Case of the Week - January 20, 2005

55 year old Male

• Call from cardiac transplant coordinator
• 55 year old gentleman 5 years post heart transplant for ischemic cardiomyopathy now with abnormal CXR found on yearly screening film
• Immunosuppressants – cyclosporine, prednisone, (I don’t think he was on azathioprine)

Differential Diagnosis:
Cavitary Lung Lesion

• < 4 weeks
  • Nosocomial technical
    • MRSA, candida, aspergillus, aspiration, line infection, C. difficile
    • Nosocomial pthogens, donor-derived recipient colonizers
• 1-6 months
  • Opportunistic, relapsed, residual activation of latent infection
    • HSV, CMV, HBV, HCV, EBV, listeria, TB, PCP, BK virus, nocardia, toxoplasma, strongyloides, leishmania
    • Period of most intensive immune suppression
• >6-12 months
  • Community acquired
    • Community acquired pneumonia, aspergillus, dermatophytes, CMV colitis, UTI
    • Common to rare (depends on exposures and net state of immune suppression)

timeline from - www.uptodate.com

Diagnosis: Squamous Cell Lung Carcinoma

• Are heart transplant patients at higher risk for solid organ malignancy?
• What malignancies are they are higher risk for?

Of note 2002 CDC data with incidence of lung cancer in general population between 67-85/100,000 (0.08%)

Solid Organ Transplant and Malignancy Risk:

• Higher risks of some malignancies
  • Skin Cancers – Squamous Cell Carcinoma
  • Post Transplant Lymphomas and Lymphoproliferative Disorders (PTLD)
  • Kaposi’s Sarcoma and other sarcomas
  • Cervical Cancer - in situ carcinomas
  • Hepatobiliary carcinomas
  • Ano-genital carcinomas

What about lung cancer?

• Israel Penn – “most of the common malignancies seen in the general population are not increased in incidence.”
  • Started the Cincinatti Transplant Tumor Registry in 1968. By 1998, tracked > 10000 transplant patients with malignancies
• Another American Registry
  • Columbia University, from 1977-1994, 571 patients with heart transplants
  • 9 develop lung cancer (1.5%)
• Multicenter Italian Registry of Heart Transplanted Patients (MIRHT)
  • Mostly agree with Dr. Penn
  • Of 1000 patients with cancer after heart transplant, 31 had non-cutaneous carcinomas
    • 14 patients with lung cancer
• German Experience: Tenderich et al
  • From 1989 – 1998, 1084 heart transplant patients followed
    • 10% , 114 develop a malignancy
    • Pulmonary neoplasms in 22 patients (15.9%)
      • Overall 2% of all heart transplant patients
• From France:
  • 756 patients with heart transplants from 1982 – 1998
    • 16 developed lung cancer (2.1%)

Risk factors in heart transplant pts?:

1. Smoking History > 30 pack years
2. Male Gender
3. Age > 50
4. Controversial if Immunosuppressant regimen plays a role in lung cancer

Disclaimer:  This information is intended solely for resident review of presented cases which may or may not be pathologically proven. Information is derived from a number of published sources of varying reliability and does not represent original research from the institution. It is not intended to be comprehensive and should therefore not substitute for careful review of the literature. 

Our Pulmonary Archived Cases

2006