Correct!
5. 1 or 3
Either percutaneous fine needle aspiration biopsy or bronchoscopy with transbronchial biopsy could be performed for this patient, and both would offer a high likelihood for obtaining a diagnosis. Bronchoscopic procedures have the advantage of fewer complications than percutaneous needle procedures, although the latter has the advantage of obtaining a relatively larger tissue sample when core biopsy is performed. Note that core biopsy was not mentioned as part of choice d; only fine needle aspiration biopsy was indicated in the question. Core biopsy can be performed as part of percutaneous transthoracic biopsy procedures, but the operator must choose to perform the core procedure in addition to, or in place of, the fine needle aspiration. Fine needle aspiration procedures provides material for cytology, which is often sufficient for the diagnosis of carcinoma and sometimes sarcoma, as the abnormal cells may be visible with this procedure. However, the architecture of the tissue sample is not maintained with fine needle aspiration samples, as it is with core biopsy, and therefore a histopathological diagnosis may not be possible for lesions sampled using fine needle aspiration. Some conditions require histopathology for a confident diagnosis, including some malignancies and, notably, fibrous lesions and some benign causes of lung nodules. As such, many operators choose to perform both fine needle aspiration and core biopsy with every percutaneous procedure, particularly if on-site cytological evaluation is not available at the time of the procedure. Video-assisted thoracoscopic (VATS) biopsy is not a “wrong” choice- the left lower lobe lesion could be sampled with this technique, given its proximity to the pleural surface, and the procedure provides ample tissue for diagnosis. If there are only one lesion in the lung, VATS could be the best choice- if cancer we found, an operation could then be performed for staging at a single sitting, rather than one or more minimally invasive procedures followed by a surgical procedure. However, in this case, given the multiplicity of findings, a minimally invasive approach to obtaining the diagnosis may be advisable. Finally, mini-thoracotomy is needlessly invasive at this point, and is typically reserved for situations in which less invasive attempts at diagnosis have not been successful.
Percutaneous fine needle aspiration biopsy was performed, and showed a blood-diluted specimen with benign bronchoepithelial cells as well as reactive bronchoalveolar cells with scattered multinucleated giant cells and chronic inflammation; no specific diagnosis was offered.
Which of the following represents an appropriate step for the evaluation of this patient? (Click on the correct answer to proceed to the eighth of nine panels)