Detecting Lung Cancer as a Cause of Hemoptysis in Patients with a Normal Chest Radiograph: Bronchoscopy vs CT

doi:10.1378/chest.111.4.877

Chest

Volume 111, Issue 4, April 1997, Pages 877-884

https://doi.org/10.1378/chest.111.4.877 Get rights and content

Objective

To determine whether fiberoptic bronchoscopy (FOB) or CT results in the lowest number of tests needed to diagnose (NTND) lung cancers in patients presenting with hemoptysis and a normal chest radiograph (CXR).

Design

Calculation of the NTND in a hypothetical cohort of patients presenting with hemoptysis and a normal CXR.

Interventions

In the primary analysis, either FOB or CT is performed to detect lung cancers. FOB is used to diagnose endobronchial abnormalities, and transthoracic needle aspirate is relied on to diagnose parenchymal findings. Patients then undergo serial follow-up CXRs. In a secondary analysis, sputum cytologic tests are performed prior to FOB and CT. Abnormal cytologic results require FOB. Unremarkable cytologic results allow a choice between FOB or CT.

Measurements

NTND and number of lung cancers detected during serial follow-up CXRs.

Results

Performing FOB results in a much lower NTND than CT with a similar number of lung cancers detected during serial follow-up with each approach. Reducing the false-positive rate for lung cancers of airway evaluations by CT reduces the NTND for the CT strategy. Performing both FOB and CT results in a large NTND. Adding sputum cytology as a guide for performing FOB substantially reduces the NTND for the FOB approach.

Conclusion

A strategy relying on initial sputum cytologic testing as a screen for choosing either FOB as an immediate diagnostic step or serial follow-up CXR to detect lung cancer in patients presenting with hemoptysis and a normal CXR results in the lowest NTND with only a marginal reduction in the early detection of all cancers.

Section snippets

Baseline Model

In patients presenting with hemoptysis and a normal CXR, there would be an initial choice between performing FOB or CT. A positive CT result requires a follow-up test to obtain histologic/cytologic confirmation of malignancy. Central airway abnormalities seen on CT would be assessed by FOB and parenchymal abnormalities suspicious for a lung cancer by TTNA. Because both FOB and CT may not detect all lung cancers, serial follow-up CXRs follow each negative result. During this follow-up period,

Baseline Model and Estimates

Using the baseline model and assumptions, with both the FOB and CT approaches, five cancers are discovered during the initial evaluation and one cancer is found through serial follow-up (Fig 1). Because both approaches result in approximately the same number of serial follow-up CXR examinations for all analyses, the NTND has been calculated as the number of FOB, CT, and TTNA studies performed with each option. The CT approach results in a NTND of 133, higher than the NTND of 101 for FOB, due to

Discussion

Objective guidelines are becoming increasingly important to clinicians in their choice of diagnostic strategies for solving clinical problems. The NTND is relatively simple to calculate and provides readily understandable information to the clinician about the impact of a first diagnostic test on the workload needed to solve a clinical problem. In the clinical scenario of a patient presenting with hemoptysis and a normal CXR, the dilemma revolves around identifying the few patients with lung

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Cited by (43)

Diagnosis and Treatment of Hemoptysis
2016, Archivos de Bronconeumologia
La hemoptisis es la expectoración de sangre proveniente del árbol traqueobronquial. Las enfermedades que más frecuentemente la originan son las bronquiectasias, la bronquitis crónica y el carcinoma broncogénico. Las arterias bronquiales son el origen de la mayoría de las hemoptisis. Ante un paciente con sospecha de hemoptisis se debe confirmar su existencia, establecer su gravedad, localizar el origen y determinar su causa. La radiografía de tórax posteroanterior y lateral es la primera prueba de imagen que debe realizarse, aunque la existencia de una radiografía de tórax normal no excluye la posibilidad de malignidad u otra patología de base. Debe realizarse TC multidetector (TCMD) de tórax en todos los pacientes con hemoptisis franca, en los que presentan esputo hemoptoico y sospecha de bronquiectasias o factores de riesgo de carcinoma broncogénico, y en los que tienen radiografía de tórax patológica. La angio-TCMD ha sustituido a la arteriografía como método diagnóstico de las arterias que son fuente de sangrado en las hemoptisis. La angio-TCMD es una técnica de imagen no invasiva que identifica correctamente la presencia, el origen, el número y el trayecto de las arterias sistémicas torácicas, bronquiales y no bronquiales, y de las arterias pulmonares que pueden ser fuente del sangrado. El tratamiento más seguro y eficaz para detener el sangrado en la mayoría de los casos de hemoptisis masiva o recurrente es la embolización endovascular. La embolización está indicada en todos los pacientes con hemoptisis amenazante o recurrente en los que se detectan arterias patológicas en la angio-TCMD. La broncoscopia flexible juega un papel primordial en el diagnóstico de la hemoptisis, tanto de la expectoración hemoptoica como de la hemoptisis franca. Puede ser realizada rápidamente en la cama del paciente (UCI) y, además de su utilidad en el control inmediato de la hemorragia, tiene una alta rentabilidad en la localización del sangrado. La broncoscopia flexible es el procedimiento inicial de elección en pacientes con hemoptisis amenazante e inestabilidad hemodinámica, donde el control de la hemorragia es vital. La cirugía en estos casos tiene una tasa de mortalidad muy alta, por lo que la indicación actual de cirugía en la hemoptisis amenazante está reservada para aquellas situaciones en las que la causa de la misma sea tributaria de tratamiento quirúrgico y haya una localización concreta y fiable del origen de la hemorragia.
Hemoptysis is the expectoration of blood from the tracheobronchial tree. It is commonly caused by bronchiectasis, chronic bronchitis, and lung cancer. The expectorated blood usually originates from the bronchial arteries. When hemoptysis is suspected, it must be confirmed and classified according to severity, and the origin and cause of the bleeding determined. Lateral and AP chest X-ray is the first study, although a normal chest X-ray does not rule out the possibility of malignancy or other underlying pathology. Multidetector computed tomography (MDCT) must be performed in all patients with frank hemoptysis, hemoptoic sputum, suspicion of bronchiectasis or risk factors for lung cancer, and in those with signs of pathology on chest X-ray. MDCT angiography has replaced arteriography in identifying the arteries that are the source of bleeding. MDCT angiography is a non-invasive imaging technique that can pinpoint the presence, origin, number and course of the systemic thoracic (bronchial and non-bronchial) and pulmonary arterial sources of bleeding. Endovascular embolization is the safest and most effective method of managing bleeding in massive or recurrent hemoptysis. Embolization is indicated in all patients with life-threatening or recurrent hemoptysis in whom MDCT angiography shows artery disease. Flexible bronchoscopy plays a pivotal role in the diagnosis of hemoptysis in patients with hemoptoic sputum or frank hemoptysis. The procedure can be performed rapidly at the bedside (intensive care unit); it can be used for immediate control of bleeding, and is also effective in locating the source of the hemorrhage. Flexible bronchoscopy is the first-line procedure of choice in hemodynamically unstable patients with life-threatening hemoptysis, in whom control of bleeding is of vital importance. In these cases, surgery is associated with an extremely high mortality rate, and is currently only indicated when bleeding is secondary to surgery and its source can be accurately and reliably located.
Clinical Aspects of Lung Cancer
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Clinical and organizational factors in the initial evaluation of patients with lung cancer: Diagnosis and management of lung cancer, 3rd ed: American college of chest physicians evidence-based clinical practice guidelines
2013, Chest
Citation Excerpt :
Patients may dismiss small amounts of blood streaking in sputum as related to bronchitis and cough. However, hemoptysis may be the presenting symptom of lung cancer even in the setting of a normal or nonlocalizing chest radiograph.12 Persistent hemoptysis, even in scant amounts, in patients with a history of smoking and COPD should raise concern about the possibility of endobronchial tumor.
This guideline is intended to provide an evidence-based approach to the initial evaluation of patients with known or suspected lung cancer. It also includes an assessment of the impact of timeliness of care and multidisciplinary teams on outcome.
The applicable current medical literature was identified by a computerized search and evaluated using standardized methods. Recommendations were framed using the approach described by the Guidelines Oversight Committee of the American College of Chest Physicians. Data sources included MEDLINE and the Cochrane Database of Systematic Reviews.
Initial evaluation should include a thorough history and physical examination; CT imaging; pulmonary function tests; and hemoglobin, electrolyte, liver function, and calcium levels. Additional testing for distant metastases and paraneoplastic syndromes should be determined on the basis of these results. Paraneoplastic syndromes may have an adverse impact on cancer treatment, so they should be controlled rapidly with the goal of proceeding with definitive cancer treatment in a timely manner. Although the relationship between timeliness of care and survival is difficult to quantify, efforts to deliver timely care are reasonable and should be balanced with the need to attend to other dimensions of health-care quality (eg, safety, effectiveness, efficiency, equality, consistency with patient values and preferences). Quality care will require multiple disciplines. Although it is difficult to assess the impact, we suggest that a multidisciplinary team approach to care be used, particularly for patients requiring multimodality therapy.
The initial evaluation of patients with lung cancer should include a thorough history and physical examination, pulmonary function tests, CT imaging, basic laboratory tests, and selective testing for distant metastases and paraneoplastic syndromes.
Early diagnosis of cancer by imaging: The primary care perspective
2012, Radiography
The United Kingdom (UK) performs relatively badly in cancer survival, much of which underperformance is attributed to delays in diagnosis. As a result, increased access to cancer diagnostics for general practitioners is proposed. Four cancer sites and their associated tests have been chosen: lung/chest X-ray, colorectal/colonoscopy, ovarian/trans-vaginal ultrasound and brain tumours/MRI scanning. This article elaborates on the need for these, which patients are likely to be chosen for investigation, and the effect this will have on radiology departments.
Diagnosing Cancer in the Symptomatic Patient
2009, Primary Care - Clinics in Office Practice
Citation Excerpt :
Thus, for a patient with risk factors for and symptoms suggestive of bronchogenic cancer, such as a smoker older than the age of 40 with a history of COPD who presents with cough and hemoptysis, there should still be a high index of suspicion for lung cancer despite a normal chest radiograph. While a CT scan may be considered for further diagnostic evaluation, even CT scanning may fail to detect endobronchial cancers.53,54 Therefore, bronchoscopy is indicated when there is a high index of suspicion for lung cancer even when the chest radiograph is normal.42,45
Palliative care in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition)
2007, Chest
To review the scientific evidence on symptoms and specific complications that are associated with lung cancer, and the methods available to palliate those symptoms and complications.
MEDLINE literature review (through March 2006) for all studies published in the English language, including case series and case reports, since 1966 using the following medical subject heading terms: bone metastases; brain metastases; cough; dyspnea; electrocautery; hemoptysis; interventional bronchoscopy; laser; pain management; pleural effusions; spinal cord metastases; superior vena cava syndrome; and tracheoesophageal fistula.
Pulmonary symptoms that may require palliation in patients who have lung cancer include those caused by the primary cancer itself (dyspnea, wheezing, cough, hemoptysis, chest pain), or locoregional metastases within the thorax (superior vena cava syndrome, tracheoesophageal fistula, pleural effusions, ribs, and pleura). Respiratory symptoms can also result from complications of lung cancer treatment or from comorbid conditions. Constitutional symptoms are common and require attention and care. Symptoms referable to distant extrathoracic metastases to bone, brain, spinal cord, and liver pose additional problems that require a specific response for optimal symptom control. There are excellent scientific data regarding the management of many of these issues, with lesser evidence from case series or expert opinion on other aspects of providing palliative care for lung cancer patients.
Palliation of symptoms and complications in lung cancer patients is possible, and physicians who provide such care must be knowledgeable about these issues.

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Chest

Clinical Investigations: Lung CancerDetecting Lung Cancer as a Cause of Hemoptysis in Patients with a Normal Chest Radiograph: Bronchoscopy vs CT

Objective

Design

Interventions

Measurements

Results

Conclusion

Section snippets

Baseline Model

Baseline Model and Estimates

Discussion

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Value of bronchoscopy in clinical practice

BMJ

Cytology in fiberoptic bronchoscopy

Chest

Clinical efficacy of early and delayed fiberoptic bronchoscopy in patients with hemoptysis

Am Rev Respir Dis

Haemoptysis with no radiological evidence of tumour—the value of early bronchoscopy

S Afr Med J

Fiberoptic bronchoscopy in outpatient facilities, 1982

Arch Intern Med

Evaluation of hemoptysis in patients with a normal chest roentgenogram

West J Med

Clinical Investigations: Lung Cancer
Detecting Lung Cancer as a Cause of Hemoptysis in Patients with a Normal Chest Radiograph: Bronchoscopy vs CT