Correct!
1. Continue to treat for mycobacterial infection and observe
While making another attempt at obtaining a tissue diagnosis is reasonable, aggressive surgical options are probably not the best choice, given that the right lower lobe mass has demonstrated some features suggesting a benign etiology (low tracer utilization at 18FDG-PET scan, the lack of malignancy at histopathological examination following a successful percutaneous transthoracic needle biopsy procedure, and, most importantly, stability at repeat imaging at just greater than 7 months). Repeat bronchoscopy would not be contraindicated, although this procedure has failed to retrieve diagnostic material for both the right lower lobe and left upper lobe mass previously. Similarly, percutaneous repeat percutaneous transthoracic needle biopsy of the right lower lobe mass failed to establish a definitive diagnosis previously and therefore repeating this procedure, given that there is no specifically suspicious area of the lesion to target that may not have been sampled previously, stands a low likelihood of providing additional useful information. It is unlikely that the parotid pleomorphic adenoma is related to the pulmonary lesions.
Repeat thoracic CT (Figure ) performed one year after Figure 4, now exceeding 1.5 years following biopsy of the left upper lobe mass showed that the left apical lesion has resolved to mostly linear scar, and the right lower lobe lesion has decreased in size substantially, now manifesting a thin-walled cavity.
Figure 4. Panels A-F: Representative images of axial enhanced thoracic CT displayed in lung windows 6-7 months following biopsy of the left upper lobe mass. Lower panel: video of thoracic CT in lung windows.
Diagnosis: Mycobacterium avium complex infection presenting as a solitary left apical pulmonary mass
References