Correct!
2. Contrast-enhanced thoracic CT

Contrast-enhanced thoracic CT is the next most appropriate step for the assessment of this patient. While thoracic MRI and 18FDG-PET scanning are both reasonable considerations, contrast –enhanced CT will provide the best assessment for the anatomic extent of disease involving the right pleural space, hila, mediastinum, central airways (given the right lung volume loss) and lung parenchyma. Ventilation-perfusion scintigraphy may provide some useful information regarding relative lung perfusion, but cannot provide a detailed assessment of the anatomic disease distribution and extent for this patient. Given the extensive abnormalities at chest radiography and the patient’s symptoms, an active investigation, as opposed to a conservative surveillance posture, is warranted.

The patient underwent contrast-enhanced thoracic CT (Figure 2) was performed.

Figure 2. A-F: Representative images from the contrast-enhanced thoracic CT in soft tissue windows. Lower panel: movie of thoracic CT scan in soft tissue windows.

Which of the following statements regarding this study is most accurate? (Click on the correct answer to proceed to the next panel)

1. The thoracic CT shows a large anterior mediastinal mass
   
2. The thoracic CT shows a multilobulated right pleural space mass with pleural liquid
   
3. The thoracic CT shows a right chest wall mass invading the right pleural space
   
4. The thoracic CT shows a right-sided perihilar soft tissue mass associated with mediastinal lymph node enlargement and right pleural thickening
   
5. The thoracic CT shows bilateral peribronchial and mediastinal lymph node enlargement with low attenuation necrosis

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