Management of a Bleeding Fibrous Tumor in the Lung
For bleeding fibrous tumors in the lung, immediate airway protection with a large-diameter single-lumen endotracheal tube followed by bronchoscopy for diagnosis and intervention is the recommended first-line management approach. 1
Initial Management of Hemoptysis
Immediate Interventions
- Secure the airway with a large-diameter single-lumen endotracheal tube to facilitate bronchoscopic suctioning and removal of clots 1
- Position patient with the bleeding side down if known 1
- Perform urgent bronchoscopy for both diagnostic and therapeutic purposes 2, 1
- Assess vital signs, oxygen saturation, respiratory status, complete blood count, coagulation studies, and renal function 1
Bronchoscopic Management
Identify the anatomic site and side of bleeding, nature of the bleeding source, severity of bleeding, and therapeutic feasibility 2
For visible central airway lesions, employ endobronchial management options:
For persistent bleeding despite bronchoscopic interventions, consider bronchial blockade balloons for 24-48 hours 2
Definitive Management
Surgical Approach
- Complete en bloc surgical resection is the preferred treatment for solitary fibrous tumors of the pleura (SFTP), both benign and malignant 3
- For pedunculated tumors attached to visceral pleura, perform wedge resection of lung 3
- For sessile tumors arising on the lung, perform larger lung resection 3
- For sessile tumors on the chest wall, perform wide local excision, often with chest wall resection due to their propensity for local recurrence 3
Interventional Radiology
- If bronchoscopic measures are unsuccessful, consider bronchial artery embolization to temporize the bleeding 2, 1
- Embolization can be performed for active bleeding, is less invasive, and does not require general anesthesia 2
Radiation Therapy
- For distal or parenchymal lesions not amenable to bronchoscopic intervention, external beam radiotherapy is recommended 2
- EBRT has shown symptom relief rates of 81-86% for hemoptysis due to lung tumors 1
Special Considerations
Monitoring and Follow-up
- Close follow-up is essential as fibrous tumors can grow rapidly and aggressively 4
- Long-term follow-up for more than 10 years after surgery is necessary, particularly for tumors with areas of hypercellularity 5
- MIB-1 index can help identify malignant characteristics of recurrent tumors 5
Prognosis
- Benign SFTP has a high cure rate with an 8% local recurrence rate that is usually amenable to curative re-excision 3
- Malignant SFTP, especially the sessile type, has a 63% recurrence rate even with complete resection 3
- Overall long-term cure rate for all patients is 88-92% 3
Pitfalls to Avoid
- Delaying airway protection can lead to asphyxiation and increased mortality 1
- Underestimating the severity of hemoptysis can lead to increased morbidity and mortality 1
- Delaying bronchoscopy in massive hemoptysis increases morbidity and mortality 1
- Failing to coordinate care with a multidisciplinary approach involving pulmonology, interventional radiology, and thoracic surgery can lead to poor outcomes 1
Thorough exploration of the pleural cavity before tumor resection is mandatory to exclude any pleural involvement that may not be radiologically apparent 6.