Lung Transplantation after Allogeneic Stem Cell Transplantation: A Single-Centre Experience

PURPOSE: Pulmonary chronic graft versus host disease (GVHD) is one of the thoracic manifestations that can complicate allogeneic hematopoietic stem cell transplantation (HSCT) causing respiratory failure and death. Lung transplantation (LTx) often remains the only therapeutic option for progressive forms although it has been reported in a small number of patients worldwide. METHODS: This retrospective study focused on patients who underwent LTx for pulmonary GVHD in our Centre and consisted in a careful review of all crucial post-transplantation clinical (primary graft dysfunction, CLAD-free survival, overall survival) and pathological data [acute rejection and infection indices in all follow-up scheduled bronchoscopies (total number of biopsies: 35, total number of bronchoalveolar lavages: 33), signs of chronic rejection]. RESULTS: 467 patients underwent LTx in the 1995-2019 period: in 5 cases the referral diagnosis was pulmonary chronic GVHD (1%) [all males, mean age: 27±13 yrs, two patients aged ≤16, developed 23±14 months following HSCT for neoplastic conditions (mean±SD)]. At census date, 2 were alive (40%) with a median (Q1-Q3) follow-up of 59 (17-64) months. At 5 years post-LTx the overall survival was 60%. One patient died for multiorgan failure early after LTx. Two deaths occurred after 17 and 64 months due to infectious complications (cytomegalovirus, CMV) and, interestingly, only these cases developed CLAD with features of obliterans bronchiolitis during follow-up (at 8 and 13 months, respectively). At the last follow-up, no patients had a recurrence of haematological malignancy and the two patients who are still alive (at 80 and 59 months) have had viral infections but never CMV. Acute rejection index was 18% (12%-23%), if we consider only the first year post-LTx it was 10% (0%-32%) while in age-matched patients transplanted for cystic fibrosis (CF) at our centre it was 29% (12.5%-50%). Finally, the infection index was 50% (32%-66%). All indices are expressed as median (Q1-Q3). CONCLUSION: LTx is a feasible option for patients with severe GVHD. Survival is in line with data reported in the literature, as well as with the general LTx population; deaths were mainly related to CMV infections. Concerning acute rejection indexes, they were lower than those detected at our Centre when considering all LTx patients or only those with CF.