25 Malignancy after heart transplantation

In the current era, approximately 50% of heart transplant (HTx) recipients survive more than 13 years, with an increasing population of patients surviving beyond 20 years. Previous studies have suggested that HTx recipients are at particularly high risk of developing de novo malignancies due to more intensive immunosuppression. The perception of higher risk for post-transplant lymphoproliferative disease (PTLD; e.g. lymphoma) associated with OKT3 led to a fall in the use of OKT3 during the 1990s. Main advances in post-HTx management with probable reduction of risk for neoplasia are introduction of (1) antiviral prophylaxis, (2) induction agents that are more specific in their actions and (3) the mammalian target-of-rapamycin inhibitors (mTORs). Reported incidence of post-transplant malignancy in HTx recipients ranged from 2.3% to 27% and skin malignancies represented up to 50% of post-transplant malignancies. The second most common cancer in HTx recipients was PTLD. A retrospective analysis included 17 587 adult HTx recipients who were followed for up to five years post-operation.1 The incidence of de novo malignancy was 10.7% one to five years after transplantation, with higher prevalence in the contemporary era. Considering the increased burden of de novo malignancy in HTx recipients, additional effort needs to be directed towards formulating evidence-based cancer screening recommendations and optimised immunosuppression protocols for these patients. It may be reasonable to consider the risk of de novo post transplant malignancy in older patients when making decisions regarding candidacy for HTx versus left ventricular assist device as destination. References Youn JC, Stehlik J, Wilk AR, Cherikh W, Kim IC, Park GH, Lund LH, Eisen HJ, Kim DY, Lee SK, Choi SW, Han S, Ryu KH, Kang SM, Kobashigawa JA. Temporal trends of de novo malignancy development after heart transplantation. J Am Coll Cardiol 2018;71:40–49.