Factors Associated with Fatal Hemoptysis in Cancer Patients: Results
Patients were grouped by the type of neoplasm: hematologic malignancy or solid tumor. These groups were further subdivided by the severity of hemoptysis: fatal hemoptysis or nonfatal hemoptysis. Inadequate documentation of the quantity of hemoptysis in the medical records prevented further grading of the severity of hemoptysis.
Differences in frequencies of various occurrences were analyzed by a Fishers exact test A p value less than 0.05 was considered significant
Of 58 cancer patients found to have hemoptysis, 24 had a hematologic malignancy, while 34 had a solid tumor.
The clinical characteristics of patients with fatal hemoptysis or nonfatal hemoptysis are presented in Table 1. The two groups were comparable with respect to age, distribution of leukemia and lymphoma, use of chemotherapy, frequency of granulocytopenia, thrombocytopenia, or abnormal coagulation parameters, requirement for mechanical ventilation, and presence of bacteremia. However, a fungal pneumonia was strongly associated with fatal hemoptysis (p<0.05). In contrast, IAH was associated with nonfatal hemoptysis (p<0.05).
The fungal pathogen, the granulocyte count, and the histologic features in the patients with fungal pneumonia are presented in Table 2. Of those patients with fatal hemoptysis, four were granulocytopenic throughout the period of pulmonary hemorrhage. Examination of autopsy specimens from three of these patients (Nos. 1 to 3) revealed fungal invasion of blood vessels, vascular thrombosis, and extensive hemorrhagic infarction without evidence of granulocytic inflammation. In another two patients with fatal hemoptysis (Nos. 5 and 6), hemoptysis occurred after bone marrow recovery and granulocytic infiltration was demonstrated in pathologic specimens. Histologic features of fungal vascular invasion in the absence and in the presence of granulocytes are shown in Figures 1 and 2, respectively. naturalbreastenhancementpill.com
Both patients with nonfatal hemoptysis and a fungal pneumonia developed hemoptysis while granulocytopenic. Examination of autopsy specimens from one of these patients (No. 7), who died following bone marrow recovery, revealed disruption of the microvasculature by a necrotizing granulocytic inflammation without fungal vascular invasion.
Table 1—Clinical Features of Patients with Hematologic Malignancy
|Feature||Fatal Hemoptysis, no. (%)||Nonfatal Hemoptysis, no. (%)|
|No. of patients||10||14|
|Age (x±SD), yr||54.7± 14.8||57.1 ±14.8|
|Type of malignancy|
|Administration of chemotherapy||10 (100)||13(93)|
|Use of cytosine arabinoside||5(50)||6(43)|
|Number with granulocytopenia||8(80)||10 (71)|
|Number with thrombocytopenia||4(40)||9(64)|
|Abnormal PT and PTT||2(22)||4(29)|
|Number requiring mechanical||6(60)||10 (71)|
|Number with bacteremia||6(60)||5(36)|
|Cause of hemoptysis|
Table 2-Grantdocyte Count and Histologic Features in Pbtients with Fungal Pneumonia
|Patient Fungal Pathogen||Granulocyte Count, no./cu mm||Autopsy Findings|
|At Onset of Hemoptysis||AtDeath||GranulocyticInfiltration||Fungal Vascular Invasion with Thrombosis|
|1 Aspergillus spp||<100||<100||–||+|
|2 Aspergillus spp||<100||<100||–||+|
|3* Candida tropicalis||0||0||–||+|
|4 A fumigatus,||<100||0||Not performed|
|7 C albicans||<100||2,200||+||–|
|8 A spp||150||120||Not performed|
Figure 1. Invasive pulmonary aspergillosis in patient l with leukemia and no bone marrow recovery A left’: Thrombosis of a pulmonary artery by Aspergillus hvphae (arrwsj without inflammatory disruption of the vessel wall. Surrounding pulmonary parenchyma shows hemorrhagic infarction (hematoxylin and eosin stain, original magnification x 2.5). B (right): Invasion and disruption of a pulmonary artery wall by Aspergillus hyphae (arrows) without granulocytic inflammation (periodic acid-Schiff stain, original magnification, x230.)
Figure 2. Invasive pulmonary aspergillosis in a patient 4 with leukemia and bone marrow recovery. A (upper). Thrombosis of a pulmonary artery by Aspergillus hyphae (thin arrows) with inflammatory necrosis of the pulmonary arterial wall (thick arrows). (Hematoxylin and eosin stain, original magnification X2.5.) B (lower). Disruption and necrosis of pulmonary artery wall with infiltration of Aspergillus hyphae and polymorphonuclear leukocytes (periodic acid-Schiff stain, original magnification X 100.)