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2. Bronchoscopy with transbronchial biopsy
Bronchoscopy with transbronchial biopsy is the most appropriate next step among the choices listed. A case could be made for choice 3. Open surgical lung biopsy. However, video-assisted thoracoscopic surgical biopsy is generally favored over the open form of the procedure for the diagnosis of interstitial lung abnormalities. Furthermore, a surgical lung biopsy may not be required at all if the less morbid and less expensive bronchcoscopic biopsy establishes a diagnosis. Serial imaging to assess for change is not appropriate given what is apparently an acute and potentially serious abnormality. 18FDG-PET scan would likely not be management-altering in this case. Even if tracer accumulation was seen within the pulmonary opacities at 18FDG-PET, that finding would be non-specific and a tissue diagnosis would be pursued regardless. Needle biopsy offers no advantage over bronchoscopy and has a higher complication rate.
The patient did consent to bronchoscopy but refused transbronchoscopic biopsy. Bronchoscopy with bronchoalveolar lavage which was performed 1/7/13. Cultures were negative and
cytology was negative for malignancy.
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