Correct!
3. Pulmonary medicine consultation for bronchoscopy
Several of the listed choices are appropriate steps for establishing the diagnosis for the right apical mass in this patient. However, given the suspicion for neoplasia, the least invasive method for establishing the diagnosis and simultaneously staging the suspected malignancy is bronchoscopy with endobronchial ultrasound directed towards sampling the enlarged, metabolically active right paratracheal lymph node. Video-assisted thoracoscopic surgery could also provide simultaneous sampling of both the right apical lesion and the enlarged right paratracheal lymph node, but is more invasive than bronchoscopy and thus may be avoided if bronchoscopic evaluation successfully establishes a diagnosis for the lung lesion and mediastinal lymphadenopathy. Pleuroscopy could not provide the diagnostic and potential staging information needed for this patient, and CT-guided transthoracic biopsy could establish the etiology of the right apical mass, but could not address the right paratracheal lymph node etiology. Chest MRI could provide useful information regarding the behavior of the right apical lesion but would not obviate the need for a tissue diagnosis.
The patient was referred to pulmonary medicine for further evaluation and bronchoscopy was performed. No endobronchial abnormalities were present. The right paratracheal lymphadenopathy seen at chest CT and 18FDG-PET scan was identified at endobronchial ultrasound and was biopsied and the right apical lesion was also sampled. Squamous cell carcinoma was found in the right apical lesion, but sampling of the right paratracheal lymphadenopathy was negative for malignancy.
Which of the following represents an appropriate next step for the patient’s management? (Click on the correct answer to be directed to the eleventh of 12 pages)