Correct!
3. Thoracentesis
Video-assisted thoracoscopic lung biopsy certainly could obtain a diagnosis in this patient with extensive interstitial abnormalities, but is needlessly invasive at this point- less invasive options, such as flexible fiberoptic bronchoscopy with transbronchial biopsy [this option was not offered in the choices above] and thoracentesis may be performed. Mediastinoscopy is generally reserved for patients with enlarged mediastinal lymph nodes in need of staging for malignancy, or to sample mediastinal masses, and neither are present in this patient. Repeat cross sectional imaging, either CT or MR, is unlikely to provide additional management-altering information to that already known.
Thoracentesis was performed for the right pleural effusion and disclosed an extensive histiocytic infiltration on a background of reactive mesothelial cells; rare atypical epithelioid cells with large, irregular nuclei were seen, but no definite malignancy was present. Percutaneous biopsy of a mildly enlarged retroperitoneal lymph node disclosed only inflammatory tissue and fibroadipose tissue.
The patient underwent bone marrow biopsy which showed metastatic malignancy due to adenocarcinoma with a signet-ring morphology. This morphology promoted a gastrointestinal evaluation and upper endoscopy with biopsy revealed gastric malignancy.
Diagnosis: Pulmonary lymphangitic carcinomatosis due to gastric carcinoma.
References