The most appropriate next step in management is to perform repeat CT imaging of the chest. This patient has a history of previously diagnosed silicosis, and silicosis is an independent risk factor for the development of lung cancer. Additionally, this patient also has a smoking history that increases the risk for malignancy. This increased risk, in combination with his history of weight loss, warrant further evaluation for malignancy. Evaluation may be more difficult in patients with silicosis, in whom lung findings tend to be upper lobe predominant, which tends to be the same distribution where lung cancers are more likely to occur. Because of this, plain chest radiography may not define small lesions in the background of nodularity and scarring. Therefore, a more sensitive imaging modality, such as CT, is indicated despite this patient's unchanged plain chest radiograph.

Chest MRI may be useful in evaluating chest wall, pleural, and mediastinal pathology, but it has limited utility in assessing bronchial or parenchymal lesions, primarily due to poorer spatial resolution and longer imaging times required than CT. Therefore, even in the presence of significant lung disease such as in this patient, CT is the preferred imaging modality.

Patients with silicosis are also at increased risk for tuberculosis (TB), which may also cause blood in the sputum and systemic features such as weight loss. This patient's persistently negative tuberculin skin tests and unchanged chest radiograph make this a less likely diagnosis; therefore, empiric treatment for TB would be an inappropriate next step in management. However, further diagnostic evaluation for TB would be reasonable if his evaluation for malignancy is negative.

Although patients with silicosis often have a concomitant smoking exposure and smoking-related lung disease, there is little role for the use of glucocorticoids in treating patients with silicosis who do not have another indication for their use.