Correct!
3. Bronchoscopy with bronchoalveolar lavage and biopsy
4. Percutaneous transthoracic fine needle aspiration biopsy
6. 3 or 4
Given the progressive nature of the abnormalities, 18FDG-PET scanning would likely contribute little management-altering information. Relatively little tracer accumulation in the lesions at 18FDG-PET would not allow a conservative, observatory approach. In fact, such an approach has already occurred and progression of the abnormalities has clearly been established. Elevated tracer uptake within the pulmonary abnormalities would not distinguish among the numerous infectious, inflammatory, and neoplastic etiologies that must be considered in this case. Percutaneous transthoracic fine needle aspiration biopsy would be a reasonable choice, particularly if directed at the mass within the right middle lobe abutting the chest wall. Percutaneous transthoracic fine needle aspiration biopsy of cysts and cavities is also possible, but laceration of the cavity wall may occur because the needle is frequently directed towards the cavity wall to maximize the possibility of obtaining sufficient tissue for diagnosis, and, if the internal wall of the cavity is vascularized, this can result in significant bleeding. Additionally, while not confirmed in all reports on the subject, some feel that percutaneous transthoracic fine needle aspiration biopsy of cavitary lesions is associated with an increased rate of biopsy-related complications, including cough, hemoptysis, and air embolism. Bronchoscopy with bronchoalveolar lavage and biopsy would be a reasonable choice for this patient given the close association of a mass with the posterior segment right upper lobe bronchus. In this patient, surgical lung biopsy may be considered in the event that either percutaneous transthoracic fine needle aspiration biopsy or bronchoscopy with bronchoalveolar lavage and biopsy are unable to obtain a diagnosis.).
The patient subsequently underwent two additional thoracic CT studies just over 1 year (Figure 5) following presentation.
Figure 5. Thoracic CT obtained just over 1 year following presentation, shown in lung and soft tissue windows.
The imaging findings of the various studies presented suggest which of the following diagnoses?