A 65-year-old male smoker presents with a 2.8 cm spiculated right upper lobe nodule on CT. PET-CT shows intense FDG uptake (SUVmax 9.2). Bronchoscopy with endobronchial biopsy is inconclusive. The next diagnostic step per BTS/NICE guidelines is:
- A Repeat CT in 3 months
- B CT-guided percutaneous needle biopsy (PCNB) ✓
- C Surgical resection (VATS lobectomy) without tissue diagnosis
- D EBUS-TBNA to sample mediastinal nodes
Explanation
For a peripheral lung nodule >2 cm with high FDG avidity and spiculated margins (high probability of malignancy) where bronchoscopy is inconclusive, CT-guided percutaneous needle biopsy (transthoracic PCNB) is the recommended next step. It yields tissue for histological diagnosis and molecular profiling (EGFR, ALK, ROS1, PD-L1) needed for treatment planning. VATS resection without tissue is acceptable if biopsy is risky or impossible, but tissue diagnosis is preferred for treatment selection. EBUS-TBNA is for mediastinal staging after confirming the primary, not for peripheral nodule biopsy.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.