Rethinking the Impact of Pretransplant Malignancy (Pre-TM) on Double Lung Transplantation (DLT) Eligibility: An Analysis of 23,291 DLT Recipients

Background: Given the increasing need for lung transplants among older patients with a history of cancer, this study analyzed database registry to assess outcomes for DLT recipients with Pre-TM. Methods: This study evaluated the United Network for Organ Sharing (UNOS) registry for adult DLT performed between 2005 and 2023. Patients with a history of previous or multi-organ transplants, and those with donors who had cancer history, were excluded. Propensity-score matching was used to compare patients with or without Pre-TM. Overall and Post-TM-free survival were analyzed. Results: Among the 23,291 recipients of DLT, 8.0%(1,870) had Pre-TM. Compared to those without Pre-TM, patients with Pre-TM had worse overall (hazard ratio[HR] 1.20, 95% confidence interval[CI] 1.12-1.29, p<0.001) and Post-TM-free survival (HR 1.32, 95% CI 1.24-1.41, p<0.001). However, after adjusting for age, sex, and race through propensity-score matching, the survival difference between the groups became non-significant (HR 1.05, 95% CI 0.97-1.13, p=0.229). While the Pre-TM group still had worse Post-TM-free survival, this difference diminished after excluding cutaneous Post-TM (HR 1.06, 95% CI 0.99-1.15, p=0.116). Additionally, the recurrence rate of Pre-TM after transplant wasn't higher than de novo cancers in patients without Pre-TM. Conclusion: Patients with Pre-TM had similar overall survival rates after DLT as those without Pre-TM. Importantly, there is no increased risk of the primary Pre-TM type recurring post-transplant compared to patients without Pre-TM. These findings highlight the necessity for a more nuanced evaluation of transplant candidacy to prevent premature exclusion of Pre-TM patients from life-saving surgeries.