Sarcoidosis as a benign cause of lymphadenopathy in cancer patients

Azacitidine induced lung injury: report and contemporary discussion on diagnosis and management

Azacitidine, a hypomethylating agent, has caused a paradigm shift in the outcomes of patients with myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) who are not eligible for stem cell transplantation, particularly in combination with BCL2 and IDH inhibitors. Azacitidine and Azacitidine-based combinations have been widely considered a safe low-intensity therapy when compared to traditional conventional treatments. The development of lung toxicity from azacitidine is not a well-characterized adverse event. However, if it happens, it can be fatal, especially if not recognized and treated promptly. In this review, we aim to familiarize the reader with the presentation of azacitidine-induced lung injury, provide our suggested approach to management based on our experience and the current understanding of its mechanism, and review the literature of 20 case reports available on this topic.

Growing Teratoma Syndrome in the Setting of Sarcoidosis: A Case Report and Literature Review

Growing teratoma syndrome (GTS) is rare and can mimic disease recurrence in patients with a history of immature teratoma. Benign hypermetabolic lymphadenopathy found on staging and surveillance computed tomography (CT) and positron emission tomography (PET) may lead to the presumption of metastatic malignancy. We report a case of a 38 year old with mixed mature and immature teratomas who developed new peritoneal masses after adjuvant chemotherapy despite a normalization of tumor markers. In addition to low FDG uptake observed in these peritoneal masses, a PET scan showed hypermetabolic lymphadenopathy and pulmonary and spleen lesions suggesting widespread metastases. Subsequent surgical resection confirmed a mixed pathology with GTS and sarcoidosis. We reviewed the current literature evidence of GTS and sarcoidosis as a benign cause of lymphadenopathy in cancer patients. We emphasize the importance of a tissue diagnosis before instituting therapy for presumed cancer recurrence to avoid potentially fatal diagnostic traps and management errors. A multiple disciplinary team approach is imperative in managing patients with suspected recurrent immature teratomas.

Case series of concurrent occurrence of sarcoidosis and breast cancer - A diagnostic dilemma

Sarcoidosis is a multi-system granulomatous disorder characterized by involvement of multiple systems with or without lymphadenitis. Pulmonary complications are common and may lead to morbidity. Breast cancer is one of the commonest malignancy among women across the world. There is an increased risk of malignancies in sarcoidosis. This association with cancer creates a diagnostic dilemma due to the predominant involvement of nodes and organ systems in both conditions. Here we report three cases of sarcoidosis with breast cancer diagnosed over one year.

Pulmonary adverse events due to immune checkpoint inhibitors: A literature review

Cancer immunotherapy aims to stimulate the immune system to fight against tumors, utilizing the presentation of molecules on the surface of the malignant cells that can be recognized by the antibodies of the immune system. Immune checkpoint inhibitors, a type of cancer immunotherapy, are broadly used in different types of cancer, improving patients' survival and quality of life. However, treatment with these agents causes immune-related toxicities affecting many organs. The most frequent pulmonary adverse event is pneumonitis representing a non-infective inflammation localized to the interstitium and alveoli. Other lung toxicities include airway disease, pulmonary vasculitis, sarcoid-like reactions, infections, pleural effusions, pulmonary nodules, diaphragm myositis and allergic bronchopulmonary aspergillosis. This review aims to summarize these pulmonary adverse events, underlining the significance of an optimal expeditious diagnosis and management.

Sarcoidosis-Like Cancer-Associated Granulomatosis: Characteristics and a Case-Control Comparison with Sarcoidosis

(1) Background: Systemic granulomatosis developed in a context of malignancy has already been reported. Our objective was to describe the clinical, radiological, functional, biological, and evolutive characteristics of sarcoidosis-like cancer-associated granulomatosis (SLCAG) and to compare them to those of sarcoidosis. (2) Methods: 38 patients with a biopsy-proven SLCAG developed after a diagnostic of malignancy were included. The control group consisted of sarcoidosis patients matched for age, sex, and radiologic stage. Clinical, biological, physiological, radiological, and outcome data were collected. (3) Results: The mean age of SLCAG patients was 51 ± 14 years. They were diagnosed within 15 ± 14 months of the cancer diagnosis (breast cancer most frequently). All SLCAG patients presented a thoracic involvement, extrathoracic locations were observed in 32% of subjects. SLCAG was more often asymptomatic than sarcoidosis (p < 0.0001). During follow-up, systemic treatment was less often required in SLCAG than in sarcoidosis (58% vs. 32%, p = 0.04 respectively) and SLCAG were characterized by a significantly less severe progression profile according to the Sarcoid Clinical Activity Classification, with a complete recovery more frequent at 5 years (p = 0.03). (4) Conclusion: This case-control study shows that SLCAG differs from sarcoidosis with a significantly more benign course. These results might argue for true differences in the physiopathology, which remain to be elucidated.

Sarcoid-like reaction in cases treated by checkpoint inhibitors

Sarcoidosis is a multisystem granulomatous disorder characterized by helper T cell inflammation. Sarcoid-like reaction (SLR) is a well-defined entity and may be related with several malignant disorders and/or their therapies. SLR has been reported more than 20 years ago and in recent years in cases treated by checkpoint inhibitors (CPIs). Better outcome has been reported in cases developing granulomatous reaction and/or SLRs during CPI treatments. However, these lesions clinically may be thought as disease progression and may cause to stop treatment or alterations. These therapeutic manipulations may be harmful for the patients. Clinicians should be aware of SLRs in cases treated by CPIs and tissues must be sampled and reviewed by an experienced pathologist to avoid misdiagnosis and also unnecessary CPI treatment cessations.Significance StatementClinicians should be aware of sarcoid-like reactions in cases treated by checkpoint inhibitors and tissues must be sampled and reviewed by an experienced pathologist to avoid misdiagnosis and CPI treatment stops.

Sarcoidosis: Pitfalls and Challenging Mimickers

Sarcoidosis, a systemic granulomatous disease of unknown etiology, may mimic other conditions at presentation often resulting in delayed diagnosis. These conditions include infections, neoplasms, autoimmune, cardiovascular, and drug-induced diseases. This review highlights the most common sarcoidosis mimics that often lead to pitfalls in diagnosis and delay in appropriate treatment. Prior to invasive testing and initiating immunosuppressants (commonly corticosteroids), it is important to exclude sarcoid mimickers.

The Clinical Features of Patients with Sarcoidosis and Malignant Diseases in Japan

Objective Recent studies suggest a significant association between sarcoidosis and malignancy, although the results have remained controversial. The aim of this study is to evaluate the clinical features of patients with sarcoidosis associated with malignant diseases in Japan. Patients We conducted a medical record review of all sarcoidosis patients in Tohoku University Hospital between January 1, 1981, and May 31, 2017. Methods The clinical records and pathology reports for each patient were screened, and the clinical characteristics of malignancies as well as sarcoidosis were reviewed. Results A total of 52 (18.8%) patients with malignancy were identified among 277 patients with sarcoidosis. Among those 52 patients, we identified 62 with malignant diseases. These patients were older and more likely to be women than the remaining 225 (81.2%) sarcoidosis patients without malignancy. The most prevalent malignant disease was breast cancer (14 cases, 22.6%), followed by stomach cancer (8 cases, 12.9%) and lung cancer (7 cases, 11.3%). Among the 14 patients with both sarcoidosis and breast cancer, 8 (57.1%) were diagnosed with breast cancer before sarcoidosis. All of these eight cases had undergone surgical resection of the cancer. Conclusion This study showed a higher incidence of patients with both sarcoidosis and malignancy in Japan than in some western countries. Breast cancer is the most prevalent malignant disease. The high frequency of sarcoidosis after surgical resection of breast cancer may suggest a causative association between malignancy and the development of sarcoidosis.

Systemic sarcoidosis mimicking metastatic renal cell carcinoma with subsequent cardiac involvement

There exists a well-established association between sarcoidosis and many solid and hematologic malignancies however it is a less frequently described phenomenon in patients with renal cell carcinoma. Moreover the majority of described cases presented with local sarcoid-like reactions in close proximity to the tumor with comparatively few reports of more distant disease. Given the relatively low number of cases there remains a great deal of uncertainty surrounding the clinical behaviour of sarcoidosis in the setting of renal cell carcinoma. We report the case of a patient with surgically resected renal cell carcinoma who, several years later, developed bilateral pulmonary nodules, intra-thoracic lymphadenopathy as well as splenic, hepatic and osseous lesions. After extensive investigation, culminating in video-assisted thoracoscopic surgical resection, he was found to have sarcoidosis. He remained asymptomatic for many years before being diagnosed with cardiac sarcoidosis, which was found to be inactive and did not require any treatment. Both his sarcoidosis and underlying renal cell carcinoma have remained in remission to date. This case highlights the variable behaviour of sarcoidosis in these patients and underscores the importance of obtaining an accurate tissue diagnosis in the setting of suspected metastatic disease. Additionally, it underscores the importance of close monitoring and long-term follow up as these patients may develop significant organ involvement, even many years after diagnosis. Interestingly the patient's renal cell carcinoma remained in remission, raising questions about whether the development of sarcoidosis portends a better prognosis in patients with an underlying solid malignancy.

Presence of concurrent sarcoid-like granulomas indicates better survival in cancer patients: a retrospective cohort study

Introduction

An increased risk of sarcoidosis and sarcoid-like reactions in subjects with a history of malignancy has been suggested. We assessed the incidence and clinical characteristics of cancer patients with biopsies containing sarcoid-like granulomas on cancer metastasis and patient survival.

Methods

This is a retrospective, multicentre, observational study involving endobronchial ultrasound transbronchial needle aspiration and a melanoma patient dataset at the University of Miami, USA, and a sarcoidosis patient database at Chiba University, Japan. Subjects with a confirmed diagnosis of cancer and who subsequently developed granulomas in different organs were enrolled. The study was registered at Clinicaltrials.gov (NCT03844698).

Results

133 patients met the study's criteria. The most common primary cancer sites were the skin (22.5%), breast (20.3%) and lymph node (12.8%). 24 (18%) patients developed sarcoid-like granulomas within 1 year of cancer diagnosis, 54 (40.6%) between 1 and 5 years and 49 (36.8%) after 5 years. Imaging showed possible sarcoid-like granulomas in lymph nodes in 51 cases (38.3%) and lung tissue and mediastinal lymph nodes in 73 cases (54.9%); some parenchymal reticular opacity and fibrosis was found in 5 (3.7%) and significant parenchymal fibrosis in 2 (1.5%) subjects. According to logistic regression analysis, the frequency of metastatic cancer was significantly lower in patients with sarcoid-like granulomas than in controls. Moreover, multivariate Cox proportional hazard analysis showed a significant survival advantage in those with sarcoid-like granuloma.

Conclusion

Sarcoid-like granulomas are uncommon pathology findings in cancer patients. There is a significant association between the presence of granulomas and reduced metastasis and increased survival. Further study is warranted to understand the protective mechanism involved.

Unusual case of splenic sarcoidosis without morphological lesions detected by PET-CT in a patient with breast cancer: functional imaging between pitfalls and therapeutic guide

A 60-year-old woman under treatment with letrozole for metastatic breast cancer underwent ¹⁸F-FDG PET-CT for restaging. A new widespread intense splenic FDG uptake without nodular lesions and multiple FDG-avid mediastinal and abdominal nodes were observed. Based on these findings, a nodal and transbronchial lung biopsy was performed. Histological results were compatible with sarcoidosis. The patient began steroid treatment and 6 weeks after a PET-CT showed normalisation of both splenic and nodal uptake. In our case, ¹⁸F-FDG PET-CT has been useful in detecting a rare case of splenic sarcoidosis without typical nodular lesions on CT images, impacting the patient’s treatment and prognosis.

Pembrolizumab reactivates pulmonary granulomatosis

Sarcoid like reaction is a well-known entity that occurs as a consequence to several malignancies or their therapies. Immunotherapy has gained a lot of interest in the past few years and has recently gained approval as first line therapy in multiple advanced stage malignancies. Pneumonitis has been described as complication of such therapy. Granulomatous inflammation has been only rarely reported subsequent to immunotherapy. We describe a case of granulomatous inflammation reactivation affecting the lungs in a patient previously exposed to Pembrolizumab and have evidence of a distant granulomatous infection. We discuss potential mechanisms of the inflammation and assert the importance of immunosuppression in controlling the dis-inhibited immune system.

CT differentiation of enlarged mediastinal lymph node due to anthracosis from metastatic lymphadenopathy: a comparative study proven by endobronchial US-guided transbronchial needle aspiration

PURPOSE

Anthracosis often results in mediastinal nodal enlargement. The aim of this comparative study was to evaluate if it is possible to differentiate endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) proven anthracotic lymph nodes from malignant lymph node enlargement by means of multislice computed tomography (MSCT).

METHODS

We compared the MSCT findings of 89 enlarged lymph nodes due to anthracosis with 54 malignant lymph nodes (non-small cell lung cancer 75.9%, small cell lung cancer 18.5%, and non-Hodgkin lymphoma 5.6%). The lymph nodes were assessed for density (calcification, fat, and necrosis), shape (oval, round), contrast enhancement, and contour (sharp, ill-defined).

RESULTS

Malignant lymph nodes showed significantly greater axis diameters (P < 0.001). Both anthracotic and malignant nodes were most often oval (86.5% of all malignant nodes vs. 81.5% of all anthracotic nodes, P = 0.420) and showed confluence in a remarkable percentage (28.1% vs. 42.6%, P = 0.075). Anthracotic nodes showed calcifications more often (18% vs. 0%, P < 0.001). Malignant lymph nodes showed a significantly greater short and long axis diameter (P < 0.001), and they had a higher frequency of ill-defined contours (27.8% vs. 2.2%, P < 0.001) and contrast enhancement (27.8% vs. 5.6%, P < 0.001). Nodal necrosis, which appeared in one third of the malignant nodes, was not observed in anthracosis (35.2% vs. 0%, P < 0.001). Confluence of enlarged lymph nodes was seen in malignant lymph nodes (42.6%), as well as in lymph node enlargement due to anthracosis (28.1%, P = 0.075).

CONCLUSION

Our results show that there are significant differences in MSCT findings of malignant enlarged lymph nodes and benign lymph node enlargement due to anthracosis.

Granulomatosis after autologous stem cell transplantation in nonHodgkin lymphoma - experience of single institution and a review of literature

Background

Sarcoidosis before and after treatment of malignancy is an important differential diagnosis that has to be distinguished from lymphoma.

Patients and methods

Hodgkin lymphoma, diffuse large B-cell lymphoma and aggressive follicular lymphoma are being staged and treatment effect is evaluated with PET-CT. We report three cases of aggressive lymphoma after high dose therapy and autologous stem cell transplantation with positive lymph nodes on PET-CT, which were histologically diagnosed as sarcoidosis/granulomatosis. In the literature, we found that false positive lymph nodes were more common after allogeneic than after autologous transplantation.

Conclusions

Post-treatment PET-CT positive lymph nodes should always be examined histologically prior to any further treatment decision to avoid unnecessary toxic procedures.

Sarcoidosis imitating breast cancer metastasis: a case report and literature review

Sarcoidosis is a benign systematic granulomatous disorder of unknown etiology and is associated with various malignancies. However, granulomatous and metastatic lymph node lesions are difficult to distinguish even when using precise and modern diagnostic methods, such as positron emission tomography. Thus, histological verification is the only method that can be used to accurately describe the nature of this disease. In this article, we report a case of non-luminal HER-2/neu-positive breast cancer in a patient without history of sarcoidosis and suspected to have metastatic disease.

Endometrial Cancer with Sarcoidosis in Regional Lymph Nodes: A Case Report

Sarcoidosis is a chronic, multisystemic disease commonly affecting the lungs and lymphatic system and is characterized by the formation of noncaseating granulomas. Although several reports are available on cases developing both sarcoidosis and cancer metachronously, cases of simultaneous diagnosis of these diseases have rarely been reported. A 67-year-old woman diagnosed with endometrial cancer had developed systemic lymph node swelling, including bilateral hilar, paraaortic, and a few pelvic lymph nodes, as observed on preoperative imaging. During surgery, frozen sections of a paraaortic lymph node were examined, revealing noncaseating granulomas compatible with sarcoidosis. Next, modified radical hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy were performed. Postoperative pathological analysis revealed endometrioid adenocarcinoma of the uterus, and no metastasis but noncaseating granulomas were detected in the resected lymph nodes. Postoperatively, we identified cutaneous sarcoidosis and uveitis in the presence of a tuberculin-negative test. On the basis of these findings, we diagnosed the patients with endometrial cancer complicated by sarcoidosis. She underwent adjuvant chemotherapy, and at the 1-year follow-up, the lymph node swelling due to sarcoidosis was stable, and no recurrence of the cancer was observed. This turned out to be a case of early endometrial cancer mimicking advanced cancer by sarcoidosis. Histological confirmation and additional examination for sarcoidosis are necessary in cancer patients suspected of sarcoidosis.

Sarcoidosis Occurring After Solid Cancer: A Nonfortuitous Association: Report of 12 Cases and Review of the Literature

The association between cancer and sarcoidosis is controversial. Some epidemiological studies show an increase of the incidence of cancer in patients with sarcoidosis but only few cases of sarcoidosis following cancer treatment have been reported. We conducted a retrospective case study from internal medicine and oncology departments for patients presenting sarcoidosis after solid cancer treatment. We also performed a literature review to search for patients who developed sarcoidosis after solid cancer. We describe the clinical, biological, and radiological characteristics and outcome of these patients. Twelve patients were included in our study. Various cancers were observed with a predominance of breast cancer. Development of sarcoidosis appeared in the 3 years following cancer and was asymptomatic in half of the patients. The disease was frequently identified after a follow-up positron emission tomography computerized tomography evaluation. Various manifestations were observed but all patients presented lymph node involvement. Half of the patients required systemic therapy. With a median follow-up of 73 months, no patient developed cancer relapse. Review of the literature identified 61 other patients for which the characteristics of both solid cancer and sarcoidosis were similar to those observed in our series. This report demonstrates that sarcoidosis must be considered in the differential diagnosis of patients with a history of malignancy who have developed lymphadenopathy or other lesions on positron emission tomography computerized tomography. Histological confirmation of cancer relapse is mandatory in order to avoid unjustified treatments. This association should be consider as a protective factor against cancer relapse.

Evaluation of Mediastinal Lymph Nodes in Sarcoidosis, Sarcoid Reaction, and Malignant Lymph Nodes Using CT and FDG-PET/CT

The aim of this study was to analyze the clinical, computed tomography (CT), and positron emission tomography (PET) findings of sarcoidosis, sarcoid reaction, and malignant lymph nodes (LNs) to the results of transbronchial LN aspiration and biopsy (TBNA).The TBNA results of mediastinal and hilar LNs of 152 patients in our hospital from July 2008 to March 2013 were retrospectively reviewed. Two independent radiologists measured the size and attenuation of LNs on CT and assessed the probability of the 3 categories: sarcoidosis (n = 36), sarcoid reaction (n = 25), or malignant LNs (n = 91). The total volume and attenuation of LNs were measured using Image J (NIH). The median maximum standardized uptake value (maxSUV) of the 3 mediastinal and hilar LNs on PET/CT was obtained.There was no significantly different CT finding between sarcoidosis and sarcoid reaction. Multivariate analysis showed that the age, total volume of LNs, and number of enlarged LNs significantly differed between sarcoid reaction and malignant LNs. Sarcoid reaction tends to be occurred in young patients (P = 0.007), the total volume of LNs was smaller (P = 0.04) than that of malignant LNs, and there were significantly more LNs >1 cm (P = 0.005). The median maxSUV of the 3 highest SUVs of the LNs did not significantly differ between the 3 entities.

Ratio of Lymph Node to Primary Tumor SUV on PET/CT Accurately Predicts Nodal Malignancy in Non-Small-Cell Lung Cancer

Thoracic lymph nodes with marginally elevated maximum standardized uptake value (SUVmax) on PET/CT a diagnostic challenge in staging non-small-cell lung cancer. We evaluated the ratio of lymph node to primary tumor SUVmax (SUVN/T) in predicting nodal malignancy among 132 sampled nodes from 85 patients both a primary tumor SUVmax > 2.5 and LN SUVmax 2.0 to 6.0. SUVN/T was more accurate than SUVmax for this subset of patients.

INTRODUCTION/BACKGROUND

Among non-small-cell lung cancers with appreciable functional activity, positron emission tomography/computed tomography (PET/CT) is the most accurate imaging modality for clinical staging. However, lymph nodes (LN) with marginally elevated standardized uptake value (SUV) present a diagnostic challenge. In this retrospective study, we hypothesized that normalizing the LN SUV by using the ratio of the LN to primary tumor SUVmax (SUVN/T) may be a better predictor of nodal malignancy than using SUVmax alone for nodes with low to intermediate SUV.

PATIENTS AND METHODS

We identified 172 patients with newly diagnosed non-small-cell lung cancer who underwent pathologic LN staging and PET/CT within 31 days before biopsy. Receiver operating characteristic curves with area under the curve (AUC) calculations were used to evaluate SUVmax and SUVN/T for their ability to predict nodal malignancy for both the entire cohort of 504 LNs and a subset of 132 LNs from 85 patients who had both primary tumor SUVmax > 2.5 and LN SUVmax 2.0 to 6.0.

RESULTS

In patients with primary tumor SUVmax > 2.5 and LN SUVmax 2.0 to 6.0, SUVN/T was significantly more accurate in predicting nodal malignancy (AUC, 0.846; 95% confidence interval, 0.775-0.917) than SUVmax (AUC, 0.653; 95% confidence interval, 0.548-0.759). The optimal cutoff value of SUVN/T to predict nodal malignancy was 0.28 (90% sensitivity, 68% specificity). Sensitivity was > 95% for SUVN/T < 0.21, whereas specificity was > 95% for SUVN/T > 0.50.

CONCLUSION

The ratio of LN SUV to primary tumor SUV on PET/CT is more accurate than SUVmax when assessing nodes of low to intermediate SUV.

A New Isolated Mediastinal Lymph Node or Small Pulmonary Nodule Arising during Breast Cancer Surveillance Following Curative Surgery: Clinical Factors That Differentiate Malignant from Benign Lesions

PURPOSE

A newly isolated mediastinal lymph node (LN) or a small pulmonary nodule, which appears during breast cancer surveillance, may pose a diagnostic dilemma with regard to malignancy. We conducted this study to determine which clinical factors were useful for the differentiation of malignant lesions from benign lesions under these circumstances.

MATERIALS AND METHODS

We enrolled breast cancer patients who were presented with a new isolated mediastinal LN or small pulmonary nodule that arose during surveillance, and whose lesions were pathologically confirmed. Tissue diagnosis was made by mediastinoscopy, video-assisted thoracic surgery or thoracotomy.

RESULTS

A total of 43 patients were enrolled (mediastinal LN, 13 patients; pulmonary nodule, 30 patients). Eighteen patients (41.9%) were pathologically confirmed to have a benign lesion (benign group), and 25 patients (58.1%) were confirmed to have malignant lesion (malignant group). Between the two groups, the initial tumor size (p=0.096) and N stage (p=0.749) were similar. Hormone receptor negativity was more prevalent in the malignant group (59.1% vs. 40.9%, p=0.048). The mean lesion size was larger in the malignant group than in the benign group (20.8 mm vs. 14.4 mm, p=0.024). Metastatic lesions had a significantly higher value of maximal standardized uptake (mSUV) than that of benign lesions (6.4 vs. 3.4, p=0.021).

CONCLUSION

Hormone receptor status, lesion size, and mSUV on positron emission tomography are helpful in the differentiation of malignant lesions from benign lesions in breast cancer patients who were presented with a new isolated mediastinal LN or small pulmonary nodule during surveillance.

Benefit of a second opinion: From metastatic disease to resectable lung cancer with sarcoid-like reaction

Background

Mediastinal lymphadenopathy in combination with lung cancer is suggestive for lymph node metastases but can also have other origins.

Case report

We describe a patient diagnosed with stage IV lung cancer presenting with parenchymal lesions and enlarged mediastinal lymph nodes. A second opinion including FDG-PET scan review and a mediastinoscopy followed by surgery revealed tumor specimens originating from a single primary tumor with a sarcoid-like reaction in the mediastinal lymph nodes, changing the diagnosis from metastasized to resectable lung cancer.

Discussion

PET positive lesions are not always synonymous with metastatic disease in the presence of a malignant tumor. Conscientious review of FDG-PET scans and tissue sampling are therefore mandatory to determine definitive staging and subsequent interventions.

FDG-PET/CT of sarcoidosis and sarcoid reactions following antineoplastic treatment

Sarcoidosis or sarcoid reactions, which appear as FDG-avid lesions in oncologic patients, need to be differentiated from disseminated malignancies. We aimed to promote awareness of development of sarcoidosis or sarcoid reactions after antineoplastic therapy to avoid diagnostic errors with FDG-PET/CT findings and assess the utility of FDG-PET/CT for follow-up. We retrospectively reviewed radiological reports of FDG-PET/CT scans performed between January 2009 and December 2011. Among oncologic patients with more than 2 FDG-PET/CT scans, those with nearly symmetrical increases in FDG uptake in the hilar or mediastinal lymph nodes were identified, and those with known sarcoidosis, concurrent diagnoses of sarcoidosis with malignancy, or histopathologically proven malignancies were excluded. Then, only those cases were selected for which sarcoidosis or sarcoid reactions were diagnosed. Four of 376 oncologic cases met the criteria. At 9 months to 6 years after antineoplastic therapy, abnormal FDG uptakes were observed in the hilar, mediastinal, abdominal, pelvic, and inguinal nodes, and/or spleen and lung parenchyma with SUVmax up to 17.7. On the basis of these findings, 1 patient received anticancer chemotherapy because of tumor recurrence suspicion. A gradual decrease in FDG uptake was observed on subsequent PET/CT scans. Sarcoidosis or sarcoid reactions should be considered in differential diagnosis of oncologic patients who have developed FDG-avid lesions any time after antineoplastic therapy. FDG-PET/CT can be used for follow-up in nondiagnostic situations to detect decreases in FDG uptake due to presence of sarcoidal granulomas.

False Positive 18F-FDG Uptake in Mediastinal Lymph Nodes Detected with Positron Emission Tomography in Breast Cancer: A Case Report

Breast cancer is the most frequently diagnosed cancer among females. It is accepted that lymph node involvement with metastatic tumor and the presence of distant metastasis are the most important prognostic factors. Accurate staging is important in determining prognosis and appropriate treatment. Positron emission tomography with computed tomography detects malignancies using 2-[18F]-fluoro-2-deoxy-d-glucose (18F-FDG PET CT) with high accuracy and they contribute to decisions regarding diagnosis, staging, recurrence, and treatment response. Here, we report a case of false positive metastatic mediastinal lymph nodes that were diagnosed by 18F-FDG PET CT in a 40-year-old breast cancer patient who had undergone preoperative evaluation. Right paratracheal, prevascular, aorticopulmonary, precarinal, subcarinal, hilar, and subhilar multiple conglomerated mediastinal lymph nodes were revealed in addition to left breast mass and axillary lymph nodes. Mediastinoscopy was performed with biopsy and pathology was reported as granulomatous lymphadenitis. In conclusion, any abnormal FDG accumulation in unusual lymph nodes must be evaluated carefully and confirmed histopathologically.

Sarcoidosis mimicking metastatic gynaecological malignancies: a diagnostic and therapeutic challenge?

Several case reports describing the coexistence of sarcoidosis and malignancy have been published. Therefore, sarcoidosis should always be considered as a differential diagnosis when a cancer patient develops lymphadenopathy. Positron-emission tomography (PET) 2-[18F]-fluoro-2-deoxy-d-glucose (FDG) combined with computed tomography (CT) is widely used for cancer staging and surveillance because it permits localization of metabolically active malignant tissue. PET/CT or CT findings in patients with suspected cancer recurrence can be used to guide early and aggressive therapy. However, benign hypermetabolic lymphadenopathy can mimic malignant lymphadenopathy, both on a conventional CT scan and on PET/CT. Thus, it is important to obtain a histological diagnosis before initiating antineoplastic therapy based on imaging findings. Four cases of patients affected by gynaecological malignancies and coexisting sarcoidosis are reported in this study. Furthermore, the clinical relevance of making a differential diagnosis between gynaecological cancer recurrence and granulomatous disorder is given specific mention.

PET/CT in Patients with Sarcoidosis or IgG4 Disease

Sarcoidosis as a distinct disease entity was diagnosed more than 100 years ago. The signs and symptoms of the disease are nonspecific, posing a challenge for early and accurate diagnosis. IgG4 disease or syndrome has various clinical manifestations, such as sclerosing pancreatitis, sclerosing cholangitis, prostatitis, tubulointerstitial nephritis, interstitial pneumonia, and enlargement of salivary glands. This article discusses the role of the different diagnostic imaging modalities in sarcoidosis and IgG4 disease, including radiographs, computed tomography, magnetic resonance imaging, and conventional nuclear medicine, with a special emphasis on positron emission tomography as a superior modality for assessing these inflammatory diseases.

Prevalence of enlarged mediastinal lymph nodes in heavy smokers--a comparative study

OBJECTIVE

To evaluate the frequency of enlarged hilar or mediastinal lymph nodes in heavy smokers (more than 10 pack years) compared with non- smokers.

MATERIAL AND METHODS

In a prospective study the CT findings of 88 consecutive patients (44 heavy smokers, 44 non- smokers) were analysed. Exclusion criteria were history of thoracic malignancy, sarcoidosis, occupational dust exposure or clinical evidence of pneumonia. Prevalence, size and site of enlarged lymph nodes were assessed by multidetector computed tomography (MDCT) and correlated with the cigarette consumption and the CT- findings of bronchitis and emphysema.

RESULTS

Twenty-three of the 44 heavy smokers (52%) showed enlarged mediastinal lymph nodes. Non- smokers showed enlarged lymph nodes in 9% (4/44). The most common site of enlarged lymph nodes was the regional station 7 according to the ATS mapping (subcarinal). The difference between the frequency of enlarged lymph nodes in heavy smokers and non- smokers was significant (chi- square 19.3, p < 0.0001). Airway wall thickening and emphysema were often associated with an increased number of enlarged nodes.

CONCLUSION

The present study demonstrates that enlarged mediastinal lymph nodes may occur in a rather high percentage of heavy smokers, especially in those with a MDCT finding of severe bronchitis.

Enlarged hilar and mediastinal lymph nodes in chronic obstructive pulmonary disease

INTRODUCTION

To evaluate the frequency of enlarged hilar or mediastinal lymph nodes in patients suffering from chronic obstructive pulmonary disease (COPD).

METHODS

In a retrospective study, 89 patients with proven COPD were analysed. Exclusion criteria were history of malignant disease or clinical evidence of pneumonia. Prevalence, size, and localisation of enlarged lymph nodes were assessed by multi-slice computed tomography (MSCT) and correlated with the clinical stages following the GOLD classification as well as the MSCT findings of bronchitis and emphysema.

RESULTS

44/89 (49%) of our patients showed enlarged lymph nodes. Lymph node enlargement was more often seen in the mediastinum (48%) than the hilar region (20%). The most common localisation of enlarged mediastinal lymph nodes was the regional station 7 following the ATS mapping (infracarinal). Patients with a stage I following the GOLD classification showed enlarged lymph nodes in 49% (18/37), stage II in 46% (12/26), stage III in 58% (7/12) and stage IV in 50% (7/14). These findings did not differ significantly (P > 0.05). Severe airway wall thickening (42/89) was significantly more often associated with an increase of nodal enlargement (64%) (P < 0.05).

CONCLUSION

The present study demonstrates that enlarged hilar and mediastinal lymph nodes may occur in a rather high percentage of patients suffering from COPD, especially in those with the MSCT finding of severe bronchitis.

Multi-technique imaging of sarcoidosis

Sarcoidosis is a multisystem granulomatous disorder of unknown aetiology. The diagnosis is suggested on the basis of wide ranging clinical and radiological manifestations, and is supported by the histological demonstration of non-caseating granulomas in affected tissues. This review highlights the multisystem radiological features of the disease across a variety of imaging methods including multidetector computed tomography (CT), magnetic resonance imaging (MRI) as well as functional radionuclide techniques, particularly 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography/computed tomography (PET/CT). It is important for the radiologist to be aware of the varied radiological manifestations of sarcoidosis in order to recognize and suggest the diagnosis in the appropriate clinical setting.