- Email: [email protected]
Pre- and Post- Transplantation Lung Cancer in Heart Transplant Recipients
CASE REPORTS
Pre- and Post- Transplantation Lung Cancer in Heart Transplant Recipients Ciprian Pricopi, MD, Caroline Rivera, MD, Shaida Varnous, MD, Alex Arame, MD, Franc¸oise Le Pimpec Barthes, MD, PhD, and Marc Riquet, MD, PhD Department of General Thoracic Surgery, Georges Pompidou European Hospital, Descartes University, Paris; and Department of Cardiac and Thoracic Surgery, La Pitie hospital, Paris, France
M
alignancy has emerged as an important cause of death in long-surviving transplant recipients [1]. Recent analysis of the U.S. National Transplant Database by Sampaio and colleagues [2] demonstrated lung cancer to be the first cancer occurring after heart transplantation (HT; 3.4% of 16,511 recipients). Concurrently, an encouraging decrease in mortality after organ transplantation has been observed over the last decades, and older patients are now more frequently accepted for transplantation, which is resulting in more transplant patients presenting with a history of pretransplantation malignancy [1]. The cancer-free waiting time period required before transplantation in the case of previous lung cancer is not well established, but was estimated to be a minimum of 2 years by the American and Canadian Societies of Transplantation as far as the kidney was concerned [3].To our knowledge, few data are available in the literature regarding the situation in HT. We report two patients who underwent HT after pretransplantation non-small cell lung cancer (NSCLC) surgery.
Patient 1 A 54-year-old man who was a heavy smoker underwent a right lung upper lobectomy in 2008 for a pT1N0 adenocarcinoma. This NSCLC had been diagnosed during a pre-HT evaluation. The heart failure (dilated cardiomyopathy) was managed successfully until 2010, when HT was performed. The patient at that time was considered as being free from any lung disease. The postoperative course was uneventful but in July 2011, during routine follow up investigation, a left upper lobe (LUL) nodule was detected. In March 2012, the nodule had slightly increased in size, while a second lesion was detected in the apical segment of the left lower lobe (LLL). Positron emission tomography-tomodensitometry (PET-TDM) was normal. The patient underwent a diagnostic minithoracotomy. Both lesions were classified as synchronous NSCLCs and were subsequently treated by lung resection along with hilar and mediastinal lymphadenectomy. A large lingular wedge resection for a pT2aN0 squamous cell carcinoma (measuring 19 mm) invading visceral pleura and an LLL-segmentectomy for a pT1aN0 acinar adenocarcinoma were performed. The postoperative course was uneventful, and in April 2014, 6 years after the first NSCLC and 4 years after the HT, the patient was still alive without any major health problems.
Patient 2 A 45-year-old man, also a heavy smoker, was initially hospitalized in 1994 for heart failure. After a symptomatic treatment, his condition improved for a short time and he was rehospitalized for a pre-HT checkup. A slightly cavitated nodule was discovered in the apical segment of the LLL. Despite the poor cardiac function (left ventricular ejection fraction ¼ 28%), the patient underwent an LLL-segmentectomy without lymphadenectomy in June 1995. Histologic examination demonstrated a pT1aN0 adenosquamous carcinoma. The postoperative course was uneventful, and HT was performed 3 months later. The patient remained well until March 2013, when a LUL nodule was detected on TDM. PET-TDM showed hypermetabolism of parenchymal and hilar lymph node. At that time, forced expiratory volume in 1 s was 45% despite a rehabilitation program. In September 2013, the patient underwent an LUL wedge resection with hilar and mediastinal lymphadenectomy. Postoperative acidosis and hypercapnia were corrected with noninvasive ventilation. Histologic examination found a pT1N1 acinar adenocarcinoma. The patient died in March 2014 from septicemia and bone metastases, 19 years after the first NSCLC and the HT.
Comment Accepted for publication July 21, 2014. Address correspondence to Dr Riquet, Department of General Thoracic Surgery, Georges Pompidou European Hospital, 20 rue Leblanc, 75015 Paris, France; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
There is growing evidence that NSCLC incidence is not higher in HT survivors than in nontransplant patients with similar risk factors [4]. The major risk is smoking [5], a common factor in both heart and lung diseases. NSCLC 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.07.081
FEATURE ARTICLES
Heart transplantation after lung cancer surgery can be questionable because of the high risk of cancer recurrence. We report the results of two patients. The first underwent right lobectomy in 2008 for pT1N0 adenocarcinoma, heart-transplantation in 2010, and surgery for synchronous adenocarcinoma and squamous-cell carcinoma in 2012. The second underwent left segmentectomy for pT1aN0 adenosquamous carcinoma and transplantation in 1995 and then surgery for pT1aN1 adenocarcinoma in 2013. Posttransplantation lung cancer histologic analysis results were different in both cases, demonstrating the absence of metastatic recurrence. Thus, early stage lung cancer might not be a contraindication to heart transplantation, nor are long delays be necessary before registering on a waiting list. (Ann Thorac Surg 2015;99:1793–4) Ó 2015 by The Society of Thoracic Surgeons
Case Reports
1794
CASE REPORT HEALY ET AL LVAD CONDITIONING FOR RECOVERY
is not induced by posttransplantation immunosuppressive drug therapy, and in the same way, NSCLC postoperative course was demonstrated to be independent from a continuation of this treatment [6], which appears to be different from that observed in other immunodeficiencies such as HIV infection. Thus, early detection of post-HT NSCLC gives the patient a greater chance to be eligible for surgery and provides a significant survival rate [6]. When feasible, surgery is the first choice of treatment, alone or associated with multimodal therapy. It should be stressed, however, that no current recommendations can actually be stated regarding any waiting time before enlisting for HT patients with a history of malignant tumor, especially for lung cancer. According to the International Society for Heart and Lung Transplantation, recommendations regarding cancer are formulated as follows [7]:
FEATURE ARTICLES
Pre-existing neoplasms are diverse and many are treatable with excision, radiotherapy or chemotherapy to induce cure or remission. In these patients needing cardiac transplantation, collaboration with oncology specialists should occur to stratify each patient as to their risk of tumor recurrence. Cardiac transplantation should be considered when tumor recurrence is low based on tumor type, response to therapy and negative metastatic work-up. The specific amount of time to wait to transplant after neoplasm remission will depend on the aforementioned factors and no arbitrary time period for observation should be used (Level of Evidence: C).
Kauffman and colleagues [8] collected several reports on heart transplantation in patients with a history of a preexisting malignancy—a significant variability has been demonstrated in recurrence rates during the course of follow-up. They reported recurrence of treated malignancy and occurrences of new primary localizations. There were 52 HT, but none with a history of previous lung cancer. NSCLC prognosis is generally poor; however, in the case of pre-HT diagnosis, tumors are usually early stage and therefore associated with a higher rate of resectability. Furthermore, Kauffman and colleagues’ review [8] showed that the incidence of metastasis was lower than that of de novo malignancy after NSCLC surgery. In conclusion, the reported cases suggest that a long delay between NSCLC resection and HT is not mandatory, and patients should be registered early on an HT waiting list. In our opinion, early stage resected NSCLC should not represent a contraindication for transplantation.
References 1. Brattstr€ om C, Granath F, Edgren G, Smedby KE, Wilczek HE. Overall and cause-specific mortality in transplant recipients with a pretransplantation cancer history. Transplantation 2013;96:297–305. 2. Sampaio MS, Cho YW, Qazi Y, Bunnapradist S, Huthchinson IV, Shah T. Posttransplant malignancies in solid organ adult recipients: an analysis of the U.S. National Transplant Database. Transplantation 2012;94:990–8. 3. Batabyal P, Chapman JR, Wong G, Craig JC, Tong A. Clinical practice guidelines on wait-listing for kidney transplantation: consistent and equitable? Transplantation 2012;94:703–13. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2015;99:1794–6
4. Potaris K, Radovancevic B, Thomas CD, et al. Lung cancer after heart transplantation: a 17-year experience. Ann Thorac Surg 2005;79:980–3. 5. Kellerman L, Neugut A, Burke B, Mancini D. Comparison of the incidence of de novo malignancies after heart transplantation to that in the general population. Am J Cardiol 2009;103:562–6. 6. Jonhson WM, Baldursson O, Gross TJ. Double jeopardy: lung cancer after cardiac transplantation. Chest 1998;113:1720–3. 7. Mehra MR, Kobashigawa J, Starling R, et al. Listing criteria for heart transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates—2006. J Heart Lung Transplant 2006;25:1024–42. 8. Kauffman HM, Cherikha WS, McBride MA, Chenga YA, Delmonicob FL, Hantoc DW. Transplant recipients with a history of a malignancy: risk of recurrent and de novo cancers. Transplant Rev 2005;19:55–64.
Patient-Controlled Conditioning for Left Ventricular Assist Device–Induced Myocardial Recovery Aaron H. Healy, MD, Antigoni Koliopoulou, MD, Stavros G. Drakos, MD, PhD, Stephen H. McKellar, MD, MS, Josef Stehlik, MD, MPH, and Craig H. Selzman, MD Departments of Surgery and Medicine, University of Utah School of Medicine, Salt Lake City, Utah
Although medical protocols exist to promote reverse remodeling in left ventricular assist device–supported patients, there are scant data about device management in these patients. We report the use of a Jarvik 2000 left ventricular assist device (Jarvik Heart Inc, New York, NY) to facilitate myocardial recovery leading to device explantation using a sequential, patient-controlled approach. Sequential conditioning of the left ventricular assist device–supported heart is a promising strategy for bridging patients to recovery and pump removal. (Ann Thorac Surg 2015;99:1794–6) Ó 2015 by The Society of Thoracic Surgeons
A
subset of advanced heart failure patients, when unloaded with a left ventricular assist device (LVAD), may experience return of cardiac function and subsequently become candidates for LVAD explantation [1]. Although medical protocols exist to promote reverse remodeling in the LVAD-supported patient [2], there is currently no well-established method of managing the device itself to facilitate myocardial recovery. The Jarvik 2000 LVAD (Jarvik Heart Inc, New York, NY) differs from other continuous-flow LVADs in that it allows patients to adjust the speed settings from speed 1 to speed 5, with corresponding pump speeds of 8,000 Accepted for publication July 14, 2014. Address correspondence to Dr Selzman, Division of Cardiothoracic Surgery, University of Utah School of Medicine, 30 N 1900 E, SOM 3C 127, Salt Lake City, UT 84132; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.07.058
Pre- and Post- Transplantation Lung Cancer in Heart Transplant Recipients Ciprian Pricopi, MD, Caroline Rivera, MD, Shaida Varnous, MD, Alex Arame, MD, Franc¸oise Le Pimpec Barthes, MD, PhD, and Marc Riquet, MD, PhD Department of General Thoracic Surgery, Georges Pompidou European Hospital, Descartes University, Paris; and Department of Cardiac and Thoracic Surgery, La Pitie hospital, Paris, France
M
alignancy has emerged as an important cause of death in long-surviving transplant recipients [1]. Recent analysis of the U.S. National Transplant Database by Sampaio and colleagues [2] demonstrated lung cancer to be the first cancer occurring after heart transplantation (HT; 3.4% of 16,511 recipients). Concurrently, an encouraging decrease in mortality after organ transplantation has been observed over the last decades, and older patients are now more frequently accepted for transplantation, which is resulting in more transplant patients presenting with a history of pretransplantation malignancy [1]. The cancer-free waiting time period required before transplantation in the case of previous lung cancer is not well established, but was estimated to be a minimum of 2 years by the American and Canadian Societies of Transplantation as far as the kidney was concerned [3].To our knowledge, few data are available in the literature regarding the situation in HT. We report two patients who underwent HT after pretransplantation non-small cell lung cancer (NSCLC) surgery.
Patient 1 A 54-year-old man who was a heavy smoker underwent a right lung upper lobectomy in 2008 for a pT1N0 adenocarcinoma. This NSCLC had been diagnosed during a pre-HT evaluation. The heart failure (dilated cardiomyopathy) was managed successfully until 2010, when HT was performed. The patient at that time was considered as being free from any lung disease. The postoperative course was uneventful but in July 2011, during routine follow up investigation, a left upper lobe (LUL) nodule was detected. In March 2012, the nodule had slightly increased in size, while a second lesion was detected in the apical segment of the left lower lobe (LLL). Positron emission tomography-tomodensitometry (PET-TDM) was normal. The patient underwent a diagnostic minithoracotomy. Both lesions were classified as synchronous NSCLCs and were subsequently treated by lung resection along with hilar and mediastinal lymphadenectomy. A large lingular wedge resection for a pT2aN0 squamous cell carcinoma (measuring 19 mm) invading visceral pleura and an LLL-segmentectomy for a pT1aN0 acinar adenocarcinoma were performed. The postoperative course was uneventful, and in April 2014, 6 years after the first NSCLC and 4 years after the HT, the patient was still alive without any major health problems.
Patient 2 A 45-year-old man, also a heavy smoker, was initially hospitalized in 1994 for heart failure. After a symptomatic treatment, his condition improved for a short time and he was rehospitalized for a pre-HT checkup. A slightly cavitated nodule was discovered in the apical segment of the LLL. Despite the poor cardiac function (left ventricular ejection fraction ¼ 28%), the patient underwent an LLL-segmentectomy without lymphadenectomy in June 1995. Histologic examination demonstrated a pT1aN0 adenosquamous carcinoma. The postoperative course was uneventful, and HT was performed 3 months later. The patient remained well until March 2013, when a LUL nodule was detected on TDM. PET-TDM showed hypermetabolism of parenchymal and hilar lymph node. At that time, forced expiratory volume in 1 s was 45% despite a rehabilitation program. In September 2013, the patient underwent an LUL wedge resection with hilar and mediastinal lymphadenectomy. Postoperative acidosis and hypercapnia were corrected with noninvasive ventilation. Histologic examination found a pT1N1 acinar adenocarcinoma. The patient died in March 2014 from septicemia and bone metastases, 19 years after the first NSCLC and the HT.
Comment Accepted for publication July 21, 2014. Address correspondence to Dr Riquet, Department of General Thoracic Surgery, Georges Pompidou European Hospital, 20 rue Leblanc, 75015 Paris, France; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
There is growing evidence that NSCLC incidence is not higher in HT survivors than in nontransplant patients with similar risk factors [4]. The major risk is smoking [5], a common factor in both heart and lung diseases. NSCLC 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.07.081
FEATURE ARTICLES
Heart transplantation after lung cancer surgery can be questionable because of the high risk of cancer recurrence. We report the results of two patients. The first underwent right lobectomy in 2008 for pT1N0 adenocarcinoma, heart-transplantation in 2010, and surgery for synchronous adenocarcinoma and squamous-cell carcinoma in 2012. The second underwent left segmentectomy for pT1aN0 adenosquamous carcinoma and transplantation in 1995 and then surgery for pT1aN1 adenocarcinoma in 2013. Posttransplantation lung cancer histologic analysis results were different in both cases, demonstrating the absence of metastatic recurrence. Thus, early stage lung cancer might not be a contraindication to heart transplantation, nor are long delays be necessary before registering on a waiting list. (Ann Thorac Surg 2015;99:1793–4) Ó 2015 by The Society of Thoracic Surgeons
Case Reports
1794
CASE REPORT HEALY ET AL LVAD CONDITIONING FOR RECOVERY
is not induced by posttransplantation immunosuppressive drug therapy, and in the same way, NSCLC postoperative course was demonstrated to be independent from a continuation of this treatment [6], which appears to be different from that observed in other immunodeficiencies such as HIV infection. Thus, early detection of post-HT NSCLC gives the patient a greater chance to be eligible for surgery and provides a significant survival rate [6]. When feasible, surgery is the first choice of treatment, alone or associated with multimodal therapy. It should be stressed, however, that no current recommendations can actually be stated regarding any waiting time before enlisting for HT patients with a history of malignant tumor, especially for lung cancer. According to the International Society for Heart and Lung Transplantation, recommendations regarding cancer are formulated as follows [7]:
FEATURE ARTICLES
Pre-existing neoplasms are diverse and many are treatable with excision, radiotherapy or chemotherapy to induce cure or remission. In these patients needing cardiac transplantation, collaboration with oncology specialists should occur to stratify each patient as to their risk of tumor recurrence. Cardiac transplantation should be considered when tumor recurrence is low based on tumor type, response to therapy and negative metastatic work-up. The specific amount of time to wait to transplant after neoplasm remission will depend on the aforementioned factors and no arbitrary time period for observation should be used (Level of Evidence: C).
Kauffman and colleagues [8] collected several reports on heart transplantation in patients with a history of a preexisting malignancy—a significant variability has been demonstrated in recurrence rates during the course of follow-up. They reported recurrence of treated malignancy and occurrences of new primary localizations. There were 52 HT, but none with a history of previous lung cancer. NSCLC prognosis is generally poor; however, in the case of pre-HT diagnosis, tumors are usually early stage and therefore associated with a higher rate of resectability. Furthermore, Kauffman and colleagues’ review [8] showed that the incidence of metastasis was lower than that of de novo malignancy after NSCLC surgery. In conclusion, the reported cases suggest that a long delay between NSCLC resection and HT is not mandatory, and patients should be registered early on an HT waiting list. In our opinion, early stage resected NSCLC should not represent a contraindication for transplantation.
References 1. Brattstr€ om C, Granath F, Edgren G, Smedby KE, Wilczek HE. Overall and cause-specific mortality in transplant recipients with a pretransplantation cancer history. Transplantation 2013;96:297–305. 2. Sampaio MS, Cho YW, Qazi Y, Bunnapradist S, Huthchinson IV, Shah T. Posttransplant malignancies in solid organ adult recipients: an analysis of the U.S. National Transplant Database. Transplantation 2012;94:990–8. 3. Batabyal P, Chapman JR, Wong G, Craig JC, Tong A. Clinical practice guidelines on wait-listing for kidney transplantation: consistent and equitable? Transplantation 2012;94:703–13. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2015;99:1794–6
4. Potaris K, Radovancevic B, Thomas CD, et al. Lung cancer after heart transplantation: a 17-year experience. Ann Thorac Surg 2005;79:980–3. 5. Kellerman L, Neugut A, Burke B, Mancini D. Comparison of the incidence of de novo malignancies after heart transplantation to that in the general population. Am J Cardiol 2009;103:562–6. 6. Jonhson WM, Baldursson O, Gross TJ. Double jeopardy: lung cancer after cardiac transplantation. Chest 1998;113:1720–3. 7. Mehra MR, Kobashigawa J, Starling R, et al. Listing criteria for heart transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates—2006. J Heart Lung Transplant 2006;25:1024–42. 8. Kauffman HM, Cherikha WS, McBride MA, Chenga YA, Delmonicob FL, Hantoc DW. Transplant recipients with a history of a malignancy: risk of recurrent and de novo cancers. Transplant Rev 2005;19:55–64.
Patient-Controlled Conditioning for Left Ventricular Assist Device–Induced Myocardial Recovery Aaron H. Healy, MD, Antigoni Koliopoulou, MD, Stavros G. Drakos, MD, PhD, Stephen H. McKellar, MD, MS, Josef Stehlik, MD, MPH, and Craig H. Selzman, MD Departments of Surgery and Medicine, University of Utah School of Medicine, Salt Lake City, Utah
Although medical protocols exist to promote reverse remodeling in left ventricular assist device–supported patients, there are scant data about device management in these patients. We report the use of a Jarvik 2000 left ventricular assist device (Jarvik Heart Inc, New York, NY) to facilitate myocardial recovery leading to device explantation using a sequential, patient-controlled approach. Sequential conditioning of the left ventricular assist device–supported heart is a promising strategy for bridging patients to recovery and pump removal. (Ann Thorac Surg 2015;99:1794–6) Ó 2015 by The Society of Thoracic Surgeons
A
subset of advanced heart failure patients, when unloaded with a left ventricular assist device (LVAD), may experience return of cardiac function and subsequently become candidates for LVAD explantation [1]. Although medical protocols exist to promote reverse remodeling in the LVAD-supported patient [2], there is currently no well-established method of managing the device itself to facilitate myocardial recovery. The Jarvik 2000 LVAD (Jarvik Heart Inc, New York, NY) differs from other continuous-flow LVADs in that it allows patients to adjust the speed settings from speed 1 to speed 5, with corresponding pump speeds of 8,000 Accepted for publication July 14, 2014. Address correspondence to Dr Selzman, Division of Cardiothoracic Surgery, University of Utah School of Medicine, 30 N 1900 E, SOM 3C 127, Salt Lake City, UT 84132; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.07.058