Correct!
5. Any of the above
How to proceed at this juncture depends on local facilities and expertise as well as the patient’s wishes. I would actually oppose empiric corticosteroids in the event this patient’s interstitial disease proves to be a disorder worsen by corticosteroids (e.g. tuberculosis), however, this is commonly done. A transbronchial biopsy can diagnose sarcoidosis and cancer but is usually not good at separating out other forms of interstitial lung disease. A bronchoscopic cryobiopsy might be considered but this facility did not have the equipment or the expertise for performing cryobiopies. VATS is quite aggressive and many physicians and patients are unwilling to proceed unless symptoms and interstitial abnormalities persist. In this case, proceeding with bronchoscopy and transbronchial biopsy was chosen. The biopsy was interpreted as showing nonspecific organizing pneumonia which can either be a primary disease known as cryptogenic organizing pneumonia (COP) or secondary to a wide variety of lung injuries (infections, medications, inhalation of toxins, connective tissue diseases, malignancies, autoimmune diseases, bone marrow and organ transplantation, and radiotherapy) (3).
The patient chose to begin empiric corticosteroids rather than proceed with VATS. He rapidly improved. His symptoms resolved and his thoracic CT scan and PFTs improved. After his corticosteroids were tapered, he continued to do well for about 6 months. Unfortunately, his symptoms returned with worsening of his CT scan and PFTs.
What should be done next? (Click on the correct answer to be directed to the fifth of six pages.)