Correct!
1. Bronchoscopy with biopsy and possibly lymph node biopsy
Bronchoscopy with transbronchial biopsy of the lung lesion and endosonographically-guided lymph node biopsy of the mediastinal lymph nodes provides the least invasive method to obtain a diagnosis for this patient. The right upper lobe lesion, which has an endobronchial component, as well as the metabolically active lymph nodes, can be targeted in a single procedural sitting. Repeating the thoracic CT would not provide useful information in addition to what is already known, even with the addition of high-resolution technique. Similarly, thoracic MRI would not add additional diagnostically useful information to what is already known through the combination of thoracic CT and 18FDG-PET scanning. As noted previously, both cervical mediastinoscopy and video-assisted thoracoscopic biopsy would provide sufficient material to establish a diagnosis, but both are needlessly invasive and would merit consideration only if bronchoscopy were contraindicated or failed to provide a diagnosis.
The patient underwent bronchoscopy with biopsy of the right upper lobe focal lesion (Figure 9).
Figure 9. Bronchoscopy shows an endobronchial lesion within a proximal posterior subsegmental airway within the apical segment of the right upper lobe. The lesion was biopsied.
An endobronchial lesion was identified within a posterior subsegmental airway in the apical segment of the right upper lobe and was biopsied. Endobronchial ultrasound-guided fine needle aspiration biopsy of station 4R (right paratracheal), station 7 (subcarinal) lymph nodes, and right peribronchial lymph nodes (station 11) was also performed. Following the procedure, the patient developed chest pain with ST segment elevation on ECG, associated with hypotension. Dobutamine stress echocardiography suggested myocardial ischemia when apical and anterior wall motion abnormalities were noted during the stress test; however, subsequent cardiac catheterization showed no flow-limiting atherosclerosis.
The specimens obtained at bronchoscopy showed a possible granuloma within the biopsy performed for the right peribronchial lymph node. Only blood, without any specific pathological abnormalities, was seen in the sampled mediastinal lymph nodes. Dedicated biopsy of the right upper lobe lesion showed bronchial cells and spindle cells suspicious for a low-grade spindle cell neoplasm.
At this point, which of the following represents the most appropriate step in this patient’s management? (Click on the correct answer to be directed to the ninth and last page)