Correct!
2. Bronchoscopy with transbronchial biopsy and possibly lymph node biopsy
Given the slow growth in the focal right upper lobe opacity, neither positive nor negative 18FDG-PET scan findings would be clearly contributory towards the patient’s management. Similarly, given that new borderline-to-mild mediastinal lymph node enlargement has occurred on the presentation thoracic CT (Figure 1) compared with the previous thoracic CT performed 8 years earlier (Figure 6), whether or not these lymph nodes are 18FDG-avid probably will not impact the next management steps. If the nodes are 18FDG-avid, they may serve as a target for bronchoscopic biopsy; however, bronchoscopy is likely indicated regardless, given the enlargement of the right apical opacity, and it also matters little if this focal right apical opacity shows 18FDG tracer avidity or not. In fact, one may suspect that the focal right upper lobe lesion may show little tracer activity given its minimal enlargement over an 8-year period. There is always the possibility that 18FDG-PET scanning will disclose an unsuspected, more readily accessible, target for intervention and obviate the need for bronchoscopy, but there is little to indicate such a possibility at this point. Cervical mediastinoscopy would be able to access the right paratracheal lymph nodes but is needlessly invasive when bronchoscopy could access these nodes as well as the focal right upper lobe opacity in the same procedure. Similarly, both open surgical lung biopsy and video-assisted thoracoscopic biopsy of the lung lesion could provide tissue for a diagnosis, but both are needlessly invasive when bronchoscopy with transbronchial biopsy of the lung lesion and sonographically-guided lymph node biopsy of the mediastinal lymph nodes could be performed.
However, 18FDG-PET scanning was performed (Figure 8).
Figure 8. Upper 3 images are representative axial 18FDG-PET scan images. Lower image is a video of the 18FDG-PET scan.
Which of the following represents the most accurate assessmentof the 18FDG-PET scan findings? (Click on the correct answer to be directed to the seventh of nine pages)