Survival outcomes and risk factors after lung transplantation in patients with pre-transplant malignancy: a national cohort study.

Background: Pre-transplant malignancy (PTM) is a relative contraindication for lung transplantation (LTx). The proportion of patients with PTM in LTx is increasing annually. We sought to identify modifiable risk factors affecting patient survival and evaluate the prognosis of different types of PTM. Methods: We retrospectively reviewed primary adult lung transplantation recipients (LTR) in the United Network for Organ Sharing (UNOS) registry. Primary stratification was performed by PTM and secondary stratification by tumor type. Kaplan-Meier survival analysis was used to estimate survival and Cox proportional hazards model was used to assess risk factors. Results: Compared to patients without PTM, patients with PTM exhibit a significantly higher mortality rate starting 1 year post-transplantation (1-year: P=0.02; 3-, 5-, 10-year: P<0.001). Multivariate Cox regression analysis identified age, male sex, single LTx, and high lung allocation score (LAS) as independent risk factors for 5-year mortality in PTM patients. After stratifying PTM, lung PTM was an independent risk factor for death at all periods after transplantation (1-year: P<0.001; 3-year: P=0.001; 5-year: P=0.002; 10-year: P=0.005), and leukemia PTM significantly impacted medium- and long-term mortality (3-year: P=0.03; 5-year: P=0.01; 10-year: P=0.004). Additionally, cutaneous melanoma and genitourinary PTM were associated with long-term mortality. Skin cancer, lung cancer and leukemia were significantly associated with cancer-specific mortality (P<0.05). Conclusions: The prognosis of patients with PTM after LTx is worse than that of patients without PTM. When focusing on long-term survival, patients with a history of lung cancer, leukemia, melanoma and genitourinary system malignant tumors require more careful selection.