Rethinking the impact of pretransplant malignancy on eligibility for double lung transplantation (DLT): An analysis of 23,291 recipients.

Abstract

11180 Background: The outcomes for double lung transplant recipients with a history of pretransplant malignancy (PreTM) have not been extensively studied in a large, multicenter database. Given the rising need for transplants among older patients with a history of cancer and the improving outcomes of DLT, this study aimed to analyze recipient outcomes in the modern era. Methods: This study evaluated the United Network for Organ Sharing (UNOS) registry for adult DLT performed between 2005 and 2023. Patients with a history of previous or multi-organ transplants, and those with donors who had a history of malignancy, were excluded. Propensity-score matching was used to compare patients with or without PreTM. Posttransplant malignancies (PostTM) were classified into cutaneous and non-cutaneous types. The primary outcomes were overall and PostTM-free survival. Results: Of the 23,291 DLT recipients, 1,870 recipients (8.0%) had a history of PreTM, which was classified into twelve types. Patients with PreTM experienced worse overall (HR 1.20 [95% CI 1.12-1.29], p<0.001) and PostTM-free survival (HR 1.32 [95% CI 1.24-1.41], p<0.001). After propensity-score matching for age, sex, and race, the differences in overall survival between the two groups were diminished (HR 1.05 [95% CI 0.97-1.13], p=0.229). Although PostTM-free survival was still worse in the PreTM group, this difference was not observed after excluding cutaneous PostTM (HR 1.06 [95% CI 0.99-1.15], p=0.116). The incidence of PostTM of the same PreTM type among patients with PreTM was 13.5% (253/1870), which was not higher than the incidence of de novo PostTM incidence among patients without PreTM (p=0.633). Conclusions: Patients with PreTM show similar overall survival rates after DLT as those without PreTM, despite a higher incidence of PostTM, mainly cutaneous. Importantly, there is no increased risk of the original cancer type recurring in PreTM patients compared to the risk of de novo malignancy. These findings highlight the necessity for a more nuanced evaluation of transplant candidacy to prevent premature exclusion of PreTM patients from potentially life-saving surgeries. [Table: see text]