Correct!
2. Bronchoscopy
Bronchoscopy represents the next most appropriate step for this patient as the thoracic CT clearly shows the lesion(s) to reside within the proximal airways. Upper endoscopy is not appropriate for this patient as the abnormalities seen at thoracic CT are endobronchial, not within the esophagus or periesophageal mediastinum. Bronchial arteriography is primarily used as part of an embolization procedure for patients with hemoptysis, often in the setting of chronic inflammatory pulmonary diseases. While this patient does have blood-streaked sputum, the nature this complaint is insufficient to prompt consideration for bronchial arteriography. Prone CT is often used in patients with suspected interstitial lung disease to determine if basal lung opacities seen at supine thoracic CT persist, which would suggest fibrotic lung disease or alveolitis over dependent atelectasis, but that consideration is not relevant to this patient. Decubitus and dynamic expiratory CT are both techniques that can be used to assess for air trapping, typically for the detection of small airway obstruction. Given the endobronchial right mainstem bronchial and bronchus intermedius location of the hyperattenuating opacities, air trapping may occur in this patient if decubitus or dynamic expiratory CT were performed, but the presence of air trapping in this patient would merely reinforce the already known endobronchial nature of the abnormality, whereas the lack of air trapping would not change what is already known and would probably be explained on a technical basis (suboptimal expiratory effort, inadequate timing of the expiratory effort such that the technique “missed” transient air trapping, etc.). Virtual bronchoscopy would be capable of showing the endoluminal perspective of the lesions seen at unenhanced thoracic CT, but would not provide additional, management-altering information.
Which of the following represents the most likely diagnosis for this patient? (Click on the correct answer to procced to the last panel).