Correct!
5. More than one of the above
Attention should be directed towards pleural space intervention, and both medical pleuroscopy and surgical consultation for thoracoscopic intervention are appropriate considerations. CT-guided transthoracic biopsy of the pleura is feasible but generally only pursued when a pleural space mass or nodule can be targeted, and such is not the case for this patient. 18FDG – PET scan may be a useful procedure should pleural space malignancy subsequently be proven but remains premature at this point..
The patient reported no improvement in dyspnea on exertion following the evacuation of 800 mL right pleural fluid. Pulmonary function testing showed a forced vital capacity (FVC) of 1.44 L (50% predicted), forced expiratory volume (FEV)= 1.1 L (49% predicted), FEV1 / FVC = 76%, forced expiratory flow rate (FEF)25 – 75 = 0.84 L/sec (42% predicted), and diffusion capacity of carbon monoxide (DLCO) = 12.79 ml/min/mmH (62% predicted). Surgical consultation was initiated. The patient was considered to not be a candidate for medial pleuroscopy. She was simultaneously evaluated by cardiology for placement of a left atrial occlusion device for her atrial fibrillation. After placement of the left atrial occlusion device, the patient underwent thoracoscopic examination of the right pleural space. During the procedure the surgeon noted bloody fluid, removing 750 ml, and also noted an “abscess-like” appearance in the right lower lobe subpleural lung parenchyma. The patient tolerated the procedure well. Frozen sections obtained during the procedure were suspicious for malignancy.
Based on the information thus far, which of the following represent likely diagnoses for this patient? (Click on the correct answer to be directed to the eleventh of seventeen pages)