Evaluation of Patients Referred for Lung Transplantation: Fourteen Years Experience

Prognosis of incidental lung cancer in lung transplant candidates

BACKGROUND

Incidental lung cancer, in the field of lung transplantation (LTx), is more often related to malignancies diagnosed in explants or transplanted organs. Little is known about cancer diagnosed during the medical evaluation of potential LTx candidates. What are the clinical, and prognostic differences between lung cancers diagnosed before or after transplantation in LTx candidates?

METHODS

We performed a retrospective, observational, single-center study to describe the characteristics of lung malignancies first discovered during the pre-transplant assessment and then identified in lung explants, over the same period.

RESULTS

From 1630 consecutive patients referred to Paris-Bichat Lung Transplant Program from 2006 to 2022, 288 were deemed not suitable for transplantation. The reason was lung malignancy in 20 patients (15 non-small cell lung cancer (NSCLC) proved). The one-year survival rate was 55 %. Seven died from their respiratory insufficiency, and six died from lung cancer progression. Over the same period, 611 patients received LTx. NSCLC were identified in six explants (1 %). One-year survival was 66.7 % in these transplanted patients.

CONCLUSIONS

Lung cancer diagnosed during the medical evaluation of potential LTx candidates is rare. However, this represents a critical issue because it contraindicates LTx and leads to a non-optimal management of both lung cancer and of end-stage lung disease. We report an encouraging one-year survival rate in transplanted patients with a pathological lung malignancy diagnosis in lung explant, compared to their counterpart in whom lung cancer discovery contraindicated LTx. A multicenter observational study is mandatory in order to confirm such observation, as it might change current standard to deny LTx in patients with incidental localized NSCLC.

Analysis of patients referred to a lung transplantation unit

This cross-sectional, concurrent and descriptive study presents the decisions regarding patients referred to our Lung Transplantation Unit (LTxU). Each patient is discussed in a multidisciplinary clinical session (phase I), rejecting some and accepting others for assessment in our LTxU (phase II) according to criteria of the National and International Guidelines for Transplantation. A protocol assessment in phase II, leads to a decision to reject, accept, or follow-up the candidate for LTx. Among 214 evaluation requests received in our unit from May 2008 to December 2011, 37 patients (17%) were rejected based on the information sent to our LTxU. Among the patients evaluated in phase II, 62 (28.9%) were put on the waiting list, 125 (58.4%) were rejected, and twenty-seven (12.6%) were postponed for future reconsideration, results that were similar to those described in the literature. The main disease referred for LTx was obstructive airflow (n = 98; 45.7%), followed by interstitial lung disease (ILD; n = 66; 30.8%), cystic fibrosis or bronchiectasis (n = 20; 9.3%), or primary pulmonary hypertension group 1 (n = 20; 9.3%). Ten patients (4.6%) were diagnosed with other respiratory diseases. Most patients (n = 165; 77.1%) lived in the region of our hospital (Madrid). The main reasons to reject patients for LTx were malnutrition, severe disease in other organs, toxic habits, and refusal of treatment. Finally, one out of four referred patients was accepted for LTx. In addition to serious comorbidities in various organs, a high percentage of patients who were not accepted for LTx because of these factors might have been of accepted had these conditions been corrected before patient referral.