Background: Malignancy is a relative contraindication in transplant candidates given the increased neoplastic risk accompanying post-transplant immunosuppression. However, the number of patients receiving a lung transplant despite pre-transplant malignancy (PTM) is rising, and their outcomes remain unclear. Our purpose was to examine the outcomes of lung transplant recipients with PTM in the modern era.
Methods: We evaluated the United Network for Organ Sharing (UNOS) registry for adult lung transplants between June 2005 and September 2016. Transplant recipients were stratified by pre-transplant malignancy, with subgroup analysis by gender and active malignancy. The primary outcome was five-year mortality and the secondary outcome was cause of death. Kaplan–Meier estimates illustrated 5-year survival while multivariable Cox proportional hazards regressions controlled for demographics and comorbidities.
Results: Of 18,032 transplant patients, 1,321 transplant recipients (7.3%) possessed a pre-transplant malignancy. Patients with PTM faced significantly greater five-year mortality (36.0% vs. 32.8%, p=0.017), an effect greatest in men with PTM (39.2% vs. 33.7%, p=0.002). Patients with PTM also faced greater risk of death from post-transplant malignancy (15.6% vs. 9.4%, p<0.001), particularly for those with active malignancy at transplant (34.8% vs. 9.8%, p<0.001). PTM remained a significant predictor of five-year mortality in adjusted Cox regressions (HR: 1.16 [1.05-1.27], p=0.003).
Conclusions: Patients with any PTM, and particularly men with PTM and those with active malignancy at transplant, are at increased risk of five-year mortality and post-transplant death from malignancy. Balancing individual risk of post-transplant malignancy with immunosuppressive care will be key to optimizing outcomes for patients with PTM.