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3. Percutaneous fine needle aspiration biopsy
Mediastinoscopy is useful for assessing lesions found in particular mediastinal locations, typically the right paratracheal and anterior subcarinal spaces; such lesions are frequently due to lymphadenopathy. This patient, however, does not clearly have abnormally enlarged mediastinal lymph nodes accessible with either cervical mediastinoscopy or the Chamberlain procedure (a left anterior mediastinotomy), and neither procedure can access the two left-sided lung nodules. Similarly, esophageal endoscopic ultrasound (upper endoscopy) is an excellent tool for visualizing and possibly biopsying lesions in close proximity to the esophagus, such as lymph nodes or masses in the left paratracheal space (2L and 4L), subcarinal space (station 7), periesophageal spaces (station 8), and aorto-pulmonary window (station 5), but is not appropriate for pulmonary nodule evaluation. Video-assisted thoracoscopic surgical lung biopsy could obtain a diagnosis for this patient, but is more invasive percutaneous fine needle aspiration biopsy, and the latter stands a good chance of obtaining tissue that could establish a diagnosis for this patient. Therefore, video-assisted thoracoscopic lung biopsy may be pursued if percutaneous fine needle aspiration biopsy fails to obtain a diagnosis.
The patient underwent percutaneous fine needle aspiration biopsy (Figure 3).
Figure 3. Axial unenhanced prone thoracic CT (image rotated to resemble the typical display of axial CT images) shows the fine needle aspiration biopsy needle (arrowhead) approaching the larger, more caudally located, pulmonary nodule (arrow).
The cytological analysis of the material obtained at this procedure showed granulomatous inflammation, with no organisms identified. No specific features of malignancy were noted, but no definitive diagnosis was offered.
Based on this information, which of the following would be an appropriate next management step for this patient? (Click on the correct answer to proceed to the eigth of nine pages)