SESSION TITLE: Diffuse Lung Disease Global Case Reports
SESSION TYPE: Global Case Report Poster
PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM
INTRODUCTION: Mediastinal lymphadenopathy and pulmonary nodules in advanced cancer patients are likely to be assumed as metastases. Sarcoidosis appears as FDG-avid lesions in oncologic patients and needs to be differentiated from disseminated malignancies. Our goal is to be aware of development of sarcoidosis after antineoplastic therapy to avoid erroneus diagnosis with FDG-PET/CT scan
CASE PRESENTATION: Our patient is a 60-year-old woman presented with a tumor in her left breast (Endocrine receptor negative and HER2 positive). After being diagnosed with invasive ductal carcinoma, she underwent chemotherapy (Docetaxel-Carboplatin-Trastuzumab 6 cycles) followed by left mastectomy and axillary lymph node dissection. Mediastinal and hilar lymph nodes were not noticed that time. Follow-up revealed no recurrence for one year after therapy, but enlarged mediastinal and hilar lymph nodes were subsequently detected by a CT scan. She was referred for a FDG-PET/CT scan because recurrence was suspected. On the FDG-PET/CT scan, there were multiple abnormal uptakes in the bilateral mediastinal and bilateral hilar nodes. Due to the suspicion of metastases, malignant lymphoma, or the less probable sarcoidosis, an EBUS-TBNA was performed, sampling right and left lower paratracheal (4R/4L) and subcarinal (7) stations. Histological analysis of the biopsies taken from the lymph nodes displayed sarcoidosis, showing a non-caseating granulomatous inflammation without evidence of tumor recurrence. Since the patient did not suffer from any respiratory symptoms, her sarcoidosis was untreated. Chemotherapy treatment was not necessary as it initially was thought.
DISCUSSION: Although the relationship between sarcoidosis and malignancies is controversial, sarcoidosis develops frequently in oncologic patients. FDG-PET/CT scan is a useful tool in managing a malignancy and assessing the extent of the organ involvement of sarcoidosis. The differential diagnosis for newly developed multiple FDG-avid lesions in mediastinal lymph nodes, apart from malignancy, includes sarcoidosis, lymphoma and infectious diseases such as mycosis. PET/CT scan identifies the organs that are candidates for diagnostic biopsy and does not distinguish between disseminated malignancies and granulomatous diseases. Since the characteristics of hilar FDG uptake in patients with granulomatous disease can be similar to those in patients with metastatic disease, a biopsy is recommended. EBUS-TBNA has emerged as a powerful and minimally invasive procedure with high specificity to diagnose sarcoidosis.
CONCLUSIONS: Our case highlights the importance of non-malignant differential diagnosis in patients with prior malignancies and the need for histological evaluations, even though there is an intensive FDG uptake in PET/CT scan. A pattern of hypermetabolic mediastinal and hilar lymphadenopathy could indicate the presence of sarcoidosis, rather than metastasis, even in patients with a known malignancy.
Reference #1: Kim HS, Lee SY, Oh SC, Choi CW, Kim JS, Seo JH. Case Report of Pulmonary Sarcoidosis Suspected to be Pulmonary Metastasis in a Patient with Breast Cancer. Cancer Res Treat. 2014;46(3):317-21.
Reference #2: Waanders F, Hengel P, Krikke A, Wesseling J, Nieboer P. Sarcoidosis mimicking metastatic disease: a case report and review of the literature. Neth J Med. 2006 Oct;64(9):342-5.
Reference #3: Dragoumis DM, Tsiftsoglou AP, Assimaki AS. Pulmonary sarcoidosis simulating metastatic breast cancer. J Can Res Ther. 2008;4:134-6
DISCLOSURE: The following authors have nothing to disclose: María José Bernabé Barrios, Gema Rodríguez Trigo, Celia Pinedo Sierra, Mariara Calderón Alcalá, José Luis Álvarez-Sala Walther, José Luis Marugán Guijo, María Jesús Fernández Aceñero, Marta García García-Esquinas
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