Correct!
3. Video-assisted thorascopic surgery (VATS)

Neither a blind pleural biopsy or coccidioidomycosis serology is necessarily wrong. However, in a series of pleural effusions secondary to coccidioidomycosis none were grossly bloody (2). In metastatic malignancy to the pleura, the surface is studded with areas of cancer. If the biopsy is done through one of the abnormal areas a diagnosis can be made, but if it is done between the studs of cancer, the biopsy will be nondiagnostic (1). In the case of mesothelioma, a histologic diagnosis is often difficult and often requires the confirmation of the surgeon.

A VATS was performed. There was extensive fibrinous, bloody adhesions in the chest.  
In excess of one liter dark bloody pleural fluid was obtained. There were no obvious areas of malignancy that could be seen.  Random biopsies were obtained from the parietal pleura in two separate locations.

The biopsy is shown in Figure 2.

Figure 2. High power view of pleural biopsy (H&E).

Which of the following is true regarding the pleural biopsy? (Click on the correct answer to proceed to the fifth of six panels)

1. The biopsy is normal
2. There are numerous granuloma with caseous necrosis
3. There are numerous granuloma without necrosis
4. There are numerous mitotic figures suggesting malignancy
5. There are numerous spherules within the biopsy suggesting Coccidioidomycosis

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