Correct!
1. Consult thoracic surgery for diagnostic options for obtaining tissue
Repeat bronchoscopy is not unreasonable, but given that this procedure did not yield a diagnosis previously, the likelihood of a repeat procedure providing adequate tissue for a diagnosis, while not zero, is probably low. Therefore, consulting thoracic surgery may be the best course of action, as the patient clearly has a progressive, undiagnosed infiltrative right upper lobe abnormality that could reflect an undiagnosed infection or neoplasm, among other rare proliferative lesions. As noted above, cryobiopsy may eventually play a role for the diagnosis of localized pulmonary opacities, but the limited data for this procedure currently suggests that the primary application of this procedure is in the diagnosis of diffuse fibrotic lung diseases. Continuing to monitor the process will likely be unrewarding, given the imaging evidence of progression, and any presumptive therapy would be merely a guess, without any clear target and therefore the endpoint to therapy would be unclear, and would incur monetary cost and possibly result in complications. Pleuroscopy would not play a role in this patient as he has no discernable pleural disease.
At this point, which of the following represents the most likely diagnosis for this patient? (Click on the correct answer to proceed to the sixteenth of nineteen pages)