Correct!
3. Flexible fiberoptic bronchoscopy with transbronchial biopsy
At this point, the patient has new clinical findings and new abnormalities on imaging that could represent an aggressive process, but without a clear context to allow presumptive treatment; therefore, a tissue diagnosis is warranted. Given the interstitial-appearing pulmonary abnormalities at thoracic CT, flexible fiberoptic bronchoscopy with transbronchial biopsy is the single best approach for obtaining a diagnosis. Video-assisted thoracoscopic surgery, open surgical biopsy, and, given the mediastinal lymph node enlargement, mediastinoscopy, all could readily obtain tissue for diagnosis as well, but are more invasive than bronchoscopy and should be reserved for use if bronchoscopy with transbronchial biopsy fails to obtain a diagnosis. 68Ga-citrate scanning does not have a role in the evaluation of this patient. 18FFDG-PET scan may also be performed, but the lack of tracer utilization would not provide useful information given the new and significant clinical symptoms and imaging abnormalities; similarly, increased tracer utilization at one or more of the abnormal sites on the patient’s chest CT would be non-specific and still require a tissue diagnosis. The one circumstance in which 18FFDG-PET scanning could prove useful for this patient’s evaluation is if an unsuspected site of disease that is peripheral and easily percutaneously approach were found- biopsying this site could prove less expensive and potentially morbid than bronchoscopy.
Note that several possible methods that could be used to obtain a tissue diagnosis in this patient were not listed as possibilities- in particular, thoracentesis is a fairly simple procedure that could disclose a diagnosis and, even malignancy is found, provide staging information as well. Furthermore, the patient presented with a painful left supraclavicular lesion- this lesion could be imaged and, if approachable and appropriate, could be biopsied percutaneously.
18FDG-PET scan was performed (Figure 5).
Figure 5. Axial 18FDG-PET images show areas of intense hypermetabolism within hilar and mediastinal lymphadenopathy (arrowheads) and the cranial thoracic spine (double arrowheads). Mild hypermetabolism is present within an apical right lung nodule (arrow).
This examination shows active tracer uptake at many of the abnormal sites seen on the patient’s thoracic CT, particularly the enlarged hilar and mediastinal lymph nodes. The 18FDG-PET scan also showed thoracic spine hypermetabolic foci. Although the 18FDG-PET scan did not disclose easily percutaneously accessible extrathoracic disease, hypermetabolic lower cervical and supraclavicular lymph nodes were detected, the latter correlating with the painful mass in the left supraclavicular region that caused the patient’s presentation.
The hypermetabolic nodal mass in the left supraclavicular space was identified using ultrasound (Figure 6), and was biopsied under ultrasonographic guidance (Figure 6).
Figure 6. Transverse (A) and longitudinal (B) ultrasonographic images performed in the left base of neck, near the left supraclavicular region, shows a hypoechoic mass (arrowheads; also marked by calipers in [B]) correlating with the physical examination findings and 18FDG-PET scan abnormalities. Ultrasound-guided percutaneous biopsy (C) of this mass was performed; note presence of needle (arrows) within the mass.
A diagnosis of metastatic lung adenocarcinoma was established.
Diagnosis: Pulmonary lymphangitic carcinomatosis due to lung carcinomaReferences