Correct!
5. Plan to resect the right middle lobe lesion
Given the leading consideration of primary bronchogenic malignancy, absent surgical contraindications, the best chance of long-term cure is through surgical resection. Continuing to follow the lesion for growth with serial imaging is not appropriate. Cryobiopsy is an emerging technique that may increase the diagnostic yield for patients with diffuse lung disease compared with bronchoscopy, yet is less invasive than surgical lung biopsy, but is not generally utilized for the diagnosis of focal nodular lesions in the lung. As part of the pre-operative evaluation, the patient underwent bronchoscopy with endobronchial ultrasound and sampling of both the right middle lobe lesion, which was found to occlude the medial segmental bronchus of the right middle lobe, and level 4 (right paratracheal) and level 10 (right hilar) lymph nodes on the right side. These tissue sampling procedures showed that the right middle lobe lesion was adenocarcinoma, but the mediastinal and peribronchial lymph nodes sampled were negative for malignancy.
The patient underwent mediastinoscopy followed by surgical resection of the right middle lobe lesion without complications. The lesion was staged as T1bN0M0. The patient recovered uneventfully and was discharged from the hospital. Approximately 6 months later, the patient underwent routine follow up unenhanced thoracic CT (not shown) which showed no evidence of lesion at the right middle lobe bronchial stump as well as no lymph node enlargement, and the cystic lesion at the right base was unchanged.
The patient did well overall for the next several years, although she complained of intermittent cough, presumably bronchitis, at various clinical encounters, treated with board-spectrum antibiotics. Slightly over 2 years after her surgical procedure, she developed a productive cough with fever, which prompted chest radiography (Figure 4).
Figure 5. Frontal chest radiography 2 years after initial presentation.
Which of the following represents the most accurate assessment of the chest radiography (Figure 5) findings? (Click on the correct answer to be directed to the tenth of sixteen pages)