ABSTRACT
I. Introduction Lung transplantation (LTx) is now recognized as an effective treatment option for a variety of end-stage lung diseases and is associated with improvements in life expectancy and quality of life. Patients who have undergone solid-organ transplantation (SOT) have a higher prevalence of malignancy than the general population, with estimates suggesting a three-to fourfold increase in the risk of any malignancy and a 100-fold increase in specific malignancies (1,2). The incidence of malignancy may be even higher in LTx recipients (3). The risk of oncogenesis after transplantation is thought to correlate with the overall burden of immunosuppression (1). Developments in surgical techniques, lung preservation, immunosuppression, and management of infections have resulted in a slight improvement in long-term survival, and combined with the recent trend toward transplanting a greater proportion of older recipients, the incidence of post-transplant malignancy is increasing and is expected to be among the leading causes of death in all transplant recipients in the next two decades (1,4). The prevalence of malignancy increases with time post LTx from 3.7% in 1-year survivors and 12.4% in 5-year survivors to 25% in 10-year survivors (4). Beyond the first year, malignancy accounts for 9.3% of deaths. Skin cancers and post-transplantation lymphoproliferative disorders (PTLDs) are the most common malignancies. PTLD is the most common cancer in the first two years after transplantation and in pediatric recipients (1). Skin cancers are the most common malignancy thereafter (4,5). Current candidate selection guidelines consider malignancy within two years an absolute contraindication to LTx, and also recommend excluding patients with malignancy within five years of candidacy (6). There are currently no consensus guidelines for post-transplant cancer screening but general recommendations advise adherence to standard cancer screening guidelines (7). Transplant recipients present an even more complicated picture than the usual cancer patient because of the added burden of immunosuppression and infection risk with treatment as well as difficulties with diagnosis because of atypical presentation. Cancers that develop in transplant recipients are often more aggressive than in the general population, but with new insights into the pathophysiology, available prevention methods, and advances in immunomodulation, the potential to improve the outcome is promising.
