Lung cancer in lung transplant-management and outcomes

Risk factors for lung cancer and end-stage lung disease significantly overlap, therefore index of suspicion for lung cancer should be high in lung transplant candidates. Thoracic surgeons can be faced with clinical scenarios where lung cancer can be discovered in the setting of lung transplant in three distinct categories: (I) transplant candidates who are known to have active or treated lung cancer, (II) transplant recipients who have unexpected incidental cancer discovered in their lung explant, and (III) transplant recipients who develop de novo lung cancer in the lung allograft or native lung after single-lung transplant. While previously considered "lung-limited" disease, bronchioloalveolar carcinoma (BAC) is no longer accepted as an indication for lung transplant due to poor outcomes with high recurrence rates and reclassification as invasive cancer. Any active lung cancer is considered a contraindication to transplant; however, if there is no evidence of disease after 5 years of definitive therapy, lung transplant can be offered. Indeterminate pulmonary nodules are common in lung transplant candidates and should be evaluated in a multidisciplinary fashion. Incidental lung cancer found in explanted lungs portends poor survival. De novo lung cancer after transplant is more common in the native lung after single-lung transplant. Cancer that develops in the allograft can be treated with definitive local therapies and systemic therapies, but long term survival has not yet been demonstrated.