Coexistence of sarcoidosis and metastatic lesions: A diagnostic and therapeutic dilemma

A Unique Case of Sarcoid-associated Myelopathy Accompanied by Lung Cancer

The differential diagnosis of myelopathy in patients with malignancies may be challenging, as a spinal biopsy is not always applicable. A 66-year-old woman who had shown transient double vision and nausea developed spasticity and impaired deep sensation in both feet. Magnetic resonance imaging showed abnormal gadolinium enhancement of the brainstem, spinal meninges, and nerve root. Cerebrospinal fluid (CSF) revealed mild pleocytosis and elevated protein and decreased glucose levels, although CSF cytology was normal. Lung carcinoma was simultaneously detected, and noncaseating granuloma was detected from the hilar and axillary lymph nodes, so she was diagnosed with sarcoid-associated myelopathy. Her symptoms were kept stable by intravenous methylprednisolone, oral prednisolone, and methotrexate. This is the first case of sarcoid-associated myelopathy accompanied by lung cancer, suggesting the importance of clinical course, repetitive CSF cytology, and a biopsy of the lymph nodes to distinguish sarcoid-associated myelopathy from meningeal metastasis in patients with malignancies.

The Association Between Lung Cancer and Sarcoidosis: A Literature Review

Lung cancer is responsible for a significant number of cancer-related deaths worldwide. While various factors can lead to lung cancer, such as tobacco smoking, this article focuses on the relationship between sarcoidosis, a multisystem granulomatous disorder, and lung neoplasm. To investigate this association, the authors conducted a literature search using relevant keywords. The analysis of these reports concluded that while Sarcoidosis and lung cancer together is rare, it is possible. The presenting symptoms, age, gender, and diagnostic procedures of each case should be evaluated, and appropriate diagnostic procedures should be carried out to determine the appropriate treatment for each patient. Clinicians need to be aware of the possibility of these two diseases co-occurring, as they can impact the management of the patient's condition, whether it is curative or palliative. It is essential to rule out metastatic cancer in individuals with sarcoidosis-like clinical and radiographic features.

[Metastasis or sarcoidosis - a diagnostic pitfall in metastatic rectal carcinoma]

BACKGROUND

Granulomatous diseases as sarcoidosis can impair the staging of metastatic diseases since metastasis are hard to distinguish from granulomas in standard imaging. This case report describes the diagnostic workup and therapy in a patient with simultaneous sarcoidosis and rectal cancer with hepatic metastasis and how a curative stadium was achieved.

CASE DESCRIPTION

A 71-year old male patient was diagnosed with an adenocarcinoma of the rectum after presenting with involuntary weight loss and anemia. Further diagnostics raised strong suspicion of hepatic, pulmonary and splenic metastasis. Histology after bronchoscopy surprisingly discovered non-caseating granulomas, leading to the diagnosis of sarcoidosis. Due to an obstructive tumor, a rectum resection was performed. Due to a high suspicion of splenic metastasis during surgery, the spleen was removed. Histology revealed no metastasis in the spleen but multiple granulomas due to sarcoidosis. After surgery, biopsy of a suspicious lesion in the liver revealed both metastasis and sarcoidosis in the same sample. The patient was treated with a pseudo(neo)adjuvant chemotherapy with 5-Fluorouracil, Leukovorin, Oxaliplatin (FOLFOX) and Panitumumab (Anti-EGF-antibody). After treatment, CT scan revealed two hepatic lesions decreasing in size, while all other lesions were metrically stable. A right hemihepatectomy followed and histology revealed both sarcoidosis and metastasis. The curated patient was sent to aftercare and there is no suspicion for a relapse (13 month after last surgery).

DISCUSSION

The simultaneous appearance of metastatic tumors and sarcoidosis creates a diagnostic dilemma since both manifestations can barely be distinguished in regular imaging technologies. This case report demonstrates that the histological work-up of affected organs with consecutive resections can cure a patient of a metastatic tumor disease, even in the context of simultaneous sarcoidosis.

A Case of Synchronous Occurrence of Intracranial Germinoma and Systemic Sarcoidosis

Although the synchronous occurrence of testicular seminoma and systemic sarcoidosis has been reported, that of intracranial germinoma and systemic sarcoidosis is unknown. A 26-year-old man presented with symptoms of panhypopituitarism and consciousness disturbance. Imaging demonstrated a large nodule in the upper right lung field and swelling of multiple bilateral pulmonary and mediastinal lymph nodes in addition to the bifocal pineal and suprasellar tumors with obstructive hydrocephalus. The pathological diagnosis of the intracranial bifocal tumors was pure germinoma, whereas that of the mediastinal lymph nodes was epithelioid granuloma. Three courses of chemotherapy using carboplatin and etoposide were administered, followed by whole ventricle irradiation. The intracranial tumors completely disappeared, but the lung nodule and mediastinal lymph nodes progressed. Whole-body fluorine-18-fluorodeoxyglucose positron emission tomography demonstrated accumulation in the mediastinal lymphadenopathy, lung masses, and multiple lymph nodes of the whole body. Transbronchial lung biopsy revealed epithelioid granuloma with multinucleated giant cells. In conjunction with the high blood concentration of angiotensin-converting enzyme and soluble interleukin-2 receptor, these findings established a diagnosis of sarcoidosis. This is the first report of synchronous occurrence of intracranial germinoma and sarcoidosis. Such coexistence is extremely rare, but we should mind that sarcoidosis can occur with intracranial germinoma.

The Association of Lung Cancer and Sarcoidosis: A Systematic Review

Lung cancer has been the leading cause of cancer-associated deaths worldwide. While numerous reasons, including tobacco smoking, may lead to lung cancer, the purpose of this article was to explore the association between sarcoidosis, a multisystem granulomatous disorder, and lung neoplasms. A literature search was done on multiple databases with appropriate keywords, and the authors selected case reports where patients were diagnosed with sarcoidosis and lung cancer. These reports were analyzed in detail, and nine reports were included in this study. Each case was evaluated for the presenting symptoms, age, gender, and diagnostic procedures, including a follow-up analysis. After the evaluation, it can be concluded that sarcoidosis and lung cancer can occur simultaneously, despite being rare. Appropriate diagnostic procedures, including histopathological examination of the affected lymph nodes, showed either cancerous or non-cancerous cells (granulomas), thus altering the treatment on a case-by-case basis. Being aware of all possible associations between these two diseases could alter the clinical management, whether curative or palliative, and clinicians must rule out metastatic cancer in individuals with sarcoidosis-like clinical and radiographic features.

Sarcoidosis: Various Presentations, Coexisting Diseases and Malignancies

Sarcoidosis is a rare, chronic inflammatory disease with a characteristic non-caseating granuloma formation. It affects women more than men. The lung is the most commonly affected organ, however, extrapulmonary involvement is also seen. Sarcoidosis can affect any organ or tissue and can also involve multiple organs simultaneously. As a disease, it shares clinical symptoms with a variety of autoimmune, non-autoimmune disorders and malignancies. Not only it mimics clinically, but it also coexists with these diseases, posing a significant diagnostic challenge. During this literature review, we obtained data from the previously published PubMed articles within the last five years and reviewed the possible etiological association and clinical coexistence between sarcoidosis and other diseases/malignancies. We aimed to determine the common clinical manifestations, various complex presentations of sarcoidosis and pathophysiological considerations for the association, and to emphasize the link with other diseases, particularly thyroid disorders/malignancies. Physicians should be aware of these associated diseases and should always make a clinical suspicion when confronting a sarcoidosis patient. Thus, a comprehensive diagnostic evaluation for these associated conditions ought to be done in sarcoidosis patients to avoid any delay in the curative treatment for these coexisting diseases and to prevent substandard outcomes.

Thyroid sarcoidosis: a rare entity in the differential diagnosis of thyroid cancer

SUMMARY

We present two cases of thyroid sarcoidosis that were misdiagnosed as thyroid cancer. In the first patient, fine needle aspiration cytology (FNAc) of a suspicious thyroid nodule indicated the presence of papillary thyroid cancer, and the patient underwent thyroid surgery. However, histopathology identified a sarcoid granuloma, without any sign of malignancy. The second patient had a history of papillary microcarcinoma with suspicious lymph nodes diagnosed years after the initial diagnosis and was referred for assessment of cervical lymphadenopathy. Fine needle aspiration cytology (FNAc) of the suspicious lymph nodes erroneously indicated metastasis from thyroid cancer, and lateral modified lymph node dissection was performed, based on FNAc and ultrasonographic features. Histopathology excluded malignancy and identified non-caseating granulomas. Sarcoidosis of the thyroid may have a clinical presentation similar to well-differentiated thyroid carcinoma and, although rare, should be considered in the differential diagnosis, especially when other signs of the disease are already present. In these cases, FNAc provided a false diagnosis of papillary thyroid carcinoma and lymph node metastases that led to unnecessary surgery.

LEARNING POINTS

Sarcoidosis may share clinical and ultrasonographic features with papillary thyroid carcinoma. Fine needle aspiration cytology is helpful in the diagnosis of both conditions; however, the overlapping cytological characteristics may lead to erroneous diagnosis. The present cases illustrate the importance of cytological identification of these difficult cases. Every piece of information provided by the clinician is essential to the cytologist.

Sarcoidosis vs. Colon Cancer Metastasis: Diagnostic Dilemma and the Role of PET Scan in Monitoring Disease Activity

Sarcoidosis is a systemic inflammatory disorder characterized by “noncaseating granulomas.” It primarily affects the lungs, but multiple other organs can be involved. Sarcoidosis has been increasingly reported in association with cancer. It can precede, follow or occur at the same time as the diagnosis of cancer. We report a case of sarcoidosis that was diagnosed concomitantly with colon cancer, highlighting the diagnostic dilemma of sarcoidosis vs. cancer metastasis, the relationship between the two, and the value of PET scan in follow-up and monitoring of disease activity.

Melanoma and Sarcoidosis in Patients Receiving or Not Antineoplastic Therapy

Sarcoidosis and sarcoid-like reactions have been associated with many solid tumors including malignant melanoma. There are reports of melanoma patients who develop sarcoidosis without having received any antineoplastic treatment, but there are also melanoma patients who have received immunotherapy or targeted therapy and, therefore, develop drug-associated sarcoidosis. Herein, we describe 2 cases of thoracic sarcoidosis which occurred in asymptomatic patients with known malignant melanoma. The first patient had metastatic disease, and she was under melanoma treatment with BRAF/MEK inhibitors at the time of sarcoidosis diagnosis. The second case involves a patient with early stage melanoma who had received no antineoplastic treatment. In both cases, the thoracic lesions were suspicious for metastatic involvement, and it was the biopsy which gave the diagnosis of granulomatous disease. Sarcoidosis induced by immune checkpoint or BRAF/MEK inhibitors seems to be more frequent in real-world studies than in large phase 3 melanoma trials. Sarcoidosis can mimic metastasis, predominately in mediastinum, representing a diagnostic pitfall. Therefore, biopsies must always be performed to exclude the metastatic spread before initiation of any antineoplastic treatment.

Diffuse lesions secondary to sarcoidosis mimicking widespread metastatic breast cancer: A case report

This case of sarcoidosis mimicking metastatic breast cancer serves as a reminder of the need to consider differential diagnoses even when the clinical scenario and imaging findings are highly suggestive of metastases.

Sarcoidosis and Cancer: A Complex Relationship

Sarcoidosis is a systemic disease of unknown etiology, characterized by the presence of non-caseating granulomas in various organs, mainly the lungs, and the lymphatic system. Since the individualization of sarcoidosis-lymphoma association by Brincker et al., the relationship between sarcoidosis or granulomatous syndromes and malignancies has been clarified through observational studies worldwide. Two recent meta-analyses showed an increased risk of neoplasia in sarcoidosis. The granulomatosis can also reveal malignancy, either solid or hematological, defining paraneoplastic sarcoidosis. Recent cancer immunotherapies, including immune checkpoint inhibitors (targeting PD-1, PD-L1, or CTLA-4) and BRAF or MEK inhibitors were also reported as possible inducers of sarcoidosis-like reactions. Sarcoidosis and neoplasia, especially lymphoma, can show overlapping presentations, thus making the diagnosis and treatment harder to deal with. There are currently no formal recommendations to guide the differential diagnosis workup between the evolution of lymphoma or a solid cancer and a granulomatous reaction associated with neoplasia. Thus, in atypical presentations (e.g., deeply impaired condition, compressive lymphadenopathy, atypical localization, unexplained worsening lymphadenopathy, or splenomegaly), and treatment-resistant disease, targeted biopsies on suspect localizations with histological examination could help the clinician to differentiate neoplasia from sarcoidosis. Pathological diagnosis could sometimes be challenging since very few tumor cells may be surrounded by massive granulomatous reaction. The sensitization of currently available diagnostic tools should improve the diagnostic accuracy, such as the use of more “cancer-specific” radioactive tracers coupled with Positron Emission Tomography scan.

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.

Pulmonary sarcoidosis masquerading as metastatic cervical cancer: a pitfall in CT scans and positron emission tomography (PET)

Sarcoidosis has been associated with co-existing malignancies in several organs, including the breast and thyroid gland as well as lymphomas. However, the occurrence of sarcoidosis with cervical cancer is rare with only nine previous cases reported in the published literature. We present a case of pulmonary sarcoidosis imitating mediastinal lymph node metastases on the staging CT scan and positron emission tomography imaging. The presence of thoracic lymphadenopathy without any pelvic lymphadenopathy prompted histological confirmation of sarcoidosis on endobronchial ultrasound guided biopsy. Misdiagnosing pulmonary sarcoidosis as metastases would have precluded the patient from receiving the curative treatment and likely resulted in suboptimal outcomes.

Testicular seminoma with a progressing pulmonary nodule and mediastinal lymphadenopathy without retroperitoneal metastasis

INTRODUCTION

Testicular germ cell cancer has a relatively good prognosis even if visceral and/or lymph node metastases are present thanks to chemotherapy. Yet chemotherapy can lead to various adverse events. Therefore, it is crucial to distinguish whether a suspected metastatic disease is metastasis or not.

CASE PRESENTATION

A 33-year-old male visited our hospital to receive subsequent therapy for suspected recurrent seminoma with a progressing pulmonary nodule and mediastinal lymphadenopathy after orchiectomy. The pathological diagnosis of needle aspiration and resected specimen of the several lesions was consistent with epithelioid cell granuloma without caseous necrosis. Based on these findings, the lung and mediastinal lymph node lesions were diagnosed as sarcoidosis.

CONCLUSION

In cases where the simultaneous occurrence of other benign or malignant diseases is suspected, pathological confirmation is necessary for appropriate decision-making.

A red herring, a wild-goose chase, and an unexpected diagnosis of concomitant malignancy and sarcoidosis

A 49-year-old male was evaluated in our hospital for chronic cough, cervical lymphadenopathy, and a testicular mass. As a part of the management, he underwent a cervical lymph node biopsy, which showed metastatic deposits from papillary carcinoma thyroid. Subsequently, he underwent orchidectomy for suspected testicular malignancy, but the biopsy showed discrete granulomatous inflammation consistent with sarcoidosis. This was followed by total thyroidectomy with neck node dissection. Nodal histopathological examination, this time, revealed a single node containing both malignancy and granulomas. Prior to the thyroid surgery, he underwent a mediastinoscopic sampling of the mediastinal nodes, which also showed granulomatous inflammation consistent with sarcoidosis. Sarcoidosis affecting the genitourinary system is a rare entity. The coexistence of sarcoidosis and thyroid malignancy poses a diagnostic challenge. A thorough review of the literature was done, and there are no reports from India on the above association. This is a unique case, which could possibly suggest an association between sarcoidosis and malignancy and highlights the importance of obtaining a tissue diagnosis in such cases.

Concurrent sarcoidal granulomas and melanoma micrometastasis in a sentinel node - a case report

Incidental findings of non-caseating granulomas and metastasis in sentinel lymph nodes are rare but cause clinical challenges. We report a case of coinciding unexpected asymptomatic lymphoid sarcoidosis and a micrometastasis in a sentinel node of a patient, who was newly diagnosed with 2.0 mm thick melanoma on the left calf.

Case Report: Sarcoidosis mimicking head and neck cancer progression

Several case reports have been published describing the coexistence of sarcoidosis and cancer. In the literature, simultaneous occurrence of head and neck cancer and sarcoidosis is rarely reported.

In this paper we present a case of a 42-year-old man with squamous cell carcinoma of the oral cavity, locally advanced, which after surgery and adjuvant radiotherapy developed local persistence and progression in the mediastinal lymph nodes. The patient was submitted to chemotherapy and after a complete response, new suspicious mediastinal and hilar lymph nodes appeared in the thoracic computed tomography (CT) scan and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) scan. To enroll the patient in a clinical trial, the patient underwent mediastinoscopy with mediastinal lymph node dissection. The histopathological findings were consistent with sarcoidosis and no metastatic disease was found. Since the patient had no symptoms and the levels of serum angiotensin converting enzyme were normal, no further pharmacological intervention was done. After 4 years of follow up the patient remains without evidence of cancer.

This case shows that although imagological techniques (CT and FDG-PET scan) are extensively used to assess the tumor response, false-positive cases can occur. Whenever it is possible a biopsy of the suspected metastatic site should always be performed.