TOPIC: Transplantation
      TYPE: Fellow Case Reports
      INTRODUCTION: Solid lung transplant recipients are at a two-fold increase risk of developing malignancy. Lung cancer, post-transplant lymphoproliferative disorder, and squamous cell skin cancer are common causes of malignancy in solid organ transplant. We present a rare case of malignant melanoma after 2 years of status post double lung transplant.
      CASE PRESENTATION: Our patient is a 61 yr old Caucasian male with a history of idiopathic pulmonary fibrosis status post double lung transplant with a recent second anniversary presented with complaints of progressive shortness of breath and increased oxygen requirements. He had normal pathology on transbronchial biopsies at two years of a double lung transplant. He denied any fevers, chills, night sweats, cough, or unintentional weight loss. On evaluation, He was noted to have exertional hypoxia with oxygen saturation of 86%. He was on tacrolimus, mycophenolate, and prednisone 5mg for immunosuppression. He was taking Bactrim for PCP prophylaxis and Azithromycin and Statin for bronchiolitis obliterans syndrome prophylaxis. Both Donor and Recipient had positive CMV and EBV status. The concern for transplant rejection was discussed with the primary transplant team. The primary transplant team requested for PET scan for further evaluation, which showed bilateral pleural-based hypermetabolic lung nodules, mediastinal and hilar lymphadenopathy. Diagnostic bronchoscopy with fine-needle aspiration (EBUS-FNA) for further evaluation. The airway inspection showed stenosis at surgical anastomosis of bronchus intermedius, which was treated with balloon dilatation. No endobronchial lesions were noted. FNA samples obtained from the left interlobar lymph node showed malignant cells on rapid onset evaluation. The final pathology showed malignant melanoma. After diagnosis, the patient's clinical status worsened quickly with worsening oxygen requirements, and the patient died even before he received chemotherapy for malignant melanoma.
      DISCUSSION: Although rare, lung transplant recipients are at risk of developing malignant melanoma. The relative risk in solid transplant patients is around 2.7 times when compared to non-transplant patients. The male sex and increased age at the time of transplantation are considered risk factors for malignant melanoma in transplant patients.
      CONCLUSIONS: The learning objective is to screen and evaluate for skin cancer in lung transplant patients. Proper education should be provided to transplant patients about sun-protective clothing, broad-brimmed hat, and UV-blocking sunglasses to decrease the risk of skin cancer. The cancer history of the donor should be recorded as malignant melanoma is a more commonly reported donor-derived cancer, although the cancer history of our patient's donor is unknown.
      REFERENCE #1: Tejwani V, Deshwal H, Ho B, et al. Cutaneous Complications in Recipients of Lung Transplants: A Pictorial Review. Chest 2019;155:178-93. 10.1016/j.chest.2018.08.1060
      DISCLOSURES: No relevant relationships by Muhammad Ahmad, source=Web Response
      No relevant relationships by Greg Fuhrer, source=Web Response
      No relevant relationships by Rajesh Kunadharaju, source=Web Response
      No relevant relationships by Kathyayini Tappeta, source=Web Response