Management of Pulmonary Nodules in Patients Undergoing Liver Transplantation for Hepatocellular Carcinoma

Abstract

The lungs are among the most common sites of recurrence in patients undergoing liver transplantation(LT) for hepatocellular carcinoma (HCC). The optimal management of pulmonary nodules in this patient group remains controversial. We retrospectively evaluated twelve patients who underwent liver transplantation for HCC and subsequently had surgical resection of pulmonary nodules. Demographic characteristics, tumor features, surgical techniques (video-assisted thoracoscopic surgery (VATS) or thoracotomy), immunosuppression protocols, and survival data were analyzed using the Kaplan-Meier method. Overall survival rates at 1, 3, and 5 years were 83%, 42%, and 17%, respectively. One patient underwent five separate pulmonary metastasectomy procedures and survived for 82 months. Pathological examination revealed a second primary lung cancer(two squamous cell carcinomas, one adenocarcinoma, and one sarcomatoid carcinoma)in four patients(33%) and benign lesions (organizing pneumonia and Pneumocystis carinii infection) in two patients (17%). VATS was performed in 67% of patients. Among patients with HCC metastasis, those converted to mTOR inhibitor-based immunosuppression had longer survival than those maintained on calcineurin inhibitors. The median survival was 23.5 months. Surgical resection of pulmonary nodules provides a significant survival benefit in selected patients. Minimally invasive techniques markedly reduce morbidity. However, given the high incidence of second primary lung cancer, histopathological confirmation is strongly recommended rather than assuming all pulmonary nodules are HCC metastases. The immunosuppression regimen appears to influence outcomes in HCC recurrence.