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Thomas B. Zanders, DO; Michael Morris, MD, FCCP; Matthew McNeil, MD
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Affiliations: Brooke Army Medical Center Fort Sam Houston, TX,  William Beaumont Army Medical Center El Paso, TX

Correspondence to: Thomas B. Zanders, DO, Brooke Army Medical Center, Pulmonary Critical Care Medicine, 3851 Roger Brooke Dr, San Antonio, TX 78234; e-mail: thomas.zanders@amedd.army.mil


The authors have 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):944. doi:10.1378/chest.09-1013
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To the Editor:

We appreciate the comments made by both Drs. Reich and Marruchella regarding our patient with the synchronous diagnosis of systemic sarcoidosis and lung cancer.1 The focus of our report was to highlight the challenges of correctly staging a patient with a lung malignancy and diffuse lymph node inflammation consistent with sarcoidosis. Sarcoid-like reactions (SLRs) have long been associated with malignancy and are thought to be secondary to an immunogenic response to the cancer cells. The granulomas are typically found adjacent to the tumor or lymphatic drainage route. SLRs have also been reported2,3 with metastatic breast cancer and invasive adenocarcinoma of the colon. In these cases, the patients' mediastinal adenopathy resolved with cancer therapy. Debate remains over an increased risk of malignancy for those patients with sarcoidosis. There have been varying rates of both lung cancer and lymphoma diagnosed in sarcoid patients.46 Clearly our patient's significant tobacco abuse history outweighed any marginal increased malignancy risk from potentially long-standing sarcoidosis.

Our patient demonstrated diffuse tree-in-bud opacities, mediastinal adenopathy, and increased metabolic activity seen on CT/PET scanning. He also had remote inguinal adenopathy that was not sampled. His surgical pathology after adjuvant chemotherapy followed by right upper lobectomy revealed no lymphatic or vascular invasion by his tumor. All 13 lymph nodes sampled during surgery demonstrated noncaseating granulomas without malignant cells; the pulmonary parenchyma not adjacent to the tumor also had diffuse noncaseating granulomas. The findings of mediastinal adenopathy, tree-in-bud opacities, and increased metabolic activity seen on CT/PET scanning remained stable and was present on all subsequent imaging studies. Repeat bronchoscopic lymph node sampling failed to reveal malignant cells. For these reasons, we feel our patient truly does have synchronous diagnoses of sarcoidosis and lung cancer, and not an SLR related to cancer. One should not be persuaded away from a diagnosis of malignancy when noncaseating granulomas are present. Also, one should employ thorough mediastinal lymph node sampling when there is increased lymph node metabolic activity with a known malignancy.

Regarding the temporal sequence of the patient's tumor, it is true the patient had a sizable tumor burden and invasion. He did not undergo routine chest radiographs prior to diagnosis as this is not standard practice for military aviators. Our patient initially presented with thoracic and scapular pain, which prompted the chest radiograph. The doubling time argument and presumed long-standing tumor is not valid. There are numerous reports and personal experiences where a small nodule may “take off,” rapidly enlarge, and become an invasive malignancy.

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]
 
Risbano MG, Groshong SD, Schwarz MI. Lung nodules in a woman with a history of breast cancer. Chest. 2007;132:1697-1701. [PubMed]
 
Malani AK, Gupta C, Singh J, et al. A 63-year old woman with colon cancer and mediastinal lymphadenopathy. Chest. 2007;131:1970-1973. [PubMed]
 
Brinker H. Sarcoidosis and malignancy. Chest. 1995;108:1472-1474. [PubMed]
 
Marschke R. Sarcoid and malignant neoplasm: the Mayo Clinic experience. Sarcoidosis. 1986;3:149-150
 
Seersholm N, Vestbo J, Viskum K. Risks of malignant neoplasm in patients with pulmonary sarcoidosis. Thorax. 1997;52:892-894. [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]
 
Risbano MG, Groshong SD, Schwarz MI. Lung nodules in a woman with a history of breast cancer. Chest. 2007;132:1697-1701. [PubMed]
 
Malani AK, Gupta C, Singh J, et al. A 63-year old woman with colon cancer and mediastinal lymphadenopathy. Chest. 2007;131:1970-1973. [PubMed]
 
Brinker H. Sarcoidosis and malignancy. Chest. 1995;108:1472-1474. [PubMed]
 
Marschke R. Sarcoid and malignant neoplasm: the Mayo Clinic experience. Sarcoidosis. 1986;3:149-150
 
Seersholm N, Vestbo J, Viskum K. Risks of malignant neoplasm in patients with pulmonary sarcoidosis. Thorax. 1997;52:892-894. [PubMed]
 
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