Objectives: Thoracic pathologies are important causes of morbidity in solid-organ transplant recipients because of chronic immunosuppression, transplant-related complications, and diverse underlying etiologies. We aimed to evaluate thoracic pathologies requiring surgical or interventional management after solid-organ transplantation, present our clinical outcomes, and propose an anatomical management framework for these complex conditions.
Materials and Methods: We conducted a retrospective cohort study at a tertiary referral center of solid-organ transplant recipients who underwent surgical or interventional treatment for thoracic pathologies between 2010 and 2025. Patients who were managed conservatively or patients who had incomplete clinical data were excluded. Demographic characteristics, transplant-related variables, thoracic pathology type, surgical or interventional procedures, histopathological findings, postoperative complications, and clinical outcomes were analyzed descriptively.
Results: Twenty-one transplant recipients underwent 28 thoracic interventions during the study period. The cohort included 12 liver, 8 kidney, and 1 heart transplant recipient, with a mean age of 42.0 ± 22.2 years; 66.7% were male. Thoracic pathologies involved pleural, parenchymal, and mediastinal compartments and required individualized management using tube thoracostomy, video-assisted thoracoscopic surgery, thoracotomy, or mediastinoscopy. Histopathological evaluation demonstrated a broad spectrum of infectious, inflammatory, and malignant diseases, including aspergilloma, tuberculosis, primary lung carcinoma, hepatocellular carcinoma metastasis, inflammatory pseudotumor, and polymorphic post-transplant lymphoproliferative disease. Postoperative complications occurred in 2 patients (9.5%). One patient required 2 subsequent thoracotomies for prolonged air leak caused by a parenchymal fistula and postoperative hemothorax, whereas another under-went re-thoracotomy for recurrent hemorrhage after initial surgical treatment of hemothorax.
Conclusions: Thoracic pathologies following solid-organ transplant comprise a heterogeneous group of conditions requiring individualized multidisciplinary management. Surgical and interventional procedures play a pivotal role in both establishing definitive diagnoses and providing effective treatment. Early recognition, careful patient selection, and pathology-specific management strategies may improve clinical outcomes in this complex and high-risk population.

Key words : Organ transplantation, Thoracic diseases, Thoracic surgery

Introduction

Solid-organ transplantation, including kidney, liver, and heart transplantation, has become an effective therapeutic option for patients with end-stage organ failure, resulting in significant improvements in long-term survival. As survival rates have increased, transplant recipients are followed over extended periods, during which various pathological conditions may arise. Among these, thoracic pathologies rep-resent a clinically important group due to their impact on morbidity and mortality.
Thoracic pathologies in solid-organ transplant recipients may develop because of multifactorial mechanisms. Chronic immunosuppression, hemody-namic instability, coagulopathy, prolonged mec-hanical ventilation, and invasive procedures all contribute to an increased risk of pleural and pulmonary complications. Consequently, transplant recipients may develop a broad spectrum of pleural, parenchymal, and mediastinal thoracic pathologies, some of which require interventional or surgical treatment.
The management of thoracic pathologies in solid-organ transplant recipients is complex and requires careful consideration of the risks associated with immunosuppression and coexisting comorbidities. In this study, we aimed to present our single-center experience in the management of thoracic pathologies requiring surgical or interventional treatment in patients who underwent kidney, liver, or heart transplantation. Specifically, we aimed to evaluate the thoracic pathologies encountered, the treatments performed, and the postoperative outcomes.

Materials and Methods

This study was designed as a retrospective cohort analysis conducted at a single tertiary referral center, which evaluated the spectrum, management strategies, and clinical outcomes of thoracic pathologies in solid-organ transplant recipients. The study was conducted in accordance with the principles of the Declaration of Helsinki and approved by the Baskent University Institutional Review Board and Ethics Committee (Project no: KA26/305). The requirement for informed consent was waived owing to the retrospective nature of the study.
Patients with a history of solid-organ transplant (kidney, liver, or heart) who developed a thoracic pathology requiring surgical or interventional management between 2010 and 2025 were included. Patients with incomplete clinical data or those managed exclusively with conservative approaches were excluded. If a patient underwent more than 1 thoracic intervention, each intervention was recorded.
We retrieved retrospective clinical patient data from the institutional database. We collected demog-raphic characteristics such as age, sex and transplant-related parameters, including type of transplanted organ and time interval between transplant and development of thoracic pathology. We also collected clinical characteristics, including comorbidities.
Type and etiology of thoracic pathologies were analyzed. In addition, pathologies were anatomically classified into 3 main groups: pleural, parenchymal, and mediastinal pathologies. Patients had indivi-dualized management strategies according to the underlying thoracic pathology, although a stan-dardized institutional management framework was generally followed (Figure 1).
Patients had interventional procedures such as tube thoracostomy and surgical approaches, which included video-assisted thoracoscopic surgery (VATS), thoracotomy, and mediastinoscopy. We collected perioperative variables, including the type of procedure and intraoperative findings. We obtained histopathological results from surgical or diagnostic procedures that were used to establish the definitive diagnosis. We also collected postoperative outcomes, such as complications and mortality.
We used IBM SPSS Statistics for Windows version 23.0 (IBM Corp) for statistical analyses. Data were analyzed descriptively. We presented continuous variables as mean ± SD and range and categorical variables as frequencies and percentages.

Results

Our study included 21 solid-organ transplant recipients who met the inclusion criteria. During the study period, the included cohort had 28 thoracic interventions. The study population consisted of 8 kidney, 12 liver, and 1 heart transplant recipients. The mean age of the patients was 42.0 ± 22.2 years (range, 1-70 years). The study population included 14 male patients (66.7%) and 7 female patients (33.3%). Table 1 summarizes the spectrum of thoracic pathologies and corresponding interventions.
Postoperative complications occurred in 2 patients (9.5%), including multiple complications in 1 patient. After VATS drainage and pleural biopsy for pleural effusion, 1 patient developed a prolonged air leak secondary to a parenchymal fistula and required thoracotomy. The same patient subsequently deve-loped postoperative hemothorax necessitating a second thoracotomy. One patient who underwent thoracotomy for hemothorax developed recurrent hemorrhage and required rethoracotomy for defi-nitive control of the bleeding source.

Discussion

Our study revealed a wide variety of thoracic pathologies following solid-organ transplant. These pleural, parenchymal, and mediastinal diseases show highly variable clinical courses, influenced by immunosuppression, comorbidities, and transplant-related factors. Our findings highlight the important role of thoracic interventions in both the diagnosis and management of these complex conditions.
Pleural effusion can develop due to systemic causes, such as hypoproteinemia, hypoalbuminemia, and transfusions, as well as due to local diaphragmatic factors.^1-3 The first step in management is drainage of the fluid via thoracentesis or catheterization. Surgical intervention may be necessary in cases of recurrent effusions, and VATS can allow for both therapeutic drainage and diagnostic pleural biopsy. Pleural effusion can develop in the early postoperative period, but pleural effusion may also occur years after transplant and become a chronic or recurrent condition.⁴ Fibrinous pleuritis observed in our patient may reflect a chronic inflammatory process related to recurrent pleural effusions, previous pleural interventions, or subclinical infection, all of which are common in transplant recipients under immunosuppressive therapy. In our cohort, pleural effusion was observed in 2 patients. One patient developed pleural effusion in the early postoperative period, and the other developed pleural effusion many years after transplant. In the latter patient, the loculated pleural spaces were connected by use of VATS, drainage was achieved, and then pleurodesis was performed with talc. This patient developed prolonged air leak and postoperative hemothorax, necessitating thoracotomy and repair of a parenchymal fistula. These findings suggest that pleural effusions in transplant recipients may follow a complicated clinical course and therefore require careful management.
Hemothorax in solid-organ transplant recipients is usually an iatrogenic complication related to invasive procedures and may be aggravated by underlying coagulation abnormalities, particularly in liver transplant recipients, in whom persistent postoperative coagulopathy is more common than in the general population. The focus of patient management is both hemodynamic resuscitation and bleeding control. In our patient, chest tube thoracostomy was performed concurrently with packed red blood cell, fresh frozen plasma, and platelet transfusions. Because the initial amount of fluid drained from the chest tube exceeded 1500 mL and the bleeding continued, urgent surgical explo-ration was undertaken, revealing active bleeding from a diaphragmatic artery that was successfully ligated. In emergency settings, tube thoracostomy should not be delayed while correction of coagulopathy with blood product replacement is ongoing. High-volume drainage or continued bleeding despite transfusion support should warrant early surgical exploration.
Pneumothorax may develop due to various causes, including rupture of a subpleural bleb, tracheobronchial injury occurring during orotracheal intubation, inadvertent lung puncture during central venous catheter placement, diaphragmatic per-foration during dissection, barotrauma related to mechanical ventilation, or the formation of a pleuroparenchymal fistula. Chest tube insertion is generally the first-line treatment. Surgical repair may be required in cases of major airway injury or in the presence of a prolonged air leak. In our cohort, both conservative management with tube thoracostomy and surgical treatment were required depending on the clinical course of the pneumothorax.
Pulmonary nodules detected after solid-organ transplant represent a broad differential diagnosis that includes recurrent malignancy, de novo primary lung cancer, opportunistic infections, posttransplant lymphoproliferative disease (PTLD), and inflam-matory lesions. Distinguishing among these entities based solely on radiological findings is often challenging because of overlapping imaging characteristics. Recurrence has been reported to occur within the first 2 years in liver transplant recipients with hepatocellular carcinoma, with the lung being the most common site of recurrence.^5,6 In addition, the reported incidence of de novo primary lung cancer in solid-organ transplant recipients ranges from 0.3% to 0.85%.7,⁸ In our cohort, recurrence was observed in 1 patient at 1 year after transplant, whereas, in another patient, pulmonary nodules were ultimately diagnosed as primary lung carcinoma (Figure 2). These findings emphasize that newly detected pulmonary nodules in transplant recipients should not automatically be attributed to metastatic recurrence. They should also be recognized as potential mimics of infectious processes. Furthermore, an inflammatory pseudotumor was identified in 1 liver transplant recipient in our cohort, demonstrating that pulmonary nodules in transplant recipients are not invariably attributable to malig-nancy or infection. Although exceedingly rare, inflammatory pseudotumor should be considered in the differential diagnosis because it may radiolo-gically mimic primary lung cancer, metastatic disease, and opportunistic infections. Definitive diagnosis requires histopathological examination.
Infectious etiologies should also be considered in the differential diagnosis of pulmonary nodules in solid-organ transplant recipients. Long-term immunosuppression predisposes these patients to opportunistic pulmonary infections, which may progress to pulmonary necrosis and cavitary lesions. In advanced cases, parenchymal destruction may result in pleuroparenchymal fistula formation and persistent air leakage.^9,10 Pulmonary Aspergillus infections represent a significant complication in this patient population. In our cohort, 2 patients underwent pulmonary resection, and histopathological examina-tion revealed aspergilloma (Figure 3). Because radiolo-gical findings may overlap with those of pulmonary malignancies, histopathological confirmation is often required. Surgical resection should be considered in selected patients with localized disease who are refractory to medical therapy, have persistent symptoms, or develop significant parenchymal destruction.
Posttransplant lymphoproliferative disease is a serious complication that can develop in appro-ximately 2% of solid-organ transplant recipients.¹¹ The use of intensive immunosuppressive therapy increases the risk of developing PTLD. Thoracic involvement has been reported in approximately 7% of PTLD cases.¹² This disease presents as single or multiple pulmonary nodules accompanied by mediastinal and/or hilar lymphadenopathies.¹³ In our cohort, polymorphic PTLD presented with only mediastinal lymphadenopathy without pulmonary parenchymal involvement, a finding that emphasizes the need to consider PTLD in the differential diagnosis of mediastinal lymphadenopathies in transplant recipients. Given its nonspecific radiological presentation, tissue diagnosis remains indispensable for differentiating PTLD from other causes of mediastinal lymphadenopathy in transplant recipients.
From a technical perspective, thoracic procedures in solid-organ transplant recipients require meticulous surgical technique. Prolonged immunosuppressive therapy may impair and delay tissue healing, thereby predisposing patients to postoperative complications such as pleuroparenchymal fistula and prolonged air leak. Therefore, gentle manipulation of the lung parenchyma, meticulous preservation of tissue integrity, and parenchyma-sparing resection whenever feasible should be considered fundamental surgical principles. Based on our experience, when repair of the lung parenchyma is required, reinforcement with Teflon pledgeted sutures provides additional tissue support and may reduce the risk of postoperative air leakage. These technical principles may be valuable when surgeons are performing thoracic surgery in immunosuppressed solid-organ transplant recipients.

Conclusions

Thoracic pathologies in solid-organ transplant recipients represent a heterogeneous and clinically challenging group of conditions that may require interventional or surgical management. The comp-lexity of these cases is driven by immunosup-pression, comorbidities, and the wide spectrum of underlying etiologies. Early recognition, accurate differentiation between infectious and malignant processes, and a multidisciplinary approach are essential for optimal outcomes.
The structured management framework pro-posed in this study may serve as a practical guide for clinicians dealing with this high-risk population. However, further large-scale, multicenter studies are required to validate these findings and to develop standardized guidelines for the management of thoracic pathologies in transplant recipients.