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1. Bronchoscopy with endobronchial ultrasound (EBUS) biopsy
Although the most likely diagnosis seems to be metastatic melanoma to the mediastinal lymph nodes, it seems unusual that while the presumed metastases in the liver have regressed, new lesions have occurred in the chest. A tissue biopsy is probably indicated. The easiest procedure to obtain tissue from the mediastinal lymph nodes is bronchoscopy with EBUS. For lung cancer, the most common situation for performing mediastinal lymph node biopsy, bronchoscopy with EBUS has largely supplanted mediastinoscopy (2). There does not appear to be any parenchymal lung lesions which would be more readily sampled by VATS and there is now no increased uptake in the liver making it an unlikely source to obtain a tissue diagnosis. S100 calcium-binding protein B (S100B) has been touted as a biomarker for melanoma, but in this case, it seems tissue is needed (3).
Bronchoscopy with EBUS was performed. All lymph node stations were negative for malignancy. Station 7 (right upper hilum) showed a biopsy with noncaseating granulomas.
Which of the following should be done next? (Click on the correct answer to proceed to the fourth and final page)