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Recipient-Origin Non-small Cell Lung Cancer After Bilateral Lung Transplantation FREE TO VIEW

Rafid Fadul, MD; Neethi Venkatappa, MD; Ana Lucia Ruano Mendez, MD; Marie Budev, DO
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Cleveland Clinic Foundation, Cleveland, OH

Chest. 2013;144(4_MeetingAbstracts):613A. doi:10.1378/chest.1662811
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SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Wednesday, October 30, 2013 at 11:30 AM - 12:30 PM

INTRODUCTION: Occurrence of lung cancer after lung transplantation has been well-described ranging from 0.25%-2.3%1,2. However, its incidence after bilateral lung transplantation (BLT) is thought to be much lower. We present a case of recipient-origin bronchogenic carcinoma manifesting in donor lungs after gender-mismatched BLT, proven by fluorescence in-site hybridization (FISH) chromosomal analysis.

CASE PRESENTATION: A 51 year-old male former smoker with a history of IPF, COPD and colonization with Burkholderia Cepacia underwent BLT. The recipient’s pre-transplant work-up was negative for malignancy. The donor was a 49-year-old, extended-criteria female with a seventy pack-year smoking history. Donor chest CT prior to procurement demonstrated no evidence of emphysematous changes, lymphadenopathy or abnormal masses or nodules. On gross visual inspection by the procurement surgeon, there was mild anthracosis but no other visible parenchymal abnormalities. The recipient’s explant lung pathology demonstrated no evidence of malignancy in the parenchyma or the sampled lymph nodes. The post-operative course was complicated by significant graft dysfunction, respiratory failure necessitating tracheostomy, and multiple bouts of septic shock. Because of his colonization with B. cepacia and sepsis, immunosuppression was maintained lower than per routine protocol (tacrolimus level 4-6 ng/ml versus 12-14ng/ml as per routine). At 3 months post-transplant, chest CT demonstrated bilateral, multifocal consolidation. Work-up including bronchoscopy, blood and fungal cultures, all of which were negative. Six weeks later, repeat chest CT demonstrated a new large, indeterminate necrotic mass centered about the posterior left upper chest wall. The patient continued to deteriorate rapidly and care was ultimately withdrawn.

DISCUSSION: On autopsy the patient exhibited an 8x6cm mass in the left posterior pleura with visible involvement of the posterior lung, chest wall, and rib bone involvement. Histologic sections of the mass demonstrated a poorly-differentiated, extensively necrotic neoplasm formed by discohesive cells with spindle and giant cells. The immunohistochemical profile and morphology were consistent with pleomorphic carcinoma of pulmonary origin. Because the patient had received a gender-mismatched graft, FISH analysis was performed to assess the chromosomes and thus the origin of the malignancy, identifying XY chromosome and thus implicating the male recipient as opposed to the female donor.

CONCLUSIONS: Current literature sugguests BLT might be more beneficial in preventing the development of bronchogenic cancer in a high-risk recipient, our case demonstrates this risk is not completely eliminated.

Reference #1: Robbins HY, Arcasoy SM. Malignancies following lung transplantation. Clin Chest Med.2011;32:343-55.

Reference #2: Minai OA, Shah S, Mazzone P. Bronchogenic carcinoma after lung transplantation: Characteristics and outcomes. J Thorac Oncol.2008;3:1404-1409.

DISCLOSURE: The following authors have nothing to disclose: Rafid Fadul, Neethi Venkatappa, Ana Lucia Ruano Mendez, Marie Budev

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