STAGE III ADENOCARCINOMA IN THE PNEUMONECTOMY SPECIMEN AT TIME OF LUNG TRANSPLANT RESULTING IN POSTTRANSPLANT METASTASIS DESPITE EXPLANTATION

Abstract

TOPIC: Transplantation TYPE: Fellow Case Reports INTRODUCTION: Only a few reports have detailed the discovery of non-small cell lung adenocarcinoma in the explanted lung at the time of lung transplant (1). Herein, we present the case of a lung adenocarcinoma, identified in the pneumonectomy specimen, determined to have metastasized in the post-transplant period. CASE PRESENTATION: We reviewed the case of a 61-year-old Caucasian male bilateral lung transplant recipient secondary to end-stage pulmonary fibrosis and pulmonary hypertension. Evaluation of the right lung pneumonectomy specimen revealed multiple foci of lung adenocarcinoma in the right upper, middle, and lower lobes (Figure A – pre-transplant; Figure B – post-transplant). DISCUSSION: Final histopathological evaluation confirmed non-resectable lung adenocarcinoma, pT4N2M0, stage IIIB. The patient was not an ideal candidate for adjuvant radiotherapy due to post-transplant anastomosis site healing. He was also not an ideal candidate for immune checkpoint inhibitors due to insufficient evidence for safety in the solid organ transplant setting. His immunosuppression was reduced, and treatment with adjuvant chemotherapy (pemetrexed/cisplatin) was initiated. The patient suffered complications including pancytopenia and acute renal failure, although his allograft function remained stable through 6 months post-transplant. De novo-donor specific antibodies to DQA1 (20,000 MFI) were detected in sera at 6 months post-transplant, requiring plasmapheresis. At 9 months post-transplant, surveillance bronchoscopy with transbronchial biopsy to evaluate for cellular rejection revealed lung adenocarcinoma associated with lymphangitic carcinomatosis. Follow-up imaging with positron emission tomography and magnetic resonance imaging showed brain, bone, and adrenal gland metastasis. The patient is currently receiving palliative-intent chemotherapy and suffering ongoing pancytopenia and myelosuppression. CONCLUSIONS: Pre-transplant malignancies can remain unidentified due to architectural distortion of the lung parenchyma, even despite appropriately timed, aggressive radiographic surveillance. These malignancies portend worse post-transplant outcomes. REFERENCE #1: Choi YJ, Kim SY, Park MS, Lee JG, Paik HC, Lee SH. Incidental Lung Cancer of Explanted Lungs from Lung Transplant Recipients: Incidence, Characteristics, and 5-Year Survival. Yonsei Med J. 2020 Nov;61(11):958-964. doi: 10.3349/ymj.2020.61.11.958. PMID: 33107239; PMCID: PMC7593106. DISCLOSURES: No relevant relationships by Hesham Abdelrazek, source=Web Response No relevant relationships by Ashwini Arjuna, source=Web Response No relevant relationships by Michael Olson, source=Web Response Speaker/Speaker's Bureau relationship with Genentech Please note: $5001 - $20000 by Rajat Walia, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Boehringer Ingelheim Please note: $5001 - $20000 by Rajat Walia, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Grifols Please note: $5001 - $20000 by Rajat Walia, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Shire Please note: $1001 - $5000 by Rajat Walia, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Astellas Please note: $5001 - $20000 by Rajat Walia, source=Web Response, value=Honoraria