Bilateral lung transplantation in a patient with metastatic lung adenocarcinoma: a potential opportunity to expand lung transplant candidacy

SESSION TITLE: Transplantation Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: Lung cancer is unexpectedly found in 1-3% of explanted lungs of subjects undergoing lung transplantation (1). We here present a patient who had bilateral lung transplant for hypoxemic respiratory failure secondary to systemic sclerosis related interstitial lung disease (SSC-ILD) and was diagnosed to have bilateral lung adenocarcinoma with bony metastasis after transplantation. CASE PRESENTATION: A 63-year-old woman with past medical history of CREST (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia) syndrome and pulmonary artery hypertension was admitted with worsening shortness of breath and hypoxia. She used supplemental oxygen for 7 years prior to presentation with increase in oxygen requirement to 15L/min at the time of admission. CT chest on admission showed Interval marked worsening and new areas of ground-glass and consolidative opacities involving all lobes, stable enlargement of mediastinal and hilar lymph nodes measuring up to 1.5 cm (Images 1 and 2). Infectious on admission was negative and was treated with steroids for ILD flare. Simultaneously evaluation for lung transplantation was initiated. The patient's oxygen requirement gradually worsened, and she was placed on veno-venous ECMO on day 43 of her hospital stay. She underwent bilateral lung transplant on day 66 of hospital stay. The lung allografts were assessed on Ex Vivo Vivo Lung Perfusion (EVLP) prior to transplantation. The pathology of the explanted lung showed pneumonic type, poorly differentiated, invasive adenocarcinoma of both lungs involving all five lobes with hilar involvement bilaterally in the background of fibrosing non-specific interstitial pneumonia (NSIP). PET scan showed pelvic lesion and was proven to be metastatic adenocarcinoma with a lung primary on biopsy. Patient was started on systemic chemotherapy with Carboplatin and Pemetrexed 3 months post-transplant which was later changed to Trametinib and Docetaxel given progression along with radiation to the pelvis. Towards 25th month of her transplant, her metastatic disease progressed, she transitioned to hospice care and passed away. The lung allografts were functional at the time of death (PFT trends in image 3) and there was no evidence of recurrence of the adenocarcinoma in the lungs. DISCUSSION: Adenocarcinoma of the lung is an indication for lung transplantation but is rarely performed for this indication (1). In a retrospective study of the United Network for Organ Sharing registry, 15 out of 21,533 lung transplants were performed for bronchioalveolar cell carcinoma (BAC) with comparable outcomes to other diagnosis (2). To our knowledge this is the first case of a lung transplant performed utilizing grafts that underwent EVLP in a patient with metastatic lung adenocarcinoma. CONCLUSIONS: Expansion of the donor pool with technologies like EVLP (3) and bioengineered lungs, the development of new cancer therapies, and individualized immunosuppression regimens could potentially expand the candidacy for lung transplantation to patients with advanced lung adenocarcinoma. REFERENCE #1: Allan R Glanville, Brooke E Wilson, Lung transplantation for non-small cell lung cancer and multifocal bronchioalveolar cell carcinoma, The Lancet Oncology, Volume 19, Issue 7, 2018, Pages e351-e358 REFERENCE #2: U Ahmad, Z Wang, AS Bryant, et al. Outcomes for lung transplantation for lung cancer in the United Network for Organ Sharing Registry Ann Thorac Surg, 94 (2012), pp. 935-940 REFERENCE #3: Mallea, J.M., et al. Remote ex vivo lung perfusion at a centralized evaluation facility. J Heart Lung Transplant 41, 1700-1711 (2022). DISCLOSURES: No relevant relationships by Francisco Alvarez No relevant relationships by Prasanth Balasubramanian Consultant relationship with Lung Bioengineering Please note: 2020-2023 Added 04/08/2023 by Jorge Mallea, source=Web Response, value=Consulting fee No relevant relationships by Yujie Zhao