Correct!
2. Bronchoscopy with transbronchial biopsy
Bronchoscopy with transbronchial biopsy is the most appropriate next step among the choices listed. A case could be made for choice 3. Open surgical lung biopsy. However, video-assisted thoracoscopic surgical biopsy is generally favored over the open form of the procedure for the diagnosis of interstitial lung abnormalities. Furthermore, a surgical lung biopsy may not be required at all if the less morbid and less expensive bronchcoscopic biopsy establishes a diagnosis. Serial imaging to assess for change has little relevance here given that the abnormalities have persisted- indeed, slightly progressed- over time. The small interstitial nodular opacities on this patient’s CT are too small to target with percutaneous transthoracic fine needle biopsy. Finally, 18FDG-PET scan would not be management-altering in this case. First, given the slow progression of the abnormalities, 18FDG-PET would likely show no significant tracer accumulation. However, even if tracer accumulation was seen within the pulmonary opacities at 18FDG-PET, that finding would be non-specific and a tissue diagnosis would be pursued regardless.
The patient underwent bronchoscopy with transbronchial biopsy. The histopathological material obtained from biopsy is shown in Figure 4.
Figure 4. Histopathological specimen obtained at bronchoscopy with transbronchial biopsy
What is the most likely diagnosis?