A 49-Year-Old Woman with a Well-Circumscribed PET Avid Lesion after Lung Transplantation: Thinking Outside the Box

Lung transplantation is increasingly being utilized as therapy for patients with end stage lung diseases. Incidence of lung cancer after lung transplantation is rare (1 4%), but is associated with high mortality and morbidity. Lung transplant recipients have one of the highest standardized risk of developing lung cancers among all solid organ transplants. Origin of such cancers can be localized to one of the following: incidental cancer on lung explant, donor derived malignancy, lung cancer in the native lung of single lung transplant recipients and new lung cancers developing after lung transplant without prior association. Clinical and radiographic presentations can be atypical in these immunosuppressed patients and hence a high index of suspicion is required. We present an interesting case of a 49-year old non-smoker woman who presented with fever, weakness, myalgia and a well circumscribed left lower lobe lung mass one year after bilateral lung transplantation. The diagnosis was made while she was being treated for Aspergillus tracheobronchitis. CT revealed a 25 x 19 mm left lower lobe lung base nodule and transthoracic CT guided biopsy revealed poorly differentiated squamous cell carcinoma. Staging PET scan confirmed a stage IA tumor for which she underwent lobectomy with systematic lymph node sampling. Her immunosuppression has been lowered to target lower troughs while she undergoes close clinical surveillance.