Whether further evaluation to detect these cancers should be undertaken routinely, and if so, what form it should take, is not yet clear. Repeat bronchoscopy failed to detect the two cancers which appear to have been missed at initial bronchoscopy in our series, presumably because of their peripheral location. Serial chest roentgenograms may be worthwhile, but their value in screening other high-risk populations for lung cancer remains unproven. Computerized tomography can occasionally detect cancers missed by chest roentgenogram and bronchoscopy, as shown in our series and others, but its overall impact may be too small to justify routine use. Thus, while some form of continued observation of the high-risk patient with hemoptysis and a negative bronchoscopic examination appears warranted, management must be individualized pending further study. Reading here
We advise caution in extrapolating the frequency with which cancer was detected in this series to all men more than 40 years old with a history of heavy smoking who present with hemoptysis and a nonsuspicious chest roentgenogram. A limitation of all studies to date, including our own, is that they include only those patients referred for bronchoscopy. Patients with hemoptysis who are not referred for bronchoscopy by their primary physician could have a lower probability of cancer. Although predictors of lung cancer other than age, male sex, and smoking history have not been defined in this population, it is possible that physicians base referral decision on other factors which might affect the likelihood of cancer. For example, patients with a lesser amount or duration of hemoptysis, or those with concurrent symptoms of bronchitis, could constitute a lower-risk group with a lower probability of being referred for bronchoscopy. The fact that most of our patients had no more than 5 ml per day of hemoptysis, half had hemoptysis for less than one week, and a third had purulent sputum, suggests that these factors did not greatly bias referral in our series. Nevertheless, further studies involving all patients who present to a physician with hemoptysis will be needed before the likelihood of lung cancer in this setting can be accurately known.
We conclude from this study that (1) hemoptysis with a nonsuspicious chest roentgenogram carries an appreciable risk of cancer in older men with substantial smoking histories, (2) these cancers often are early and surgically resectable, (3) a chest roentgenogram in which the central lung fields are obscured in any way should not be considered negative, and (4) a negative bronchoscopic examination does not exclude the possibility of cancer in these patients.
Hemoptysis with a nonsuspicious chest roentgenogram remains an indication for bronchoscopy in older men with substantial smoking histories. Continued observation is warranted in these patients even when bronchoscopy is negative.