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A 63-year-old man comes to the office for an annual examination. He has a history of coronary artery disease, diabetes, and hypertension. These conditions currently are controlled well. He has no allergies. He is a businessman and recently spent extensive time in the southwestern United States. He has an extensive history of cigarette smoking. He denies chest pain, fever, chills, shakes, cough, or shortness of breath. Vital signs are stable. Lungs are clear. Heart is regular, rate and rhythm. Chest x-ray reveals a 3 × 3-cm mass in the left upper lobe. Fungal serology, including Coccidioides immitis, is negative. Which of the following is the most appropriate next step in management?
A. Bronchoscopy
B. CT scan of the chest
C. Mediastinoscopy and biopsy of the mass
D. Obtain induced sputum for tuberculosis
E. Referral for resection of mass
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B to better deliniate anatomy of the mass before biopsy
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E. Referral for resection of mass
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The correct answer is C. Because this patient was recently in a region that places him at high risk for a fungal infection, checking the fungal serology is the appropriate first step. Given the patient™s significant smoking history, he is at risk for lung cancer. It is thus essential to get a pathologic diagnosis. Furthermore, it is necessary to biopsy any lymph nodes to determine the extent of the disease, because this knowledge guides the therapeutic approach.
Bronchoscopy (choice A) is not needed at this time because the patient does not have hemoptysis, and pathologic diagnosis is needed. If the mass is endobronchial and amenable to approach by way of a bronchoscopy, this option will be considered.
CT scan of the chest would not help to establish the diagnosis (choice B).
The patient is not presenting with symptoms that raise concern for tuberculosis (choice D).
The mass may need to be resected (choice E) if there is no metastasis. Pathology is needed, however, to determine if further treatment is required.
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You sure? I mean you need either CT/MRI before proceeding for a scopy.
