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The identification of incidentally explanted lung cancer should not immediately rule out lung transplant in candidates with end-stage pulmonary disease.

“Lung transplants are used to treat end-stage pulmonary disease, such as COPD and interstitial lung disease,” Ryan Rebernick, BS, notes. “Currently, if a patient has end-stage pulmonary disease and needs a lung transplant, they are almost always excluded as a candidate if they have lung cancer. The underlying assumption is that these patients will have worse outcomes compared with patients without lung cancer.”

However, Rebernick explains that “outcomes for patients with lung cancer are highly dependent on the stage of the tumor and the histologic subtype of the cancer,” while also noting that early-stage lung cancer is often treated with surgery.

For a study published in the American Journal of Transplantation, Rebernick and colleagues aimed to examine whether patients undergoing lung transplant who had lung cancer “actually had worse outcomes—and whether outcomes varied by stage or histologic subtype,” he continues.

“If patients with early-stage lung cancers or cancers of a certain histologic subtype did not have worse outcomes, it would indicate that these patients should be considered further for transplantation.”

The researchers used the Scientific Registry of Transplant Recipients and the National Cancer Database to identify patients who received a lung transplant and were subsequently diagnosed with lung cancer. These patients were found to have incidentally explanted lung cancers (IELC) and were compared with a control group of patients who received a lung transplant but were not diagnosed with IELC.

Outcomes in Patients With Lung Cancer 

The analysis included 186 patients, most of whom (n=144) had non-small cell lung cancer. Other subtypes included small cell lung cancer (n=6) and neuroendocrine cancer (n=36).

Compared with controls, patients with stage 1/2 NSCLC or neuroendocrine cancer of any stage had comparable overall survival and rates of cancer-related mortality. Conversely, patients with stage 3/4 NSCLC had poorer overall survival, higher rates of cancer-related mortality, and rarely received cancer-specific non-operative treatment (Table).

“We looked at patients with had incidentally explanted lung cancer, or lung cancer identified after the lung pathologic review of the candidate’s explanted lungs,” Rebernick notes. “We found that patients undergoing lung transplant who had early-stage NSCLC or certain subtypes or neuroendocrine cancers of any stage had comparable outcomes to patients undergoing lung transplant who did not have lung cancer. Patients with early-stage NSCLC or patients with certain neuroendocrine cancer subtypes of any stage had comparable overall survival to matched controls and all control patients receiving a lung transplant.” 

In assessing treatment implications, the researchers found that 10 of 30 patients with stage 3/4 NSCLC received cancer treatment following lung transplant, with a median time to treatment of 45 days (range, 20-163 days). The study results failed to show that treatment led to improved outcomes through analysis.

Directions for Future Research 

The findings “indicate that patients with lung cancer should not be immediately ruled out of consideration for a lung transplant,” Rebernick explains. “Rather, they should undergo further staging and histologic workup to determine whether transplant might still be an option.”

Further, the analysis “shed[s] light on a rare patient population by linking two large and nationally representative databases to identify patients with IELC,” the researchers noted in the study.

The study also serves as a starting point for future research.

“Future studies that examine outcomes for incidentally explanted stage 3/4 NSCLC and account for the challenges of a post-transplant setting would be welcomed,” the researchers wrote.

“Very little guidance currently exists for whether lung transplant candidates with a known lung cancer should receive neoadjuvant therapy,” Rebernick adds. “Future work exploring the role of neoadjuvant treatment for these patients is needed.”