The ABCs of LTX for BAC.

See related article on page 45. L ung transplantation (LTX) is an effective form of palliative therapy for a variety of end-stage lung diseases, but access to LTX is severely limited by a scarcity of suitable donors. Fewer than 900 LTX procedures are performed annually in the United States although over 4000 patients are currently listed for LTX.1 In part, because of the scarcity of donors, strict listing criteria for potential LTX recipients are espoused.2 Current malignancy is considered an absolute contraindication to LTX, because of the concern that poor prognosis due to the malignancy and possible acceleration of tumor growth secondary to immunosuppression would surely jeopardize long-term survival. As deaths on the waiting list increase, there is growing pressure not to squander such a scarce and precious resource as transplantable lungs. In this issue of the Journal, Zorn and associates3 challenge this paradigm by reporting their experience with LTX for a subset of patients with bronchioalveolar carcinoma (BAC). They tested the hypothesis that total lung replacement could be curative for the diffuse form of BAC by transplanting 9 patients presumed to have this diagnosis. One of the 9 was found to have adenocarcinoma, not BAC, after lung replacement, and so was not included in the Kaplan-Meier survival analysis. Arguably, by intention-to-treat analysis, this patient should have been included, because if LTX is to be recommended as a therapy for BAC, then this misdiagnosis would presumably occur with a similar frequency as it did in this report. This inclusion would not change the provocative finding that survival of patients with BAC who underwent LTX was similar to that of patients having LTX for other indications. The fact that patients with BAC did just as well as patients with other indications for LTX is just as much a sad commentary on the long-term results of LTX as it is a sterling recommendation for this strategy as a therapy for BAC. Zorn and associates titillate with their impressive survival statistics and aggressive surgical approach to disease recurrence, but leave the reader to speculate just how many patients with lung cancer were evaluated to select the 9 study patients. How realistic is this option for those with diffuse BAC? How many patients were eliminated because of metastatic disease or mediastinal lymph node involvement? Two of their 9 patients who had LTX had positive N2 nodes at operation (although only 1 of these patients had “true” BAC). The recurrence rate was disappointing, with 6 of 8 patients having recurrent disease, and many of their patients ultimately died of BAC. Thus, it would appear that their hypothesis was not true; LTX is not a “curative” strategy for BAC. However, LTX is not a curative therapy for any end-stage lung disease. As a form of palliation, LTX for selected patients with BAC may have merit, based on this initial report in a small number of presumably highly selected patients. The authors report that they have abandoned LTX for BAC because of the high From the Division of Cardiothoracic Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.