Incidentally discovered lung cancer in explanted lungs at the time of lung transplantation: Management and outcomes.

Abstract

e20087 Background: Lung transplantation is an established therapy for end-stage pulmonary disease. Occult lung cancer is incidentally identified in 2% of explanted lungs at time of transplant. Pre-operative detection of cancer is particularly challenging in patients (pts) with ILD, where radiographic findings may obscure malignancy. We report a single-center series of pts with lung cancer incidentally discovered in explanted lungs and describe tumor characteristics, management, and clinical outcomes. Methods: We retrospectively reviewed adult lung transplant recipients at the University of Pennsylvania Health System (2015–2025). Pts with lung cancer identified in explanted lungs were confirmed by chart review. Clinical features, pathologic staging, oncologic and immunosuppressive management, and outcomes post-transplant were abstracted. Results: Eleven pts, all male, were identified. Median age was 65.1 years. Median follow-up post-transplant was 27.1 months. Ten pts (91%) had a smoking history (median 30 pack-years). Transplant indications included fibrotic ILD (45%), CPFE(18%), and COPD (36%). Adenocarcinoma was the most common identified cancer (64%), followed by squamous (27%) and adenosquamous (9%) histologies. Most tumors were early stage (pT1, 64%); nodal disease was present in 36% (all N1) and one pt had M1a disease involving the contralateral lung and pleura. One KRAS G12C mutation was identified. Management included surveillance (55%) or adjuvant chemotherapy (27%); two pts died before discharge after transplantation (excluded from table). Immunotherapy was avoided in adjuvant and recurrent settings. Immunosuppression was modified in 55%, mostly by holding mycophenolate. Chemotherapy was poorly tolerated; only one pt completed therapy. Lung cancer recurred in 27%. Six patients (55%) died, including 2 from lung cancer. Conclusions: We report one of the largest single-center series of incidentally discovered lung cancer in explanted lungs, a high-risk entity with important oncologic management implications. In this series, immunotherapy was not given, immunosuppression was modified, and adjuvant chemotherapy was poorly tolerated. Lung cancer recurred in a quarter of these pts. Pt # Lung Disease Histology Stage Management Time to recurrence (mo) Time to death (mo) Time to last contact (mo) 1 ILD secondary to scleroderma adenocarcinoma pT3, pN1, M0 adjuvant chemo 41 46 2 hypersensitivity pneumonitis squamous pTxpN1M0 adjuvant chemo 44 3 CPFE adenocarcinoma pT1c, cN0, M0 surveillance 29 4 IPF adenocarcinoma cT4, cN1, M1a adjuvant chemo 14 15 6 CPFE with secondary pulmonary hypertension adenocarcinoma pT1b, pN0, M0 surveillance 18 8 mixed COPD/fibrosis squamous pT1aN0M0 surveillance 28 9 COPD adenocarcinoma pT1aN0M0 surveillance 127 10 COPD adenosquamous pT1b, cN0, M0 surveillance 23 11 mixed COPD/fibrosis adenocarcinoma pT1aN0M0 surveillance 17 27