Factors Associated with Fatal Hemoptysis in Cancer Patients
Pulmonary hemorrhage occurs frequently in patients with neoplastic diseases and may become life-threatening in a significant proportion of these patients. The factors contributing to the development of fatal pulmonary hemorrhage in patients with malignant disease have not been well delineated. To address these issues, we reviewed the clinical records and available pathologic specimens from patients with a malignancy and evidence of pulmonary hemorrhage.
Material and Methods
During the period from January 1980 to June 1986, patients with a diagnosis of malignancy and hemoptysis were identified from the medical records, bronchoscopy records, or reports of the pulmonary consultation service at the University of Maryland Hospital. Complete autopsies were obtained in 26 cases and post-mortem lung biopsies were available in another two cases.
Review of Cases
The clinical and laboratory data abstracted from the medical records included: granulocyte count, platelet count, prothrombin time (PT), partial thromboplastin time (PTT), type of chemotherapy administered, history of prior radiation therapy; use of mechanical ventilatory support, presence and type of pneumonia, and results of diagnostic procedures.
The histopathologic data were reviewed by one of us (TJW) without prior knowledge of the clinical findings. Lung tissue was fixed, embedded, sectioned, and stained with hematoxylin-eosin, periodic-acid Schif£ Gomori-methemamine silver, and when indicated, Brown and Brenn stain. The specimens were evaluated for evidence of pulmonary hemorrhage, extent of tumor invasion, presence of vascular thrombosis and infarction, and the extent of vessel involvement by either granulocytes or infectious pathogens.
Specific definitions were used for the following clinical and diagnostic terms:
Hemoptysis: expectoration of gross blood or blood-streaked sputum
Fatal hemoptysis: hemoptysis directly contributing to death Nonjutal hemoptysis: hemoptysis that was self-limited and not significant in the cause of death Idiopathic alveolar hemorrhage (IAH): alveolar hemorrhage without evidence of pneumonitis from either the clinical or autopsy data Hemoptysis of unknown cause: cause of hemoptysis could not be determined from the clinical data and tissue specimens were not obtained
Bacterial pneumonia: presence of pulmonary infiltrates on chest roentgenogram and either a) histologic demonstration of bacterial organisms, or b) positive blood cultures and a compatible Grams stain
Fungal pneumonia: presence of pulmonary infiltrates on chest roentgenogram and either (a) histologic demonstration of invasive fungal disease on transbronchial biopsy or autopsy specimens, or (b) culture of the organism from bronchoscopically obtained secretions accompanied by a compatible clinical course Necmtic tumor: determined by findings observed on pathologic specimens, by direct visualization through a bronchoscope, or inferred by the presence of cavities on chest roentgenogram Granulocytopenia: granulocyte count less than 500/cu mm Bone marrow recovery: return of the granulocyte count to greater than or equal to 500/cu mm after a period of granulocytopenia Thrombocytopenia: platelet count less than 20,000/cu mm Abnormal prothrombin time (PT): a value greater than 15 s Abnormal partial thromboplastin time (PTT): a value greater than 40 s.