High frequency of bronchogenic carcinoma after single-lung transplantation

Transplantation for lung cancer

PURPOSE OF REVIEW

Recent advances have led to improved outcomes in lung transplantation. The International Society for Heart and Lung Transplantation Registry data have shown a steady increase in the number of cases performed annually. Although somewhat controversial, lung transplantation (LTx) for lung cancer has also slowly increased. The current role of LTx for malignant diseases and the management challenge of incidental lung cancer in the explanted lungs are reviewed herein.

RECENT FINDINGS

For a few particular scenarios (advanced multifocal bronchioloalveolar carcinoma causing chronic respiratory failure, end-stage lung disease concomitant with early stage lung cancer, and metastatic disease restricted to the lungs with the primary site controlled) in which nonsurgical alternatives fail to provide adequate palliation, LTx may be considered. Nevertheless, in order to achieve acceptable results, careful patient selection and staging are paramount. In patients with incidental bronchogenic carcinoma in the explanted lung following transplantation, the prognosis is mainly driven by the malignancy stage.

SUMMARY

LTx can be performed to treat malignant diseases with results approaching those for nonneoplastic indications, given that patients are carefully selected and staged. Although they have not been widely applied in the reported lung transplant literature, modalities such as endobronchial ultrasound and positron emission tomography scan are strongly encouraged and have the potential to further refine staging in this population.

Probable Phaeoacremonium parasiticum as a cause of cavitary native lung nodules after single lung transplantation

Lung nodules after lung transplantation most often represent infection or post-transplant lymphoproliferative disorder in the allograft. Conversely, native lung nodules in single lung transplant recipients are more likely to be bronchogenic carcinoma. We present a patient who developed native lung cavitary nodules. Although malignancy was anticipated, evaluation revealed probable Phaeoacremonium parasiticum infection. Phaeoacremonium parasiticum is a dematiaceous fungus first described as a cause of soft tissue infection in a renal transplant patient. Lung nodules have not been previously described and this is the first case, to our knowledge, of P. parasiticum identified after lung transplantation.

Risk of skin cancer and other malignancies in kidney, liver, heart and lung transplant recipients 1970 to 2008--a Swedish population-based study

Organ transplant recipients are at increased risk of a wide range of malignancies, especially cutaneous squamous cell carcinomas (SCC). Few previous population-based studies have quantified and compared cancer risks according to graft type and with long-term follow-up. Using nationwide Swedish registers, we identified 10,476 recipients transplanted from 1970 to 2008 and followed them for cancer occurrence. Relative risks of cancer in comparison with the general population were expressed as standardized incidence ratios (SIR) and within the transplanted cohort as incidence rate ratios (IRR). During a total follow-up of 93,432 person-years, patients were diagnosed with 1,175 cancers excluding SCC, and with 2,231 SCC, SIR(cancer excl SCC) 2.4 (95% CI, 2.2-2.5); SIR(SCC) 121 (95% CI, 116-127). Cancer risks were most increased among heart and/or lung recipients SIR(cancer excl SCC) 3.3 (95% CI, 2.8-4.0); SIR(SCC) 198 (95% CI, 174-224), followed by kidney SIR(cancer excl SCC) 2.3 (95% CI, 2.1-2.4); SIR(SCC) 121 (95% CI, 116-127) and liver recipients SIR(cancer excl SCC) 2.3 (95% CI, 1.9-2.8); SIR(SCC) 32 (95% CI, 24-42). During follow-up, risk of cancer excluding SCC remained stable while risk of SCC tripled over 20 years irrespective of graft type, partly due to a subgroup of patients developing new SCCs at a rapidly increasing rate. In summary, post-transplant cancer risk varied by transplanted organ and by cancer site, with the bulk of the excess risk driven by an exceptionally high and accelerating risk of SCC. These findings underscore the importance of regular skin screening in organ transplant recipients.

Lung cancer in idiopathic pulmonary fibrosis patients diagnosed during or after lung transplantation

Lung transplantation is an accepted therapy for patients with end-stage lung disease and offers a major survival benefit in selected patients. The most important indications are chronic obstructive pulmonary disease and idiopathic pulmonary fibrosis besides cystic fibrosis and pulmonary arterial hypertension. The incidence of lung cancer in patients after Ltx is 20–25 times higher than in the general population. Diagnosis is often difficult in IPF patients because of the diffuse lung abnormalities due to the underlying fibrosis. Moreover, the lung cancer may mimic a pulmonary infection. Symptoms are often aspecific, diagnosis is difficult, and prognosis is extremely poor. We describe three patients who were transplanted for idiopathic pulmonary fibrosis and who developed a primary lung cancer.

Mediastinal Small-Cell Lung Carcinoma after Right Lung Transplant for Pulmonary Interstitial Fibrosis

Pulmonary carcinoma is uncommon after lung transplant, but doubtlessly affects recipient survival independently of other complications. Small cell lung cancer is much rarer after transplant than non-small cell lung cancer. We report a case of mediastinal small cell lung carcinoma confirmed by endobronchial ultrasound biopsy that occurred 18 months after a single lung transplant for interstitial pulmonary fibrosis in a 58-year-old male non-smoker. The patient died shortly after of distant metastasis. Our report confirms the usefulness of tumor markers and positron-emission tomography-computed tomography as routine tests for earlier detection of malignant disease after lung transplant.

Spectrum of cancer risk among US solid organ transplant recipients

CONTEXT

Solid organ transplant recipients have elevated cancer risk due to immunosuppression and oncogenic viral infections. Because most prior research has concerned kidney recipients, large studies that include recipients of differing organs can inform cancer etiology.

OBJECTIVE

To describe the overall pattern of cancer following solid organ transplantation.

DESIGN, SETTING, AND PARTICIPANTS

Cohort study using linked data on solid organ transplant recipients from the US Scientific Registry of Transplant Recipients (1987-2008) and 13 state and regional cancer registries.

MAIN OUTCOME MEASURES

Standardized incidence ratios (SIRs) and excess absolute risks (EARs) assessing relative and absolute cancer risk in transplant recipients compared with the general population.

RESULTS

The registry linkages yielded data on 175,732 solid organ transplants (58.4% for kidney, 21.6% for liver, 10.0% for heart, and 4.0% for lung). The overall cancer risk was elevated with 10,656 cases and an incidence of 1375 per 100,000 person-years (SIR, 2.10 [95% CI, 2.06-2.14]; EAR, 719.3 [95% CI, 693.3-745.6] per 100,000 person-years). Risk was increased for 32 different malignancies, some related to known infections (eg, anal cancer, Kaposi sarcoma) and others unrelated (eg, melanoma, thyroid and lip cancers). The most common malignancies with elevated risk were non-Hodgkin lymphoma (n = 1504; incidence: 194.0 per 100,000 person-years; SIR, 7.54 [95% CI, 7.17-7.93]; EAR, 168.3 [95% CI, 158.6-178.4] per 100,000 person-years) and cancers of the lung (n = 1344; incidence: 173.4 per 100,000 person-years; SIR, 1.97 [95% CI, 1.86-2.08]; EAR, 85.3 [95% CI, 76.2-94.8] per 100,000 person-years), liver (n = 930; incidence: 120.0 per 100,000 person-years; SIR, 11.56 [95% CI, 10.83-12.33]; EAR, 109.6 [95% CI, 102.0-117.6] per 100,000 person-years), and kidney (n = 752; incidence: 97.0 per 100,000 person-years; SIR, 4.65 [95% CI, 4.32-4.99]; EAR, 76.1 [95% CI, 69.3-83.3] per 100,000 person-years). Lung cancer risk was most elevated in lung recipients (SIR, 6.13 [95% CI, 5.18-7.21]) but also increased among other recipients (kidney: SIR, 1.46 [95% CI, 1.34-1.59]; liver: SIR, 1.95 [95% CI, 1.74-2.19]; and heart: SIR, 2.67 [95% CI, 2.40-2.95]). Liver cancer risk was elevated only among liver recipients (SIR, 43.83 [95% CI, 40.90-46.91]), who manifested exceptional risk in the first 6 months (SIR, 508.97 [95% CI, 474.16-545.66]) and a 2-fold excess risk for 10 to 15 years thereafter (SIR, 2.22 [95% CI, 1.57-3.04]). Among kidney recipients, kidney cancer risk was elevated (SIR, 6.66 [95% CI, 6.12-7.23]) and bimodal in onset time. Kidney cancer risk also was increased in liver recipients (SIR, 1.80 [95% CI, 1.40-2.29]) and heart recipients (SIR, 2.90 [95% CI, 2.32-3.59]).

CONCLUSION

Compared with the general population, recipients of a kidney, liver, heart, or lung transplant have an increased risk for diverse infection-related and unrelated cancers.

Lung cancer in lung transplant recipients: experience of a tertiary hospital and literature review

BACKGROUND

Lung transplantation is a viable therapy for patients with end-stage lung disease and is being increasingly performed worldwide. The incidence of lung cancer after lung transplantation has increased concomitantly, although data are still sparse.

METHODS

The computerized medical records of the Pulmonary Institute of a tertiary care medical center were searched for patients who underwent lung transplantation from 1997 to 2009 and acquired lung cancer postoperatively. The prevalence, potential contributing factors, and outcome of bronchogenic cancer were determined, and the medical literature was reviewed.

RESULTS

Bronchogenic cancer developed in 7 of the 290 lung transplant recipients (2.4%). All had received a single lung transplant and in most cases, the cancer developed in the native lung. These findings were similar to reports in the literature. The indication for transplantation was chronic obstructive pulmonary disease or idiopathic pulmonary fibrosis/interstitial lung disease. All had a history of smoking. The average interval from transplantation to development of lung cancer was 5 years (range 1-9). Five patients had stage 4 cancer at diagnosis and 2 had stage 1. Six patients died from 10 days to 1 year after diagnosis.

CONCLUSION

Lung transplantation is associated with a relatively high prevalence of bronchogenic cancer, particularly in the native lung, in patients with primary chronic obstructive pulmonary disease/idiopathic pulmonary fibrosis, and a history of smoking. The cancer is usually diagnosed at an advanced stage with poor outcome. Efforts to improve screening are recommended, as aggressive management and treatment may be beneficial for earlier stage disease.

Malignancies following lung transplantation

Malignancy is an important complication of thoracic organ transplantation and is associated with significant morbidity and mortality. Lung transplant recipients are at greater risk for cancer than immunocompetent persons, with cancer-specific incidence rates up to 60-fold higher than the general population. The increased risk for cancer is attributed to neoplastic properties of immunosuppressive medications, oncogenic viruses, and cancer-specific risk factors. This article addresses the epidemiology, presentation, and treatment of the most common malignancies after lung transplantation, including skin cancer, posttransplant lymphoproliferative disorder, and bronchogenic carcinoma.

[Bronchogenic carcinoma after lung transplantation: a case report and literature review]

背景与目的

肺移植是治疗终末期肺部疾病的有效手段，然而对肺移植术后肺癌却缺乏了解。我们通过对1例肺移植术后肺癌患者临床资料的报道，并结合相关文献复习，以提高对肺移植术后肺癌的认识、诊断及治疗水平。

方法

2007年5月我院为一例65岁、术前诊断为两肺特发性肺间质纤维化（idiopathic pulmonary fibrosis, IPF）的男性患者在体外膜肺氧合（extracorporeal membrane oxygenation, ECMO）辅助下成功进行了右侧单肺移植，患者术后46 d恢复良好出院。术后免疫抑制方案为他克莫司（Tac）+吗替麦考酚酯（骁悉）+类固醇激素。出院后患者定期随访。

结果

在移植术后13个月随访确诊为非移植侧左肺小细胞肺癌伴多发骨转移。患者给予依托泊苷联合顺铂（EP方案）化疗4次症状有所缓解，患者在诊断肺癌后11个月死亡。

结论

肺移植术后肺癌严重影响移植患者远期存活，慢性阻塞性肺病（chronic obstructive pulmonary disease, COPD）、IPF、吸烟史及免疫抑制剂等为其危险因素，为改善预后，需要早期诊断及早期治疗。

Lung transplantation in advanced COPD: is it worth it?

Chronic obstructive pulmonary disease (COPD) is a condition of progressive airflow obstruction occurring primarily as a result of tobacco use that accounts for substantial worldwide morbidity and mortality. Medical therapy, with the exception of oxygen and smoking cessation, does not appreciably alter the natural progression of the disease. In contrast, when performed in carefully selected candidates, lung transplantation can provide substantial benefits in physiology, function, quality of life, and survival. Strict selection criteria limit transplant to highly compliant candidates with advanced disease but preserved functional status who are capable of successfully undergoing the operation. Although either single or bilateral lung transplant may be offered in COPD, recent evidence suggests that bilateral transplant is the preferred operation due to superior long-term outcomes. Regardless of the type of transplant operation, however, all lung transplant recipients are susceptible to numerous complications, including posttransplant infection and rejection. Despite these and other potential complications, advances in medical and surgical management now make lung transplantation a worthwhile therapeutic option in appropriately selected patients. In fact, lung transplant represents the only intervention that can substantially improve long-term outcomes in COPD patients with very advanced disease. Further work to refine recipient selection, improve lung allocation algorithms, and develop better treatments of chronic allograft dysfunction will lead to an even greater benefit to lung transplantation in this ill patient population.

[Medical complications of lung transplantation]

In 2010, lung transplantation is a valuable therapeutic option for a number of patients suffering from of end-stage non-neoplastic pulmonary diseases. The patients frequently regain a very good quality of life, however, long-term survival is often hampered by the development of complications such as the bronchiolitis obliterans syndrome, metabolic and infectious complications. As the bronchiolitis obliterans syndrome is the first cause of death in the medium and long term, an intense immunosuppressive treatment is maintained for life in order to prevent or stabilize this complication. The immunosuppression on the other hand induces a number of potentially severe complications including metabolic complications, infections and malignancies. The most frequent metabolic complications are arterial hypertension, chronic renal insufficiency, diabetes, hyperlipidemia and osteoporosis. Bacterial, viral and fungal infections are the second cause of mortality. They are to be considered as medical emergencies and require urgent assessment and targeted therapy after microbiologic specimens have been obtained. They should not, under any circumstances, be treated empirically and it has also to be kept in mind that the lung transplant recipient may present several concomitant infections. The most frequent malignancies are skin cancers, the post-transplant lymphoproliferative disorders, Kaposi's sarcoma and some types of bronchogenic carcinomas, head/neck and digestive cancers. Lung transplantation is no longer an exceptional procedure; thus, the pulmonologist will be confronted with such patients and should be able to recognize the symptoms and signs of the principal non-surgical complications. The goal of this review is to give a general overview of the most frequently encountered complications. Their assessment and treatment, though, will most often require the input of other specialists and a multidisciplinary and transversal approach.

Risk factors and outcomes for the development of malignancy in lung and heart-lung transplant recipients

BACKGROUND

Many factors may limit survival from lung and heartlung transplantation, including malignancy.

OBJECTIVE

To investigate factors associated with the development of malignancy following transplantation and its effect on survival by retrospectively reviewing a population of lung transplant recipients.

METHODS

Data from 342 consecutive lung transplant patients were collected. Results were analyzed by fitting variables into a multivariate logistic regression model predicting the development of post-transplant malignancies. Covariates were selected based on crude associations that reached a level of significance at P ≤ 0.10. Length of survival was analyzed using the Kaplan-Meier method.

RESULTS

Fifty-eight subjects developed post-transplant malignancies, which were the cause of death of 14 patients. Twenty-one patients had a pretransplant malignancy, of whom six developed a malignancy posttransplant--of these, two were fatal recurrences. No risk factors were significantly associated with all forms of post-transplant malignancy. When adjusted for age at transplantation and donor smoking history, Epstein-Barr virus seropositivity at the time of transplant was significantly associated with a reduced risk of a post-transplant lymphoproliferative disorder (OR 0.17; 95% CI 0.05 to 0.59). The median survival time in individuals without a post-transplant malignancy was significantly shorter than in those with a post-transplant malignancy (P = 0.018 Wilcoxon [Breslow]). This may be secondary to the length of time required to develop malignancy and the fact that not all malignancies that developed were fatal. The median time to develop malignancy was greater than two years. In addition, the 14 patients who died as a result of their malignancy had a significantly shorter survival time than the 44 who died because of nonmalignant causes (P < 0.001).

CONCLUSIONS

Malignancy was not associated with an overall decrease in survival time when compared with those who did not develop a malignancy. Risk factors specific for the development of malignancies remain difficult to specify.

Cancer incidence and risk factors after solid organ transplantation

Iatrogenic immunosuppression is a unique setting for investigating immune-related mechanisms of carcinogenesis. Solid organ transplant recipients have a 3-fold excess risk of cancer relative to the age- and sex-matched general population. Population-based studies utilizing cancer registry records indicate that a wide range of cancers, mostly those with a viral etiology, occur at excess rates. To date, cancer risk has predominantly been examined in adult kidney transplant recipients in Western countries. It is yet to be established whether a similar incidence profile exists in the long-term for other solid organ, pediatric and non-Western transplant recipients. The cancer incidence profile before and after kidney transplantation strongly suggests a relatively minor contribution by both preexisting cancer risk factors and the conditions underlying end-stage kidney disease, and points to a causal role for immunosuppression. Within-cohort risk factor analyses have largely been performed on cohorts with voluntary cancer notification, and very few have incorporated biomarkers of the level of immunosuppression, the current receipt of immunosuppressive agents, or genetic risk factors. Because of their markedly high risk of certain cancers, findings from comprehensive studies in transplant recipients have the potential to raise new avenues for investigation into causal mechanisms and preventive measures against immune-related and infectious causes of cancer.

Lung cancer and lung transplantation: a review

With the increase in the number of lung transplants, it is expected that there will be a corresponding increase in the number of lung cancers reported in these patients. Longevity of the transplant recipients, lung transplantation for chronic obstructive pulmonary disease and idiopathic pulmonary fibrosis, a history of smoking, and the increasing age of the lung donors make lung cancer more likely. Nodules and masses seen in chest imaging in lung transplant patients call for work up until a final diagnosis is achieved because there is a high likelihood of a serious infection or malignancy. The presence of a native lung is a major risk factor for lung cancer occurring in the transplant setting. Lung cancer of donor origin is rare. Bronchioloalveolar carcinoma confined to one lung can potentially be treated by transplanting the affected lung. Treatment for patients with lung cancer in the lung transplant setting has to be individualized because of the complexity of their medical problems and multiple medications. Attention needs to be focused on detecting lung cancer early in these patients to achieve a favorable outcome.

Bronchogenic carcinoma after lung transplantation: characteristics and outcomes

BACKGROUND

Lung cancer may occur in the lung transplant population because many patients are former smokers. Not much is known about risk factors and outcomes in these patients.

METHODS

We performed a search of the lung transplant database at our institution to identify patients who had been diagnosed with lung cancer. Records and reports were reviewed for demographics, risk factors for malignancy, lung transplant characteristics, radiographic characteristics, treatment, and outcomes.

RESULTS

We identified 12 lung transplant patients with bronchogenic carcinoma at our institution [age 47.2 +/- 13.2 years (mean +/- SD); 7 (58%) men and 5 (42%) women]. Eleven patients were transplanted for chronic obstructive pulmonary disease (COPD). Time from transplantation to diagnosis of cancer was 119 (21-416) [mean (range)] weeks. Eleven cancers occurred in the native lung; most common cancer cell types were adenocarcinoma (N = 5). Incidence among patients with COPD, who received single lung transplantation was 5.15%. Time from diagnosis of bronchogenic carcinoma to death was 10.8 (1-60) [mean (range)] weeks with a 75% (9/12) 1-year mortality.

CONCLUSIONS

Among our patients, almost all cancers occurred in native lung in ex-smokers who received a lung transplant for COPD. The cancer was often an incidental finding on a routine chest radiograph; however, the disease was usually at an advanced stage at diagnosis, limiting therapeutic options.

Incidence of Malignancies in Heart and/or Lung Transplant Recipients: A Single-Institution Experience

BACKGROUND

The purpose of this study was to determine the incidence and type of malignancies in heart and/or lung transplant recipients at a single institution in Victoria, Australia, and to compare these findings with the non-transplant general Victorian population.

METHODS

Recipients of heart and/or lung transplants at the Alfred Hospital between February 1989 and January 2004 were cross-referenced with the Victorian Cancer Registry. The medical records of all patients with a cancer diagnosis by January 1, 2005 were reviewed. Data were collected on baseline demographics, including cancer type, stage, treatment and survival. Cancer incidence was then compared with rates found in the Victorian population.

RESULTS

There were 907 transplants (Tx) conducted between February 1989 and January 1, 2004 on 905 patients, which included 424 heart (HTx), 56 heart-lung (HLTx), 200 single-lung (SLTx), and 227 double-lung (DLTx) procedures. Of these patients, 606 (67%) were male and 299 (33%) were female. Mean age at transplantation was 46.4 years (range 12.6 to 70.4 years). Four hundred twenty-four (47%) deaths have occurred. Median survival for all patients after transplantation was 8.6 years. One hundred two cancers were confirmed, translating to a 7.1-fold increased incidence compared with the non-transplant population. The most common cancer diagnoses were lymphoproliferative disorders (692 per 100,000 person-years), head and neck cancer (336 per 100,000 person-years) and lung cancer (251 per 100,000 person-years). Compared with the non-transplant population this translates into a 26.2-, 21.0- and 9.3-fold increased risk for developing these cancers, respectively, after cardio-pulmonary transplantation.

CONCLUSIONS

Certain malignancies are more common after heart and/or lung transplantation. The most predominant in our cohort were lymphoproliferative disorders, head and neck cancer and lung cancer.