The increased uptake of FDG is not a normal finding in heart failure. High glucose levels can decrease the uptake of FDG in a lung PET scan, not increase it as seen in this patient. Therefore, bronchoscopy is the only reasonable choice. The results demonstrated a tumor in the left lower lobe (Figure 4).

Figure 4. Bronchoscopic views in the (A) left lower lobe bronchus, (B) left lobe subsegmental bronchi and (C) subsegmental bronchus showing the presence of a tumor.

Biopsy of the lesion showed poorly differentiated squamous cell cancer which was PD-L1 negative. The patient was offered chemotherapy and radiation therapy but opted for radiation therapy alone due to his debilitated condition.

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