Factors Associated with Fatal Hemoptysis in Cancer Patients: Solid Tumors
The clinical characteristics of patients with fatal hemoptysis or nonfatal hemoptysis are presented in Table 3. The two groups contained similar proportions of patients with a bronchogenic carcinoma or a malignancy metastatic to the lung. Two patients with esophageal carcinoma and contiguous extension to the tracheobronchial tree had fatal hemoptysis. In patients with bronchogenic cancer, necrotic squamous cell carcinoma was strongly associated with fatal hemoptysis (p<0.01). Of the seven patients with necrotic squamous cell carcinoma, evidence of tissue necrosis was demonstrated on autopsy specimens (two), at bronchoscopic study (four), or by roentgenographic evidence of cavity formation (one).
In patients with metastatic lung disease, fatal hemoptysis occurred in only two of ten patients. Both patients had received chemotherapy causing thrombocytopenia and developed respiratory failure requiring mechanical ventilation with high fractional inspired oxygen concentrations and positive end-expiratory pressures. Histopathologic data revealed diffuse alveolar damage and alveolar hemorrhage. An endobronchial lesion was frequently the cause of nonfatal hemoptysis. The sites of the primary tumor were melanoma (three), breast (one), kidney (one), and colon (one).
This study demonstrates that hemoptysis in certain patients with a malignancy frequently heralds the occurrence of a massive pulmonary hemorrhage leading to death. In patients with a hematologic malignancy, fatal hemoptysis was frequently associated with a fungal pneumonia. Early recognition, therefore, of a pulmonary fungal infection in these patients with hemoptysis may be important in alerting the physician to the possibility of a fatal pulmonary hemorrhage, for which preventive measures can be instituted. These include administration of antifungal therapy and aggressive correction of thrombocytopenia and coagulation abnormalities. Furthermore, investigators have reported the beneficial effects of surgical resection of cavitary or localized lesions. These therapeutic options are feasible, because a signal bleed usually occurs before the fatal event. Of the six patients with fatal hemoptysis, only two died on the day of the initial episode of hemoptysis, whereas in the other four the onset of hemoptysis occurred between 12 and 18 days before the fatal event.
Table 3—Clinical Features of Patients with Solid Tumors
|Nonfatal Hemoptysis, no. (%)|
|No. of patients||11||23|
|Age (x± SD), yr||65.7 ± 4.5||62.2 ±2.5|
|Bronchogenic carcinoma||7(64)||15 (65)|
|Squamous cell/necrosis||6/6* (86)||7/1 (47)|
|Adenosquamous||0 (0)||2 (13)|
|Adenocarcinoma||0 (0)||4 (27)|
|Large cell||1 (14)||1 (7)|
|Small cell||0 (0)||1 (7)|
|Endobronchial lesion||0 (0)||6 (75)|
|Diffuse alveolar damage||2 (100)||0 (0)|
|Unknown||0 (0)||2 (25)|