Approach to Hemoptysis

Dr. Luqman Rahmanshal Nanakali

Consultant Medical Oncologist
MD. MSc, PhD
Dep. Of Medicine, College of Medicine/ HMU
4th year
2nd Oct 2019
Hemoptysis
defined as the expectoration of blood originating from the
tracheobronchial tree or pulmonary parenchyma.

• Classified as massive or non-massive based

• Massive hemoptysis accounts for only 5-15%, it is an alarming

symptom with an associated mortality of more than 50%
Hemoptysis
• The first step in making a diagnosis is to differentiate
hemoptysis
from pseudo hemoptysis or hematemesis
 
All hemoptysis etiologies can potentially cause massive
hemoptysis.
Case 1
• Mrs S.A., a 55-year-old house wife whom you last saw two
years ago, visited your clinic complaining of blood in her
sputum when she clears her throat. She coughed up
approximately 10 mL of bright red blood in the morning on the
day of her visit. She had no complaints of chest pain or
shortness of breath.
• Mrs S.A has a past medical history of HTN and was diagnosed
with type 2 DM during her recent hospital admission for acute
appendicitis. She does not smoke and has no family history of
lung disease.
Case 2
• A 46-year-old man presents with a cough that has produced
blood-streaked sputum for the past two days. Associated
symptoms include rhinorrhea, congestion, and subjective fever.
He estimates the total amount of blood loss to be less than 1
tablespoon. The medical history is unremarkable. He has never
used tobacco and has not recently traveled, lost weight, or had
night sweats.
• Vital signs are within normal limits, and the patient appears to
breathe comfortably, other than intermittent cough. No blood
is produced in the clinic. Pulmonary examination demonstrates
normal breath sounds. Nasal, oropharyngeal, cardiovascular,
and abdominal examinations are unremarkable.
Case 3
• A 74-year-old woman presents to the emergency department
after coughing up blood. She brings a container with
approximately 100 mL of blood-tinged sputum produced over
the past 24 hours. She reports that she has had similar episodes
in the past, which were diagnosed as bronchitis, and that the
symptoms resolved within a few days of initiating oral
antibiotic therapy. Her medical history is significant for Sjögren
syndrome, bronchiectasis, and microcytic anemia. She has a 50
pack-year smoking history and quit smoking five years ago. She
does not drink alcohol. She has lost 40 lb (18 kg) over the past
12 months.
Case 3 continued…
• Vital signs at the time of presentation include a temperature of
37.2 °C, BP 146/73 mm Hg, PR 127 bpm, RR of 36, and SPO2 of
83% in room air. the patient does not appear to be in distress.
Nasal examination demonstrates normal mucosa without
epistaxis. Oropharyngeal examination reveals normal dentition
and mucosa without signs of bleeding or ulceration. The neck is
supple and without lymphadenopathy. Pulmonary examination
reveals diffuse inspiratory rales. Cardiovascular examination is
normal except for tachycardia. Abdominal examination is
unremarkable.
Case Discussion
A.M, a 59 year old man, presented to his GP with:
•Increasing cough and breathlessness for past 3 weeks
•Weight loss of 1 kg over the same period
•2 episodes of hemoptysis
•Increasing fatigue
•Smoker of 20/day for 40 years

Examination findings:
•Nicotine staining of fingers
•No palpable lymphadenopathy
•Remainder of clinical examination unremarkable
Which of the following investigations would you not arrange
urgently?

Chest x-ray (CXR)

Sputum O&S
Mediastinoscopy
Sputum Cytology
•Chest x-ray shows right sided mass
•A.M. is told of clinical suspicion of lung cancer

•What is next?

Bronchoscopy arranged and lesion biopsied

Histology reveals small cell carcinoma
Cont…
Which one of the following is true of small cell lung cancer
(SCLC)?

• It accounts for most cases of lung cancer

• 80-90% of SCLC have spread beyond the thorax at the time of diagnosis

• Surgery offers the best chance of cure

• CT chest and abdomen should only be arranged if A.M.has suggestive symptoms

• Staging: CT showed presence of liver metastases
• It was explained to A.M. that he had extensive stage disease
and he was referred to oncology
What would you tell A.M. about his prognosis?
• His disease is curable
• Chemotherapy is unlikely to be effective
• Radiotherapy is indicated at this stage
• The intent of treatment is palliative
Cont..
Oncology review:
• The extent of disease was discussed with A.M. and the
palliative nature of treatment
• He elected to have chemotherapy and was treated with
cisplatin and etoposide
• He had 4 cycles of treatment which required in-patient stays
every 3 weeks
LUNG CANCER
 INTRODUCTION

• Worldwide, lung cancer is still the leading cause of cancer death.

• Both the absolute and relative frequency of lung cancer has risen dramatically.
Around 1953, lung cancer became the most common cause of cancer deaths in
men, and in 1985, it became the leading cause of cancer deaths in women.
Lung cancer deaths have begun to decline in both men and women, reflecting
a decrease in smoking.
• The term lung cancer, or bronchogenic carcinoma, refers to malignancies that
originate in the airways or pulmonary parenchyma. Approximately 95 percent
of all lung cancers are classified as either small cell lung cancer (SCLC) or non-
small cell lung cancer (NSCLC).
• This distinction is essential for staging, treatment, and prognosis. Other cell
types comprise approximately 5 percent of malignancies arising in the lung.
 Risk Factors
• A number of environmental and lifestyle factors have been associated with the subsequent development of
lung cancer, of which cigarette smoking is the most important.

• Smoking — The primary risk factor for the development of lung cancer is cigarette smoking, which is
estimated to account for approximately 90 percent of all lung cancers. The risk of developing lung cancer for a
current smoker of one pack per day for 40 years is approximately 20 times that of someone who has never
smoked. Factors that increase the risk of developing lung cancer in smokers include the extent of smoking and
exposure to other carcinogenic factors, such as asbestos.

• Thus, the most important aspects of lung cancer prevention are preventing people from starting to smoke and
inducing those who already smoke to stop. In individuals who do quit smoking, the risk of developing lung
cancer falls compared with those who continue to smoke; the benefit is greatest in those who stop by age 30.
Despite stopping smoking, the risk for lung cancer continues to rise with age at a faster rate than those who
never smoked.

• Other factors — A number of other factors may affect the risk of developing lung cancer:

• Radiation therapy (RT) can increase the risk of a second primary lung cancer in patients who have been
treated for other malignancies. This increased risk has been demonstrated in patients with both Hodgkin
lymphoma and breast cancer.
• Environmental toxins – Environmental factors have been associated with an increased risk for developing lung cancer.
These include exposure to secondhand smoke, asbestos, radon, metals (arsenic, chromium, and nickel), ionizing
radiation, and polycyclic aromatic hydrocarbons.

• Pulmonary fibrosis – Several studies have shown that the risk for lung cancer is increased approximately sevenfold in
patients with pulmonary fibrosis. This increased risk appears to be independent of smoking.

• HIV infection – The incidence of lung cancer among individuals infected with HIV is increased compared with that
seen in uninfected controls.

• Genetic factors – Genetic factors can affect both the risk for and prognosis from lung cancer. Although the genetic
basis of lung cancer is still being elucidated, there is a clearly established familial risk.

• Alcohol – Data are unclear as to whether alcohol intake increases the risk for lung cancer. Since there is a strong
association between smoking and drinking throughout the world, studies may be confounded if not adequately
controlled for tobacco use. While certain studies have suggested the link of alcohol consumption with increased risk
of lung cancer, after adjusting for smoking, other studies could not show this link.

• Dietary factors – Epidemiologic evidence has suggested that various dietary factors (antioxidants, cruciferous
vegetables, phytoestrogens) may reduce the risk of lung cancer, but the role of these factors is not well established.
Attempts to confirm these epidemiologic findings and to decrease the incidence of lung cancer in high-risk patients
have not been successful.
 Screening
• The diagnosis of lung cancer is primarily based upon evaluation of individuals with symptoms.
Screening for lung cancer was not previously recommended because chest radiography and
sputum cytology had not been shown to reduce mortality from lung cancer.
• However, studies have shown that a large percentage of lung cancers detected by computed
tomography (CT) screening are early-stage tumors, which have a favorable prognosis. These
findings led to the randomized National Lung Screening Trial that compared CT screening with a
chest radiograph. This trial demonstrated a 20 percent decrease in lung cancer mortality in heavy
smokers who were screened annually for three years and is the only trial to show benefit in
mortality reduction.
• The US Preventive Services Task Force has given low-dose CT scanning a "B" recommendation for
those at high risk for lung cancer. Screening is currently only approved for the high-risk groups
which include those aged 55 to 77 who have no symptoms of lung cancer, have a 30 pack-year
smoking history, and if they have quit, have done so within 15 years.
 Pathology
• The relative incidence of adenocarcinoma has risen dramatically, and there has been a corresponding
decrease in the incidence of other types of non-small cell lung cancer (NSCLC) and small cell lung cancer
(SCLC). The increased incidence of adenocarcinoma is thought to be due to the introduction of low-tar filter
cigarettes in the 1960s, although this relationship is unproven.
• Until recent years, the simple pathologic separation of NSCLC from SCLC along with stage was adequate to
make treatment decisions for a new diagnosis of lung cancer. Since 2008, it has been shown that separation
of adenocarcinoma and squamous cell carcinoma is important in determining optimal therapy for stage IV
disease. The development of targeted therapy for specific gene mutations has resulted in the reality of
individually tailored therapy. Subtype analysis of NSCLC has come full circle now that epidermal growth
factor receptors (EGFR), anaplastic lymphoma kinase (ALK), and c-ROS oncogene 1 (ROS1) mutations are not
only identifiable but their targeted treatment results in responses better than that with standard
chemotherapy.
• The improved response to tyrosine kinase inhibitors specific to these mutations has led to the
recommendation of testing for EGFR and ALK mutations in all advanced-stage adenocarcinomas, mixed
cancers, and those with NSCLC in whom an adenocarcinoma component cannot be excluded.
 Clinical Presentation

• The majority of patients with lung cancer have advanced disease at clinical presentation. This may
reflect the aggressive biology of the disease and the frequent absence of symptoms until locally
advanced or metastatic disease is present. High-risk patients may be diagnosed while
asymptomatic through screening with low-dose computed tomography (CT). Unfortunately, the
majority of patients who get lung cancer do not fall into the high-risk category identified to
benefit from screening.

• Symptoms may result from local effects of the tumor, from regional or distant spread, or from
distant effects not related to metastases (paraneoplastic syndromes). Approximately three-
fourths of non-screened patients have one or more symptoms at the time of diagnosis. A study of
2293 consecutive patients with non-small cell lung cancer (NSCLC) noted that the mean age was
64 years and the most common symptoms at presentation were cough (55 percent), dyspnea (45
percent), pain (38 percent), and weight loss (36 percent).
 Intrathoracic effects of the cancer
• There are a wide range of symptoms due to the intrathoracic effects of the cancer, the most common of which are cough, hemoptysis,
chest pain, and dyspnea.

• Cough — Cough is present in 45 to 75 percent of lung cancer patients at presentation and occurs most frequently in patients with
squamous cell and small cell carcinomas because of their tendency to involve central airways. The new onset of cough in a smoker or
former smoker should raise suspicion that lung cancer is present. The presenting symptom has some bearing on prognosis; patients
presenting with cough had a better prognosis than those presenting with other symptoms.

• Hemoptysis — Hemoptysis is reported by 20 to 50 percent of patients who are diagnosed with lung cancer, although bronchitis is the
most common cause of this symptom. Any amount of hemoptysis can be alarming to the patient, and large volumes of hemoptysis may
cause asphyxia.

• Chest pain — Chest pain is present in approximately 20 to 40 percent of patients presenting with lung cancer. Pain is typically present
on the same side of the chest as the primary tumor. Dull, aching, persistent pain may occur from mediastinal, pleural, or chest wall
extension.

• Dyspnea — Shortness of breath is a common symptom in patients with lung cancer at the time of diagnosis, occurring in approximately
25 to 40 percent of cases. Dyspnea may be due to extrinsic or intraluminal airway obstruction, obstructive pneumonitis or atelectasis,
lymphangitic tumor spread, tumor emboli, pneumothorax, pleural effusion, or pericardial effusion with tamponade.
• Hoarseness — The differential diagnosis of persistent hoarseness in a smoker includes both laryngeal
cancer and lung cancer. In patients with lung cancer, this is due to malignancy involving the recurrent
laryngeal nerve along its course under the arch of the aorta and back to the larynx.
• Pleural involvement — Pleural involvement can manifest as pleural thickening without pleural effusion
or as malignant pleural effusion. During the course of their disease, approximately 10 to 15 percent of
patients who have lung cancer will have malignant pleural effusions.
• Superior vena cava syndrome — Obstruction of the superior vena cava (SVC) causes symptoms that
commonly include a sensation of fullness in the head and dyspnea. Cough, pain, and dysphagia are less
frequent. Physical findings include dilated neck veins, a prominent venous pattern on the chest, facial
edema, and a plethoric appearance. The chest radiograph typically shows widening of the mediastinum
or a right hilar mass. CT can often identify the cause, level of obstruction, and extent of collateral venous
drainage..
• The SVC syndrome is more common in patients with SCLC than NSCLC. For most patients who have SVC
syndrome secondary to lung cancer, the symptoms resolve after treatment of the mediastinal tumor.
• Pancoast syndrome — Lung cancers arising in the superior sulcus cause a characteristic Pancoast
syndrome manifested by pain (usually in the shoulder, and less commonly in the forearm, scapula, and
fingers), Horner syndrome, bony destruction, and atrophy of hand muscles.
 Extrathoracic metastases
• Lung cancer can spread to any part of the body tissue. Metastatic spread may result in the presenting
symptoms or may occur later in the course of disease.
• The most frequent sites of distant metastasis are the liver, adrenal glands, bones, and brain. Signs and
symptoms will rely on the site of metastases.
• Paraneoplastic phenomena — Paraneoplastic effects of tumor are remote effects that are not related to the
direct invasion, obstruction, or metastasis, such as:
1) Hypercalcemia — Hypercalcemia in patients with lung cancer may arise from a bony metastasis or less
commonly tumor secretion of a parathyroid hormone-related protein (PTHrP), calcitriol or other
cytokines, including osteoclast activating factors.
2) SIADH secretion — The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is frequently
caused by SCLC and results in hyponatremia. Approximately 10 percent of patients who have SCLC exhibit
SIADH. SCLC accounts for approximately 75 percent of all malignancy-related of SIADH.
3) Neurologic — Lung cancer is the most common cancer associated with paraneoplastic neurologic
syndromes; typically these are associated with SCLC. Paraneoplastic neurologic syndromes are thought to
be immune-mediated, and autoantibodies have been identified in a number of instances.
• These diverse neurologic manifestations include, but are not limited to, Lambert-
Eaton myasthenic syndrome (LEMS), cerebellar ataxia, sensory neuropathy, limbic
encephalitis, encephalomyelitis, autonomic neuropathy, retinopathy, and
opsomyoclonus.

• The most common of these is LEMS, which may be seen in approximately 3 percent
of patients with SCLC. The neurologic symptoms of LEMS precede the diagnosis of
SCLC in more than 80 percent of cases, often by months to years.
 Diagnosis
 Initial Evaluation
• The initial evaluation of a patient with suspected lung cancer begins with a history and physical examination;
complete blood count; measurement of alkaline phosphatase, hepatic transaminase, and calcium levels;
chemistries (electrolytes, blood urea nitrogen, creatinine); and chest radiography. Normal findings on a chest
radiograph do not rule out lung cancer because a small tumor can be hidden within the mediastinum or
elsewhere in the chest. If suspicion remains high because a likely alternative diagnosis is not identified on
the chest radiograph, contrast-enhanced computed tomography (CT) should be performed, followed by
positron emission tomography if necessary.
• A multidisciplinary team consisting of a pulmonologist, medical oncologist, radiation oncologist, pathologist,
radiologist, and thoracic surgeon then plans the diagnostic evaluation, the results of which guide treatment
and determine prognosis.
 Diagnostic Evaluation
• The diagnostic evaluation includes three simultaneous steps: tissue diagnosis, staging, and functional
evaluation.
 Tissue Diagnosis

• Although experienced physicians can often diagnose the type of lung cancer based on
clinical presentation and radiographic appearance, an adequate tissue sample is imperative
to optimize the diagnosis and plan treatment. Molecular testing requires a significant
amount of tissue. Targeted therapies can increase treatment options for patients with
advanced disease or poor functional status.

• A variety of diagnostic methods are available that yield cytology samples or small biopsies.
The choice of procedure depends on the type, location, and size of the tumor;
comorbidities; and accessibility of metastases. In general, the least invasive method possible
should be used. If the procedure fails to obtain tissue, a more invasive method is needed.
Conventional bronchoscopy works best for central lesions, whereas CT-guided transthoracic
needle aspiration is typically the first-line method for peripheral lesions. Endobronchial
ultrasound may increase the diagnostic yield of bronchoscopy for select patients with
mediastinal or peripheral lesions.
 Staging and Treatment
STAGING
• Clinical staging is based on all information obtained before treatment, including findings from CT and
positron emission tomography and invasive staging such as mediastinoscopy. Pathologic staging is
performed after surgical resection and may upgrade or downgrade the clinical staging. NSCLC is
staged according to the TNM (tumor size, nodes, metastasis) system.
• Treatment of lung cancer depends on patient and disease factors.
• Regarding the disease, factors include histology, TNM staging, molecular profile, among others.
• In general, early stages of lung cancer are treated by curative surgery when possible. In borderline
cases, concurrent or sequential chemo-irradiation is used to downstage the disease or as a definitive
treatment.
• In an otherwise stages, patients are treated with palliative intentions.
Which one of the following is true of small cell lung cancer (SCLC)?

a) It accounts for most cases of lung cancer.

b) 80-90% of SCLC have spread beyond the thorax at the time of diagnosis,

c) Surgery offers the best chance of cure.

d) CT chest and abdomen should only be arranged if A.M. has suggestive

symptoms.

e) Very unlikely to cause any paraneoplastic features.

Answer: b
What proportion of lung cancers are small cell lung cancers?

a) About 15%

b) About 25% - 35%

c) About 40%—50%

d) About 70%

Answer: a
In terms of the number of cancer-related deaths worldwide, where does
lung cancer rank?

a) Second after prostate cancer.

b) Second, after colorectal cancer.

c) Third, after colorectal cancer and stomach cancer.

d) First.

Answer: d
What proportion of cases of lung cancer are caused by smoking?

a) About 50%-60%

b) About 75%

c) About 85%-90%

d) About 95%-99%

Answer: c