Pre-transplant malignancy: an analysis of outcomes after thoracic organ transplantation

Abstract

Background: Pre-transplant malignancy (PTM) is a relative contraindication to organ transplantation. Studies examining the effect of PTM on outcomes after lung transplantation (LTx) or orthotopic heart transplantation (OHT) are limited. We evaluated the effect of PTM on outcomes after LTx and OHT.

Methods: We retrospectively reviewed primary adult LTx and OHT recipients in the United Network for Organ Sharing database. Primary stratification was by PTM and secondary stratification by tumor type. Matched cohorts (2:1) and multivariable Cox proportional hazards regression models were used to evaluate mortality.

Results: From 2000 to 2011, 13,613 adults underwent LTx and 19,817 underwent OHT. PTM was present in 740 LTx patients (5.4%) and in 1,117 OHT patients (5.6%). On unadjusted analysis, LTx patients and OHT patients with PTM had similar 30-day, 1-year, and 5-year survivals (p<0.05) compared with patients with no PTM. These findings persisted after risk-adjustment . No tumor types were associated with increased mortality in LTx patients. OHT patients with leukemia, lymphoma, or myeloma (LLM) had a significant increase in univariate mortality at 30 days (hazard ratio [HR], 1.82; p = 0.04), 1 year (HR, 1.93; p<0.001), and 5 years (HR, 1.54; p = 0.01). Matched cohort analysis revealed comparable outcomes in LTx patients but confirmed increased univariate 1-year mortality (HR, 1.89; p = 0.006) in OHT patients with LLM.

Conclusions: This large study evaluating the effects of PTM found the incidence of PTM was in LTx 5.4% and in OHT 5.6%. In general, PTM does not increase mortality in either cohort; however, OHT patients with LLM have an increased hazard of mortality. Therefore, carefully selected patients with PTM should not be excluded from LTx or OHT.

Figure 1

1 and 5 year Kaplan-Meier survival curve of the LTx Cohort stratified by Pre-Transplant Malignancy (PTM). Patients without PTM are depicted as a solid line while patients with PTM are depicted with a dash-dot line. (B) 1 and 5 year Kaplan-Meier survival curve of the LTx Cohort stratified by type of malignancy. Patients without cancer are depicted with a dark blue line, patients with melanoma are depicted with a purple line, patients with non-melanoma skin cancer are depicted with a dark green line, patients with a solid organ tumor are depicted with an orange line, patients with a hematologic tumor are depicted with a light green line, patients with multiple tumors are depicted with a red line and patients with other tumors are depicted with a light blue line. (C) 1 and 5 year Kaplan-Meier survival curve of the LTx Cohort stratified by the presence of the Lung Allocation Score (LAS). The solid line depicts the era before the LAS and the dash-dot line depicts the era after the LAS. p values were determined by the log-rank test.

Figure 1

1 and 5 year Kaplan-Meier survival curve of the LTx Cohort stratified by Pre-Transplant Malignancy (PTM). Patients without PTM are depicted as a solid line while patients with PTM are depicted with a dash-dot line. (B) 1 and 5 year Kaplan-Meier survival curve of the LTx Cohort stratified by type of malignancy. Patients without cancer are depicted with a dark blue line, patients with melanoma are depicted with a purple line, patients with non-melanoma skin cancer are depicted with a dark green line, patients with a solid organ tumor are depicted with an orange line, patients with a hematologic tumor are depicted with a light green line, patients with multiple tumors are depicted with a red line and patients with other tumors are depicted with a light blue line. (C) 1 and 5 year Kaplan-Meier survival curve of the LTx Cohort stratified by the presence of the Lung Allocation Score (LAS). The solid line depicts the era before the LAS and the dash-dot line depicts the era after the LAS. p values were determined by the log-rank test.

Figure 1

1 and 5 year Kaplan-Meier survival curve of the LTx Cohort stratified by Pre-Transplant Malignancy (PTM). Patients without PTM are depicted as a solid line while patients with PTM are depicted with a dash-dot line. (B) 1 and 5 year Kaplan-Meier survival curve of the LTx Cohort stratified by type of malignancy. Patients without cancer are depicted with a dark blue line, patients with melanoma are depicted with a purple line, patients with non-melanoma skin cancer are depicted with a dark green line, patients with a solid organ tumor are depicted with an orange line, patients with a hematologic tumor are depicted with a light green line, patients with multiple tumors are depicted with a red line and patients with other tumors are depicted with a light blue line. (C) 1 and 5 year Kaplan-Meier survival curve of the LTx Cohort stratified by the presence of the Lung Allocation Score (LAS). The solid line depicts the era before the LAS and the dash-dot line depicts the era after the LAS. p values were determined by the log-rank test.

Figure 2

1 and 5 year Kaplan-Meier survival curve of the OHT Cohort stratified by Pre-Transplant Malignancy (PTM). Patients without PTM are depicted as a solid line while patients with PTM are depicted with a dash-dot line. (B) 1 and 5 year Kaplan-Meier survival curve of the OHT Cohort stratified by type of malignancy. Patients without cancer are depicted with a dark blue line, patients with melanoma are depicted with a purple line, patients with non-melanoma skin cancer are depicted with a dark green line, patients with a solid organ tumor are depicted with an orange line, patients with a hematologic tumor are depicted with a light green line, patients with multiple tumors are depicted with a red line and patients with other tumors are depicted with a light blue line. (C) 1 and 5 year Kaplan-Meier survival curve of the OHT Cohort stratified by the type of malignancy. The solid line depicts patients without PTM, the dotted line depicts patients with other types of malignancy and the dash-dot line depicts patients with hematologic tumors. (D) 5 year Kaplan-Meier survival curve of the OHT Cohort conditional on 1 year survival, stratified by the type of malignancy. The solid line depicts patients without PTM, the dotted line depicts patients with other types of malignancy and the dash-dot line depicts patients with hematologic tumors. p values were determined by the log-rank test.

Figure 2

1 and 5 year Kaplan-Meier survival curve of the OHT Cohort stratified by Pre-Transplant Malignancy (PTM). Patients without PTM are depicted as a solid line while patients with PTM are depicted with a dash-dot line. (B) 1 and 5 year Kaplan-Meier survival curve of the OHT Cohort stratified by type of malignancy. Patients without cancer are depicted with a dark blue line, patients with melanoma are depicted with a purple line, patients with non-melanoma skin cancer are depicted with a dark green line, patients with a solid organ tumor are depicted with an orange line, patients with a hematologic tumor are depicted with a light green line, patients with multiple tumors are depicted with a red line and patients with other tumors are depicted with a light blue line. (C) 1 and 5 year Kaplan-Meier survival curve of the OHT Cohort stratified by the type of malignancy. The solid line depicts patients without PTM, the dotted line depicts patients with other types of malignancy and the dash-dot line depicts patients with hematologic tumors. (D) 5 year Kaplan-Meier survival curve of the OHT Cohort conditional on 1 year survival, stratified by the type of malignancy. The solid line depicts patients without PTM, the dotted line depicts patients with other types of malignancy and the dash-dot line depicts patients with hematologic tumors. p values were determined by the log-rank test.

Figure 2

1 and 5 year Kaplan-Meier survival curve of the OHT Cohort stratified by Pre-Transplant Malignancy (PTM). Patients without PTM are depicted as a solid line while patients with PTM are depicted with a dash-dot line. (B) 1 and 5 year Kaplan-Meier survival curve of the OHT Cohort stratified by type of malignancy. Patients without cancer are depicted with a dark blue line, patients with melanoma are depicted with a purple line, patients with non-melanoma skin cancer are depicted with a dark green line, patients with a solid organ tumor are depicted with an orange line, patients with a hematologic tumor are depicted with a light green line, patients with multiple tumors are depicted with a red line and patients with other tumors are depicted with a light blue line. (C) 1 and 5 year Kaplan-Meier survival curve of the OHT Cohort stratified by the type of malignancy. The solid line depicts patients without PTM, the dotted line depicts patients with other types of malignancy and the dash-dot line depicts patients with hematologic tumors. (D) 5 year Kaplan-Meier survival curve of the OHT Cohort conditional on 1 year survival, stratified by the type of malignancy. The solid line depicts patients without PTM, the dotted line depicts patients with other types of malignancy and the dash-dot line depicts patients with hematologic tumors. p values were determined by the log-rank test.

Figure 2

1 and 5 year Kaplan-Meier survival curve of the OHT Cohort stratified by Pre-Transplant Malignancy (PTM). Patients without PTM are depicted as a solid line while patients with PTM are depicted with a dash-dot line. (B) 1 and 5 year Kaplan-Meier survival curve of the OHT Cohort stratified by type of malignancy. Patients without cancer are depicted with a dark blue line, patients with melanoma are depicted with a purple line, patients with non-melanoma skin cancer are depicted with a dark green line, patients with a solid organ tumor are depicted with an orange line, patients with a hematologic tumor are depicted with a light green line, patients with multiple tumors are depicted with a red line and patients with other tumors are depicted with a light blue line. (C) 1 and 5 year Kaplan-Meier survival curve of the OHT Cohort stratified by the type of malignancy. The solid line depicts patients without PTM, the dotted line depicts patients with other types of malignancy and the dash-dot line depicts patients with hematologic tumors. (D) 5 year Kaplan-Meier survival curve of the OHT Cohort conditional on 1 year survival, stratified by the type of malignancy. The solid line depicts patients without PTM, the dotted line depicts patients with other types of malignancy and the dash-dot line depicts patients with hematologic tumors. p values were determined by the log-rank test.

Figure 3

1 and 5 year Kaplan-Meier survival curve of the Matched OHT Cohort stratified by Pre-Transplant Malignancy (PTM). Patients without PTM are depicted as a solid line while patients with PTM are depicted with a dash-dot line. (B) 1 and 5 year Kaplan-Meier survival curve of the Matched OHT Cohort stratified by type of malignancy. Patients without cancer are depicted with a dark blue line, patients with melanoma are depicted with a purple line, patients with non-melanoma skin cancer are depicted with a dark green line, patients with a solid organ tumor are depicted with an orange line, patients with a hematologic tumor are depicted with a light green line, patients with multiple tumors are depicted with a red line and patients with other tumors are depicted with a light blue line. (C) 1 and 5 year Kaplan-Meier survival curve of the Matched OHT Cohort stratified by the type of malignancy. The solid line depicts patients without PTM, the dotted line depicts patients with other types of malignancy and the dash-dot line depicts patients with hematologic tumors. p values were determined by the log-rank test.