Correct!
4. All of the above
The first three choices- thoracoscopic lung biopsy, bronchoscopy, and percutaneous fine needle aspiration / core biopsy- all represent methods for obtaining a tissue diagnosis, which is indicated in this patient with progressive clinical symptoms and imaging findings. Thoracoscopic lung biopsy has the potential advantage of being the procedure most likely to provide a definitive diagnosis, although it is the most invasive, potentially morbid, and expensive among those listed. On the other hand, while bronchoscopy with bronchoalveolar lavage and transbronchial biopsy may have a lesser capability for providing a definitive diagnosis, it is the last invasive; percutaneous transthoracic fine needle aspiration / core biopsy is intermediate between thoracoscopic lung biopsy and bronchoscopy as regards both diagnostic capabilities and complication rate. The choice of procedure in this circumstance largely rests with available expertise and patient preference.
Further clinical course: The patient subsequently underwent thoracoscopic lung biopsy, which showed bronchiectasis, chronic bronchitis, bronchiolectasis, and chronic bronchiolitis with prominent peribronchiolar metaplasia, mucostasis, organizing pneumonia, and lymphoid hyperplasia. Tissue eosinophilia was present, but no features to suggest allergic bronchopulmonary aspergillosis were seen. The sample also showed marked lymphoid hyperplasia but no convincing evidence of malignant lymphoma was present. The patient subsequently underwent repeat thoracic CT (Figure 9) several months later.
Figure 9. Repeat thoracic CT scan several months later. Panels A-I: Static images in lung windows. Lower panel: Movie of the CT scan in lung windows.
Which of the following represents the most appropriate next stepfor the management of this patient? (Click on the correct answer to proceed to the next panel)