Hemoptysis in Cancer Patients

Abstract

Hemoptysis in cancer patients can occur for various reasons, including infections, tumors, blood vessel abnormalities and inflammatory conditions. The degree of hemoptysis is commonly classified according to the quantity of blood expelled. However, volume-based definitions may not accurately reflect the clinical impact of bleeding. This review explores a more comprehensive approach to evaluating hemoptysis by considering its risk factors, epidemiology and clinical consequences. In particular, this review provides insight into the risk factors, identifies mortality rates associated with hemoptysis in cancer patients and highlights the need for developing a mortality prediction score specific for cancer patients. The use of hemoptysis-related variables may help stratify patients into risk categories; optimize the control of bleeding with critical care; implement the use of tracheobronchial or vascular interventions; and aid in treatment planning. Effective management of hemoptysis in cancer patients must address the underlying cause while also providing supportive care to improve patients' quality of life.

Keywords: cancer; etiology; hemoptysis; investigations; lung cancer; management; oncology; prediction score; prognosis; risk factors.

Figure 1

(A) A young man with acute lymphoid leukemia presented with significant hemoptysis. He had both neutropenia and lymphopenia due to recent treatments. A CT angiogram showed irregular soft-tissue encasement of the lower-order branches of the left pulmonary artery (arrowhead) and consolidation (arrow) and air bronchograms in the left lower lobe. Bronchoscopy revealed that the left lower lobe collapsed without endobronchial lesions. Surgical intervention with left lower lobectomy confirmed invasive mucormycosis and left pulmonary artery branches were full of thrombi. (B) A middle-aged man with adenoid cystic cancer presented with hemoptysis mixed with mucus over the previous few weeks. A CT angiogram excluded pulmonary emboli but showed diffuse nodules and mass-like consolidation (arrows) along with ground glass infiltrates peripherally (arrowhead). No endobronchial component was identified, and since the hemoptysis was of a small volume, no further intervention was warranted. (C) An elderly woman with a history of Hodgkin lymphoma presented with hemoptysis, dyspnea and a syncopal episode. A chest radiograph demonstrated bilateral infiltrates (arrowheads) and small bilateral effusion (arrows) with blunting of the costophrenic angles. She had volume overload with pulmonary edema, and an echocardiogram demonstrated severe aortic valve stenosis. (D) A patient with acute myelogenous leukemia after hematopoietic allogenic stem cell transplantation from a matched sibling presented with hemoptysis and epistaxis. A chest radiograph showed bilateral diffuse infiltrates (arrows), and a bronchoscopy revealed blood-tinged secretions throughout the tracheobronchial tree. He had diffuse alveolar hemorrhage due to thrombotic microangiopathy related to calcineurin inhibitors.

Figure 2

(A) A patient with metastatic lung cancer treated with radiation 1 month prior to the right upper lobe presented with hemoptysis. The coronal CT of the chest revealed a cavitary lesion (arrowheads) contiguous with the right mainstem bronchus (arrow). The patient expired from massive hemoptysis shortly after presenting to the emergency center. (B) A patient with leukemia with pancytopenia (white blood cells 0.0 × 10⁹/L platelets 14,000 × 10⁹/L) and fever presented with hemoptysis. The patient had sepsis with bacteremia. A chest CT revealed consolidation in the left upper lobe (arrow) with air bronchograms. (C) A patient with gastroesophageal junction cancer presented with dyspnea and mild hemoptysis. Bronchoscopy revealed a mass at the main carina obstructing 90% of the left mainstem and 20% of the right mainstem. The mass (arrow) was large, exophytic and friable. The tumor was debulked using rigid bronchoscopy, and argon plasma coagulation was used to achieve hemostasis. Biopsies were consistent with metastatic disease. (D) A patient with metastatic colorectal cancer had dyspnea and mild hemoptysis. The patient had mucopurulent and blood-tinged secretions emanating from the right middle lobe. An endoluminal tumor mass (arrow) obstructing the superior segment of the left lower lobe was found. The hemoptysis resolved after treatment of a respiratory infection.

Figure 3

Hemoptysis management summary scheme. BAE, bronchial artery embolization.

Figure 4

Hemoptysis management with considerations for lung cancer patients.