SESSION TYPE: ILD Student/Resident Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Sarcoidosis and lung cancer are not rare conditions but co-existence of the two is rare and poses a diagnostic conundrum. We present this rare phenomenon.
CASE PRESENTATION: Eighty year old female with hypertension was evaluated for 21 pound weight loss over 6 month period, asymptomatic anemia. Computerized tomography of chest, abdomen and pelvis revealed 2.8 cm right upper lobe lung nodule with spiculated margins, other 3mm and 2mm nodules in right upper lobe and lingula respectively, mediastinal and hilar lymphadenopathy but no pelvic or abdominal lymphadenopathy. Trans-bronchial biopsy of right upper lobe lesion showed non-caseating granulomatous inflammation. Mediastinoscopic bilateral lymph node biopsy revealed non-caseating granulomas and thus confirmed diagnosis of sarcoidosis. Steroids were started with transient radiologic improvement but followed by symptomatic pleural effusions. Thoracocentesis revealed malignant cells and Video assisted thoracic surgery revealed numerous pleural, pericardial and diaphragmatic metastases. Biopsy was positive for adenocarcinoma of lung, positive for epidermal growth factor mutation. She was treated with erlotinib with initial decrease in tumor burden but follow-up gallium scan was unchanged. After six months of therapy, tumor burden increased with new metastatic lesions. Currently decision is pending to start crizotinib as opposed to pemetrexed depending on results of anaplastic lymphoma kinase (ALK) test.
DISCUSSION: Link between sarcoidosis and lung cancer has been controversial ever since Brincker and Wilbek’s investigation. Epidemiological studies, linkage analysis provides evidence that sarcoidosis and malignancy may be etiologically related in at least a quarter of cases in which both are present. In our case, initial lung mass and lymph node biopsies were consistent with non caseating granulomatous inflammation but negative for malignant cells. Thoracocentesis six months later showed malignant cells which was confirmed with biopsy of pleural tissue as non small cell adenocarcinoma. This suggests possible consequential rather than synchronous malignancy and this may support the sarcocentric (sarcoid induced malignancy) view point albeit weakly. With this stated, is still does not rule out the oncocentric view that postulates sarcoidosis may present an immunological reaction to dispersal of tumor antigen (sarcoid reaction). Only few cases of lung cancer and sarcoidosis co-diagnosis have been reported and data on course of disease and management is scanty but in most cases the two were managed as if they existed separately.
CONCLUSIONS: Clinicians should be aware of the potential risk of lung malignancy in sarcoid patients where the clinical picture fits.
1) Brincker H, Wilbek E. The incidence of malignant tumours in patients with respiratory sarcoidosis. Br J Cancer 1974; 29: 247-251.
2) Reich MJ. Concurrent sarcoidosis and lung cancer. Chest 2009;136;943.
DISCLOSURE: The following authors have nothing to disclose: Pius Ochieng, Amit Kachalia, Habibur Rahman
No Product/Research Disclosure InformationQueens Hospital Center, Mount Sinai School of Medicine, Jamaica, NY