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

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.

Management of Native Lung Malignancy in a Lung Transplant Recipient

A 75-year-old male patient with a history of previous right lung transplant presented with left upper lobe squamous cell carcinoma. Endobronchial ultrasound and positron emission tomography displayed no mediastinal lymphadenopathy. A ventilation-perfusion scan displayed minimal perfusion to the native lung. Left robot-assisted lysis of adhesions, decortication, left upper lobectomy, and mediastinal lymphadenectomy were performed. The patient tolerated the procedure well. Final pathology displayed pT2a, n0, m0. Lobectomy is a safe and efficient treatment of native lung malignancy in the setting of previous lung transplant with minimally functioning native lung.

The role of radiology in addressing the challenge of lung cancer after lung transplantation

The importance of lung cancer as a complication of lung transplantation is increasingly recognised. It may become an important survival-limiting factor in lung transplant patients as management of other complications continues to improve and utilisation of extended criteria donors grows. Radiology can play a key role in tackling this issue at multiple stages in the transplantation pathway and follow-up process. Routine chest CT as part of pre-transplant recipient assessment (and donor assessment if available) can identify suspicious lung lesions with high sensitivity and detect chronic structural lung diseases such as pulmonary fibrosis associated with an increased risk of malignancy post-transplant. Pre-transplant CT also provides a comparison for later CT studies in the assessment of nodules or masses. The potential role of regular chest CT for lung cancer screening after transplantation is less certain due to limited available evidence on its efficacy. Radiologists should be cognisant of how the causes of pulmonary nodules in lung transplant patients may differ from the general population, vary with time since transplantation and require specific recommendations for further investigation/follow-up as general guidelines are not applicable. As part of the multidisciplinary team, radiology is involved in an aggressive diagnostic and therapeutic management approach for nodular lung lesions after transplant both through follow-up imaging and image-guided tissue sampling. This review provides a comprehensive overview of available clinical data and evidence on lung cancer in lung transplant recipients, and in particular an assessment of the current and potential roles of pre- and post-transplant imaging. KEY POINTS: • Lung cancer after lung transplantation may become an increasingly important survival-limiting factor as mortality from other complications declines. • There are a number of important roles for radiology in tackling the issue which include pre-transplant CT and supporting an aggressive multidisciplinary management strategy where lung nodules are detected in transplant patients. • The introduction of routine surveillance chest CT after transplant in addition to standard clinical follow-up as a means of lung cancer screening should be considered.

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.

Advances in lung transplantation for interstitial lung diseases

PURPOSE OF REVIEW

Lung transplantation (LTx) is increasingly used as ultimate treatment modality in end-stage interstitial lung diseases (ILDs). This review aims to give an overview of the latest evolutions in this field.

RECENT FINDINGS

In the last two years, important new findings regarding LTx outcomes in specific ILD entities have been reported. More data are available on optimization of pre-LTx management of ILD patients especially with regard to pretransplant antifibrotic treatment.

SUMMARY

LTx is the only treatment option with curative intent for ILDs and is increasingly used for this indication. Several studies have now reported adequate outcomes in different ILD entities, although outcome is shown to be affected by underlying telomeropathies. As new studies could not replicate inferior survival with single compared with double LTx, both options remain acceptable. ILD specialists can beneficially impact on post-LTx outcome by optimizing pre-LTx management: corticosteroids should be avoided, antifibrotics should be initiated whenever possible and BMI and nutritional status optimized, rehabilitation and depression-screening strategies should be implemented in all LTx candidates, as these interventions may all improve postlung transplant survival.

Clinically latent and autopsy-verified inflammatory disorders and malignant tumours in transplant patients

AIMS

The number of clinical autopsies decreases while the rate of missed relevant diagnoses is known to be 2%-20%. In this study, we focused on postmortem examinations of patients after transplantation of solid organs.

METHODS

A total of 122 cases were assessed for this study. Transplant organs included liver (LiTx; n=42/122, 34%), heart (n=8/122, 7%), lungs (n=32/122, 26%), kidney (KTx; n=38/122, 31%) and KTx+LiTx (n=2/122, 2%).

RESULTS

The most frequent autopsy-verified causes of death were cardiac or respiratory failure (together n=85/122, 70%). The frequency of malignant tumours that were identified at autopsy was 5% (n=6/122). In 3% (n=4/122) of cases, Goldman class I discrepancies between clinical diagnosis and autopsy findings were identified.

CONCLUSIONS

The rate of missed relevant diagnoses might be relatively low, but these cases nevertheless refute the contention that modern diagnostic techniques negate the need for autopsies in patients who died after transplantation.

Characteristics of lung cancer in idiopathic pulmonary fibrosis with single lung transplant versus non-transplanted patients: a retrospective observational study

BACKGROUND

Patients with idiopathic pulmonary fibrosis (IPF) have significantly higher incidence of lung cancer (LC) relative to the general population. There is a further increase in LC incidence in patients with IPF subsequent to lung transplant, specifically in patients with IPF undergoing single lung transplant.

OBJECTIVES

To examine the incidence and characteristics of LC in patients with IPF during follow-up and after lung transplantation (LTX).

METHODS

We conducted a retrospective analysis of all patients with IPF diagnosed with LC in Rabin Medical Center, Israel, over an 11-year period. We compared the characteristics of transplanted patients with IPF diagnosed with LC to patients with IPF who did not undergo lung transplant. Data were accessed from database registries using the words 'fibrosis', 'lung-cancer' and 'lung-transplantation'. Demographic parameters included age, gender and smoking history (pack years). Clinical-pathological parameters included lapse in time from IPF diagnosis to LC, type of malignancy, affected pulmonary lobe, and stage at diagnosis, oncological treatment and survival.

RESULTS

Between 2008 and 2018, 205 patients with IPF underwent lung transplantation at our medical centre. Double LTX was performed in 83 and single LTX in 122 cases. Subsequently, 15 (12.3%) single LTX patients were diagnosed with LC during the study period. During the same period, of 497 non-transplanted patients with IPF followed in our centre, 45 (9.1%) were diagnosed with LC. In all 15 transplanted patients with IPF, LC was diagnosed exclusively in the native fibrotic lung. LC incidence was higher in the transplanted as compared with the non-transplanted group, but this difference did not reach statistical significance (OR=0.7, 95% CI 0.38 to 1.32, p=0.28). At LC diagnosis, the non-transplanted group was older than the transplanted group with average age of 67.7 versus 60.8 years, respectively (p=0.006). Both groups showed male predominance. In both groups, LC was primarily peripheral, lower lobe predominant and most frequently squamous cell carcinoma. The median survival time after LC diagnosis was 4 months in the transplanted group and 11 months in the non-transplanted group (p=0.19). Multivariate analysis showed improved survival in the non-transplanted group among those patients who received oncological treatment.

CONCLUSION

Chest CT should be performed regularly in order to evaluate IPF patients for potential LC. Single lung transplant IPF patients face an increased risk of post-transplant LC in the native fibrotic lung. Where practicable, IPF patients should be prioritised for double lung transplant.

Characteristics and outcomes of lung cancer in solid organ transplant recipients

OBJECTIVES

Lung cancer is the third most common malignancy that develops in patients following solid organ transplantation and is the leading cause of cancer deaths in the general population. The aims of this study are to examine the characteristics of patients who developed lung cancer following solid organ transplantation at our institution and to compare their outcomes to those of lung cancer patients without a history of transplant.

MATERIALS AND METHODS

We performed a single-institution retrospective study of 44 solid organ transplant recipients who developed lung cancer and compared their characteristics to a cohort of 74 lung cancer patients without a history of transplant. We performed propensity score weighted analyses to compare outcomes between the two groups, including a cox proportional hazards model of overall survival.

RESULTS

52 % of post-transplant patients who developed lung cancer were diagnosed with stage III or IV disease. In the propensity score weighted analysis that accounted for age at diagnosis, sex, lung cancer stage at diagnosis, Charlson comorbidity index score, and ECOG performance score, post-transplant patients were more likely to have squamous cell histology (p < 0.01) and had worse overall survival compared to the non-transplant cohort (HR = 1.88, 95 % CI 1.13-3.12, p = 0.02). The difference in survival remained significant after accounting for differences in lung cancer histology and treatment (HR = 2.40, 95 % CI 1.27-3.78, p < 0.01).

CONCLUSIONS

When compared to non-transplant patients with lung cancer, post-transplant patients have worse overall survival after accounting for differences in age, sex, lung cancer stage, comorbidities, and performance status. This survival difference is not solely attributable to differences in tumor histology and treatments received. This may suggest that post-transplant malignancies are more aggressive and difficult to treat.

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.

Inflammatory Myofibroblastic Tumor After Lung Transplant-A Rare and Aggressive Complication: A Case Report

INTRODUCTION

Malignant diseases are well-known complications after lung transplantation (LT). Among these, inflammatory myofibroblastic tumor (IMT) is a rare neoplasm with a not well-known and often aggressive biological behavior.

MATERIAL AND METHODS

We hereby describe 2 cases of cystic fibrosis patients who underwent bilateral sequential LT (BSLT) complicated by IMT.

RESULTS

A 26-year-old man presented a right endobronchial lesion 6 months after BSLT. Two consecutive fiber bronchoscopic biopsies showed granulation tissue. For the persistent lesion growth, the patient underwent a transthoracic biopsy showing histologic diagnosis of IMT. Therefore, he underwent to right pneumonectomy that was unfortunately complicated after 6 months with a late bronchopleural fistula and empyema with exitus 6 months later. A 31-year-old woman 1 year after BSLT presented with a left voluminous pleural-parenchymal lesion; the histologic examination after biopsy revealed an IMT. She underwent a removal of the lesion with a macroscopic R0 resection. Histologic, immunophenotypic, and cytogenetic examinations showed a strong overexpression of anaplastic lymphoma kinase requiring biological adjuvant therapies; however, the patient refused it. Four years later, she presented a recurrence treated with debulking procedure and adjuvant radiotherapy. At last follow-up, the patient was alive with stable disease and optimal graft function.

CONCLUSIONS

Although IMT is a rare complication after lung transplant, to obtain a careful diagnosis, an early and aggressive treatment is mandatory.

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.

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.

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.

Tacrolimus Levels Are Not Associated with Risk of Malignancy in Lung Transplant Recipients

BACKGROUND Lung transplant (LTx) recipients suffer from high rates of malignancy. Exposure to immunosuppressive medication such as tacrolimus has been proposed as a risk factor for tumorigenesis. We hypothesized that chronically high levels of tacrolimus would be associated with risk of malignancy. MATERIAL AND METHODS The study was performed in a transplant center in Israel, with a nested case-control design. Cases were LTx recipients who were diagnosed with any solid or hematological malignancy except non-melanoma skin cancer. Controls were tumor-free during their entire follow-up after LTx and had at least the same follow-up time as their matched case. Controls were matched to cases by age and type of transplant received (single/double). Tacrolimus levels were extracted and analyzed for median drug level and also integrated over time (area under the curve - AUC-tacrolimus). RESULTS We reviewed 412 LTx recipients in our registry. Thirty-nine cases of malignancy were diagnosed and 160 controls were matched, giving a crude tumor incidence rate of 26/100 000/year. Lung cancers were the commonest diagnosis. Cases and controls were well matched by age, smoking status, and LTx type. Median tacrolimus levels were 11.0 ng/ml and 11.3 ng/ml in cases and controls, respectively (p=0.88). The median log (AUC-tacrolimus) was 9.4 in the cases and 9.5 in the controls (p=0.59). CONCLUSIONS In this nested case-control study, exposure to tacrolimus was similar in tumor cases and non-tumor controls. These data, based on a cohort with modest size, suggest either that tumorigenesis in LTx recipients is unrelated to tacrolimus exposure or that levels in these patients are above an unknown threshold at which the dose-response effect is saturated.

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.

Lung cancer in renal transplant recipients: A case-control study

INTRODUCTION

Solid organ transplant patients are at heightened risk of several cancers compared to the general population. Secondary to a higher number of procedures and better survival after transplantation, cancer is a rising health concern in this situation. Limited data exist for lung cancer (LC) after renal transplantation. We report here the most important series of renal transplant recipients with lung cancer.

METHODS

Retrospective study of all cases of LC diagnosed in three French Renal Transplant Units from 2003 to 2012. A control group consisted of non-transplant patients with LC matched with the cases for age (<30; 30-50; 50-65; >65 years), gender and diagnosis date. We recruited two controls for each case.

RESULTS

Thirty patients (median age 60 years; range 29-85; male/female ratio 80/20%) with LC were analysed. LC incidence was 1.89/1000 person-years over the period 2008-2012. All patients were former or active smokers (median 30 pack-years). Transplanted patients had significantly more comorbidities, mainly cardiovascular disease. The median interval of time from kidney transplantation (KT) to diagnosis of LC was 7 years (range 0.5-47 years). LC was incidentally diagnosed in 40%. Most patients (70%) had advanced LC (stage III or IV) disease. Stage of LC at diagnosis was similar in cases and controls. Surgery and chemotherapy were proposed to the same proportion of patients. In cases, mortality was cancer related in 87% and median survival time after diagnosis was 24 months. Survival was not significantly different between the 2 groups.

CONCLUSION

Despite frequent medical and radiological examinations, diagnosis of LC is usually made at an advanced stage and the overall prognosis remains poor.

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.

Posttransplant solid organ malignancies in lung transplant recipients: a single-center experience and review of the literature

PURPOSE

Solid-organ tumor incidences are higher in solid organ transplant patients than in the general population. The aim of this study was to analyze solid-organ tumor frequency and characteristics in a population of lung transplant patients and provide a brief review of the literature.

METHODS

A retrospective analysis was conducted of all patients who underwent a lung transplant in the Lung Transplant Program at the University Hospital of Siena, Italy, from 2001 to 2014 (n = 119). Patients' demographics, pretransplant characteristics, immunosuppressive therapy, and infectious factors were recorded.

RESULTS

Nine patients with a median age of 59.0 years (range 50-63) of our cohort developed a solid-organ tumor (7.5%). Most of the patients experienced nonmelanoma skin cancer (44.4%); the others were diagnosed with lung cancer (22.2%), breast cancer (22.2%), and colon-rectal cancer (11.2%). The median time from transplantation to tumor diagnosis was 895.0 days (range 321-2046). No differences in pretransplant characteristics, immunosuppressive therapy, or infectious factors were found between patients who developed solid organ tumors and those who did not.

CONCLUSIONS

The present study confirmed that de novo malignancies are a major issue in lung transplant patients; in particular, skin and lung cancers demonstrated a higher incidence rate. Oncologic treatment of these patients is complex, requiring close collaboration between the transplant team and oncologist. Strict screening programs are key factors for an early diagnosis and to allow for prompt treatment resulting in a better outcome.

Case report: combined small cell lung cancer in a lung transplant recipient

Lung transplantation confers an increased risk of lung cancer, especially for single lung transplant recipients, due to both the epidemiologic risk factors associated with the patient population and the posttransplantation immunosuppression required. We report what we believe to be the first case of combined small cell lung carcinoma identified in the native lung of a single lung transplant recipient. Combined small cell lung cancer is an increasingly recognized subtype of small cell carcinoma, and its possible presence is an important consideration in the interpretation of fine-needle aspiration biopsies. In our case, initial fine-needle aspiration suggested squamous cell carcinoma, and it was only after lobectomy that the diagnosis of small cell carcinoma was made. The case highlights the increased risk of malignancy in lung transplant recipients and suggests a role for adaptation of lung cancer screening guidelines to address this high-risk population.

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 adults and children: putting lung function into perspective

The number of lung transplants performed globally continues to increase year after year. Despite this growing experience, long-term outcomes following lung transplantation continue to fall far short of that described in other solid-organ transplant settings. Chronic lung allograft dysfunction (CLAD) remains common and is the end result of exposure to a multitude of potentially injurious insults that include alloreactivity and infection among others. Central to any description of the clinical performance of the transplanted lung is an assessment of its physiology by pulmonary function testing. Spirometry and the evaluation of forced expiratory volume in 1 s and forced vital capacity, remain core indices that are measured as part of routine clinical follow-up. Spirometry, while reproducible in detecting lung allograft dysfunction, lacks specificity in differentiating the different complications of lung transplantation such as rejection, infection and bronchiolitis obliterans. However, interpretation of spirometry is central to defining the different 'chronic rejection' phenotypes. It is becoming apparent that the maximal lung function achieved following transplantation, as measured by spirometry, is influenced by a number of donor and recipient factors as well as the type of surgery performed (single vs double vs lobar lung transplant). In this review, we discuss the wide range of variables that need to be considered when interpreting lung function testing in lung transplant recipients. Finally, we review a number of novel measurements of pulmonary function that may in the future serve as better biomarkers to detect and diagnose the cause of the failing lung allograft.

Assessment of chimerism in epithelial cancers in transplanted patients

Cancer is now the most severe complication in the long term in transplant recipients. As most solid-organ or hematopoietic stem-cell transplantations are allogeneic, chimerism studies can be performed on cancers occurring in recipients. We summarize here the different methods used to study chimerism in cancers developing in allogeneic-transplant recipients, analyze their respective advantages and report the main results obtained from these studies. Chimerism analyses of cancers in transplant recipients require methods suited to tissue samples. In the case of gender-mismatched transplantation, the XY chromosomes can be explored using fluorescent in situ hybridization on whole-tissue sections or Y-sequence-specific PCR after the laser microdissection of tumor cells. For cancers occurring after gender-matched transplantation, laser microdissection of tumor cells enables studies of microsatellite markers and high-resolution melting analysis of mitochondrial DNA on genes with marked polymorphism, provided these are different in the donor and the recipient. The results of different studies address the cancers that develop in both recipients and in transplants. The presence of chimeric cells in these two types of cancer implies an exchange of progenitor/stem-cells between transplant and recipient, and the plasticity of these progenitor/stem-cells contributes to epithelial cancers. The presence of chimeric cells in concomitant cancers and preneoplastic lesions implies that the oncogenesis of these cancers progresses through a multistep process.

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.

Malignancies incidentally detected at lung transplantation: radiologic and pathologic features

OBJECTIVE

The purpose of this study was to assess the CT-pathologic features of cancer incidentally detected at lung transplantation.

MATERIALS AND METHODS

Our lung transplant registry was reviewed over 7 years for incidental malignancy. Patient demographics, diffuse lung disease, surgical procedure, histopathology, and chest CT were recorded. We correlated lesion size, morphology, multiplicity, and location with surgical and pathology reports and histopathology. Cancers were pathologically staged.

RESULTS

Of 759 lung transplant recipients, cancer was incidentally detected in 22 (2.9%). Half (11 of 258) or 4.3% were detected within the past 2 years. Four patients had a history of treated malignancy, and three had recurrence. Patients had emphysema (chronic obstructive pulmonary disease [COPD]) (n = 10), fibrosis (n = 10), or combined COPD and fibrosis (n = 2). Histopathology revealed 13 solitary lung carcinomas, four multifocal adenocarcinomas, three metastases, and two lymphoproliferative diseases. Lung cancer (n = 17) stages were I or II (n = 13), IIIA (n = 2), or IV (n = 2). Metastases (n = 3) and lymphoproliferative disease (n = 2) represented advanced disease. The interval between CT and surgery was a mean of 4 months. CT-positive cases (n = 10) represented lung cancer (n = 9) and posttrans-plantation lymphoproliferative disease (n = 1). Cases with no CT findings of malignancy (n = 12) included lung cancer (n = 8), metastases (n = 3), and lymphoma (n = 1). Ten cases (45%) had other histologically benign CT abnormalities that mimicked cancer.

CONCLUSION

Detection of incidental malignancy at lung transplantation has increased over the past 2 years. Malignancies were typically stage I or II lung cancers that were occult or indeterminate on CT. Diffuse lung disease, multiple CT abnormalities, and a delay between CT and transplantation compromise the preoperative diagnosis of cancer.

Modulation of immune responses following solid organ transplantation by microRNA

Organ transplantation, an accepted treatment for end stage organ failure, is often complicated by allograft rejection and disease recurrence. In this review we will discuss the potential role of microRNAs in allograft immunity especially leading to rejection of the transplanted organ. microRNAs (miRNAs), originally identified in C. elegans, are short non-coding 21-24 nucleotide sequences that bind to its complementary sequences in functional messenger RNAs and inhibits post-translational processes through RNA duplex formation resulting in gene silencing (Lau et al., 2001). Gene specific translational silencing by miRNAs regulates pathways for immune responses such as development of innate immunity, inflammation, T-cell and B-cell differentiation and signaling that are implicated in various stages of allograft rejection. miRNAs also play a role in development of post-transplant complicacies like fibrosis, cirrhosis, carcinogenesis often leading to graft loss and poor patient outcome. Recent advancements in the methods for detecting and quantifying miRNA in tissue biopsies, as well as in serum and urine samples, has led to identification of specific miRNA signatures in patients with allograft rejection and have been utilized to predict allograft status and survival. Therefore, miRNAs play a significant role in post-transplant events including allograft rejection, disease recurrence and tumor development impacting patient outcome.