A 64-year-old man comes to the physician with a 2-month history of increasing cough. He has had a "smoker's cough" for years that has worsened. He has no fever, chills, chest pain, or hemoptysis but has lost 10 lb (4.53 kg) weight. The patient has a 45-pack-year smoking history. He emigrated from Bangladesh 20 years ago.
His vital signs are normal. Pulse oximetry is 96% on room air. Examination shows decreased breath sounds at the right lung base and normal first and second heart sounds. No peripheral lymphadenopathy is present.
Chest x-ray reveals a moderate, right-sided pleural effusion. CT scan of the chest demonstrates a 2.5-cm, spiculated lesion in the right middle lobe 2 cm from the pleural surface and confirms the right pleural effusion. There are no other lesions noted on CT scan, and no mediastinal lymphadenopathy is seen. The patient undergoes thoracentesis with removal of 250 mL of fluid, which shows an exudative effusion. Pleural cytology is negative for malignancy. Gram and acid-fast bacteria stains are negative. Culture shows no growth after 48 hours.
Which of the following is the best next step in managing this patient?

Question

A 64-year-old man comes to the physician with a 2-month history of increasing cough.  He has had a "smoker's cough" for years that has worsened.  He has no fever, chills, chest pain, or hemoptysis but has lost 10 lb (4.53 kg) weight.  The patient has a 45-pack-year smoking history.  He emigrated from Bangladesh 20 years ago.
His vital signs are normal.  Pulse oximetry is 96% on room air.  Examination shows decreased breath sounds at the right lung base and normal first and second heart sounds.  No peripheral lymphadenopathy is present.
Chest x-ray reveals a moderate, right-sided pleural effusion.  CT scan of the chest demonstrates a 2.5-cm, spiculated lesion in the right middle lobe 2 cm from the pleural surface and confirms the right pleural effusion.  There are no other lesions noted on CT scan, and no mediastinal lymphadenopathy is seen.  The patient undergoes thoracentesis with removal of 250 mL of fluid, which shows an exudative effusion.  Pleural cytology is negative for malignancy.  Gram and acid-fast bacteria stains are negative.  Culture shows no growth after 48 hours.
Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

This patient has a pulmonary nodule in the setting of a right pleural effusion. He is at high risk for malignancy due to his smoking history and age. Although the first pleural fluid cytologic study can detect malignant cells in up to 60% of effusions, 3 separate thoracenteses can detect up to 90% of malignant effusions. In theory, the older degenerated cells are largely removed in the earlier thoracenteses, leaving a higher percentage of fresher cells to be detected. As a result, a repeat thoracentesis should be done to evaluate for malignancy despite the negative cytology seen in the first. If there is still a suspicion of malignancy despite repeated thoracenteses, thoracoscopy should be performed. In several studies, thoracoscopic pleural biopsy was found to yield a diagnosis of malignancy in about 70% of patients with pleural effusion of unclear etiology. (Choice A) This patient's lung lesion is located peripherally, making bronchoscopic access difficult. He should have CT-guided biopsy of the lung nodule instead. However, establishing the cause of pleural effusion is important as it can change management if the effusion is due to lung malignancy. In general, tissue should be sampled from a lesion that can establish the highest disease stage. (Choice C) Sputum cytology has not been found to be of diagnostic yield for pleural effusion and lung cancers. (Choice D & E) Tuberculosis can cause pleural effusion without parenchymal lung disease. Given this patient's lung nodule and exudative pleural effusion, malignancy is much more likely and should be thoroughly investigated first. Educational objective: Repeated thoracentesis can detect up to 90% of malignant cells in high-risk patients. If there is still a suspicion of malignancy despite repeated negative thoracentesis, thoracoscopy should be performed. __________ References: Decision making in patients with pulmonary nodules. (http://www.ncbi.nlm.nih.gov/pubmed/21980032) Non-small cell lung cancer: evaluation of pleural abnormalities on CT scans with 18F FDG PET. (http://www.ncbi.nlm.nih.gov/pubmed/15105451) Differentiating between malignant and idiopathic pleural effusions: the value of diagnostic procedures. (http://www.ncbi.nlm.nih.gov/pubmed/17525131) Investigating suspected malignant pleural effusion. (http://www.ncbi.nlm.nih.gov/pubmed/17255615)

A 64-Year-Old Man Comes to the Physician with a 2-Month