Correct!
2. Flexible fiberoptic bronchoscopy
Among the choices listed, flexible fiberoptic bronchoscopy probably has the best chance to obtain a tissue diagnosis for this patient. Percutaneous biopsy of the liver is a reasonable consideration, but the wedge-shape of the abnormality, with little evidence of mass effect, suggest that the finding could merely reflect focal fatty infiltration rather than a true infiltrative abnormality. A hepatic infarct could present in this fashion, but percutaneous biopsy of liver infarction may disclose hepatocyte necrosis but not a specific etiology. Nephron-sparing surgery is commonly performed for suspected localized renal malignancy. Renal malignancy is a consideration for the renal lesion in this patient, and a surgical approach would certainly provide adequate material for diagnosis, but surgery would not be appropriate in the context of multiple symptoms not directly attributable to renal malignancy in the context of a number of extra-renal lesions that still require explanation. Mediastinoscopy cannot approach the lung lesion, and no lymph node enlargement or mediastinal lesion was reported at thoracic CT, so this procedure would not be appropriate. Endovascular biopsy is technically feasible but rarely performed, and usually is performed for solid intraluminal lesions, such as suspected sarcoma.
The patient underwent percutaneous liver biopsy, which showed only fatty infiltration. Flexible fiberoptic bronchoscopy was then performed and the central airways appeared normal, but biopsy of the right lower lobe lesion revealed only non-specific inflammatory changes.
Which of the following is the most appropriate next step for the evaluation of this patient? (Click on the correct answer to proceed to the fifth of seven pages)