Incidentally Detected Malignancies in Lung Transplant Explants

Abstract

Background.Active malignancy diagnosed within 5 years is an absolute contraindication for lung transplantation. In this study, we evaluated the rate of incidental malignancies detected in explanted lungs at our institution and assessed the posttransplant survival in patients with nonsmall cell lung cancer (NSCLC).Methods.A retrospective chart review of lung transplant recipients at our institution from February 1999 to June 2017 was conducted. A literature review was performed to evaluate the prevalence and survival outcomes in patients with unexpected malignancies.Results.From 407 patients who underwent lung transplantation, 9 (2.2%) were discovered to have malignant neoplasms. There were 3 cases of adenocarcinoma, 3 cases of adenocarcinoma in situ, 2 cases of squamous cell carcinoma, and 1 case of metastatic renal cell carcinoma. An extensive literature review found 12 case reports or case series reporting malignancy discovered at the time of lung transplantation. The overall prevalence of incidental neoplasms among 6746 recipients is around 1.5% (n = 103). The most common neoplasms discovered included adenocarcinoma (n = 56, 54%) and squamous cell carcinoma (n = 29, 28%). The overall 3-year survival was 54.4% for patients with localized NSCLC compared to 5.7% for those with nonlocalized disease.Conclusions.Unidentified malignancies occur despite aggressive radiographic surveillance with poor posttransplant outcomes in patients with advanced malignancy. Malignancy-related radiographic findings may be missed pretransplant secondary to architectural distortion of lung parenchyma related to end-stage lung disease or because of the critical timing of surgery when donor lungs are available.

Survival Outcomes After Double-Lung Transplantation for Refractory Lung-Limited Cancers and Incidence of Post-Transplant Lung Cancer

“…This may be attributed to the fact that the pooled data have publication bias, which is defined as the failure to publish the results of research based on the direction or strength of study outcomes [ 18 ]. Therefore, based on the assumption that OPTN data are closer to the real-world data, the 3-year overall survival after DLT for lung cancer was almost 5–10 times higher than that of previously known stage IV lung cancer and 5–8 times higher than that of non-localized lung cancers [ 19 – 21 ]. Furthermore, the causes of death were varying, and we found that cancer-related deaths were only 33% in the OPTN data [ 22 , 23 ].…”

“…Although a consensus document for the selection of lung transplant candidates recommended that lung cancer may be a special consideration in cases of AIS or MIA of histological type and refractory to conventional medical treatments or those associated with respiratory failure [ 12 ], only 0.1% of lung transplantations have been performed for lung cancer during the last 2 decades [ 2 ]. However, the incidence of unexpected malignancy found in removed lungs after lung transplantation is approximately 2.2%, which is higher than the incidence of lung cancer as a primary indication for lung transplantation [ 21 ]. These findings indicate that the practice of excluding patients with a lung cancer diagnosis from lung transplantation should be reassessed.…”