High frequency of bronchogenic carcinoma after single-lung transplantation

Native lung surgery after single lung transplantation: clinical characteristics and outcomes

PURPOSE

Single lung transplantation (SLT) is a viable option for patients with end-stage pulmonary parenchymal and vascular diseases. However, various diseases can occur in native lungs after SLT.

METHODS

Between January 2000 and December 2021, 35 patients underwent cadaveric SLT and survived for more than 30 days in our hospital. Among these 35 patients, 10 required surgery for diseases that developed in their native lungs. The clinical characteristics of these 10 patients and the outcomes of native lung surgery (NLS) were investigated.

RESULTS

Among these ten patients, the indications for lung transplantation were chronic obstructive pulmonary disease and idiopathic interstitial pneumonia in three patients each, and lymphangioleiomyomatosis and collagen vascular disease-related interstitial pneumoniain two patients each. The causes of NLS included pneumothorax (n = 4), primary lung cancer (n = 2), native lung hyperinflation (n = 2), and pulmonary aspergilloma (n = 2). The surgical procedures were pneumonectomy (n = 7), lobectomy (n = 2), and alveolar-pleural fistula repair (n = 1). Only one postoperative complication, empyema, was treated with antibiotics. The 5-year overall survival rates after transplantation with and without NLS were 70.0% and 80.0%, respectively, and did not differ to a statistically extent (p = 0.56).

CONCLUSION

NLS is an effective treatment option for diseases that develop in the native lungs after SLT.

Malignancies After Lung Transplantation

Lung transplantation (LTx) is a well-known treatment for end-stage lung disease. This study aimed to report the incidence of cancer after LTx and long-term outcome among lung transplant recipients with a pretransplant diagnosis of cancer. Patients who underwent LTx between 1990-2016 were included in the study. Detection of cancer was obtained by cross-checking the study population with the Swedish Cancer Registry and the Cause-of-Death registry. A total of 614 patients were followed for a median of 5.1 years. In all, 159 malignancies were diagnosed. The excess risk of cancer or standardized incidence ratio (SIR) following LTx was 5.6-fold compared to the general Swedish population. The most common malignancies were non-melanoma skin cancer (NMSC) (SIR 76.5 (95%CI 61.7-94.8); non-Hodgkin lymphoma (SIR 23.5, 95%CI 14.8-37.2); and lung cancer (SIR 8.89, 95%CI 5.67-13.9). There was no significant difference in overall survival between those with and without a history of cancer before LTx (p = 0.56). In total, 159 malignancies were identified after LTx, which was a 5.6-fold higher relative to the general population. A history of previous cancer yields similar survival in selected recipients, compared to those without cancer prior to LTx.

Outcomes of oncological intended thoracic surgery after lung transplantation

Background

Lung cancer following lung transplantation (LT) may require thoracic surgery (TS). There is an urgent need for data on surgical feasibility, clinical and surgical characteristics, as well as outcome data.

Methods

We reviewed the medical records of LT patients who had undergone TS at the University Hospital Leipzig between the years 2000 and 2022. Data on medical and surgical history, pulmonary function test, arterial blood gas analysis, six-minute walking distance test, and surgical approach, perioperative management, anesthesiologic, and surgical procedures were analyzed.

Results

Among 248 LT patients, 13 patients (5.2%) developed lung cancer after 4.2 years on average and on 6 of them (46.2%), major TS procedure was performed for the resection of lung cancer. In one patient who underwent TS for a suspicious pulmonary nodule, it turned out to be a parenchymal scar. TS was carried out in 57.1% on the native lung and 42.9% on the transplant lung. Pneumonia and acute renal failure were predominantly observed postoperative complications. We found that the capacity of gas exchange either before or after TS was related to the degree of postoperative complications. The in-hospital survival was 71.4%.

Conclusions

Incidence of lung cancer is increased after LT. Follow-up care allows early diagnosis with a comparably high share of operable tumor stage. Cancer as well as postoperative complications were more likely after single lung transplantation (SLT). Postoperative morbidity and mortality are higher in this scarce group of patients and hence, warrants a centered and experienced interdisciplinary approach.

Donor/recipient origin of lung cancer after lung transplantation by DNA short tandem repeat analysis

Background

Lung cancer is more common in posttransplant recipients than in the general population. The objective of this study was to examine the chimerism donor/recipient cell origin of graft cancer in recipients of lung transplant.

Methods

A retrospective chart review was conducted at Foch Hospital for all lung transplantations from 1989 to 2020. Short tandem repeat PCR (STR-PCR) analysis, the gold standard technique for chimerism quantification, was used to determine the donor/recipient cell origin of lung cancers in transplant patients.

Results

Fourteen (1.4%) of the 1,026 patients were found to have graft lung cancer after lung transplantation, and one developed two different lung tumors in the same lobe. Among the 15 lung tumors, 10 (67%) presented with adenocarcinoma, four (27%) with squamous cell carcinoma and one with small cell lung cancer. STR analysis showed that the origin of the cancer was the donor in 10 patients (71%), the recipient in three patients (21%), and was undetermined in one patient. Median time to diagnosis was 62 months.

Conclusion

The prevalence of lung cancer in lung transplant recipients is very low. However, the results of our study showed heterogeneity of genetic alterations, with 21% being of recipient origin. Our results highlight the importance of donor selection and medical supervision after lung transplantation.

Influence of De Novo Malignancies on Long-Term Survival after Lung Transplantation

(1) Background: Malignancies are an important cause of mortality after solid organ transplantation. The purpose of this study was to analyze the incidence of malignancies in patients receiving lung transplants (LT) and their influence on patients' survival. (2) Methods: Review of consecutive LT from 1994 to 2021. Patients with and without malignancies were compared by univariable and multivariable analyses. Survival was compared with Kaplan-Meier and Cox regression analysis. (3) Results: There were 731 LT malignancies developed in 91 patients (12.4%) with related mortality of 47% (n = 43). Native lung cancer, digestive and hematological malignancies were associated with higher lethality. Malignancies were more frequent in males (81%; p = 0.005), transplanted for emphysema (55%; p = 0.003), with cyclosporine-based immunosuppression (58%; p < 0.001), and receiving single LT (65%; p = 0.011). Survival was worse in patients with malignancies (overall) and with native lung cancer. Risk factors for mortality were cyclosporine-based immunosuppression (OR 1.8; 95%CI: 1.3-2.4; p < 0.001) and de novo lung cancer (OR 2.6; 95%CI: 1.5-4.4; p < 0.001). (4) Conclusions: Malignancies are an important source of morbidity and mortality following lung transplantation that should not be neglected. Patients undergoing single LT for emphysema are especially at higher risk of mortality due to lung cancer in the native lung.

Surgical and Interventional Approaches in COPD

Many patients suffer from complaints of dyspnea, cough, and sputum production, clinical symptoms that hallmark the structural abnormalities that are present in patients with COPD. Although pharmacologic and non-pharmacologic medical therapies help reduce these symptoms, many of these symptoms, especially dyspnea, remain unchecked and contribute to the burden of disease in patients with COPD. Over the last 3 decades, several surgical and interventional treatments delivered via a bronchoscopic approach have been developed to complement medical therapies and show promise to improve patient outcomes. Surgical and interventional treatments target structural abnormalities of the airway and lung parenchyma that can be identified with a combination of imaging and physiological testing, factors that are key to select patients most likely to benefit from these treatments. This paper reviews surgical and bronchoscopic interventional treatment options for patients with emphysema and airways disorders.

Lung Cancer in Lung Transplant Recipients: Clinical, Radiologic, and Pathologic Characteristics and Treatment Outcome

OBJECTIVE

This study aimed to investigate clinical and radiologic characteristics of lung cancer in lung transplant recipients and evaluate the treatment course and prognosis.

METHODS

The study included 448 patients who underwent lung transplant between 2005 and 2021. All patients had pretransplant chest computed tomography (CT), 429 patients had posttransplant CT, whereas 19 had no posttransplant CT (median number of posttransplant CT, 6; range, 0-24). Medical records of these patients were reviewed to identify patients who developed lung cancer after lung transplant. Computed tomography and positron emission tomography/CT at the time of lung cancer diagnoses were reviewed to obtain imaging features. Demographics, tumor histology, stages, and survival were compared using Fisher exact test and Wilcoxon rank sum test.

RESULTS

Among 448 lung transplant recipients with a median follow-up of 71.3 months after lung transplant, 15 patients (3.3%) developed posttransplant lung cancer (13 unilateral, 2 bilateral; 10 men, 5 women; median age, 63.1 years; median time from transplantation to cancer diagnosis, 3.1 years). Twelve cancers were in native lung, and 3 were in transplanted lung. The incidence of lung cancer was higher in single lung transplant recipients than in bilateral lung transplant recipients (10.3% vs 0.6%, respectively; P < 0.0001). Imaging manifestations varied according to tumor stages. Among 12 patients treated for lung cancer, 2 patients developed posttreatment acute respiratory distress syndrome. The median survival from cancer diagnosis of cancer was 6.2 months.

CONCLUSIONS

Posttransplant lung cancer was noted in 3% of lung transplant recipients and was more common in unilateral transplant recipients. The prognosis upon diagnosis was poor with rapid clinical deterioration and serious posttreatment complications.

Current and future role of double-lung transplantation for bilateral lung cancer

Technological advances have progressively enhanced the survival rate of lung transplant recipients and expanded its indications for various diseases, including the recent coronavirus disease 2019 (COVID-19). However, according to the International Society for Heart and Lung Transplantation, lung cancer constituted a mere 0.1% of the indications for lung transplantation over the past two decades. This statistic has remained stagnant, and numerous lung cancer patients continue to be excluded from lung transplantation candidacy. Contrary to the general exclusion of lung cancer patients from transplantation, the post-transplant survival rate for these patients is not inferior to that of patients with non-cancerous diseases. Furthermore, lung transplantation may offer curative treatment for patients with bilateral lung cancer whose respiratory insufficiency has advanced independently of cancer progression. This review aims to elucidate and examine the role of double lung transplantation (DLT) in bilateral lung cancer. We summarize the established indications for lung transplantation, appropriate histologic or molecular subtypes of lung cancer for transplantation, technical advances to minimize recurrence, post-DLT survival outcomes for lung cancer patients, and related translational research. We suggest that although DLT for bilateral lung cancer presents challenges, it may be considered a potential treatment option in select circumstances.

2022 Update of indications and contraindications for lung transplantation in France

Lung transplantation (LTx) is a steadily expanding field. The considerable developments have been driven over the years by indefatigable work conducted at LTx centers to improve donor and recipient selection, combined with multifaceted efforts to overcome challenges raised by the surgical procedure, perioperative care, and long-term medical complications. One consequence has been a pruning away of contraindications over time, which has, in some ways, complicated the patient selection process. The Francophone Pulmonology Society (Société de Pneumology de Langue Française, SPLF) set up a task force to produce up-to-date working guidelines designed to assist pulmonologists in managing end-stage respiratory insufficiency, determining which patients may be eligible for LTx, and appropriately timing LTx-center referral. The task force examined the most recent literature and evaluated the risk factors that limit patient survival after LTx. Ideally, the objectives of LTx are to prolong life while also improving quality of life. The guidelines developed by the task force apply to a limited resource and are consistent with the ethical principles described below.

Lung cancer in recipients after lung transplant: single-centre experience and literature review

Introduction

Lung cancer is a major challenge facing modern medicine. It is the leading cause of cancer-related death in the USA. Little is known of the incidence, prevalence and disease characteristics in lung transplant recipients, a population unique in its vulnerability and exposure to carcinogenic risk factors. We aimed to elaborate these characteristics of lung cancer in our population through a retrospective cohort study.

Methods

We retrospectively reviewed our institution’s 8-year experience with lung transplantation and searched for patients with a post-transplant diagnosis of lung cancer, neoplasia or mass. We focused on patient demographics, indication for transplant, smoking history, stage at diagnosis, location of the tumour, length of time between transplant and diagnosis, the treatment offered and length of time from diagnosis to death or last follow-up. Descriptive statistics and survival analysis standard Kaplan-Meier method was conducted from the date of cancer diagnosis to death from all-cause mortality or last follow-up as of August 2021.

Results

We identified 24 patients with de novo lung cancer postlung transplant in 905 recipients. More patients with an underlying diagnosis of idiopathic pulmonary fibrosis developed lung cancer. Twenty-one patients were diagnosed with non-small cell lung cancer and three had small cell lung cancer. The remaining native lung was involved most in single lung recipients with 17 patients. Patients with a diagnosis of lung cancer had a mean survival of 17.6 months after diagnosis.

Discussion

The incidence rate of lung cancer in our cohort was higher than reported for smokers from the general population in previous studies. In this study, we compare our findings with available literature. We also explore screening strategies, treatment modalities, survival and postulated mechanisms for the development of lung cancer in lung transplant recipients.

Malignancies after pediatric solid organ transplantation

As life expectancy among pediatric solid organ transplant recipients (SOTRs) improves, the risk of comorbid conditions such as malignancy post-transplantation has also increased. SOTRs are at elevated risks of post-transplantation lymphoproliferative disorders (PTLDs), and skin and solid cancers. PTLDs typically occur early following transplantation, while skin and solid cancers frequently arise in young adulthood (25-40 years). By 30 years following transplantation, 26-41% of pediatric SOTRs have developed cancer. Different risk factors exist for PTLD, and skin and solid cancers, which are modified by cumulative immunosuppression, infections, transplanted organ, and the underlying disease process associated with initial organ failure (e.g., kidney failure). Optimal cancer treatment strategies depend on the specific cancer type, stage, and patient comorbidities. Immunosuppression reduction may be beneficial for certain cancers but must be considered against the risks of acute and chronic rejection and allograft loss. Lifestyle counseling regarding smoking avoidance and sun protection, as well as human papillomavirus vaccination, is an important aspect of cancer prevention. Currently, no cancer screening guidelines exist specifically for pediatric SOTRs. Adult population screening guidelines have not been validated in transplant populations. Therefore, an individualized approach should be taken to cancer screening for pediatric SOTRs, accounting for other cancer risk factors.

The influence of the native lung on early outcomes and survival after single lung transplantation

Objective

To determine whether problems arising in the native lung may influence the short-term outcomes and survival after single lung transplantation (SLT), and therefore should be taken into consideration when selecting the transplant procedure.

Patients and methods

Retrospective review of 258 lung transplants performed between June 2012 and June 2019. Among them, 161 SLT were selected for the analysis. Complications in the native lung were recorded and distributed into two groups: early and late complications (within 30 days or after 30 days post-transplant). Donor and recipient preoperative factors, 30-day mortality and survival were analysed and compared between groups by univariable and multivariable analyses, and adjusting for transplant indication.

Results

There were 161 patients (126M/35F; 57±7 years) transplanted for emphysema (COPD) (n = 72), pulmonary fibrosis (IPF) (n = 77), or other indications (n = 12). Forty-nine patients (30%) presented complications in the native lung. Thirty-day mortality did not differ between patients with or without early complications (6% vs. 12% respectively; p = 0.56). Twelve patients died due to a native lung complication (7.4% of patients; 24% of all deaths). Survival (1,3,5 years) without vs. with late complications: COPD (89%, 86%, 80% vs. 86%, 71%, 51%; p = 0.04); IPF (83%, 77%, 72% vs. 93%, 68%, 58%; p = 0.65). Among 30-day survivors: COPD (94%, 91%, 84% vs. 86%, 71%, 51%; p = 0.01); IPF (93%, 86%, 81% vs. 93%, 68%, 58%; p = 0.19). Native lung complications were associated to longer ICU stay (10±17 vs. 33±96 days; p<0.001), longer postoperative intubation (41±85 vs. 99±318 hours; p = 0.006), and longer hospital stay (30±24 vs. 45±34 days; p = 0.03). The presence of late native lung problems predicted survival in COPD patients (OR: 2.55; p = 0.07).

Conclusion

The native lung is a source of morbidity in the short-term and mortality in the long-term after lung transplantation. This should be taken into consideration when choosing the transplant procedure, especially in COPD patients.

Pulmonary fibrosis combined with lung cancer following lung transplantation: should we do more?

Currently, lung transplantation is the standard of care for patients with end-stage lung disease, with interstitial lung disease (ILD) being the most common reason in the recent years In the other hand, in cases where stage II and III lung cancer have been identified following lung transplantation, long-term survival outcomes are poor when compared to lung cancer patients that have not received a lung transplant because the use of immunosuppressant and the problem of rejection and infection and the treatment of recurrence and so on. However, there is no statistical difference observed in stage I (pT1N0M0) patients. In this paper we report about a patient with ILD receiving left lung transplantation in the early time. A lesion of the right lung which was considered the normal ILD tissue and without enough attention. Post-transplant it showed progress and finally the whole right lung (native lung) was occupied by the tumor. Some ground glass changes could also be found in the transplanted lung several months later. A secondary lung transplant was performed for this patient, and there has been no postoperative recurrence thus far. For lung transplant patients with high-risk factors, effective surveillance methods are required for the early detection of lung cancer.

Post-transplant malignancies in pediatric organ transplant recipients

The majority of cancer diagnoses in pediatric solid organ transplant recipients (SOTRs) are post-transplantation lymphoproliferative disorders (PTLD) or skin cancers. However, pediatric SOTRs are also at significantly elevated risk for multiple other solid and hematological cancers. The risks of specific cancers vary by transplanted organ, underlying disease, and immunosuppression factors. More than one-quarter of pediatric SOTRs develop cancer within 30 years of transplantation and their risk of solid cancer is 14 times greater than the general population. Pediatric SOTRs are at significantly higher risk of cancer-associated death. Improving patient survival among pediatric SOTRs puts them at risk of adult epithelial cancers associated with environmental carcinogenic exposures. Vaccination against oncogenic viruses and avoidance of excessive immunosuppression may reduce the risk of solid cancers following transplantation. Patient and family education regarding photoprotection is an essential component of skin cancer prevention. There is significant variability in cancer screening recommendations for SOTRs and general population approaches are typically not validated for transplant populations. An individualized approach to cancer screening should be developed based on estimated cancer risk, patient life expectancy, and screening test performance.

Native lung complications after living-donor lobar lung transplantation

BACKGROUND

Living-donor lobar lung transplantation (LDLLT) is viable for critically ill patients in situations of donor shortage. Because it is sometimes difficult to find 2 ideal living donors with suitable graft sizes, we developed native lung-sparing procedures, including single LDLLT and native upper lobe-sparing LDLLT. This study aimed to investigate native lung complications (NLCs) in native lung-sparing LDLLT.

METHODS

Between April 2002 and March 2019, 92 LDLLTs and 124 cadaveric lung transplantations (CLTs) were performed at the Kyoto University Hospital. Our prospectively maintained database and clinical records were reviewed to compare NLCs among recipients who underwent native lung-sparing LDLLT (n = 21) with those among recipients who underwent single CLT (n = 61).

RESULTS

Among 21 recipients who underwent native lung-sparing LDLLT, 11 NLCs occurred in 8 recipients. No fatal NLC was noted; however, 2 required surgical intervention. Post-transplant survival was not significantly different between native lung-sparing LDLLT recipients with NLCs and those without NLCs. The incidence of NLCs was comparable between native lung-sparing LDLLT recipients and single CLT recipients (8/21 vs 26/61, p = 0.80); however, NLCs occurred significantly later in LDLLT recipients than in CLT recipients (median: 665 vs 181.5 days after transplantation, p = 0.014).

CONCLUSIONS

NLCs after native lung-sparing LDLLT had favorable outcomes. Therefore, native lung-sparing LDLLT is a useful treatment option for severely ill patients who cannot wait for CLT. However, it is important to recognize that NLCs may occur later in LDLLT than in CLT.

Cancer risk in heart or lung transplant recipients: A comprehensive analysis of 21 prospective cohorts

We performed a meta-analysis to determine cancer risks at multiple sites and their associations with tumor mutation burden (TMB), an index for immunogenicity, in heart or lung transplant recipients. A comprehensive search of PubMed, Web of Science, EMBASE, and Medline was conducted. Random effects models were used to calculate standardized incidence ratios (SIRs) versus the general population and to determine the risks of different cancers. Weighted linear regression (WLR) was used to analyze the associations between the SIRs and TMBs. (PROSPERO CRD42020159599). Data from 21 studies including 116,438 transplant recipients (51,173 heart transplant recipients and 65,265 lung transplant recipients) with a total follow-up of 601,330.7 person-years were analyzed. Compared with the general population, heart transplant recipients displayed a 3.13-fold higher cancer risk [SIR: 3.13; 95% confidence interval (CI): 2.38-4.13; p < 0.001]; lung transplant recipients displayed a 4.28-fold higher cancer risk [SIR: 4.28; 95% CI: 3.18-5.77; p < 0.001]. The correlation coefficients were 0.54 (p = 0.049) and 0.79 (p < 0.001) in heart and lung transplant recipients, respectively, indicating that 29% and 63% of the differences in the SIRs for cancer types might be explained by the TMBs. Our study demonstrated that both heart and lung transplant recipients displayed a higher risk of certain site-specific cancers. These findings can provide individualized guidance for clinicians for detection of cancer among heart or lung transplantation recipients. In addition, we provided evidence that increased risks of post-transplant cancers can be attributed to immunosuppression.

Primary lung carcinoma in cystic fibrosis: A case report and literature review

Patients with cystic fibrosis (CF) have increased life span because of improved care over last 50 years. With increasing survival, predisposition of cancer may become evident. We have observed increase risk of gastrointestinal tract cancer, testicular cancer and lymphoid leukemia. Lung cancer in patients with CF is rare. Our patient developed chronic respiratory failure due to CF related bronchiectasis. Patient had progressive disease despite optimum treatment, requiring lung transplantation. Pathology of explant lung showed focus of invasive adenocarcinoma of lung origin. Patient had no evidence of lung carcinoma recurrence in one year. To our knowledge this is the fourth reported lung cancer case in a patient with CF.

Dynamic tumor-tracking stereotactic body radiation therapy for a solitary tumor in a transplanted organ: two case reports

Solid-organ transplant recipients require long-term immunosuppressants to prevent graft rejection. However, immunosuppressant use increases the risk of malignancy. Radiotherapy can be a treatment option for patients who are medically inoperable or refuse surgery; however, whether the irradiation of transplanted organs is safe remains unclear. We present two patients with malignancies that developed in transplanted organs and were treated with dynamic tumor-tracking (DTT) stereotactic body radiation therapy (SBRT). The first patient underwent transplantation owing to liver cirrhosis caused by hepatitis C virus and subsequently developed hepatocellular carcinoma in the donated liver. There was no evidence of recurrence 12 months post-treatment, and liver function enzyme levels did not deviate from their pre-SBRT baselines. The second patient had a solitary tongue cancer metastasis in a transplanted lung; she also had a history of interstitial pneumonia caused by scleroderma. Six weeks after DTT-SBRT, she developed grade 3 radiation pneumonitis but recovered with oral steroids; she experienced no tumor recurrence after 14 months, although her respiratory function was worse than it was pre-SBRT owing to post-transplant rejection. DTT-SBRT is thus feasible for treating tumors that arise in transplanted lungs and livers.

Stereotactic body radiation therapy (SBRT) for the treatment of primary lung cancer in recipients of lung transplant

Background Lung transplantation is a life-saving treatment for patients with end stage lung disease. There may be a higher incidence of lung cancer in lung transplant recipients, and these cancers tend to be diagnosed at a more advanced stage. There is very little data on the safety and efficacy of stereotactic body radiation therapy (SBRT) for lesions in the native lung in lung-transplant recipients. Patients and methods A retrospective chart review of all patients who have undergone lung transplantation and were treated with SBRT for lung cancer in the native lung in the Davidoff Cancer Center was performed. Results Four patients who were treated with SBRT to a total of 5 lesions were included. Two patients were treated without histological confirmation of malignancy. All cases were discussed in a multidisciplinary tumor board before being referred for radiotherapy. Standard SBRT dosing was used. Responses were assessed by imaging. Three lesions exhibited a complete response and two lesions had a partial response. The patients who had partial responses developed distant metastases and died shortly. No patient developed measurable toxicity. Conclusions SBRT is effective and safe for the management of lung cancer in lung-transplant patients. Standard dose and fractionation can be used.

Malignancy after lung transplantation

Lung transplantation is an established therapeutic option for selected patients with advanced lung diseases. As early outcomes after lung transplantation have improved, chronic medical illnesses have emerged as significant obstacles to long-term survival. Among them is post-transplant malignancy, currently representing the 2^nd most common cause of death 5–10 years after transplantation. Chronic immunosuppressive therapy and resulting impairment of anti-tumor immune surveillance is thought to have a central role in cancer development after solid organ transplantation (SOT). Lung transplant recipients receive more immunosuppression than other SOT populations, likely contributing to even higher risk of cancer among this group. The most common cancers in lung transplant recipients are non-melanoma skin cancers, followed by lung cancer and post-transplant lymphoproliferative disorder (PTLD). The purpose of this review is to outline the common malignancies following lung transplant, their risk factors, prognosis and current means for both prevention and treatment.

Risk of lung cancer in lung transplant recipients in the United States

Lung transplant recipients have an increased risk of lung cancer that is poorly understood. Prior studies are largely descriptive and single-center, and have not examined risk factors or outcomes in this population. This registry-linkage study utilized matched transplant and cancer registry data from 17 US states/regions during 1987-2012. We used standardized incidence ratios (SIRs) to compare incidence with the general population, Poisson models to identify lung cancer risk factors, and Cox models to compare survival after diagnosis. Lung cancer risk was increased among lung recipients (SIR 4.8, 95% confidence interval [CI] 4.1-5.5). Those with single lung transplant had 13-fold (95% CI 11-15) increased risk in the native lung. Native lung cancer risk factors included age, prior smoking, time since transplant, and idiopathic pulmonary fibrosis. Compared with cases in the general population, lung cancers in recipients were more frequently localized stage (P = .02) and treated surgically (P = .05). However, recipients had higher all-cause (adjusted hazard ratio 1.90, 95% CI 1.52-2.37) and cancer-specific mortality (adjusted hazard ratio 1.67, 95% CI 1.28-2.18). In conclusion, lung cancer risk is increased after lung transplant, especially in the native lung of single lung recipients. Traditional risk factors are associated with lung cancer in these patients. Lung cancer survival is worse among lung recipients despite earlier diagnosis.

Survival after a cancer diagnosis among solid organ transplant recipients in the United States

BACKGROUND

Transplant recipients have an elevated risk of cancer because of immunosuppressive medications used to prevent organ rejection, but to the authors' knowledge no study to date has comprehensively examined associations between transplantation status and mortality after a cancer diagnosis.

METHODS

The authors assessed cases in the US general population (N=7,147,476) for 16 different cancer types as ascertained from 11 cancer registries. The presence of a solid organ transplant prior to diagnosis (N=11,416 cancer cases) was identified through linkage with the national transplantation registry (1987-2014). Cox models were used to examine the association between transplantation status and cancer-specific mortality, adjusting for demographic characteristics and cancer stage.

RESULTS

For the majority of cancers, cancer-specific mortality was higher in transplant recipients compared with other patients with cancer. The increase was particularly pronounced for melanoma (adjusted hazard ratio [aHR], 2.59; 95% confidence interval [95% CI], 2.18-3.00) and cancers of the breast (aHR, 1.88; 95% CI, 1.61-2.19), bladder (aHR, 1.85; 95% CI, 1.58-2.17), and colorectum (aHR, 1.77; 95% CI, 1.60-1.96), but it also was increased for cancers of the oral cavity/pharynx, stomach, pancreas, kidney, and lung as well as diffuse large B-cell lymphoma (aHR range, 1.21-1.47). Associations remained significant after adjustment for first-course cancer treatment and generally were stronger among patients with local-stage cancers for whom potentially curative treatment was provided, including patients with melanoma (aHR, 3.82; 95% CI, 2.94-4.97) and cancers of the colorectum (aHR, 2.77; 95% CI, 2.07-3.70), breast (aHR, 2.08; 95% CI, 1.50-2.88), and prostate (aHR, 1.60; 95% CI, 1.12-2.29), despite the lack of an association for prostate cancer overall.

CONCLUSIONS

For multiple cancer types, transplant recipients with cancer appear to have an elevated risk of dying of their cancer, even after adjustment for stage and treatment, which may be due to impaired immunity.

Metachronous Pulmonary Neoplasms in Lung Transplantation-When They Arise in the Donor Lung: A Case Report

Lung cancer (LC) is uncommon among lung transplant recipients, being most often described in the native lung of single-lung transplant recipients. Its appearance in the transplanted lung is a very uncommon phenomenon, in which donor and recipient factors appear to be involved. We present a case of 2 distinct metachronous lung neoplasms diagnosed in the transplanted lung of a non-smoker patient with progressive massive silicosis (PMS), who underwent left unipulmonary transplantation at 39 years. The donor was a smoker and thoracic computed tomography (CT) performed before the organ collection showed no abnormalities. Thirty months after transplantation, a new node with significant avidity in positron emission tomography (PET)-CT was diagnosed in the upper left lobe (ULL). The Thoracic Surgery team chose to proceed directly to surgery with atypical resection of the nodule. Anatomopathologic study revealed an epidermoid carcinoma (pT1aNx). Multidisciplinary group decided clinical surveillance; however, 2 years later, the appearance of 2 new nodules in the ULL (PET-CT positive) was observed. It was again decided to proceed to the surgery with a second atypical resection. The anatomopathologic study of one nodule revealed pulmonary adenocarcinoma (pT1aNx), and the other was compatible with epidermoid carcinoma (pT1aNx). One month later, the patient was hospitalized with a pulmonary abscess and posteriorly developed a probable acute allograft rejection, eventually dying at the age of 44, 51 months after transplantation. This case raises relevant questions regarding the donor selection criteria and the approach to LC diagnosed in the post-transplantation period.

Characteristics of lung cancer among patients with idiopathic pulmonary fibrosis and interstitial lung disease - analysis of institutional and population data

Background

Lung Cancer is occasionally observed in patients with Idiopathic Pulmonary Fibrosis (IPF). We sought to describe the epidemiologic and clinical characteristics of lung cancer for patients with IPF and other interstitial lung disease (ILD) using institutional and statewide data registries.

Methods

We conducted a retrospective analysis of IPF and non-IPF ILD patients from the ILD center registry, to compare with lung cancer registries at the University of Pittsburgh as well as with population data of lung cancer obtained from Pennsylvania Department of Health between 2000 and 2015.

Results

Among 1108 IPF patients, 31 patients were identified with IPF and lung cancer. The age-adjusted standard incidence ratio of lung cancer was 3.34 (with IPF) and 2.3 (with non-IPF ILD) (between-group Hazard ratio = 1.4, p = 0.3). Lung cancer worsened the mortality of IPF (p <  0.001). Lung cancer with IPF had higher mortality compared to lung cancer in non-IPF ILD (Hazard ratio = 6.2, p = 0.001). Lung cancer among IPF was characterized by a predilection for lower lobes (63% vs. 26% in non-IPF lung cancer, p <  0.001) and by squamous cell histology (41% vs. 29%, p = 0.07). Increased incidence of lung cancer was observed among single lung transplant (SLT) recipients for IPF (13 out of 97, 13.4%), with increased mortality compared to SLT for IPF without lung cancer (p = 0.028) during observational period.

Conclusions

Lung cancer is approximately 3.34 times more frequently diagnosed in IPF patients compared to general population, and associated with worse prognosis compared with IPF without lung cancer, with squamous cell carcinoma and lower lobe predilection. The causality between non-smoking IPF patients and lung cancer is to be determined.

Electronic supplementary material

The online version of this article (10.1186/s12931-018-0899-4) contains supplementary material, which is available to authorized users.

Malignancies after lung transplantation

Lung transplantation has become an efficient life-saving treatment for patients with end stage respiratory disease. The increasing good outcome following lung transplantation may be explained by growing experience of transplant teams and availability of potent immunosuppressive drugs. Nevertheless, the latter carries an inherent risk for malignancy besides other common side effects such as systemic hypertension, diabetes and renal dysfunction. Malignancies occur in a smaller proportion of patients but explain for a large proportion of deaths following transplantation. From the first year post-transplantation they will represent the third cause of death with an increasing incidence along post lung transplant survival. In this chapter, we will browse the different types of malignancies arising following lung transplantation. According to the different techniques for lung transplantation, specific types of bronchogenic carcinoma will be described in the explanted lung, in the native lung, and in the graft. Risk factors associated to immunosuppressive therapy, but also to occupational and environmental factors, especially smoking, will be discussed. Eventually, we will strive at integrating recommendations for the treatment of malignancies following lung transplantation.

The 2018 ISHLT/APM/AST/ICCAC/STSW recommendations for the psychosocial evaluation of adult cardiothoracic transplant candidates and candidates for long-term mechanical circulatory support

The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients' receipt of and response to interventions for any problems identified. This document provides recommendations on both evaluation content and process. It represents a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT) and the Academy of Psychosomatic Medicine, American Society of Transplantation, International Consortium of Circulatory Assist Clinicians, and Society for Transplant Social Workers. The Nursing, Health Science and Allied Health Council of the ISHLT organized a Writing Committee composed of international experts representing the ISHLT and the collaborating societies. This Committee synthesized expert opinion and conducted a comprehensive literature review to support the psychosocial evaluation content and process recommendations that were developed. The recommendations are intended to dovetail with current ISHLT guidelines and consensus statements for the selection of candidates for cardiothoracic transplantation and MCS implantation. Moreover, the recommendations are designed to promote consistency across programs in the performance of the psychosocial evaluation by proposing a core set of content domains and processes that can be expanded as needed to meet programs' unique needs and goals.

Devastating fast-growing lung cancer after single lung transplantation

Patients receiving lung transplantation are at increasing risk for the development of cancer due to the administration of immunosuppressive drugs. We hereby report the case of a patient with a devastating fast-growing lung cancer after single lung transplantation for pulmonary fibrosis.

Risk of cancer after lung transplantation for COPD

Background

The risk of cancer is increased and affects survival after lung transplantation (LTx), but has not been well characterized in COPD. We aimed to evaluate the incidence and prognosis of cancer following LTx for COPD.

Methods

A prospective, population-based study of patients undergoing LTx for end-stage COPD at the two transplantation centers in Sweden between 1990−2013, with follow-up for incident cancer and death, using national registers. The excess risk of cancer was calculated as standardized incidence ratios compared with the general population matched for age, sex, and calendar year. Risk factors for cancer were analyzed using Fine-Gray regression, and survival after cancer diagnosis with Kaplan–Meier.

Results

In total, 331 patients (mean age 55.4 years; 64% women; 97% former smokers) were included. At a median follow-up of 2.8 years, 35% of patients had developed cancer and the risk was increased more than 10-fold ([95% CI] 8.1−11.8). The highest excess risks were for non-Hodgkin lymphoma (20.8−66.7), skin cancer (20.3−35.2), lung (11.7−31.2), liver (3.6−51.6), and colorectal cancer (6.1−19.5). Median survival was longer for skin cancer (8 years; 95% CI, 3−15) compared with non-skin cancer (4 years; 95% CI, 2.8−4.8; p<0.001).

Conclusion

The cancer risk is markedly increased after LTx for COPD. It could not be predicted by the factors evaluated, but contributed significantly to a negative prognosis.

Lung cancer in lung transplantation: incidence and outcome

Introduction

Malignancies are one of the causes of mortality after lung transplantation. However, little is known about lung cancer outcome after lung transplantation.

Methods

We performed a retrospective search of the lung transplantation database at our institution to identify patients diagnosed with lung cancer after lung transplantation.

Results

Out of 633 lung transplant patients, lung cancer was detected in 23 of them (3.63%). The most common causes for transplantation were idiopathic pulmonary fibrosis (47.8%) and emphysema (43.4%). A total of 18 patients were diagnosed during follow-up, 12 cases in the native lung (52.2%) and 6 cases in the donor lung (26.1%). The diagnosis was evidenced in the explanted lung in five patients (21.7%). The median of time from transplantation to cancer diagnosis was 39.7 months (24.356.6). Lung cancer was the cause of death in 16 patients. Survival rate at1year from diagnosis of lung cancer was 45.64% (95% CI 0.2431 to 0.6473).

Conclusions

Lung transplant recipients constitute a high-risk group for developing lung cancer. Among our patients, lung cancer was predominantly diagnosed in the native lung and at an advanced stage. The primary tumour was the main cause of death in most of these patients.

18F-FDG PET/CT for the Diagnosis of Malignant and Infectious Complications After Solid Organ Transplantation

PURPOSE

Infection and malignancy represent two common complications after solid organ transplantation, which are often characterized by poorly specific clinical symptomatology. Herein, we have evaluated the role of ¹⁸F-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography/computed tomography (PET/CT) in this clinical setting.

METHODS

Fifty-eight consecutive patients who underwent FDG PET/CT after kidney, lung or heart transplantation were included in this retrospective analysis. Twelve patients underwent FDG PET/CT to strengthen or confirm a diagnostic suspicion of malignancies. The remaining 46 patients presented with unexplained inflammatory syndrome, fever of unknown origin (FUO), CMV or EBV seroconversion during post-transplant follow-up without conclusive conventional imaging. FDG PET/CT results were compared to histology or to the finding obtained during a clinical/imaging follow-up period of at least 6 months after PET/CT study.

RESULTS

Positive FDG PET/CT results were obtained in 18 (31 %) patients. In the remaining 40 (69 %) cases, FDG PET/CT was negative, showing exclusively a physiological radiotracer distribution. On the basis of a patient-based analysis, FDG PET/CT's sensitivity, specificity, PPV and NPV were respectively 78 %, 90 %, 78 % and 90 %, with a global accuracy of 86 %. FDG PET/CT was true positive in 14 patients with bacterial pneumonias (n = 4), pulmonary fungal infection (n = 1), histoplasmosis (n = 1), cutaneous abscess (n = 1), inflammatory disorder (sacroiliitis) (n = 1), lymphoma (n = 3) and NSCLC (n = 3). On the other hand, FDG PET/CT failed to detect lung bronchoalveolar adenocarcinoma, septicemia, endocarditis and graft-versus-host disease (GVHD), respectively, in four patients. FDG PET/CT contributed to adjusting the patient therapeutic strategy in 40 % of cases.

CONCLUSIONS

FDG PET/CT emerges as a valuable technique to manage complications in the post-transplantation period. FDG PET/CT should be considered in patients with severe unexplained inflammatory syndrome or FUO and inconclusive conventional imaging or to discriminate active from silent lesions previously detected by conventional imaging particularly when malignancy is suspected.

Lung cancer: a rare indication for, but frequent complication after lung transplantation

Lung transplantation is an effective and safe therapy for carefully selected patients suffering from a variety of end-stage pulmonary diseases. Lung cancer negatively affects prognosis, particularly in patients who are no longer candidates for complete resection. Lung transplantation can be considered for carefully selected and well staged lung cancer patients with proven, lung-limited, multifocal, (minimally invasive) adenocarcinoma in situ (AIS) (previously called bronchioloalveolar cell carcinoma) causing respiratory failure. Despite a substantial risk of tumour recurrence (33-75%), lung transplantation may offer a survival benefit (50% at 5 years) with best palliation of their disease. Reports on lung transplantation for other low-grade malignancies are rare. Lung transplant candidates at higher risk for developing lung cancer [mainly previous smokers with chronic obstructive lung disease (COPD) and idiopathic pulmonary fibrosis (IPF) or older patients] should be thoroughly and repeatedly screened for lung cancer prior to listing, and preferably also during waiting list time if longer than 1 year, including the use of PET-CT scan and EBUS-assisted bronchoscopy in case of undefined, but suspicious pulmonary abnormalities. Double-lung transplantation should now replace single-lung transplantation in these high-risk patients because of a 6-9% prevalence of lung cancer developing in the remaining native lung. Patients with unexpected, early stage bronchial carcinoma in the explanted lung may have favourable survival without recurrence. Early PET-CT (at 3-6 months) following lung transplantation is advisable to detect early, subclinical disease progression. Donor lungs from (former) smokers should be well examined at retrieval. Suspicious nodules should be biopsied to avoid grafting cancer in the recipient. Close follow-up with regular visits and screening test in all recipients is needed because of the increased risk of developing a primary or secondary cancer in the allograft from either donor or recipient origin.

Lung cancer treatment outcomes in recipients of lung transplant

BACKGROUND

Lung transplant recipients develop lung cancer more commonly than the general population. The best treatment approach for these patients is unclear. The goal of this study is to evaluate treatment outcomes in this population.

METHODS

We used the Cleveland Clinic lung transplant database to identify patients diagnosed with lung cancer at the time of or after lung transplant. Transplant and lung cancer-related data were retrospectively reviewed.

RESULTS

Among 847 patients underwent lung transplant between 2005 and 2013, 17 (2%) were diagnosed with lung cancer and included. Median age was 61 (range, 48-70) years. Majority were stage I/II (n=11), one had stage IIIA, five had stage IV. Non-small cell lung cancer (NSCLC) were more common than small cell lung cancer (SCLC) (n=15 vs. 2). Curative treatment was performed as lobectomy in native lung (n=1), and radiation in transplanted lung (n=2). Chemotherapy was given in 10 patients, primarily carboplatin-based doublets with docetaxel, pemetrexed, or etoposide. Six of these received palliative chemotherapy for either metastases at diagnosis (n=3) or recurrence after early stage disease (n=3). Except for one patient with complete response, all others had progressive disease following palliative chemotherapy. Overall, patients who received chemotherapy had a median survival of 7.5 months from the initiation of chemotherapy, but 30% developed grade 5 sepsis. Median survival for stage I-IIIA and stage IV were 23.2 and 2.5 months respectively.

CONCLUSIONS

Lung cancer in lung transplant recipients carries various clinical courses. Patients with metastatic disease have substantial toxicities from chemotherapy and poor survival. Early stage patients should be offered treatment with modified dosages to decrease the risk of severe toxicities.

Lung transplantation in chronic obstructive pulmonary disease: patient selection and special considerations

Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and morbidity. Lung transplantation is one of the few treatments available for end-stage COPD with the potential to improve survival and quality of life. The selection of candidates and timing of listing present challenges, as COPD tends to progress fairly slowly, and survival after lung transplantation remains limited. Though the natural course of COPD is difficult to predict, the use of assessments of functional status and multivariable indices such as the BODE index can help identify which patients with COPD are at increased risk for mortality, and hence which are more likely to benefit from lung transplantation. Patients with COPD can undergo either single or bilateral lung transplantation. Although many studies suggest better long-term survival with bilateral lung transplant, especially in younger patients, this continues to be debated, and definitive recommendations about this cannot be made. Patients may be more susceptible to particular complications of transplant for COPD, including native lung hyperinflation, and development of lung cancer.

Prevalence and outcome of lung cancer in lung transplant recipients

BACKGROUND

Lung transplant is the only available therapy for patients with advanced lung disease. The goal of this study was to examine the prevalence, origin, management and outcome of lung cancer in recipients of lung transplant at our institution.

METHODS

After institutional review board approval, we conducted a retrospective chart review of all lung transplantations in our institution from January 1990 until June 2012.

RESULTS

The prevalence of lung cancer in the explanted lung was 6 (1.2%) of 462 and all cases were in subjects with lung fibrosis. All 4 subjects with lymph node involvement died of causes related to the malignancy. Nine (1.9%) of 462 patients were found to have bronchogenic carcinoma after lung transplant. The most common location was in the native lung in recipients of a single lung transplant (6 out of 9 patients). In one case, the tumor originated in the allograft and was potentially donor related. The median time to diagnosis after lung transplant was 28 months with a range from 9 months to 10 years. Median survival was 8 months, with tumors involving lymph nodes or distant metastases associated with a markedly worse prognosis (median survival 7 months) than stage I disease (median survival 27 months).

CONCLUSIONS

The prevalence of lung cancer in lung transplant recipients is low. Using accepted donor screening criteria, donor derived malignancy is exceptionally rare. While stage I disease is associated with improved survival in this cohort, survival is still not comparable to that of the general population, likely influenced by the need for aggressive immune suppression.

[Lung cancer surgery in solid organ transplanted patients]

BACKGROUND

The incidence of lung cancer is reputed to be higher and prognosis worse in solid organ transplant recipients than in the general population. Our purpose was to review the results of surgery in this group of patients.

METHODS

We retrospectively reviewed 49 male and 6 female patients; mean aged 60.6 years (38-85). Transplanted organ was heart (n = 37), kidney (n=12), liver (n = 5) and both-lungs (n = 1); 48 patients had smoking habits and 42 heavy comorbidities (76.4%). Lung cancer was diagnosed during surveillance (78.2%, n = 43) or because of symptoms (21.8%, n = 12). We reviewed TNM and other main characteristics, among them histology (squamous-cell-carcinoma n = 23, adenocarcinomas n = 24, others n = 8).

RESULTS

Surgery consisted of: exploratory thoracotomy (n = 2), wedge resections (n = 6), segmentectomy (n = 1), lobectomy (n = 42), pneumonectomy (n = 4). Postoperative mortality was 7.4% (n = 4) and complication rate 34.5% (n = 19). Five-year survival rate was 46.4% (65.4% for stage I patients, n = 25). Among the 35 dead patients during follow-up, 14 died of their lung cancer (40%). Two had been re-operated from another lung cancer: one after 3 and 8 years who survived 16 years, and the other after 2 years who survived 70 months.

CONCLUSIONS

Surgery results are good and postoperative events acceptable despite theoretically increased risks. This also supports performing a close follow-up of transplanted patients and particularly those with smoking history in view of detecting lung cancer appearing at an early stage.

Primary non-small cell lung cancer in a transplanted lung treated with stereotactic body radiation therapy. A case study

The first case of primary lung cancer in a transplanted lung was described in 2001. Since then, only 5 cases of lung cancer in donated lung have been reported. We present one more patient with non-small cell cancer in the transplanted lung treated with stereotactic body radiation therapy. In most cases of primary lung cancer in transplanted lung, rapid progression of the cancer was reported. Occurrence of the locoregional failure in our case could be explained by factors related to the treatment protocol and also to underlying immunosuppression.

Lung cancer following lung transplant: single institution 10 year experience

BACKGROUND

Lung cancer following lung transplantation is an infrequent occurrence of post-transplant neoplasia. Tumors are classified based on donor or recipient origin. Recipient tumors can be diagnosed in explanted specimens or found in contralateral native lungs which remain in place during single lung transplant (SLTx). The aim of our study was to review our institution's incidence of post lung transplant lung cancer, describe tumor histology, and review our experience with their outcomes.

METHODS

A total of 335 lung transplants from 2001 to 2010 were reviewed. Patients were identified with a post-transplant diagnosis of lung cancer, neoplasia, or mass. Fifteen patients were identified; two were excluded due to concomitant cancers with which the lung cancer would represent a metastasis. Retrospective chart review was undertaken for thirteen patients for descriptive statistics, tumor characteristics and overall survival.

RESULTS

Overall incidence of lung cancer following transplant was 13 cases (3.88%). Six tumors were found in native explanted lungs and six developed subsequently in native lungs. One tumor was confirmed to be of donor origin. Histology included squamous cell in five (38.4%), adenocarcinoma in four (30.7%), and one patient each with adenosquamous (7.6%), carcinoid (7.6%), small cell (7.6%), or malignant solitary fibrous tumor (7.6%). Mean age at transplant was 65 ± 3 years. Mean time from transplant to diagnosis is reported as 241 ± 7 days (range 1-1170). Each patient had at least a 20 pack year smoking history with a mean of 45 ± 3 years. One-year survival for those with lung cancer following transplant was 42.8% while 1 year survival of all lung transplants at our institution is 85.7%.

CONCLUSION

Lung cancer incidentally found at the time of transplant or following transplantation is a serious complication with a noted effect on overall survival. The infrequent occurrence of donor tumors represents an adequate screening process of potential young donor lungs. The recognition of cancers in explanted specimens brings to question policies regarding screening of potential recipients with extensive smoking history. A high index of suspicion for native tumors is needed when conducting post-transplant surveillance as these tumors tend to be stage 4 at time diagnosis.