PET/CT-Guided Biopsy in Necrotic Lung Mass: A Diagnostic Breakthrough

A 60-year-old man who never smoked presented with a 2-month history of dull, poorly localized right-sided chest pain and a dry cough. He also reported a loss of appetite and unintentional weight loss. On clinical examination, he was hemodynamically stable, with clear breath sounds bilaterally. His hemogram and biochemical parameters were within normal limits, and electrocardiography showed a normal sinus rhythm. A posteroanterior chest radiograph revealed a suspicious mass lesion in the right upper zone. Contrast-enhanced computed tomography (CT) of the chest demonstrated a 70 mm × 40 mm × 61 mm spiculated, heterogeneously enhancing soft-tissue lesion in the apical segment of the right upper lobe. Whole-body ¹⁸F-fluorodeoxyglucose positron/emission tomography (FDG PET) showed avid uptake in the lesion (maximum standardized uptake value, 8.4), suggesting high metabolic activity consistent with malignancy. Radial endobronchial ultrasound (EBUS)-guided transbronchial lung biopsy was performed. Fiberoptic bronchoscopy showed no visible endobronchial growth. Biopsy specimens obtained under radial EBUS guidance yielded inconclusive histopathologic findings. A follow-up CT-guided percutaneous biopsy of the mass demonstrated necrotic material only, without viable tumor cells. The imaging features and metabolic activity were strongly suggestive of malignancy, yet repeated biopsy attempts failed to yield diagnostic tissue. The case underscores the diagnostic difficulty in sampling centrally necrotic tumors and the need for integrating imaging with clinical and histologic correlation.