Correct!
2.  Bronchoscopy with transbronchial biopsy / bronchoalveolar lavage

Given the close association of the right lower lobe mass with the right lower lobe medial basal bronchus, and the other features suggesting a diffuse large and small airway process, bronchoscopy with transbronchial biopsy / bronchoalveolar lavage is the most appropriate step for the evaluation of this patient. Transthoracic percutaneous lung biopsy could be considered to establish the etiology of the dominant mass in the right lower lobe, but, in general, bronchoscopy may be considered for the first step in the approach of a lesion when a clear relationship to a major airway is present, as in this patient. Transthoracic percutaneous lung biopsy may then be reserved for patients in whom bronchcoscopic evaluation was unrevealing. Thoracic MRI offers no value for the diagnosis of the lung nodules and airway disease in this patient, beyond that already known through thoracic CT. Serial thoracic CT would also not be appropriate given that a lung mass is present and other diffuse pulmonary / airway abnormalities are present in the setting of active symptoms. Finally, whole-body FDG-PET could be considered for the evaluation of the right lower lobe lesion, but that lesion contains calcium and is closely associated with an airway, which specifically suggests the diagnosis of carcinoid tumor. Because FDG-PET results may be false negative in carcinoid tumors, and elevated tracer uptake would prompt a tissue diagnosis for this lesion anyway, FDG-PET is unlikely to provide management-altering information at this point in this patient’s evaluation.
The patient subsequently underwent bronchoscopy with transbronchial biopsy of the right lower lobe lesion.  What is the most likely diagnosis?

  1. Metastatic disease, probably from a bone- or chondroid matrix forming tumor, given the increased attenuation in the right lower lob mass
  2. Multiple spindle cell tumors due to benign metastasizing leiomyomas
  3. Carcinoid tumor with diffuse neuroendocrine cell hyperplasia.
  4. Pulmonary lymphomatoid granulomatosis
  5. Pulmonary vasculitis due to granulomatosis / ANCA-associated granulomatous vasculitis  with polyangiitis ( previously known as Wegener’s granulomatosis)

Home/Imaging