = [2–8] | ||
| [8–11] | 0.83 (0.42–1.64) | 0.59 |
| [11–14] | 0.77 (0.36–1.65) | 0.51 |
| [14–21] | 0.95 (0.39–2.35) | 0.92 |
| Peripheral vascular comorbidity: yes (ref. = no) | 2.8 (0.78–10.02) | 0.11 |
| Platelets quartile: reference = [0–21] 109/L | ||
| [21–45] | 0.96 (0.44–2.12) | 0.93 |
| [54–142] | 1.29 (0.55–3.03) | 0.55 |
| [142–609] | 0.63 (0.27–1.51) | 0.30 |
| ECMO (ref. = no ECMO) | 1.12 (0.65–1.94) | 0.69 |
The ECMO Paradox in Severe ARDS
Among the 715 patients, 322 (45.7%) presented with severe ARDS at inclusion. In this high-severity subgroup, the 90-day mortality was a staggering 82.2%. Within this group, 58 patients (18%) received venovenous ECMO.
The comparison between the ECMO and non-ECMO groups revealed no significant difference in survival. Specifically, the 90-day mortality was 82.6% for those receiving ECMO versus 80.7% for those who did not (P = 0.89). Even after applying the double-adjusted overlap- and propensity-weighted Cox mixed-effects model, the adjusted hazard ratio (aHR) remained non-significant at 1.12 (95% CI 0.65–1.94; P = 0.69). This suggests that in the current clinical landscape, the addition of ECMO to standard lung-protective ventilation and prone positioning does not change the ultimate trajectory for most cancer patients with severe ARDS.
Fig. 2.
Fig. Cumulative adjusted and weighted survival according to ECMO status in the 322 patients with severe ARDS. ECMO extracorporeal membrane oxygenation
Expert Commentary: Interpreting the Data
The findings from the YELENNA study are both sobering and clinically vital. The lack of benefit from ECMO in this population stands in contrast to the EOLIA trial results, which suggested a survival advantage in the general population with severe ARDS.
Why Does ECMO Fail to Improve Outcomes?
Several factors may explain this discrepancy. First, the underlying immune status of cancer patients, particularly those with hematologic malignancies or those post-HSCT, significantly impairs the body’s ability to recover from the initial pulmonary insult and subsequent secondary infections. Second, the complications associated with ECMO—including hemorrhage, thrombocytopenia, and infection—may be more frequent or severe in patients already dealing with bone marrow suppression or coagulopathy related to their malignancy.
Nuanced Goals-of-Care
One of the most important takeaways for clinicians is the need for early and nuanced goals-of-care discussions. The high mortality rate, particularly in the severe ARDS group, suggests that for many patients, intensive care may prolong the dying process rather than offer a bridge to recovery. The finding that ‘time-limited trials’ were associated with higher mortality should not be seen as a failure of the TLT approach, but rather as a validation of its use in identifying patients for whom ongoing aggressive intervention is unlikely to be beneficial.
The Challenge of Generalizability
This study raises significant concerns about the generalizability of standard ARDS and ECMO guidelines to the oncology population. Most current guidelines are derived from trials that excluded or under-represented cancer patients. The YELENNA data suggests that a ‘one-size-fits-all’ approach to ECMO may lead to the over-utilization of resource-intensive therapies in a population where they do not improve survival.
Conclusion
The YELENNA study provides definitive evidence that ARDS in cancer patients remains a high-mortality condition, with nearly three-quarters of patients succumbing by day 90. The failure of venovenous ECMO to improve survival in severe cases is a landmark finding that should prompt critical care and oncology teams to approach the use of this technology with extreme caution. Future research should focus on identifying the specific phenotypes within the oncology population—perhaps those with highly responsive malignancies or those in early stages of treatment—who might still benefit from advanced support, while ensuring that palliative care and realistic prognosis-sharing remain central to the management of the majority.
References
1. Schellongowski P, Darmon M, Eller P, et al. Acute respiratory distress syndrome in patients with cancer: the YELENNA prospective multinational observational cohort study. Intensive Care Med. 2025 Oct;51(10):1809-1819. doi: 10.1007/s00134-025-08113-7 IF: 21.2 Q1 .2. Combes A, Hajage D, Capellier G, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. N Engl J Med. 2018;378(20):1905-1916. (The EOLIA Trial for context).
3. Azoulay E, Pickkers P, Soares M, et al. Acute hypoxemic respiratory failure in immunocompromised patients: the Efraim multinational prospective cohort study. Intensive Care Med. 2017;43(12):1808-1819.
