Correct!
3. Pulmonary medicine consultation for bronchoscopy
The consolidation is likely due to obstruction of the superior segmental left lower lobe bronchus and bronchoscopic examination, possibly tissue sampling if feasible and required, is the optimal approach to management. CT-guided percutaneous transthoracic needle biopsy could easily sample the left lower lobe superior segmental consolidation, but it is likely this opacity merely contains inflammatory material and mucous, given that the lung parenchymal findings appear post-obstructive in nature. Follow up CT is commonly used when relatively small, indeterminate and non-specific opacities, commonly lung nodules, are present, to assess treatment efficacy or if growth occurs in such opacities; the latter often prompts more definitive management. Follow up CT would not play an immediate role for the management of this patient because the bronchial obstruction merits directed evaluation directly and is unlikely to spontaneously improve or resolve if untreated. Neither 18FDG-PET scan nor contrast-enhanced MR have a role for the evaluation of this patient’s chest CT findings. 18FDG-PET scan would likely show increased tracer utilization but this result would be expected given the presumed post-obstructive consolidation; in contrast lack of tracer utilization would not preclude definitive assessment with bronchoscopy.
The patient underwent bronchoscopy (Figure 7), which showed occlusion of the orifice of the superior segmental left lower lobe bronchus.
Figure 7. Bronchoscopy shows occlusion of the superior segmental left lower lobe bronchus (arrows). Forceps could not be passed through this occlusion.
A lucent structure could be faintly visualized beyond the point of obstruction, but forceps could not be passed into the bronchus itself. A needle was passed through the area of obstruction, but bleeding occurred and the procedure was terminated once the bleeding was controlled.
Which of the following represents an appropriate next step for the patient’s management? (Click on the correct answer to be directed to the ninth of 11 pages)