Question

In order to obtain a job at a prison, a 34 year old man undergoes a required chest x-ray to screen for tuberculosis. A 14mm rounded opacity is noted, surrounded by normal lung tissue. There are small calcifications within the opacity, but no adenopathy or atelectasis is seen radiographically. The patient has never smoked and has no known exposures to tuberculosis. There is no family history of lung cancer or other malignancy. On physical exam, the patient has temperature 37.0 C (98.6 F), pulse 76, blood pressure 130/83, respirations 14/min. Lungs are clear to auscultation and percussion. No nail clubbing is seen. Which of the following is the most appropriate next step in the management of this patient?

A. Repeat CXR in 3 months
B. Begin rifampin, isoniazid, pyrazinamide and ethambutol
C. Bronchoscopy
D. CT guided needle biopsy
E. Thoracotomy

Answer 1

A CT guided needle biopsy is the most appropriate next step given the patient's normal physical exam, lack of risk factors for tuberculosis or lung cancer, which allows for sampling of the lesion to determine its nature (D).

Step-by-step explanation:

The most appropriate next step in the management of this 34-year-old man with a detected 14mm rounded opacity during a chest x-ray is to perform a CT guided needle biopsy. Considering the patient's lack of symptoms, normal physical exam, no history of smoking, exposure to tuberculosis, or family history of malignancy, other aggressive interventions or treatments like beginning tuberculosis therapy (rifampin, isoniazid, pyrazinamide, and ethambutol) or a thoracotomy are not indicated without further diagnostic confirmation.

A CT guided needle biopsy will allow for the sampling of the lesion and help identify if it is benign or malignant, infectious or noninfectious. Since the opacity has calcifications and there is no evidence of infection or cancer from the patient's history and examination, a biopsy is a prudent step to determine the nature of the opacity.