Primary bronchogenic carcinoma in the heart transplant recipient

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.

Characteristics of thoracic malignancies that occur after solid-organ transplantation

BACKGROUND

Chronic immunosuppression after solid-organ transplantation is associated with increased risk of developing malignancies. The purpose of this study was to determine the clinical characteristics and the outcome of thoracic malignancies in patients who have undergone solid-organ transplantation.

METHODS

Among a cohort of 2831 patients who received a transplant at our institution and were followed between 1984 and 2009, 24 patients (0.85%) developed thoracic malignancies. Risk factors for lung cancer, as well as demographic, cancer, and transplantation characteristics, were analyzed. Survival data were also collected.

RESULTS

Twenty-four patients were included (21 men, median age 61.7 years). Twenty-two patients were smokers. The most frequent histologic types were squamous cell carcinoma (n = 11, 46%) and adenocarcinoma (n = 9, 37%). The median time period between transplantation and diagnosis of lung cancer was 6.6 years. Ten lung malignancies occurred after kidney transplantation (0.5%), eight after liver transplantation (1.3%), and six after heart transplantation (2.8%). Seven patients underwent surgery, three had radiotherapy, four had chemotherapy, and six had multimodal treatment. The median survival time was 1.5 years, ranging from 6 months for stage IV to 3.7 years for stage I.

CONCLUSION

Solid-organ transplantation is associated with a high risk of lung cancer and may have an important synergetic part with other risk factors for lung cancer (tobacco). However, survival rates from lung cancer in our study population are similar to those of nontransplanted patients. In addition, surgery can result in favorable survival results.

Small-cell Lung Carcinoma of Recipient Origin After Bilateral Lung Transplantation For Cystic Fibrosis

Bronchial carcinoma, usually of the non-small-cell type, is uncommon after lung transplantation and occurs predominantly in single-lung transplant ex-smoker recipients on their native lung. Bronchial carcinoma of donor origin is much rarer. We report the case of a small-cell lung carcinoma of recipient origin that occurred 12 months after a bilateral lung transplantation for cystic fibrosis in a 25-year-old woman who was a non-smoker. The tumor was of recipient origin, due to a gender mismatch between donor and recipient. This unusual observation corroborates the hypothesis of chimerism of the bronchial epithelium after lung transplantation.

Routine computed tomography screening of the chest in high-risk cardiac transplant recipients may improve survival

BACKGROUND

Multiple studies have demonstrated an increased incidence of lung cancer in the heart transplant population. We reviewed our cardiac transplantation experience with respect to the development of bronchogenic carcinoma and explored the role of routine chest computed tomography (CT) in its surveillance.

METHODS

We performed a review of our cardiac transplantation experience, highlighting the incidence of lung cancer, and we analyzed our recent experience with screening chest CT in lung cancer surveillance in this patient group.

RESULTS

Eighteen patients developed 20 cases of bronchogenic carcinoma for an incidence of 6.83%. In 10 cases, the patients underwent surgical resection; however, in the remaining cases, the patients were either treated with chemotherapy and/or radiation or they died before initiation of therapy. The actuarial 1-, 2- and 5-year overall survival rates were 49%, 29% and 13%, respectively. The median survival of patients who underwent surgical resection was 28 months (3 to 85 months), whereas the median survival of patients who were either ineligible for surgery or died before initiation of treatment was only 1 month (1 to 13 months). All patients diagnosed with lung cancer by chest CT underwent surgical resection; however, only 37.5% of patients diagnosed with lung cancer by chest X-ray were found at an appropriate stage for resection (p = 0.025).

CONCLUSIONS

Cardiac transplant recipients have a significant risk of developing bronchogenic carcinoma. Routine chest CT screening in high-risk patients may enable clinicians to identify disease earlier, which is essential for the option of surgical resection and, therefore, prolonged survival.

Bronchogenic carcinoma in solid organ transplant recipients

Malignancies are increased in some types of solid organ transplant patients receiving immunosuppressive therapy and are a significant contributor to patient morbidity and mortality. There may be a 100-fold increase in the incidence of de novo neoplasia in this population. The risk of lymphoproliferative malignancies is well appreciated. In contrast, the risk of solid tumors with their consequent morbidity and mortality is less well known, probably because of their common occurrence in the general population. Lung cancer is the most common cause of cancer death in the United States; therefore, lung cancer in patients undergoing organ transplantation would be expected to occur frequently on the basis of chance alone. However, the lung cancer risk is approximately 20 to 25 times that of the general population, with an incidence of 0.28% to 4.1% in patients after heart and lung transplant. Risk factors thought to contribute include cigarette smoking, advanced age at transplantation, and chronic immunosuppressive therapy. The role of transplantation (and consequent therapy) in the development of lung cancer in this high-risk population remains unclear. As in the nontransplant population, adequate screening techniques are lacking, making early diagnosis and treatment a challenge. Despite close follow-up and routine imaging with chest radiography and CT, lung cancers continue to be discovered incidentally and at advanced stages. Treatment is similar to that of patients who are nontransplanted with similar stage, histology, and performance status.

Incidence of cancer after immunosuppressive treatment for heart transplantation

Prolonged or intensive immunosuppressive therapy used after organ transplantation is complicated by an increased incidence of cancer. Striking differences in incidence are observed in heart and heart-lung transplant recipients when compared with renal transplant patients. The most significant increase was in the incidence of lymphomas in cardiac versus renal patients. Moreover, a two-fold greater increase of all neoplasms was found in cardiac recipients, with nearly a six-fold increase in visceral tumors. Several factors may account for these differences. In cardiac allograft recipients, intensive immunosuppression is frequently used to reverse acute rejection and the highest number of cardiac transplants was performed in the era of polypharmacy, usually consisting of triple therapy.

Immediate and Long-Term Survival After Surgery for Lung Cancer in Heart Transplant Recipients

BACKGROUND

Lung cancer observed after heart transplantation is considered to have a poor prognosis. However, the results of surgical treatment have not yet been significantly evaluated. This retrospective study analyzed the immediate and long-term results after surgery.

METHODS

From May 1990 to December 2003, 25 heart transplant recipients underwent surgery for lung cancer. There were 22 men and 3 women, the mean age was 60.7 years (49-72). All patients had a smoking history. Lung tumors were discovered by routine chest roentgenograms and computed tomography scans in 17 patients (68%), because of clinical symptoms in 7 (28%), and incidentally in 1 (4%). The surgical procedures consisted of 23 lobectomies and 2 wedge resections.

RESULTS

The mean postoperative hospital stay was 14.2 days (5-34). The morbidity rate was 28% (n = 7 patients). The mortality rate was 12% patients (n = 3 patients). The postoperative complications in 7 of 10 patients were mainly from infectious origin. Five-year survival rate was 40.9% with a median survival of 45 months. Seven patients died during follow-up (3 from cancer and 4 from other diseases). Significant better survival was observed in N0 patients than in N+ patients (median survival of 56.8 months in N0 vs 13.5 months in N+ patients (p = 0.017).

CONCLUSIONS

Long-term results after surgery were satisfactory in early stage disease, despite a high risk for postoperative infection. Our results underline the efficiency of a close follow-up for transplant recipients with a smoking history, leading to cancer detection at an early stage.

Bronchogenic carcinoma after solid organ transplantation

BACKGROUND

This study assesses the risk of bronchogenic carcinoma after solid organ transplantation. Although the overall incidence of malignancy is increased after solid organ transplantation, the risk of bronchogenic carcinoma in the transplant population has not been systematically studied.

METHODS

Among a cohort of 3,374 patients transplanted in our institution between 1985 and 2000 (1,735 kidney recipients, 930 liver, 313 heart, and 396 lung recipients), 9 patients (0.3%) had a bronchogenic carcinoma develop. Lung carcinoma occurred in 3 kidney recipients, 3 liver recipients, 2 heart recipients, and 1 lung recipient.

RESULTS

Time to diagnosis after the transplant procedure ranged from 9 to 126 months (mean, 63 months). Aside from the lung transplant candidate, all recipients had a smoking history. Seven patients underwent thoracotomy and 6 had a complete resection. Tumors were classified as stage IA (n = 1), IB (n = 2), IIB (n = 2), IIIA (n = 2), IIIB (n = 1), and IV (n = 1). Genotyping demonstrated that the carcinoma arising in the lung transplant recipient originated from the donor and may have been transmitted at the time of transplantation. Two patients were alive without recurrence 21 and 42 months after the operation.

CONCLUSIONS

The risk of bronchogenic carcinoma is low and occurs mainly in recipients with a smoking history. However, bronchogenic carcinoma can also be transmitted from donor lungs at the time of transplantation. Hence careful examination of chest roentgenograms, and computed tomographic chest scan if available, as well as meticulous assessment of the lung, and biopsy of any suspicious lesions, are important to limit the risk of lung cancer transmission, especially with the liberalization of donor criteria.

Primary lung carcinoma after heart or lung transplantation: management and outcome

OBJECTIVE

We sought to examine our management and outcome of lung carcinoma occurring after thoracic organ transplantation.

METHODS

We performed a retrospective review of cases of primary lung carcinoma diagnosed between 1990 and 2000 in patients who have previously undergone thoracic transplantation at our institution.

RESULTS

Seventeen patients were identified (1 lung and 16 heart transplants). Median time from transplantation to diagnosis of lung carcinoma was 89 months (range, 46-138 months). Predominant presentation was as an incidental finding at chest radiography (13/17). All patients had smoked cigarettes before transplantation, with 5 continuing to smoke after transplantation. Histologic types were squamous (n = 11), adenocarcinoma (n = 3), small cell (n = 2), and undifferentiated (n = 1). Revised International Union Against Cancer (UICC) clinical stage at the time of diagnosis was stage I or II in 11 of 17 patients. Of these, 9 underwent surgical resection; 2 patients unfit for surgical intervention had radiotherapy. Surgical procedures were lobectomy (n = 5), wedge excision (n = 3), and no resection (n = 1). Median survival after diagnosis was 12 months for all patients and 24 months if the tumor was resected. Six patients who had surgical resection subsequently died (survival of 2, 9, 21, 21, 36, and 67 months); 2 remain alive after 12 and 54 months, respectively.

CONCLUSIONS

When possible, surgical intervention should be undertaken for early stage lung cancer occurring after thoracic transplantation because medium-term survival is achievable. Sublobar excisions and definitive radiotherapy should be considered if comorbidity prevents optimal surgical treatment.

Transdiaphragmatic hernia 1 year after heart transplantation following implantable LVAD

Complications after ventricular assist devices placement most frequently consist of bleeding, infection, and thromboembolic events. We describe a late complication after transplantation caused by transdiaphragmatic connection of the device placed in the abdominal position that presented as an acute pulmonary syndrome, misleading initial diagnosis.

Bronchogenic carcinoma complicating lung transplantation

BACKGROUND

Malignancy is a well-recognized complication of solid-organ transplantation. Although a variety of malignancies have been reported in lung transplant recipients, a paucity of information exists regarding the incidence and clinical course of bronchogenic carcinoma in this patient population.

METHODS

We conducted a retrospective cohort study of our lung transplant experience at the University of Pennsylvania.

RESULTS

We identified 6 patients with bronchogenic carcinoma detected at the time of, or developing after, transplantation. The incidence of bronchogenic carcinoma was 2.4%. All patients with lung cancer had a history of smoking, with an average of 79 +/- 39 pack-years. A total of 5 patients had chronic obstructive pulmonary disease, and 1 had idiopathic pulmonary fibrosis. Lung cancers were all of non-small-cell histology and first developed in native lungs. Three patients had bronchogenic carcinoma at the time of surgery. The remaining 3 patients were diagnosed between 280 and 1,982 days post-transplantation. Of the 6 patients, 4 presented with a rapid course suggestive of an infectious process. The 1- and 2-year survival rates after diagnosis were 33% and 17%, respectively.

CONCLUSION

Lung transplant recipients are at risk for harboring or developing bronchogenic carcinoma in their native lungs. Rapid progression to locally advanced or metastatic disease commonly occurs, at times mimicking an infection. Bronchogenic carcinoma should be considered in the differential diagnosis of pleuroparenchymal processes involving the native lung.

Neoplastic disease after heart transplantation: single center experience

OBJECTIVES

Mandatory use of prolonged immunosuppression in organ transplantation is complicated by an increased incidence of cancer. The current study represents a retrospective analysis of the incidence of neoplasms in our heart transplantation program.

METHODS

Four-hundred and seventy-four patients (403 male and 71 female; mean age, 48.6+/-12.1 years), with at least 30 days of follow-up, were enrolled in this study. Patients received triple immunosuppression with cyclosporin A, azathioprine and steroids. Moreover, as a prophylactic anti-lymphocyte therapy, 388 patients (82%) were administered RATG, 67 patients (14%) received ALG and 19 patients (4%) OKT3. The mean follow-up time was 71.1+/-43.0 months.

RESULTS

Fifty-five patients (11.6%) developed malignant neoplasms. The cancer frequencies were: solid tumors, 55%; non-Hodgkin lymphomas (NHL), 20%; Kaposi's sarcomas, 11%; skin cancers, 9%; undifferentiated sarcomas and myelomas, 5%. Solid tumors mainly affected the lung (39%), bowel (16%), stomach (6.5%), liver (6.5%), pancreas (6.5%) and oral cavity (6.5%). The times to the onset of cancer from transplantation were: Kaposi's sarcoma, 12.7+/-16.8 months; skin cancers, 34.5+/-23.8 months; solid tumors, 54.3+/-38.7 months; NHL, 60.1+/-36.4 months; undifferentiated sarcomas and myelomas, 90.0+/-15.6 months. As determined by univariate and multivariate analyses, sex, number of treated rejections, previous history of tumor, average dose of cyclosporine and prednisone and cyclosporine blood levels did not increase the incidence of malignancies. Univariate analysis suggests a significant correlation between the type of prophylactic immunoglobulins and the average dose of azathioprine with the incidence of neoplasms. Both univariate and multivariate analyses demonstrated a significant correlation between patient's age at the time of transplantation and risk of cancer occurrence (risk increased by 1.074/year; P=0.0056 with multivariate Cox regression).

CONCLUSIONS

Cancer is a strong limitation for long-term survival after heart transplantation. The only risk factor recognized is the patient's age at the time of transplant. Furthermore, the type of prophylactic globulins used for induction therapy and some specific immunosuppressant agent (azathioprine) may play a significant role in the development of malignancies after transplantation.

Primary bronchogenic carcinoma after heart or lung transplantation: radiologic and clinical findings

Chronic immunosuppression in organ transplant recipients predisposes to the development of malignant disease. The authors describe their 29-year institutional experience of bronchogenic carcinoma developing after heart and lung transplantation. Seven cases of bronchogenic carcinoma were diagnosed in 1,119 heart and lung transplant recipients. Computed tomography scans and radiographs at time of diagnosis, as well as prior radiographs available in six patients were retrospectively analyzed by two radiologists in consensus. The seven cases involved six heart and one lung transplant recipients. Six patients were smokers with a mean smoking history of 66 pack-years. Mean time interval from transplantation to cancer detection was 25 months. Radiologic findings consisted of a solitary pulmonary nodule (n = 3), mass with satellite nodules (n = 1), and obstructive pneumonitis (n = 1). In the sixth patient, the cancer was not radiographically visible because of obscuration by adjacent fibrosis. On review, radiographic abnormalities were present a mean of 12 months prior to diagnosis in 66% of patients. In the heart or lung transplant population, bronchogenic carcinoma develops in recipients with extensive smoking histories. It presents radiographically as a nodule, mass, or obstructive pneumonitis, and is usually visible on radiographs before the time of diagnosis.

Double jeopardy: lung cancer after cardiac transplantation

Two heart transplant patients were referred on the same day for evaluation of new chest radiograph abnormalities. Each proved to have advanced stage bronchogenic carcinoma. Review of the recent medical literature reveals that the combination of profound immunosuppression and a heavy smoking history puts cardiac transplant recipients at increased risk for the development of aggressive lung cancers.

Malignant neoplasms following cardiac transplantation

OBJECTIVE

Malignancies have long been recognized as a complication of long lasting immunosuppressive therapy. We reviewed our experience to investigate the incidence and the spectrum of non cutaneous de novo malignant neoplasms.

METHODS

Between March 1987 and March 1996, 296 patients underwent 303 cardiac transplantation in our service. The population at risk consists of all patients surviving more than 1 month after transplantation, leading to a total of 267 patients. A triple-immunosuppressive therapy was employed. Moderate doses of antilymphocyte globulin was used as an induction immunotherapy.

RESULTS

Neoplasms developed in 18 (6.7%) of the 267 patients at risk. Seventeen patients were male. Mean age was 56 +/- 7 years. Fourteen patients (78%) reported a significant smoking history. Mean interval between transplantation and clinical diagnosis was 36 months. Lung neoplasms (especially adenocarcinoma) were the most commonly encountered tumors (11 of 268 patients, 4.1%). Three Non-Hodgkins' Lymphoma (NHL) were identified (1.1%). No Kaposi's sarcoma were diagnosed. Mean survival after a diagnostic of tumor was 11.7 months.

CONCLUSIONS

The incidence of NHL is low in our transplant recipients. Conversely, we observed a high incidence of lung neoplasms (especially adenocarcinoma) which can be correlated with a heavy cigarette use in the study population.

Carcinoma of the lung after heart transplantation

We have recently noted an unexpected high incidence of lung cancer in our population of cardiac allograft recipients. We conducted a retrospective review of cardiac transplantation at our institution to investigate the incidence, clinical course, and outcome of patients who developed lung cancer following heart transplantation. Nine patients--each with a history of smoking at 30 pack-years--developed lung cancer following heart transplantation, for an incidence of 1.56% of patients at risk. Eight of the patients were male > or = 50 years of age, representing 3.3% of the male transplant recipients in this age group. The interval from transplantation to diagnosis clustered around 3-5 years after transplantation, but in two instances (22%), a neoplasm was discovered within 6 months of transplantation. Almost half of the cancers were discovered incidentally, despite routine radiographic surveillance. Seven of 9 (78%) patients had stage IV disease at presentation. Median survival after diagnosis was 3 months, and five of the seven patients who died survived less than 4 months after diagnosis. We conclude that cardiac transplant recipients are at increased risk for development of lung cancer. Patients with a moderate to heavy smoking history might well be advised to undergo chest CT scanning in an aggressive search for occult lung cancer before cardiac transplantation is considered further. Finally, despite frequent radiologic examinations, these lung cancers are often diagnosed incidentally, are far advanced at the time of diagnosis, are not surgically resectable, and are poorly responsive to adjuvant therapy.

Solid tumors after heart transplantation: lethality of lung cancer

BACKGROUND

Prolonged nonspecific immunosuppression after solid-organ transplantation is associated with an increased risk of certain cancers. This study examined the development of solid-organ tumors after cardiac transplantation.

METHODS

Thirty-eight solid tumors were identified in 36 (5.9%) of 608 cardiac transplant recipients who survived more than 30 days. Two patients had two types of skin tumors (basal cell and squamous cell). The tumors included the following types: skin (15), lung (10), breast (1), bladder (2), larynx (2), liver (1), parotid (1), testicle (1), uterus (2), melanoma (2), and Merkel's cell (1). Four immunosuppression regimens based on cyclosporin A or FK 506 were used during this period.

RESULTS

There was no association between the incidence of solid tumors and the use of lympholytic therapy. After the diagnosis of tumor was made, the actuarial 2-year survival rates of recipients with skin, lung, and other solid tumors were 71%, 22%, and 23%, respectively. Eight of 10 patients with lung cancer were in stage IIIA or higher at the time of diagnosis.

CONCLUSION

Skin and lung tumors are the most frequent solid tumors in heart transplant recipients. Skin tumors (except Merkel's cell carcinoma and melanoma) usually have a benign course, whereas lung and other tumors developing in cardiac transplant recipients carry a poor prognosis. Advanced disease stage at the time of diagnosis is responsible for the dismal outcome of recipients in whom solid tumors develop. Close postoperative tumor surveillance after cardiac transplantation is warranted.

De novo solid malignancies after cardiac transplantation

BACKGROUND

As long-term survival after cardiac transplantation improves, neoplastic complications are increasingly being discovered. Although lymphoproliferative disorders predominate, the incidence and clinical spectrum of solid tumors in a uniform population of heart transplant recipients remains uncertain.

METHODS

We reviewed our experience with 712 patients who underwent cardiac transplantation. Clinical charts were reviewed and telephone interviews were conducted, when possible.

RESULTS

De novo solid malignancies were identified in 3.3% of patients at risk (21 of 633 patients). Twenty patients were male; mean age was 51.5 +/- 8.6 years. Most patients reported a significant smoking history. Pulmonary, urologic, and Kaposi's sarcoma were the most common malignancies identified. Mean interval from transplantation to diagnosis was 35 months. Six patients were diagnosed within 6 months of transplantation. One-year and 5-year survival after transplantation were 90% and 49%, respectively. One-year and 3-year survival after cancer diagnosis were 60% and 52%, respectively.

CONCLUSIONS

De novo solid malignancy after transplantation occurred with about half the frequency of lymphoproliferative disorders. A striking male predominance was noted. The interval from transplantation to the appearance of cancer is variable, and no clustering was identified. A significant smoking history warrants aggressive search for occult malignancy during pretransplantation evaluation of potential heart recipients.