Sarcoid-like lymphadenopathy mimicking metastatic testicular cancer

A diagnostic dilemma: metastatic testicular cancer and systemic sarcoidosis - a review of the literature

Sarcoidosis is a multisystem disease that most commonly involves the lungs and the lymph nodes, but with genitourinary tract involvement, can easily mimic testicular cancer with metastasis to the lungs. We describe the case of a 30-year-old African-American male who presented with complaints of a headache, skin lesions, and a scrotal mass. A computed tomography scan of the head showed lesions in the frontotemporal and pons region, causing obstructive hydrocephalus. An ultrasound of the scrotum showed an enlarged epididymis bilaterally as well as a solid hypoechoic ill-defined mass on the right side, separate from the intact testis. Given the high suspicion for testicular malignancy with brain metastasis, a right orchiectomy was completed. The pathology revealed non-caseating necrotizing granulomas that stained negative for tubercular and fungal organisms, which was consistent with sarcoidosis. Additionally, the patient's skin and central nervous system (CNS) lesions improved on steroids that had been started for cerebral edema. Given the predilection of testicular cancer for CNS metastasis, neurosarcoidosis can also be mistaken for testicular cancer metastasis to the CNS, as seen in our case. Differentiating testicular cancer from genitourinary sarcoidosis is difficult but can be clarified using a combination of clinical presentation, epidemiology, serum markers (ACE, AFP, B-HCG), biopsies from skin/lymph nodes, and sometimes imaging. It is critical to differentiate genitourinary sarcoidosis from malignancy, as a misdiagnosis can lead to unnecessary surgical interventions, which have important implications for future fertility. There can also be a coexistence of as well as an association between testicular cancer and sarcoidosis, which should be recognized by health care providers.

Clinical implications of granulomatous inflammation detected by endobronchial ultrasound transbronchial needle aspiration in patients with suspected cancer recurrence in the mediastinum

BACKGROUND

Granulomatous inflammation has been previously reported in association with cancer. Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) is a new minimally invasive test for investigating mediastinal lymphadenopathy. The identification of granulomatous inflammation by EBUS-TBNA and the clinical implications of such detection in a series of patients with previously treated cancer and new mediastinal lymphadenopathy has not previously been performed.

METHODS

All 153 consecutive patients undergoing EBUS-TBNA in an academic cancer institution for suspected cancer in the mediastinum (mediastinal lymphadenopathy by CT imaging) were reviewed. Patients with non-caseating granuloma identified by EBUS-TBNA were included.

RESULTS

EBUS-TBNA identified non-caseating granuloma in 17/153 (11%) patients. A subset of 8/153 (5.2%) had sarcoid like lymphadenopathy mimicking cancer recurrence (5/5 PET positive). Another 8/153 (5.2%) patients with new mediastinal lymphadenopathy and no prior history of cancer had a clinical syndrome consistent with sarcoidosis. One other patient with a history of breast cancer was diagnosed with non-tuberculous mycobacteria infection. No patient required mediastinoscopy and there were no complications.

CONCLUSION

In an academic cancer institute, at least 5% of patients undergoing EBUS-TBNA have sarcoid-like lymphadenopathy mimicking cancer recurrence. Further studies to define the precise etiology, natural history and prognosis of this phenomenon are warranted.

Testicular presentation of sarcoidosis and organ preservation: case report and review of management strategies

We report the case of a 24-year-old Cuban-American man initially presenting with a 1-year history of bilateral testicular pain, subsequently diagnosed as sarcoidosis. The diagnosis was histologically confirmed intraoperatively with excisional biopsy of the right tunica. Genitourinary complaints are a rare initial presentation of this disease. Although therapeutic approaches have varied in published reports, no definitive protocol for treatment has been established. We suggest confirmation of the diagnosis, followed by symptomatic treatment, reserving orchiectomy and steroid therapy for severe, refractory, or disseminated cases.

Sarcoidosis and testicular carcinoma

BACKGROUND

Case reports and small case series have described patients with sarcoidosis and testicular carcinoma. The goals of this study were to determine the incidence of sarcoidosis in patients with testicular carcinoma seen at the Mayo Clinic between 1950 and 1996 and to examine the relation between these two diseases, particularly in regard to the therapy and follow-up of patients with testicular carcinoma.

METHODS

A computerized search of the patient data base at the Mayo Clinic was conducted to identify all patients seen between 1950 and 1996 who had a diagnosis of a malignant testicular tumor and sarcoidosis.

RESULTS

A total of 14 patients were identified. The median age at diagnosis of testicular carcinoma was 31.5 years. Eleven patients presented with Stage I disease and 3 with Stage II disease. Twelve patients had carcinoma diagnosed before sarcoidosis. The median age at the time of diagnosis of sarcoidosis was 36.5 years. Nine patients presented with radiographic Stage I disease, four with radiographic Stage II disease, and one with extrapulmonary disease. The estimated cumulative incidence of sarcoidosis in patients with testicular carcinoma seen at the Mayo Clinic between 1976 and 1995 was 617.3 per 100,000.

CONCLUSIONS

These data suggest that, compared with other solid tumors, testicular carcinoma has the strongest association with sarcoidosis. The observed incidence represents an approximate 100-fold increase compared with a general population of young white men. Although an etiologic relation is possible, the problems of access and surveillance bias should be addressed in prospective studies.

Coincidence of seminoma and sarcoidosis: a myth or fact?

A patient with a stage II seminoma of the testis was treated with a routine orchidectomy and irradiation. One and a half years later enlarged mediastinal lymph nodes were noted. Additional staging showed no other abnormalities and a mediastinoscopy was performed. The initial histologic examination confirmed the clinically suspected diagnosis of sarcoidosis. However, additional immunohistochemical analysis unexpectedly demonstrated that there was also a microscopic relapse of the testis tumor. The literature concerning the co-incidence of non-caseating granulomas and testis tumors is reviewed. It is not clear, whether the granulomas indicate the presence of genuine idiopathic sarcoidosis or whether they reflect a sarcoid-like reaction against tumor antigens. The immunopathogenesis of sarcoid formation and its possible biologic significance in obtaining a spontaneous tumor remission is discussed.