Correct!
2. Obtain transthoracic percutaneous needle biopsy of the right lower lobe mass
As noted previously, surgical biopsy of the lung masses is needlessly invasive when less aggressive options stand a good chance at establishing a diagnosis. Dynamic contrast-enhanced MRI is unlikely to add management-altering information. The right lower lobe mass shows low FDG uptake, which tends to favor an inflammatory, possibly infectious, cause over neoplasm, although the morphology of the lesion has some features that are consistent with a potentially aggressive process. If enhancement of the lesion were seen, this would be consistent with a potentially aggressive lesion, prompting tissue sampling, whereas the lack of contrast enhancement, while favoring a non-malignant process, would not exclude an infection requiring treatment, again prompting a tissue diagnosis. Bronchoscopy would be a reasonable choice, given the presence of some airways associated with the lesion, but the lesion is quite peripheral and is therefore amenable to percutaneous transthoracic needle biopsy. Treating for mycobacterial infection and observing is a possibility in light of the culture results obtained from the left apical lesion, but the right lower lobe mass has a morphology that differs from the left apical mass, and the FDG uptake also differs between these two lesions, which forces the consideration that these lesions represent two coincident, but distinct, processes. Therefore, the right lower lobe mass evaluation must be approached as if this lesion were an isolated finding.
The patient underwent percutaneous transthoracic needle biopsy of the right lower lobe lesion. The material obtained at biopsy showed non-specific changes, including chronic inflammation, air space fibrin, and rare giant cells, but no evidence of malignancy, fungal organisms, or acid-fast bacilli was seen.
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 ninth of ten pages)