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2. Flexible fiberoptic bronchoscopy
Mediastinoscopy is useful for assessing lesions found in particular mediastinal locations, typically the right paratracheal and anterior subcarinal spaces; such lesions are frequently due to lymphadenopathy. This patient, however, does not clearly have abnormally enlarged mediastinal lymph nodes accessible with either cervical mediastinoscopy or the Chamberlain procedure (a left anterior mediastinotomy). Similarly, esophageal endoscopic ultrasound is an excellent tool for visualizing and possibly biopsying lesions in close proximity to the esophagus, such as lymph nodes or masses in the left paratracheal space (2L and 4L), subcarinal space (station 7), periesophageal spaces (station 8), and aorto-pulmonary window (station 5), but no lesions amenable to this technique are present in this patient. Video-assisted thoracoscopic surgical lung biopsy could obtain a diagnosis for this patient, but is more invasive than flexible fiberoptic bronchoscopic biopsy, and the latter stands a good chance of obtaining tissue that could establish a diagnosis for this patient. Therefore, video-assisted thoracoscopic lung biopsy may be pursued if flexible fiberoptic bronchoscopy fails to obtain a diagnosis.
The patient underwent flexible fiberoptic bronchoscopy with biopsy. The tissue obtained showed peribronchial and perivascular dust-filled macrophages with foreign body granulomas. Birefringent particulate matter was seen on polarized light microscopy (Figure 3), consistent with talc particles.
Figure 3. Polarized light microscopy of the tissue obtained at flexible fiberoptic bronchoscopy shows particulate matter demonstrating birefringence (arrowheads), representing talc particles.
Based on this information, which of the following would be most useful for establishing a diagnosis for this patient? (Click on the correct answer to proceed to the seventh and final page)