Correct!
5. Surgical lung biopsy
Repeat flexible fiberoptic bronchoscopy is reasonable, but given that this procedure did not yield a diagnosis previously, a more aggressive posture may be warranted. Therefore, either surgical lung biopsy or cryobiopsy are the best choices, favoring surgical lung biopsy given the larger tissue sample and, presumably, a greater likelihood of a definitive diagnosis, possible with this approach. As previously, mediastinoscopy is generally reserved for patients with accessible mediastinal lymph node enlargement or masses, neither of which are present in this patient. Given the already prolonged observation period and the failure of the process to remit with conservative therapy, observation is not a rewarding strategy for the further management of this patient.).
The patient underwent repeat bronchoscopy with instillation of a fiducial marker to direct subsequent surgical lung biopsy. A repeat thoracic CT was performed (Figure 5) to assist with navigational bronchoscopy and fiducial placement.
Figure 5. A-F: Representative axial thoracic CT displayed in lung windows performed for navigational bronchoscopy planning shows persistent, although slightly improved, multifocal ground-glass opacity (arrowheads), compared to the thoracic CT performed 5 months after presentation (Figure 4). Right: video of CT scan in lung windows.
A video-assisted surgical lung biopsy was then performed. The material retrieved at this procedure (Figure 6) showed scattered particles of food / foreign material associated with airway-centered inflammation, organization, and airway-centered scarring, superimposed on a background of smoking-related changes. No evidence of malignancy or vasculitis was seen.
Figure 6. Representative photomicrographs of the lung biopsy. (A) At low power, patchy bronchiolocentric fibrosis is apparent with mild chronic inflammation. (B) At medium power, scattered fragments of foreign material (arrowheads) are embedded within the airway-centered scar. At high power, the fragments are amorphous, variably corrugated, and slightly refractile, consistent with old aspirated food particles, and are present (C) within the lumen of small airways and (D-E) in the peribronchiolar interstitium. Hematoxylin & eosin, original magnifications 40x (A), 200x (B), 400x (C-E).
Diagnosis: Aspiration of vegetable material
References