Correct!
4. Percutaneous transthoracic needle biopsy
Among the choices provided, percutaneous transthoracic needle biopsy is the best choice to provide a specific diagnosis for this patient. Flexible fiberoptic bronchoscopy, particularly using navigational techniques, could potentially allow sampling of the lesion, but the lesion’s small size and relatively peripheral nature suggest that flexible fiberoptic bronchoscopy would not be the best choice. Contrast-enhanced thoracic MRI would not add any useful information to that already available, and, in general, thoracic MRI is not rewarding for the evaluation of small pulmonary lesions. Open thoracotomy would certainly allow a definitive diagnosis, but remains needlessly aggressive at this stage. Note, however, given that several factors suggest a high pre-test probability for primary lung malignancy (morphology of the lesion, and the elevated tracer utilization at 18FDG-PET scan), a reasonable argument could be made to proceed directly to lung resection on the assumption that any non-neoplastic results obtained by less invasive methods could represent false negative results. Nevertheless, it is common practice to obtain a tissue diagnosis for indeterminate pulmonary nodules before proceeding to surgical resection. Serial thoracic CT is often chosen for the evaluation of small nodules to assess for growth and is reasonable, even in this circumstance. However, given the aforementioned risk factors suggesting a high pre-test probability for malignancy for this nodule, there is a substantial possibility that the nodule is malignant, and therefore definitive action, rather than serial evaluation, is probably the best choice.
The patient underwent percutaneous transthoracic fine needle aspiration and core biopsy which was non-diagnostic.
Which of the following now represents the next most appropriate step for the evaluation for this patient? (Click on the correct answer to proceed to the eighth of nine panels)