Lung cancer after lung transplantation: Early detection and curative surgery drive long-term survival

Lung cancer (LC) after lung transplantation (LTx) is a rare but severe complication whose treatment and outcomes remain unclear.

This multicenter retrospective observational cohort study included consecutive patients diagnosed between 2000 and 2023 with primary LC after LTx or heart-LTx. Patient characteristics, cancer stage, treatment modalities, and outcomes were analyzed. Survival was assessed using Kaplan-Meier methods. We compared the cohort to control recipients without post-transplantation LC.

Of 7,313 recipients, 143 (2%) developed LC, after a median interval of 5.3 years. Fifty-five cancers (37%) were stage I disease and 53 (35%) were metastatic disease. In 60 (42%) patients, curative-intent surgery, predominantly via a thoracotomy (79%), was performed and achieved R0 resection in 53 of 57 (93%) patients. Day-90 mortality was 5% after lobectomy and 33% after pneumonectomy. Of the 31 (21%) patients given curative-intent radiotherapy, 3 developed radiation-induced grade 3 or 4 lung toxicity. Median overall survival in patients with stage I, II, III, and IV disease was 83, 16, 10, and 6 months, respectively. Compared to controls, patients with LC were older at transplantation, had greater donor and recipient smoking exposure, and more often received single LTx (43% vs 16%). Of the 62 single-LTx recipients, 52 (84%) had LC in the native lung.

Curative-intent surgical resection, when avoiding pneumonectomy, and radiotherapy yield good long-term survival in early-stage post-transplantation LC. The dramatic survival differences between early and advanced stages emphasize the critical importance of routine low-dose computed tomography screening in all recipients, notably after single LTx.