The serious clinical presentation of the novel Influenza A (H1N1) infection in some cancer patients should be expected. Patients with cancer now live longer and immunosupression from malignant disease or its treatment renders many susceptible to infections [15] . Indeed, most of the patients in this series developed bacterial coinfections. The altered immunological response of these patients may contribute to the original article Annals of Oncology development of more severe forms of disease. In our study, three cases still excreted virus after 5 days in the ICU, as already reported [16] . Prolonged periods of viral shedding could be associated to disease severity [17] and perhaps with an oseltamivir-resistant strain of the virus [18] . Respiratory failure occurred in all patients who required ICU care and was characterized by rapidly progressive bilateral lung infiltrates with refractory hypoxemia and low left atrial pressure-ARDS. Most patients needed mechanical ventilation (five of eight), and they were all treated with protective strategies according to the ARDS Network protocol [19] . In all these patients, recruitment maneuvers were applied, with just transient improvement in oxygenation (initial median oxygen saturation rate increased from 88% to 94%), reflecting the extensive lung involvement of disease. In some cases of severe H1N1 infection, extracorporeal membrane oxygenation [20] has been proposed as an alternative support therapy with promising results [21, 22] .