Sarcoidosis is a chronic, multisystem disease of unknown etiology characterized by nonnecrotizing granulomatous inflammation. Sarcoidosis has been described occurring in conjunction with previous malignancy although any association with gynecological cancer is rare.
A 34 year-old-woman with no significant history, G1P1 was found to have an abnormal pap smear in April 2008. Cervical cone biopsy demonstrated invasive squamous cell carcinoma with adenocarcinoma in situ. Computerized tomography (CT) scan of the chest, abdomen and pelvis showed no evidence of metastatic disease. The patient underwent total laproscopic radical hysterectomy with pelvic lymph node dissection in May 2008. Final pathological stage was T1B1N0MX of poorly differentiated large cell, predominantly non-keratinizing squamous cell carcinoma. No evidence of granulomatous reaction was seen. She did not require any other form of adjuvant therapy. The patient had a CT scan of the chest as a surveillance follow-up in September 2008 which revealed new bulky mediastinal and hilar lymphadenopathy as well as multiple pulmonary nodules. A CT scan of the abdomen and pelvis showed no evidence of recurrence or malignant disease. The patient had no constitutional symptoms and detailed review of symptoms was negative. Physical examination was unimpressive for lymphadenopathy. There was no evidence of joint involvement and or erythema nodosum. PET scan exhibited significant metabolic activity in the lung parenchyma and bilateral hilar and mediastinal lymph nodes, suspicious for metastatic disease. Lymph node biopsies were performed via endobronchial ultrasound guided bronchoscopy and the pathology demonstrated non-caseating granuloma. Due to the extensive size and number of parenchymal nodules a video assisted thoracoscopic surgery (VATS) biopsies were performed that showed multiple non-caseating epitheliod granulomas while acid-fast and fungal stains remains negative. Evaluation for extrapulmonary sarcoidosis was negative. Angiotensin converting enzyme level was elevated at 85 units/litre (N<65). She had mild obstructive physiology on pulmonary function tests. The patient was thus diagnosed with Sarcoidosis with no extrapulmonary involvement and was followed by a repeat CT scan of the chest in January 2009 that showed persistence of the pathologically enlarged mediastinal and hilar lymph nodes, however less prominent. The pulmonary nodules have decreased in size with no treatment.
The development of pulmonary nodules, mediastinal and hilar lymphadenopathy subsequent to resection of neoplasm presents considerable difficulties in differentiating a sarcoid-like reaction from metastatic disease. Although association may be synchronous or metachronous, sarcoidosis usually precedes cancer in vast majority of the cases. Sarcoid-like lesions have been postulated to be due to an immunologic response to the disintegrating tumor antigen. To our knowledge 60 case reports of sarcoidosis and malignancy have been published since 1985, covering a wide variety of tumors such as melanoma, schwannoma, and carcinoma of the breast, thymus, liver and digestive tract. Sarcoidosis has been localized to the tumor area in about 50% of cases, but was multisystemic or pulmonary in the remaining 50%. The interval between the two illness ranges between 2 months to 8 years.
The etio-pathogenesis of sarcoid reaction in lungs and lymph nodes after cancer treatment remains enigmatic. Sarcoid lesions may mimic metastatic disease in patients with malignancy, potentially leading to delayed and/or inappropriate therapy. Histologic examination should always be performed. Fortunately, the prognosis for sarcoidosis is favorable since symptoms often resolve spontaneously or with corticosteroids.
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