AMERICAN COLLEGE
OF
RADIOLOGY
ACR Appropriateness Criteria Review
ACR Appropriateness Criterias Hemoptysis Loren H. Ketai, MD,* Tan-Lucien H. Mohammed, MD,w Jacobo Kirsch, MD,z Jeffrey P. Kanne, MD,y Jonathan H. Chung, MD,8 Edwin F. Donnelly, MD,z Mark E. Ginsburg, MD,# Darel E. Heitkamp, MD,** Travis S. Henry, MD,ww Ella A. Kazerooni, MD,zz Jonathan M. Lorenz, MD,yy Barbara L. McComb, MD,88 James G. Ravenel, MD,zz Anthony G. Saleh, MD,## Rakesh D. Shah, MD,*** Robert M. Steiner, MD,www Robert D. Suh, MD,zzz and Expert Panel on Thoracic Imaging
Abstract: Although hemoptysis is often self-limited and benign in origin, it can be an indicator of serious disease including bronchiectasis, granulomatous infection, and malignancy. Hemoptysis severity can be graded on the basis of the quantity of expectorated blood: 300 to 400 mL in 24 hours as massive. Among patients with hemoptysis, chest radiographs are often abnormal and can guide evaluation. The overall risk for malignancy in patients with normal radiographs is low but may be as much as 5% to 10% in patients with >30 mL of hemoptysis and those who are above 40 years of age and have significant smoking history. A combination of negative computed tomography and bronchoscopy results predicts a very low likelihood of lung malignancy diagnosis over medium-term follow-up (2 to 3 y). Bronchial and nonbronchial systemic arteries are much more frequent sources of hemoptysis than pulmonary arteries. Major or massive hemoptysis can usually be stopped acutely by bronchial arterial embolization. Recurrences, however, are common and often require repeat embolization. The ACR Appropriateness
This article is a summary of the complete version of this topic, which is available on the ACRWebsite at http://www.acr.org/ac. Practitioners are encouraged to refer to the complete version. Reprinted with permission of the American College of Radiology. From the *Department of Radiology, University of New Mexico, Albuquerque, NM; wVirginia Mason Medical Center, Seattle, WA; zCleveland Clinic, Weston; 88Mayo Clinic, Jacksonville, FL; yDepartment of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI; 8National Jewish Health, Denver, CO; zVanderbilt University Medical Center, Nashville, TN; #Department of Surgery, Society of Thoracic Surgeons, Columbia University, New York; ##The American College of Chest Physicians, New York Methodist Hospital, Brooklyn; ***North Shore University Hospital, Manhasset, NY; **Department of Radiology, Indiana University, Indianapolis, IN; wwEmory University Hospital, Atlanta, GA; zzUniversity of Michigan Medical Center, Ann Arbor, MI; yyUniversity of Chicago Hospital, Chicago, IL; zzMedical University of South Carolina, Charleston, SC; wwwDepartment of Radiology, Temple University, Philadelphia, PA; and zzzRonald Regan UCLA Medical Center, Los Angeles, CA. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criterias through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Jeffrey P. Kanne is a consultant at PTC Therapeutics. Robert M. Steiner is a consultant and course director at Education Symposium Inc. and a consultant at John and Johnson. Reprint: Loren H. Ketai, MD, Department of Radiology, 1 University of New Mexico # 105530 Albuquerque, NM 87131-0001 (e-mail:
[email protected]). Copyright r American College of Radiology. Reprinted with Permission.
J Thorac Imaging
Volume 00, Number 00, ’’ 2014
Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Key Words: Appropriateness Criteria, hemoptysis, chest computed tomography angiography, bronchial artery embolization
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emoptysis is usually benign and self-limited but may be a sign of significant underlying tracheopulmonary pathology. Causes include chronic bronchitis, bronchiectasis, pneumonia, fungal infections, tuberculosis, malignancy, and pulmonary vasculitis.1 In general, systems classifying hemoptysis severity consider 300 up to 400 mL as massive.2–5 Bleeding usually originates from systemic rather than pulmonary arteries. Notable exceptions include pulmonary artery aneurysms and, only rarely, anteriovenous malformations. The majority of patients will have an identifiable source for bleeding at presentation. Cryptogenic hemoptysis, defined as cases in which both bronchoscopy and initial computed tomography (CT) are nondiagnostic, makes up approximately 10% to 20% of hemoptysis cases.3,6,7
BRONCHOSCOPY VERSUS CT Bronchoscopy is useful in identifying the site of bleeding, diagnosing active hemorrhage, and, when performed with a rigid scope, controlling the airway in patients with catastrophic hemorrhage.6 CT, however, is equally capable of localizing bleeding and is more effective in detecting underlying neoplasms and bronchiectasis.8 Pertinent studies include: (1) Revel et al5 assessed the capacity of chest radiography, bronchoscopy, and CT to determine the cause and site of bleeding in patients with large or massive hemoptysis. Findings on chest radiography were normal in 13% of patients, of whom 70% had bronchiectasis. The chest radiographs revealed the site of bleeding in 46% of the patients and the cause in 35%, most of whom had tuberculosis or tumors. CT was more successful than www.thoracicimaging.com |
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Ketai et al
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TABLE 1. Variant Table Ratings
Radiologic Procedures
Variants Variant 1: Hemoptysis Z30 mL OR 2 risk factors (>40 y old and >30 pack-year smoking history) Variant 2: Persistent/recurrent hemoptysis (< 30 mL) and 1 risk factor (>40 y old or >30 pack-year smoking history) Variant 3: Massive hemoptysis without cardiopulmonary compromise
X-Ray Chest
CTA Chest With Contrast
CT Chest Without Contrast
Arteriography Bronchial With or Without Arteriography Embolization Pulmonary
9
8
6*
5w
2z
9
8
6*
Not rated
2
9
8
5
8
5
Rating scale: 1, 2, 3—usually not appropriate; 4, 5, 6—may be appropriate; 7, 8, 9—usually appropriate. *If there is a contraindication to iodinated contrast. wFor patients with a preprocedure diagnosis that carries a high risk for recurrent hemorrhage. zFor therapy.
bronchoscopy in identifying the cause of bleeding (77% vs. 8%, respectively; P < 0.001), whereas the 2 methods were comparable for identifying the site of bleeding (70% vs. 73%, respectively). (2) Set et al,9 in a prospective study, compared the results of CT and bronchoscopy in 91 patients with nonmassive hemoptysis. CT scans demonstrated all 27 tumors identified at bronchoscopy as well as 7 additional lesions, 2 of which were within bronchoscopic range. As expected, CT was not sensitive in squamous metaplasia and bronchitis. (3) Thirumaran et al10 studied 270 patients with hemoptysis and normal chest radiographs. Ninety percent of these patients were either active or ex-smokers. The authors found respiratory malignancy in 9.6% of their patients, and CT detected 96% of them. (4) Lee et al11 retrospectively evaluated 228 patients in whom chest CT did not demonstrate a causative lesion for hemoptysis. Bronchoscopy showed a cause of bleeding in only 16%, most commonly anthracofibrosis or bronchial inflammation, and detected only 1 cancer.
GUIDELINES Although the cause of hemoptysis among patients with negative or nonlocalizing chest radiographs is most often benign, a normal chest radiograph does not exclude malignancy. Herth et al7 reported that almost one quarter of patients presenting with acute hemoptysis secondary to malignancy had normal chest radiographs. Early literature addressing the evaluation of hemoptysis among patients with normal chest radiographs focused on finding a means to confine bronchoscopy to patients at high risk for malignancy. For example, Poe et al4 studied 196 patients with negative chest radiographs and subsequent bronchoscopy. The investigators found 3 predictors of malignancy: male sex, age 50 years or above, and >40 pack-year smoking history. In that population, all cancers detected by bronchoscopy occurred in patients with 2 or 3 risk factors or with hemoptysis in excess of 30 mL over 24 hours (n = 12). O’Neil and Lazarus12 also evaluated patients (n = 119) with hemoptysis and negative or nonlocalizing findings on chest radiographs, finding a total of 6 neoplasms (5%). The authors proposed that patients older than 40 years (rather than 50 y) be considered for bronchoscopy,
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as 2/6 neoplasms would have been missed by the higher age threshold. Male sex was not a statistically significant predictor in their data. In a more recent series of 270 patients with hemoptysis and normal chest radiographs (see above) 26 patients were ultimately found to have malignancy. Notably, 13 (50%) of these patients had reported only streaks of hemoptysis and reported having only 1 or 2 episodes. Tobacco use averaged 38 pack-years in these patients, suggesting that smoking exposures 30 pack-year smoking history for lung cancer.13 In aggregate, these studies suggest that CT imaging of patients with hemoptysis who are over 40 years old and have a significant smoking history would detect neoplasms in 5% to 10% of patients and exceed the yield from bronchoscopy. The observation that most patients with hemoptysis due to carcinoma experience only small-volume hemoptysis argues that diagnostic evaluation should not be guided by the volume of hemoptysis alone14 (see Variants 1 and 2 in Table 1). Clinical outcome is favorable when initial evaluation of hemoptysis does not reveal malignancy. Among patients with hemoptysis who subsequently underwent both negative bronchoscopy and chest CT, Lee et al11 found no lung cancers during a mean follow-up period of >2 years. In clinical practice it may be warranted to repeat chest CT several weeks to months after the initial episode of hemoptysis to assess the evolution of parenchymal lung abnormalities or detect a small malignancy initially obscured by parenchymal or endobronchial hemorrhage.6
IMAGING Chest radiograph, CT without contrast, CT angiography (CTA), and thoracic aortography (for bronchial artery embolization) are all pertinent to evaluation of hemoptysis. Radiography can lateralize the bleeding and can often help detect underlying parenchymal and pleural abnormalities.8 CT without intravenous contrast is usually sufficient to detect malignancy and bronchiectasis, 2 of the 3 most common causes of hemoptysis,14 and is also effective in the diagnosis of less common causes of hemoptysis such r
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as tuberculosis and chronic fungal infection. CTA can identify uncommon etiologies of hemoptysis that are not detectable on noncontrast CT (such as Dieulafoy vascular anomalies) and can guide therapy when treatment is warranted, particularly in the setting of major or massive hemoptysis.6,15 In the setting of major hemoptysis, CTA is effective in demonstrating normally located and ectopic bronchial arteries as well as nonbronchial systemic arteries that are sources of bleeding.16 Although CTA can provide anatomic guidance for therapy in the setting of massive hemoptysis from a known etiology (eg, cystic fibrosis), some clinicians prefer the patient be taken directly for embolization without prior CTA.
BRONCHIAL ARTERIOGRAPHY AND EMBOLIZATION Bronchial artery arteriography is usually reserved for settings in which therapeutic embolization is anticipated. Transcatheter bronchial artery embolization is an effective therapy for controlling massive hemoptysis from tuberculosis, bronchiectasis, bronchogenic carcinoma, aspergilloma, and bronchial inflammation.3,17,18 It may serve as interim management before surgery or may constitute definitive therapy. Rates of successful treatment, particularly in elderly patients, may be increased by the use of CTA before embolization.18 Success rate is lowest in patients with aspergillomas, and a greater percentage of these patients may require surgical treatment.19 Despite initial treatment success, recurrence of hemoptysis during long-term follow-up is common, occurring in between 5%– and 45% of cases.3,17,19,20 Recurrence may be diminished by newer embolic agents.21 Although bronchial arteries are responsible for most cases of hemoptysis, requiring embolization or surgery, bleeding from nonbronchial systemic arteries is not rare, and failure to recognize blood supply from these arteries may increase the likelihood of recurrent bleeding after embolization.21,22 Peripheral pulmonary artery pseudoaneurysms are identified in up to 11% of patients undergoing bronchial angiography for hemoptysis. In these patients, successful treatment for hemoptysis may also require embolization of pulmonary artery branches supplying the pseudoaneurysms23,24 (see Variant 3 in Table 1). Bronchoscopy is not necessary before bronchial artery embolization in patients in whom the etiology and site of hemoptysis has been established by chest radiography or CT.8 If airway management is needed, however, initial rigid bronchoscopy may be warranted.25
SUMMARY OF LITERATURE REVIEW Initial evaluation of patients with hemoptysis should include a chest radiograph. CT is recommended for patients who are at risk for malignancy and have suspicious chest radiograph findings. CT should also be considered in patients having >30 mL of hemoptysis and those with risk factors (above 40 y of age, >30 pack-year smoking history) despite a negative or nonlocalizing chest radiograph. Patients with negative chest radiograph, CT scan, and bronchoscopy results (cryptogenic hemoptysis) have a low risk for malignancy and can be observed for the following 3 years. If hemoptysis recurs, CTA should be considered. Copyright
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ACR Appropriateness Criteria$ Hemoptysis
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Massive hemoptysis can be effectively treated with transcatheter embolization. CTA can define the source of hemoptysis as bronchial systemic, nonbronchial systemic, and/or pulmonary arterial. Transcatheter embolization is usually successful in halting acute hemorrhage, but repeat embolization is often needed to treat recurrent hemorrhage during long-term follow-up. REFERENCES 1. Castaner E, Alguersuari A, Gallardo X, et al. When to suspect pulmonary vasculitis: radiologic and clinical clues. Radiographics. 2010;30:33–53. 2. Delage A, Tillie-Leblond I, Cavestri B, et al. Cryptogenic hemoptysis in chronic obstructive pulmonary disease: characteristics and outcome. Respiration. 2010;80:387–392. 3. Menchini L, Remy-Jardin M, Faivre JB, et al. Cryptogenic haemoptysis in smokers: angiography and results of embolisation in 35 patients. Eur Respir J. 2009;34:1031–1039. 4. Poe RH, Israel RH, Marin MG, et al. Utility of fiberoptic bronchoscopy in patients with hemoptysis and a nonlocalizing chest roentgenogram. Chest. 1988;93:70–75. 5. Revel MP, Fournier LS, Hennebicque AS, et al. Can CT replace bronchoscopy in the detection of the site and cause of bleeding in patients with large or massive hemoptysis? Am J Roentgenol. 2002;179:1217–1224. 6. Bruzzi JF, Remy-Jardin M, Delhaye D, et al. Multi-detector row CT of hemoptysis. Radiographics. 2006;26:3–22. 7. Herth F, Ernst A, Becker HD. Long-term outcome and lung cancer incidence in patients with hemoptysis of unknown origin. Chest. 2001;120:1592–1594. 8. Hsiao EI, Kirsch CM, Kagawa FT, et al. Utility of fiberoptic bronchoscopy before bronchial artery embolization for massive hemoptysis. Am J Roentgenol. 2001;177:861–867. 9. Set PA, Flower CD, Smith IE, et al. Hemoptysis: comparative study of the role of CT and fiberoptic bronchoscopy. Radiology. 1993;189:677–680. 10. Thirumaran M, Sundar R, Sutcliffe IM, et al. Is investigation of patients with haemoptysis and normal chest radiograph justified? Thorax. 2009;64:854–856. 11. Lee YJ, Lee SM, Park JS, et al. The clinical implications of bronchoscopy in hemoptysis patients with no explainable lesions in computed tomography. Respir Med. 2012;106: 413–419. 12. O’Neil KM, Lazarus AA. Hemoptysis. Indications for bronchoscopy. Arch Intern Med. 1991;151:171–174. 13. Church TR, Black WC, Aberle DR, et al. Results of initial lowdose computed tomographic screening for lung cancer. N Engl J Med. 2013;368:1980–1991. 14. McGuinness G, Beacher JR, Harkin TJ, et al. Hemoptysis: prospective high-resolution CT/bronchoscopic correlation. Chest. 1994;105:1155–1162. 15. Parrot A, Antoine M, Khalil A, et al. Approach to diagnosis and pathological examination in bronchial Dieulafoy disease: a case series. Respir Res. 2008;9:58. 16. Hartmann IJ, Remy-Jardin M, Menchini L, et al. Ectopic origin of bronchial arteries: assessment with multidetector helical CT angiography. Eur Radiol. 2007;17:1943–1953. 17. Dave BR, Sharma A, Kalva SP, et al. Nine-year single-center experience with transcatheter arterial embolization for hemoptysis: medium-term outcomes. Vasc Endovascular Surg. 2011; 45:258–268. 18. Khalil A, Fartoukh M, Parrot A, et al. Impact of MDCT angiography on the management of patients with hemoptysis. Am J Roentgenol. 2010;195:772–778. 19. Chun JY, Belli AM. Immediate and long-term outcomes of bronchial and non-bronchial systemic artery embolisation for the management of haemoptysis. Eur Radiol. 2010;20: 558–565. 20. Flume PA, Mogayzel PJ Jr, Robinson KA, et al. Cystic fibrosis pulmonary guidelines: pulmonary complications: hemoptysis
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and pneumothorax. Am J Respir Crit Care Med. 2010;182: 298–306. 21. Yoo DH, Yoon CJ, Kang SG, et al. Bronchial and nonbronchial systemic artery embolization in patients with major hemoptysis: safety and efficacy of N-butyl cyanoacrylate. Am J Roentgenol. 2011;196:W199–W204. 22. Yoon W, Kim YH, Kim JK, et al. Massive hemoptysis: prediction of nonbronchial systemic arterial supply with chest CT. Radiology. 2003;227:232–238.
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