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Correspondence |

Sarcoidosis or Sarcoid Reaction? FREE TO VIEW

Almerico Marruchella, MD, FCCP
Author and Funding Information

Istituto Nazionale per le Malattie Infettive “L. Spallanzani” Rome, Italy

Correspondence to: Almerico Marruchella, MD, FCCP, Istituto Nazionale per le Malattie Infettive, Respiratory Endoscopy Unit, Via Portuense 292, Roma 00149, Italy; e-mail: almx@libero.it


The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(3):943-944. doi:10.1378/chest.09-0472
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To the Editor:

In the February 2009 issue of CHEST, McNeill and coworkers1 reported on the association of sarcoidosis and non-small cell lung cancer in a middle-aged man and discussed the clinical roles of CT scanning, PET scanning, endoscopic ultrasound fine-needle aspiration, and transbronchial needle aspiration in mediastinal staging. The relationship between sarcoidosis and cancer is intriguing, and epidemiologic studies2 have produced inconclusive results. Moreover nonnecrotizing granulomas have been described in patients with many types of malignancy (eg, lymphoma, testicular cancer, head and neck cancer, gastric cancer, renal cancer, and breast cancer). Granulomas have been found surrounding the primary tumor (3 to 7% of cases) or in the draining lymph nodes (4.4% of cases)3 and probably reflect an immune response to tumor antigens. Many authors refer to this finding as sarcoid reaction. On the other hand, true sarcoidosis is a multisystem granulomatous disease mainly involving the lung and mediastinal nodes. The diagnosis requires a compatible clinicoradiologic picture, the demonstration of nonnecrotizing granulomas, and the exclusion of other causes of granulomatous inflammation.

In this interesting case,1 the diagnosis of sarcoidosis was based on the presence of granulomas in the right upper lobe near the lung cancer and in the mediastinal nodes, which were associated with 18-fluorodeoxyglucose uptake in two abdominal nodes. The authors did not report signs or symptoms consistent with systemic involvement, so the PET scan findings for the extrathoracic lymph nodes are not easily explainable. Furthermore, a chest CT scan did not show a nodular pattern with a lymphangitic distribution, which is the typical parenchymal lesion in the lung, and a PET scan revealed “numerous subcentimeter pulmonary nodules.”

I think that the available data, taken together, support a probable diagnosis of true sarcoidosis, but a tumor-associated sarcoid reaction should be taken into account. It would be important to know the histopathologic features corresponding to the pulmonary nodules pointed out by the PET scan and whether they were bilateral. Finally, the follow-up testing of mediastinal and abdominal adenopathies following tumor resection could help to better define the nature of the association between granulomatous inflammation and cancer in this case.

McNeill M, Zanders TB, Morris MJ. A 49-year-old man with concurrent diagnoses of lung cancer, sarcoidosis, and multiple regions of adenopathy on positron emission tomography. Chest. 2009;135:546-549. [PubMed] [CrossRef]
 
Shigemitsu H. Is sarcoidosis frequent in patients with cancer? Curr Opin Pulm Med. 2008;14:478-480. [PubMed]
 
American Thoracic Society, European Respiratory Society, World Association of Sarcoidosis and Other Granulomatous Disorders Statement on sarcoidosis: joint statement of the American Thoracic Society (ATS), the European Respiratory Society (ERS) and the World Association of Sarcoidosis and Other Granulomatous Disorders (WASOG) adopted by the ATS Board of Directors and by the ERS Executive Committee, February 1999. Am J Respir Crit Care Med. 1999;160:736-755. [PubMed]
 

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McNeill M, Zanders TB, Morris MJ. A 49-year-old man with concurrent diagnoses of lung cancer, sarcoidosis, and multiple regions of adenopathy on positron emission tomography. Chest. 2009;135:546-549. [PubMed] [CrossRef]
 
Shigemitsu H. Is sarcoidosis frequent in patients with cancer? Curr Opin Pulm Med. 2008;14:478-480. [PubMed]
 
American Thoracic Society, European Respiratory Society, World Association of Sarcoidosis and Other Granulomatous Disorders Statement on sarcoidosis: joint statement of the American Thoracic Society (ATS), the European Respiratory Society (ERS) and the World Association of Sarcoidosis and Other Granulomatous Disorders (WASOG) adopted by the ATS Board of Directors and by the ERS Executive Committee, February 1999. Am J Respir Crit Care Med. 1999;160:736-755. [PubMed]
 
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