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Mediastinal Adenopathy in a Middle-Aged Man: How to Proceed?


A PET/CT scan shows uptake of tracer consistent with malignancy in the left lower lobe and mediastinal nodes. What would be your next step?

A 57-year-old man comes to see you complaining of fevers, chills, and left-sided back pain of a week’s duration. A chest x-ray film shows a dense left-sided infiltrate, and you make a presumptive diagnosis of left lower lobe (LLL) community-acquired pneumonia. You treat him with moxifloxacin 400 mg for 10 days, but after initial improvement in symptoms of fever, chills, and malaise, his back pain persists. A repeated chest x-ray film 1 month later shows persistence of the infiltrate, and you send the patient for a CT scan of the chest. Representative images are shown at right in Figure 1 (top-sagital section), Figure 2 (center-coronoal section), and Figure 3 (bottom-coronal and sagital section, mediastinal view). (Click images to enlarge.)

Note that the arrows in the last 2 frames of Figure 3 (bottom) point to mediastinal adenopathy. A PET/CT scan shows uptake of tracer consistent with malignancy in both the LLL mass and the mediastinal nodes.


What would be the next best step?

A. Refer to oncologist for chemotherapy of advanced lung cancer
B. Refer to thoracic surgeon for immediate resection
C. Refer to thoracic surgeon for mediastinoscopy
D. Refer to pulmonologist for standard fiberoptic bronchoscopy
E. Refer to pulmonologist for fiberoptic bronchoscopy with endobronchial ultrasound (EBUS)
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