Solitary pulmonary nodule in the liver transplant candidate: Importance of diagnosis and treatment

Abstract

Our objectives were to define the incidence and etiology of solitary pulmonary nodules (SPNs) in patients undergoing living donor liver transplantation (LDLT), describe a diagnostic approach to the management of SPNs in LDLT, and define the impact of SPNs on the overall survival of adult LDLT recipients. Nine patients (9/152, 5.9%) were diagnosed with an SPN on the basis of chest radiography findings during the pretransplant survey. All were male. The mean age was 52 years. All the patients had hepatitis B virus-related cirrhosis with hepatocellular carcinoma. All were asymptomatic for the lung lesion. All underwent contrast-enhanced chest computed tomography (CT) to verify the presence and possible etiology of the SPNs. In 3 cases, CT was used to definitely determine that there was no pulmonary nodule; in 2, CT led to a definite diagnosis of pulmonary tuberculosis. In 4, CT led to a definite identification of an SPN but not to an etiological diagnosis. Two patients underwent outright thoracoscopy and biopsy of their SPNs. Biopsy showed cryptococcosis in both patients. One received a therapeutic trial of an antituberculosis treatment, and repeat CT after 1 month showed a regression in the size of the SPN. A diagnosis of tuberculosis was made. One patient had an inconclusive whole body positron emission tomography scan and subsequently underwent thoracoscopy where biopsy showed tuberculosis. A concomitant malignancy, either primary lung cancer or metastasis from the liver tumor, was not identified. All patients were surviving with their original grafts and were lung infection-free. The overall mean posttransplant follow-up was 54 months (range ¼ 33-96 months). Patients undergoing transplantation require a thorough clinical evaluation to exclude overt and occult malignancies that would preclude the planned procedure. This is important because routine immunosuppression use after transplantation may often result in the body's loss of immunoregulatory functions and thus in a myriad of problems, including oncological and infectious processes. Occult infections may manifest as fulminant, life-threatening sepsis after transplantation.Indeterminate pulmonary nodules in transplant candidates pose both diagnostic and therapeutic

Cryptococcosis in Patients With Cirrhosis of the Liver and Posttransplant Outcomes

“…In a previous report, 2 live donor liver transplant candidates underwent excisional biopsy of the lesion and received fluconazole for 2 weeks before and for a minimum of 6 months after transplantation with no recurrence at follow-up. 17 Two patients in our study with a single lung nodule because of cryptococcosis were alive approximately 2 and 8 years after transplantation after receipt of fluconazole for 261 and 60 days before transplantation and for a total duration of 1 year and 6 months, respectively (Table 4).…”

Pulmonary nodules in liver transplant candidates with hepatocellular carcinoma: Imaging characteristics and clinical outcomes

“…Concejero et al investigated the prevalence and etiology of solitary pulmonary nodules in patients undergoing liver transplantation. In their study, 9 of 152 patients (5.9%) were diagnosed with a solitary nodule on preoperative chest radiography; further workup revealed cryptococcosis and tuberculosis in 2 patients each . Although no patient was diagnosed with pulmonary metastatic HCC or other lung neoplasm, chest radiography may have underdiagnosed these malignant nodules in comparison with CT. Paterson et al examined the outcomes of pulmonary nodules diagnosed in liver transplant recipients.…”

Exposure to ionizing radiation during liver transplantation evaluation, waitlist time, and in the postoperative period: A cause for concern

“…These studies are superior to chest radiographs for diagnosis of chest disease but not necessarily a more effective surveillance strategy even in transplantation candidates. Indeterminate and solitary pulmonary nodules in transplant candidates mandate precise clarification because either malignancy or infection will be exacerbated by immunosuppression . However, the risk of having a pulmonary nodule does not necessitate CT screening in all candidates.…”

“…However, the risk of having a pulmonary nodule does not necessitate CT screening in all candidates. In one study, 9 of 152 (5.9%) HCC candidates were diagnosed with a solitary nodule on chest radiography . On chest CT, three had no corresponding nodule, two had pulmonary tuberculosis, and CT was nondiagnostic in four.…”

“…Diagnostic examinations and interventions are directed by written program policies based on American Association for the Study of Liver Diseases (AASLD) practice guidelines for liver transplantation evaluation and hepatocellular carcinoma (HCC) . Comprehensive age/history/symptom‐based evaluations assess malignancies and comorbidities that affect candidacy . Cardiovascular evaluation is based on AASLD guidelines and American College of Cardiology / American Heart Association practice guidelines for major vascular/high‐risk procedures .…”