Abstract
Long-term survival after heart transplantation (HTX) is impacted by adverse effects of immunosuppressive pharmacotherapy, and post-transplant lung cancer is a common occurrence. This study aimed to examine the risk factors, treatment, and prognosis of patients with post-transplant lung cancer. We included 625 adult patients who received HTX at Heidelberg Heart Center between 1989 and 2018. Patients were stratified by diagnosis and staging of lung cancer after HTX. Analysis comprised donor and recipient characteristics, medications including immunosuppressive drugs, and survival after diagnosis of lung cancer. A total of 41 patients (6.6%) were diagnosed with lung cancer after HTX, 13 patients received curative care and 28 patients had palliative care. Mean time from HTX until diagnosis of lung cancer was 8.6 ± 4.0 years and 1.8 ± 2.7 years from diagnosis of lung cancer until last follow-up. Twenty-four patients (58.5%) were switched to an mTOR-inhibitor after diagnosis of lung cancer. Multivariate analysis showed recipient age (HR: 1.05; CI: 1.01–1.10; p = 0.02), COPD (HR: 3.72; CI: 1.88–7.37; p < 0.01), and history of smoking (HR: 20.39; CI: 2.73–152.13; p < 0.01) as risk factors for post-transplant lung cancer. Patients in stages I and II had a significantly better 1-year (100.0% versus 3.6%), 2-year (69.2% versus 0.0%), and 5-year survival (53.8% versus 0.0%) than patients in stages III and IV (p < 0.01). Given the poor prognosis of late-stage post-transplant lung cancer, routine reassessment of current smoking status, providing smoking cessation support, and intensified lung cancer screening in high-risk HTX recipients are advisable.
Highlights
We found no statistically significant differences between both groups with regard to the remaining recipient data, previous open-heart surgery, principal diagnosis for HTX, donor data, transplant sex mismatch, or perioperative data
We found that higher recipient age (HR: 1.05; confidence interval (CI): 1.01–1.10; p = 0.02), chronic obstructive pulmonary disease (HR: 3.72; CI: 1.88–7.37; p < 0.01), and history of smoking (HR: 20.39; CI: 2.73–152.13; p < 0.01) are significant risk factors for post-transplant lung cancer
Given the particular risk for patients who take up smoking again after HTX, it is advisable to intensify efforts to ensure continued abstinence. This should begin with reassessment of smoking status at every follow-up encounter after HTX as well as offering guidance and assistance with smoking cessation if needed
Summary
Post-transplant survival has continuously been improving due to advances in surgical management, clinical experience, and immunosuppressive drug therapy [3,4,5,6]. The focus of post-transplant care has been shifting from early risks such as acute rejection or surgical complications (bleeding, thromboembolic events, and wound infections) towards late sequelae such as cardiac allograft vasculopathy or neoplasms [7,8,9]. While great effort has been put into the diagnosis and management of cardiac allograft vasculopathy [9,10], the area of malignancies after HTX remains largely unexplored, especially given the vast spectrum of tumor entities [11,12,13,14,15,16]. Cutaneous malignancies and post-transplant lymphoproliferative disorders are frequently observed post-transplant tumors [17,18,19,20,21,22,23,24], but lung cancer is the most common solid organ malignancy after HTX [25,26,27,28,29]
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