Correct!
5. Any of the above

There are a number of “targets” that would be suitable for obtaining a tissue diagnosis in this patient. Percutaneous transthoracic fine needle aspiration and core biopsy could access the right paramediastinal mass, whereas the compression and narrowing of the right lower lobe bronchus, as well as the mediastinal lymph node enlargement [especially in the right paratracheal, peribronchial, and subcarinal stations] make bronchoscopy with endobronchial ultrasound and transbronchial biopsy a potentially useful procedure in this patient. Both of these methods are minimally invasive, and have the potential advantage of providing a tissue diagnosis with less expense and potential morbidity than the more invasive surgical techniques of thoracoscopic lung biopsy and a mini-thoracotomy; however, these latter procedures have the advantage of obtaining larger tissue samples for establishing a definitive diagnosis.

Further clinical course: The patient subsequently underwent bronchoscopy (Figure 6), but the tissue obtained was non diagnostic.

Figure 6. Bronchoscopy shows few intrinsic airway abnormalities: some erythema around the orifice of the right upper lobe bronchus is present, and extrinsic compression of the right middle lobe bronchus is seen.
Lymph node stations 4R, 7, and 11R were samples, and mucosal biopsies of the right upper, middle, and lower lobes were performed. Extrinsic compression on the right middle lobe bronchus was noted, as was some erythema near the orifice of the right upper lobe bronchus.

The patient then underwent repeat chest radiography (Figure 7) repeat thoracic CT (Figure 8).

Figure 7. Frontal (A) and lateral (B) chest radiography performed 2 months following presentation imaging (Figure 1).

 

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Figure 8. A-F: Representative images from contrast-enhanced thoracic CT in lung windows performed 2 months following presentation imaging (Figure 2). Lower panel: movie of thoracic CT scan in lung windows.

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

  1. The chest radiograph and thoracic CT both show new left mediastinal lymph node enlargement and new left pleural liquid
  2. The chest radiograph and thoracic CT both show regression in the previously noted mediastinal lymph node enlargement, right pleural abnormalities, and right paramediastinal mass
  3. The chest radiograph and thoracic CT both show slight progression in the previously noted abnormalities
  4. The thoracic CT shows a new anterior mediastinal mass
  5. The thoracic CT shows a new, large pericardial effusion

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