Correct!
5. High-resolution chest CT shows features of airflow obstruction
HRCT shows multifocal questionable central airway thickening as well as bilateral inhomogeneous lung opacity with some accentuation on post-expiratory imaging, suggesting possible gas trapping. These features are subtle and not entirely convincing, but they are not normal, and suggest some element of air flow obstruction. No significant nodules are present nor is ground-glass opacity.).
Oncology was consulted and considered high-dose corticosteroid therapy (that patient had been treated similar elsewhere and noted improvement in symptoms, but symptoms recurred following taper), but deferred steroid therapy given the planned surgical resection of the pelvic mass. Consideration for additional therapies, including rituximab and siltuximab (anti-IL6 antibody, although serum IL-6 antibodies were checked and found to be in the normal range) were discussed but deferred pending surgery. Pulmonary function testing showed a forced vital capacity (FVC) of 2.84L (81% predicted), a forced expiratory volume in the first second of exhalation (FEV1) of 2.35L (82% predicted), forced expiratory flow rate25-75% = 2.39 L/sec (78% predicted), and DLCO= 98% predicted. The results were interpreted as showing mild obstruction. General surgery was also consulted, intravenous immunoglobulin administered preoperatively, and the left pelvic mass was uneventfully resected later in the same month. The pathological analysis confirmed unicentric hyaline vascular variant Castleman disease.
The patient recovered well after her pelvic surgery. Her incision was healing appropriately at post-surgical follow up one month later. During this post-operative visit, bilateral wheezing was noted. The patient said she had sick contacts at home and the wheezing was ascribed to a presumed viral illness. At her follow up oncology appointment 2 weeks later, dapsone was initiated (Pneumocystis jirovecii prophylaxis) and 40 mg prednisone daily was begun, subsequently increased to 60 mg daily. The patient’s follow up 18FDG – PET scan (Figure 8) showed only post-operative change at the surgical resection site.
Figure 8. Axial 18FDG-PET image one month following surgery shows nodular foci of hypermetabolism related to the recent post-operative state; no residual disease is evident.
Which of the following represents the most appropriate next step for the patient’s management? (click on the correct answer to be directed to the tenth of twelve pages)