Correct!
2. Obtain transthoracic percutaneous needle biopsy of the left apical mass
68Ga – PET – CT dotatate scanning is used for staging of neuroendocrine malignancies and would not play a role for this patient unless neuroendocrine malignancy is subsequently demonstrated. Surgical lung biopsy certainly could obtain tissue to establish the etiology of the left apical mass, but is unnecessarily invasive when other, less invasive, procedures may provide diagnostic material. Bronchoscopy is one such procedure but given the extreme apical location of the left upper lobe metabolically active mass, percutaneous transthoracic needle biopsy of the left apical mass would be a better choice for addressing this lesion. Note that the metabolic activity detected at 18FDG-PET scan suggests that diagnostic procedures should be directed preferentially at the left apical mass, as opposed to the right lower lobe mass. Serial CT evaluation for growth is not an appropriate management strategy for pulmonary lesions of this size.
The patient underwent navigational bronchoscopy of directed at the left apical mass, but only non-specific material was obtained. Subsequently, the patient underwent percutaneous transthoracic needle biopsy of the left apical lesion. The material obtained at biopsy showed fibrinous injury with necrosis and giant cells, with inflammation that was “vaguely granulomatous.” No acid-fast or fungal organisms were identified. There was no evidence of malignancy. Culture of the biopsy material subsequently grew Mycobacterium avium-complex (MAC).
Given the data available, which of the following represents the most appropriate management step for the evaluation of this patient? (Click on the correct answer to proceed to the eighth of ten pages)