INTRODUCTION:An increased risk of malignancies is a recognized complication of organ transplantation. An early stage bronchogenic carcinoma is not a common finding after lung transplantation. Treatment options for endobronchial tumors include photodynamic therapy.
CASE PRESENTATION:69-year-old male, former smoker with history of emphysema and bilateral lung transplant done five years ago who presented with mild increased in shortness of breath, fatigue, mild hemoptysis and decreased FEV1. Physical examination revealed an ederly gentleman, normal vital signs, in no acute distress, no palpable lymphadenopaties, lungs were cleared, no skin lesions the reaminder of the exam was normal. Serum chemistries and CBC were within normal limits Bronchoscopy demostrated a whitish polipoid mass in the right mainstem bronchus, extending from the native airway distally to the anastomosis, completly occluding the right upper lobe and partially obstructing the bronchus intermidius. There was also abnormal mucosa seen in the distal trachea, posterior membrane and right lateral aspect. Biopsies of the endobronchial lesion revealed squamous cell carcinoma of the lung and biopsies of abnormal mucosa of the trachea revealed carcinoma in situ. Whole body PET/CT scan showed an endobronchial lesions in the right main bronchus and intense focus of uptake in the right pulmonary hilum, with no secondary sites of disease identified. The endobronchial tumor was partially resected with electrocautery using Gold Probe catheter as well as mechanical debulking with the bronchoscope. Right upper lobe was then treated with photodynamic therapy (PDT) using a 2.5 cm fiber at 200 Joules/cm, for 500 seconds (1000mW). Subsequently the distal trachea, right mainstem bronchus and bronchus intermidius were treated with a 5 cm fiber at 200 Joules/cm for 500 seconds (2000mW). The patient recieved a total of 5 sessions of PDT and was also treated with external beam radiation. One year after treatment, there was no evidence of recurrence on endobronchial biopsies or CT scan.
DISCUSSIONS:Lung cancer is the most common cause of death for both men and women in the industrialized world. The incidence of lung cancer in the general population is 1-3%. The incidence of bronchogenic carcinoma in the lung transplant population is about 2% for patients with emphysema and 4 % for patients with pulmonary fibrosis. Most cases of lung cancer are associated with cigarette smoking. There is also a correlation between advancing age and the risk of developing lung cancer. These risk factors plus impaired surveillance mechanisms resulting from long-term immunosuppression in transplant recipients (which promotes development of cancer) and the increased risk of lung cancer in patients with pulmonary fibrosis, put many lung transplant recipients into a high-risk category for developing bronchogenic carcinoma. The most common radiographic finding is a pulmonary nodule or mass and sometimes there is a misinterpretation of the radiographic findings as progression of pulmonary fibrosis in the native lung. Most of the lung cancer cases in the lung transplant population are diagnosed at late stages and is very uncommon to diagnosed them as an endobronchial lesion only. Photodynamic treatment is a valid treatment option for endobronchial tumors and there is only one case report in the literature about PDT used to treat endobronchial post-transplant lymphoproliferative disorder in a lung transplant recipient. Our patient showed no evidence of recurrence after 1 year of being treated with PDT and radiotherapy.
CONCLUSION:Endobronchial early stage bronchogenic carcinoma is a very uncommon finding in lung transplant recipients. Photodynamic therapy plus radiotherapy is a valid treatment option for this type of patients. To the best of our knowledge this is the first case of endobronchial bronchogenic carcinoma successfully treated with PDT and radiotherapy, in a lung transplant recipient.
DISCLOSURE:Sebastian Fernandez-Bussy, None.