Sarcoid-like reaction to malignancy on whole-body integrated 18F-FDG PET/CT: prevalence and disease pattern

Osseous Sarcoid-like Reaction in Sigmoid Colon Cancer Requiring Differentiation from Bone Metastasis: A Case Report

Although sarcoid-like reactions are uncommon in colorectal cancer, they can coexist with other cancers. We herein report a 50-year-old woman with sigmoid adenocarcinoma and osseous sarcoid-like reactions that resembled metastases. Positron emission tomography-computed tomography revealed an uptake in the iliac bone and para-aortic lymph nodes. The depth of invasion indicates non-metastatic lesions. Bone and lymph node biopsies revealed epithelioid non-caseating granulomas with bone trabeculae, resulting in a final diagnosis of pathological T2N2aM0, Stage IIIB. When the expected depth of invasion differs from that of typical bone metastases, colorectal cancer-associated bone lesions should be evaluated for sarcoid-like reactions.

Overlap syndromes in sarcoidosis: Unveiling the masquerader

As a multi system granulomatous disease, clinical presentations of sarcoidosis are highly variable. In the absence of a stereotypical clinical presentation such as asymptomatic bilateral hilar adenopathy, Lofgren's syndrome, or lupus pernio, a diagnosis of sarcoidosis typically requires 1) compatible clinical presentation, 2) histologic evidence of granulomatous inflammation, and 3) the exclusion of other causes. The clinical presentation of sarcoidosis is often nonspecific and a variety of other causes of granulomatous inflammation can make diagnosing sarcoidosis a challenge for clinicians. "Overlap syndromes" are often used to describe clinical presentations of sarcoidosis that share histologic and clinical features of other diseases, or when the diagnosis of sarcoidosis is made in association with the coexistence of another diagnosis with similar clinical or histologic findings. Because of the risk of diagnostic delay and diagnostic errors, it is vital for clinicians to be familiar with overlap syndromes in sarcoidosis. The coexistence of sarcoidosis with other diseases can also significantly impact disease management and outcomes. This article will review the most current published data on overlap syndromes in sarcoidosis to aid clinicians in diagnosing and managing these complex patients.

Intraocular sarcoid-like reaction in patients with chronic lymphocytic leukemia

OBJECTIVE

To investigate the frequency and clinical features of intraocular paraneoplastic sarcoid-like reaction (SLR) in patients with chronic lymphocytic leukemia (CLL).

METHODS

Retrospective review of patients with CLL from January 1, 1980, to December 31, 2020. Eye examinations were searched for 22 keywords suggestive of SLR, and charts were manually reviewed.

RESULTS

Of 4209 unique patients with CLL, 1021 (24%) had at least 1 eye examination on record, and 324 (8%) had 1 or more keyword eye examination findings. After manual review, 12 patients (<1%) were identified as having probable SLR with characteristic features (n = 7), possible but not classic (n = 1), or suspect but less likely (n = 4). All patients (n = 8) with probable or possible SLR were White, and half (n = 4) were male. Intraocular SLR was diagnosed a mean of 49.7 months after the CLL diagnosis (n = 7) or preceded the CLL diagnosis by 1 month (n = 1). Involvement was bilateral in 5 patients, with 13 total affected eyes and mean presenting Snellen visual acuity of 20/50. Common characteristic features on initial examination included vitreous cell (n = 13), anterior-chamber cell (n = 10), keratic precipitates (n = 9), posterior synechiae (n = 6), chorioretinal lesions (n = 5), and vitreous haze (n = 5). Treatment included topical corticosteroids alone (n = 5), with sub-Tenon corticosteroids (n = 1), or with steroid-sparing immunosuppressive agents (n = 1) or oral corticosteroids alone (n = 1). After a mean follow-up of 19.8 months, final mean visual acuity was 20/30.

CONCLUSION

Intraocular SLRs affect fewer than 1% of patients with CLL. SLR should be on the differential diagnosis list for any CLL patient with ocular complaints, and most patients can be managed successfully with corticosteroids.

False Liver Metastasis by Positron Emission Tomography/Computed Tomography Scan after Chemoradiotherapy for Esophageal Cancer-Potential Overstaged Pitfalls of Treatment

In patients with esophageal cancer undergoing neoadjuvant chemoradiotherapy (nCRT), subsequent restaging with F-18-fluorodeoxyglucose (18F-FDG) positron emission tomography-computed tomography (PET-CT) can reveal the presence of interval metastases, such as liver metastases, in approximately 10% of cases. Nevertheless, it is not uncommon in clinical practice to observe focal FDG uptake in the liver that is not associated with liver metastases but rather with radiation-induced liver injury (RILI), which can result in the overstaging of the disease. Liver radiation damage is also a concern during distal esophageal cancer radiotherapy due to its proximity to the left liver lobe, typically included in the radiation field. Post-CRT, if FDG activity appears in the left or caudate liver lobes, a thorough investigation is needed to confirm or rule out distant metastases. The increased FDG uptake in liver lobes post-CRT often presents a diagnostic dilemma. Distinguishing between radiation-induced liver disease and metastasis is vital for appropriate patient management, necessitating a combination of imaging techniques and an understanding of the factors influencing the radiation response. Diagnosis involves identifying new foci of hepatic FDG avidity on PET/CT scans. Geographic regions of hypoattenuation on CT and well-demarcated regions with specific enhancement patterns on contrast-enhanced CT scans and MRI are characteristic of radiation-induced liver disease (RILD). Lack of mass effect on all three modalities (CT, MRI, PET) indicates RILD. Resolution of abnormalities on subsequent examinations also helps in diagnosing RILD. Moreover, it can also help to rule out occult metastases, thereby excluding those patients from further surgery who will not benefit from esophagectomy with curative intent.

Hodgkin Lymphoma: A disease shaped by the tumor micro- and macroenvironment

The tumor microenvironment (TMicroE) and tumor macroenvironment (TMacroE) are defining features of classical Hodgkin lymphoma (cHL). They are of critical importance to clinicians since they explain the common signs and symptoms, allow us to classify these neoplasms, develop prognostic and predictive biomarkers, bioimaging and novel treatments. The TMicroE is defined by effects of cancer cells to their immediate surrounding and within the tumor. Effects of cancer cells at a distance or outside of the tumor define the TMacroE. Paraneoplastic syndromes are signs and symptoms due to effects of cancer at a distance or the TMacroE, which are not due to direct cancer cell infiltration. The most common paraneoplastic symptoms are B-symptoms, which manifest as fevers, chills, drenching night sweats, and/or weight loss. Less common paraneoplastic syndromes include those that affect the central nervous system, skin, kidney, and hematological autoimmune phenomena including hemophagocytic lymphohistiocytosis (HLH). Paraneoplastic signs such as leukocytosis, lymphopenia, anemia, and hypoalbuminemia are prognostic biomarkers. The neoplastic cells in cHL are the Hodgkin and Reed Sternberg (HRS) cells, which are preapoptotic germinal center B cells with a high mutational burden and almost universal genetic alterations at the 9p24.1 locus primarily through copy gain and amplification with strong activation of signaling via PD-L1, JAK-STAT, NFkB, and c-MYC. In the majority of cases of cHL over 95% of the tumor cells are non-neoplastic. In the TMicroE, HRS cells recruit and mold non-neoplastic cells vigorously via extracellular vesicles, chemokines, cytokines and growth factors such as CCL5, CCL17, IL6, and TGF-β to promote a feed-forward inflammatory loop, which drives cancer aggressiveness and anti-cancer immune evasion. Novel single cell profiling techniques provide critical information on the role in cHL of monocytes-macrophages, neutrophils, T helper, Tregs, cytotoxic CD8+ T cells, eosinophils, mast cells and fibroblasts. Here, we summarize the effects of EBV on the TMicroE and TMacroE. In addition, how the metabolism of the TMicroE of cHL affects bioimaging and contributes to cancer aggressiveness is reviewed. Finally, we discuss how the TMicroE is being leveraged for risk adapted treatment strategies based on bioimaging results and novel immune therapies. In sum, it is clear that we cannot effectively manage patients with cHL without understanding the TMicroE and TMacroE and its clinical importance is expected to continue to grow rapidly.

Splenic sarcoid reaction mimicking metastases in patients after uterine cancer surgery: a report of two cases

BACKGROUND

Tumor-associated sarcoid reactions have been observed with various tumors; however, they have not been reported with uterine cancer. We present two cases of splenic sarcoid reactions that mimicked metastases a few years after uterine cancer surgery.

CASE PRESENTATION

Case 1 involved a 67-year-old female patient diagnosed with endometrial cancer (pT1aN0M0, pStage Ia, grade 1). The patient underwent open total abdominal hysterectomy and bilateral salpingo-oophorectomy with pelvic lymphadenectomy. Three years after the initial surgery, computed tomography (CT) and positron emission tomography CT showed multiple splenic masses with increasing numbers and sizes. Splenic metastases were diagnosed, and laparoscopic splenectomy was performed. The histopathological analysis revealed sarcoid reactions in the spleen. Case 2 involved a 47-year-old female patient diagnosed with endometrial cancer (pT1aN0M0, pStage Ia, grade 1). The patient underwent laparoscopic total abdominal hysterectomy and bilateral salpingo-oophorectomy with pelvic lymphadenectomy. Two years after the initial surgery, multiple splenic masses were observed. We performed laparoscopic splenectomy for the splenic metastases. Granuloma formations were identified in the splenic specimen and perisplenic lymph nodes that were removed simultaneously, resulting in a final diagnosis of sarcoid reaction. A review of the lymph nodes at the time of the previous uterine surgery revealed granuloma formation. Other than the presence of splenic masses, no findings suggestive of recurrence were observed in these cases. Uterine cancer and sarcoid reactions progressed without recurrence after splenectomy.

CONCLUSIONS

To the best of our knowledge, this is the first report of the late development of splenic sarcoid reactions after uterine cancer surgery. Sarcoid reactions and metastases are difficult to diagnose based on preoperative imaging results. However, reviewing the specimen at the time of the initial resection, the number of lesions, and the clinical findings (other than imaging findings) may aid in the determination of the correct diagnosis.

FDG PET/CT Imaging of Sarcoidosis

Sarcoidosis is a multisystemic granulomatous disease of unknown etiology. The diagnostic can be made by histological identification of non-caseous granuloma or by a combination of clinical criteria. Active inflammatory granuloma can lead to fibrotic damage. Although 50% of cases resolve spontaneously, systemic treatments are often necessary to decrease symptoms and avoid permanent organ dysfunction, notably in cardiac sarcoidosis. The course of the disease can be punctuated by exacerbations and relapses and the prognostic depends mainly on affected sites and patient management. FDG-PET/CT along with newer FDG-PET/MR have emerged as key imaging modalities in sarcoidosis, namely for certain diagnostic purposes, staging and biopsy guiding. By identifying with a high sensitivity inflammatory active granuloma, FDG hybrid imaging is a main prognostic tool and therapeutic ally in sarcoidosis. This review aims to highlight the actual critical roles of hybrid PET imaging in sarcoidosis and display a brief perspective for the future which appears to include other radiotracers and artificial intelligence applications.

Surgery to Oligometastatic Breast Cancer after Excellent Response to Palbociclib and Letrozole Therapy: Pitfall of Ultrasound Therapeutic Evaluation

A 48-year-old woman with regional recurrences of breast cancer in the axillar and supraclavicular regions was referred to our hospital. Under the diagnosis of recurrent luminal breast cancer with a high Ki-67 labeling index of >30% and a disease-free interval of 13 years, the patient began to receive palbociclib, letrozole, and luteinizing hormone-releasing hormone agonist, resulting in marked response of the supraclavicular lesion and stable disease of the axillar lesion on ultrasound (US) evaluation. Positron emission tomography (PET)/computed tomography of the axillar and supraclavicular foci showed high and no avidities before and after treatment, respectively. The unmovable neck lesion became movable with the treatment. The patient, therefore, underwent surgical resection of the 2 metastatic foci to examine the discordant therapeutic efficacy against the 2 metastatic foci on 2 image modalities, that is, US and PET, and to possibly get a cure of the breast cancer oligometastasis. Pathological examination showed marked fibrosis and scant cancer cell residuals with microcalcifications in the neck tumor and massive sarcoid-like reaction with scant cancer cell residuals in the axillary nodes. The residual cancer cells showed estrogen and progesterone receptor positivities, human epidermal growth factor receptor type 2 negativity, and an extremely low Ki-67 labeling index of 2.5%. The patient recovered uneventfully and has continued palbociclib-containing endocrine therapy for 1 year without any recurrences. Breast oncologists should well understand the basic principles of internal echo formation on US and take the presence of sarcoid-like reaction in the cancer cell clusters into consideration on the therapeutic evaluation of metastatic breast cancer.

Role of diffusion MRI in diagnosis of mediastinal lymphoma: initial assessment and response to therapy

Background

Malignant lymphoma accounts for nearly 20% of all mediastinal neoplasms in adults and 50% in children. Hodgkin’s disease is the most common primary mediastinal lymphoma. In non-Hodgkin’s lymphoma, the two most common forms of primary mediastinal lymphoma are lymphoblastic lymphoma and diffuse large B-cell lymphoma. The aim of this study is to implement diffusion MRI in the algorithm of diagnosis of mediastinal lymphoma, differentiating Hodgkin's from non-Hodgkin's lymphoma and assessment of post therapeutic response.

Results

Using Diffusion weighted magnetic resonance imaging DWI-MRI, there were statistic significant difference between ADC values in lymph nodes and mediastinal masses in Hodgkin and non-Hodgkin lymphomas. ADC range in non-treated Hodgkin lymphoma cases was 0.774 to 1.4, while ADC range in in non-treated non-Hodgkin lymphoma was 0.476 to 0.668. In this study, there was statistically significant difference of ADC values in lymphoma cases presented by mediastinal masses with and without chemotherapy.

Conclusions

Diffusion weighted magnetic resonance imaging DWI-MRI is a promising functional technique in diagnosis of Hodgkin's and non-Hodgkin's lymphoma and assessment of response to treatment with no need for special preparation, contrast injection or radiation exposure.

Atypical sarcoid reaction mimicking recurrence on F-18 FDG PET/CT in a patient with breast malignancy

Malignancy may lead to sarcoidosis, which is referred to as sarcoid reaction. This reaction is believed to be a host immune response to the release of soluble antigens from cancer cells. Studies have shown strong 2'-deoxy-2'-[F-18]fluoro-D-glucose (F-18 FDG) uptake in sarcoid reaction and in true sarcoidosis. Therefore, in patients with malignancy, sarcoid reactions can mimic metastasis or recurrence on F-18 FDG positron emission tomography/computed tomography (PET/CT). Herein, we report the case of a 58-year-old woman with a history of left breast cancer whose FDG PET/CT evaluated at 3 months after adjuvant chemotherapy presented hypermetabolic lymphadenopathy in the right supraclavicular and right mediastinal areas. We interpreted these as metastases because the involved lymph nodes were intensely hypermetabolic and appeared newly. Pathologic evaluation of the excised lymph node revealed noncaseating chronic granulomas without malignant cells, indicating a sarcoid reaction. After appropriate steroid therapy, both the size and metabolic activity of the lymphadenopathy substantially decreased. Most sarcoid reactions present as bilateral hilar and peribronchial lymphadenopathies. Our patient presents an atypical example that a sarcoid reaction can also present in a unilateral pattern, making its diagnosis challenging. When interpreting FDG PET/CT images, considering that the sarcoid reaction pattern can vary is crucial.

PET Imaging for Hematologic Malignancies

Hematologic malignancies are a broad category of cancers arising from the lymphoid and myeloid cell lines. The 2016 World Health Organization classification system incorporated molecular markers as part of the diagnostic criteria and includes more than 100 subtypes. This article focuses on the subtypes for which imaging with positron emission tomography/computed tomography (PET/CT) has become an integral component of the patient's evaluation, that is, lymphoma and multiple myeloma. Leukemia and histiocytic and dendritic cell neoplasms are also discussed as these indications for PET/CT are less common, but increasingly seen in clinic.

Sarcoid-like reaction in a HER2-positive breast cancer patient: A case report

INTRODUCTION AND IMPORTANCE

Sarcoid-like reaction is a systemic granulomatous reaction that may develop in the lymph nodes and organs of cancer patients. Distinguishing a sarcoid-like reaction from metastasis is difficult. Accurate diagnosis of this reaction is key to preventing overtreatment.

CASE PRESENTATION

A 51-year-old woman presented with a lump in her left breast and swollen lymph nodes in her left axilla and infraclavicular fossa. A core biopsy was performed, leading to the diagnosis of grade 2 infiltrating ductal carcinoma, clinical stage T2N3M0 with estrogen and progesterone receptor negativity and human epidermal growth factor receptor-2 positivity. After neoadjuvant therapy, the tumor in her left breast reduced in size, but the lymph nodes remained swollen. Mastectomy and axillary lymph node dissections were performed. In the pathological findings, epithelioid cell granuloma was observed in the lymph nodes. Based on these findings, lymph node swelling was attributed to a sarcoid-like reaction.

CLINICAL DISCUSSION

SLRs have been reported in 4-14% of cancer patients. Although there are various imaging modalities for detecting swollen lymph nodes, the differential diagnosis of cancer metastasis is often difficult.

CONCLUSION

Histological evaluation of swollen lymph nodes is required to prevent overtreatment; especially in cases where the tumor size is reduced by chemotherapy, but the lymph nodes remain swollen.

Sarcoid-Like Reaction in Non-Hodgkin's Lymphoma-A Diagnostic Challenge for Deauville Scoring on 18F-FDG PET/CT Imaging

The sarcoid-like reaction represents an autoinflammatory cause of mediastinal and hilar lymphadenopathy but may also involve other lymph node regions and organs. This rare phenomenon has mainly been reported in patients with Hodgkin’s lymphoma (HL) or solid tumors (particularly melanoma) undergoing immunotherapy and chemotherapy. Cases in non-Hodgkin’s lymphoma (NHL) are very uncommon. We present an uncommon case of a patient with primarily mediastinal diffuse large B-cell lymphoma (DLBCL) who showed a CT-based partial response in interim staging, whereas at end-of-treatment multiple newly enlarged and hypermetabolic mediastinal and bilateral hilar lymph nodes were detected by ¹⁸F-FDG PET/CT imaging. A subsequent histological workup determined a sarcoid-like reaction without any lymphomatous tissue. Therefore, sarcoid-like reactions should be considered as a potential pitfall in Deauville staging with ¹⁸F-FDG PET/CT imaging for patients with NHL.

PET/CT Variants and Pitfalls in Liver, Biliary Tract, Gallbladder and Pancreas

A wide variety of pathological anomalies may occur in the liver, biliary system, and pancreas. It is a necessity to use many different imaging techniques in order to distinguish such varied pathologies, especially those from malignant processes. Positron Emission Tomography/Computed Tomography (PET/CT) is an imaging method that has proven its diagnostic value in oncology and can be used for different clinical purposes. Fluoro-18 fluoro-2-deoxy-D-glucose has a wide range of uses as a dominant radiopharmaceutical in routine molecular imaging, however, molecular imaging has started to play a more important role in personalized cancer treatment in recent years with new Fluoro-18 and Gallium-68 labeled tracers. Although molecular imaging has a strong diagnostic effect, the surprises and pitfalls of molecular imaging can lead us to unexpected and misleading results. Prior to PET/CT analysis and reporting, information about possible technical and physiological pitfalls, normal histological features of tissues, inflammatory pathologies, specific clinical features of the case, treatment-related complications and past treatments should be evaluated in advance to avoid misinterpretation. In this review, the physiological and pathophysiological variants as well as pitfalls encountered in PET/CT imaging of the liver, biliary tract, gallbladder, and pancreas will be examined. Other benign and malignant pathologies that have been reported to date and that have led to incorrect evaluation will be listed. It is expected that the devices, software, and artificial intelligence applications that will be developed in the near future will enable much more effective and faster imaging that will reduce the potential causes of error. However, as a result of the dynamic and evolving structure of the information obtained by molecular imaging, the inclusion of the newly developed radiopharmaceuticals in routine practice will continue to carry new potentials as well as new troubles. Although molecular imaging will be the flagship of diagnostic oncology in the 21st century, the correct analysis and interpretation by the physician will continue to form the basis of achieving optimal performance.

Sarcoidosis-Like Cancer-Associated Granulomatosis: Characteristics and a Case-Control Comparison with Sarcoidosis

(1) Background: Systemic granulomatosis developed in a context of malignancy has already been reported. Our objective was to describe the clinical, radiological, functional, biological, and evolutive characteristics of sarcoidosis-like cancer-associated granulomatosis (SLCAG) and to compare them to those of sarcoidosis. (2) Methods: 38 patients with a biopsy-proven SLCAG developed after a diagnostic of malignancy were included. The control group consisted of sarcoidosis patients matched for age, sex, and radiologic stage. Clinical, biological, physiological, radiological, and outcome data were collected. (3) Results: The mean age of SLCAG patients was 51 ± 14 years. They were diagnosed within 15 ± 14 months of the cancer diagnosis (breast cancer most frequently). All SLCAG patients presented a thoracic involvement, extrathoracic locations were observed in 32% of subjects. SLCAG was more often asymptomatic than sarcoidosis (p < 0.0001). During follow-up, systemic treatment was less often required in SLCAG than in sarcoidosis (58% vs. 32%, p = 0.04 respectively) and SLCAG were characterized by a significantly less severe progression profile according to the Sarcoid Clinical Activity Classification, with a complete recovery more frequent at 5 years (p = 0.03). (4) Conclusion: This case-control study shows that SLCAG differs from sarcoidosis with a significantly more benign course. These results might argue for true differences in the physiopathology, which remain to be elucidated.

Hepatocellular carcinoma with regional lymphadenopathy caused by sarcoid-like reaction: a case report

BACKGROUND

Sarcoid-like reaction (SLR) is a histological pattern of granulomatous inflammation that is clinically differentiated from sarcoidosis. Since SLR is known to occur in several neoplasias and occasionally causes lymphadenopathy and mimics metastatic malignancy, it needs to be considered whether lymphadenopathy is due to metastasis or SLR for the choice of cancer treatment. Few cases of hepatocellular carcinoma (HCC) with SLR have been reported. Here, a case of HCC with lymphadenopathy diagnosed as SLR without metastasis is presented.

CASE PRESENTATION

A 69-year-old woman was admitted to our hospital because of upper abdominal pain. She tested positive for hepatitis C virus ribonucleic acid. Imaging modalities showed an 81 × 65-mm-sized tumor with multiple nodules in segment 3 and a 17 × 12-mm-sized tumor in segment 5 with a common HCC enhancement pattern. In addition, a lymph node in the hepatoduodenal ligament was enlarged at 13 mm in size, suggesting the metastasis of HCC. Hepatectomy of the lateral segment and segment 5 and lymph node dissection in the hepatoduodenal ligament were performed. Both tumors in segments 3 and 5 were pathologically diagnosed as HCC without vessel invasion. The tumors contained necrotic cells and epithelioid cell granulomas with multinucleated giant cells, which is typically observed in sarcoidosis. The dissected lymph nodes also contained epithelioid cell granulomas, as well as giant cells with asteroid bodies. There was no malignancy in the lymph nodes. The pathological findings suggested the coexistence of malignancy and sarcoidosis. However, since the patient did not show any typical findings of pulmonary or cardiac sarcoidosis, the case was diagnosed as HCC with SLR in the primary lesion and regional lymph nodes.

CONCLUSIONS

SLR needs to be considered in the differential diagnosis when a cancer patient develops lymphadenopathy. However, lymphadenopathy due to SLR is indistinguishable from that due to metastasis even when using multiple imaging modalities. Pathological examinations may be helpful for the diagnosis.

Spectrum of [18F]FDG-PET/CT Findings in Benign Lymph Node Pathology

Diffuse lymphadenopathy has a long differential diagnosis that includes both malignant and benign causes. As part of the lymphadenopathy work-up, many patients undergo [¹⁸F]FDG-PET/CT for purposes of ruling out malignancy. FDG-avid lymph nodes, however, are not specific for malignancy. This review will illustrate the spectrum of nodal findings on FDG-PET/CT with correlation to other cross-sectional imaging and clinical history in patients with representative infectious, inflammatory, and benign lymphoproliferative disorders. These findings are important for the nuclear medicine radiologist to understand, as they can represent common pitfalls in the work-up of lymphadenopathy. While FDG-PET/CT may be limited in ascertaining a definitive diagnosis in a disease process as the cause of lymphadenopathy, it can help to narrow this differential and rule out certain diseases in the correct clinical context.

Therapy-Related Imaging Findings in Patients with Sarcoma

Knowledge of imaging findings related to therapy administered to patients with sarcoma is pivotal in selecting appropriate care for these patients. Imaging studies are performed as surveillance in asymptomatic patients or because symptoms, including anxiety, develop. In addition to detection of recurrent disease and assessment of response to therapy, diagnosis of conditions related to therapy that may or may not need treatment has a marked positive impact on quality of life. The purpose of this review is to assist radiologists, nuclear physicians, and others clinicians involved in the diagnosis and treatment of these patients in recognizing imaging findings related to therapy and not to activity of the previously treated sarcoma. Imaging findings are time dependent and often specific in relation to therapy given.

Granulomatous lung disease: clinical aspects

INTRODUCTION

Granulomatous lung diseases (GLD) are heterogeneous group of diseases that can be broadly categorized as infectious or noninfectious. This distinction is extremely important, as the misdiagnosis of a GLD can have serious consequences. In this manuscript, we describe the clinical manifestations, histopathology, and diagnostic approach to GLD. We propose an algorithm to distinguish infectious from noninfectious GLD.

AREAS COVERED

We have searched PubMed and Medline database from 1950 to December 2019, using multiple keywords as described below. Major GLDs covered include those caused by mycobacteria and fungi, sarcoidosis, hypersensitivity pneumonitis, and vasculidities.

EXPERT OPINION

The cause of infectious GLD is usually identified through microbiological culture and molecular techniques. Most noninfectious GLD are diagnosed by clinical and laboratory criteria, often with exclusion of infectious pathogens. Further understanding of the immunopathogenesis of the granulomatous response may allow improved diagnosis and treatment of GLD.

Paraneoplastic ocular sarcoidosis in the setting of recurrent rectal carcinoid tumor diagnosed by F18-fluorodeoxyglucose PET CT

Purpose

Nuclear medicine imaging can provide a noninvasive means of distinguishing inflammatory mass lesions from oncologic intraocular tumors.

Observation

We report a case of paraneoplastic ocular sarcoidosis with choroidal mass lesions that was initially concerning for choroidal metastasis of a primary carcinoid tumor. PET CT was utilized with two different tracers to characterize the choroidal mass as being FDG-avid, consistent with a sarcoid-like lesion, and lacking the Gallium (Ga-68) DOTATAE uptake of carcinoid tumor metastases.

Conclusions and Importance

Functional imaging is valuable to distinguish clinically similar inflammatory verses oncologic intraocular pathology.

Overlap Syndromes in Sarcoidosis: Clinical Features and Outcomes

Sarcoidosis is a multisystem inflammatory disease characterized by noncaseating granulomatous inflammation. While pulmonary sarcoidosis is most common, extrapulmonary involvement occurs in 50 to 74% of patients and can be the presenting abnormality in some patients. The diagnosis of sarcoidosis is based on a compatible clinical presentation in combination with granulomas on histology and exclusion of other causes. However, the absence of a diagnostic biomarker for sarcoidosis, in addition to the overlap of granulomatous inflammation and nonspecific clinical findings with other diseases, often results in a delayed diagnosis. Sarcoidosis overlap syndromes are typically described when sarcoidosis is diagnosed in the presence of another disease (concurrently or sequentially) with shared clinical and histologic features, or when sarcoidosis presents with clinical features typically observed in, but not diagnostic of, other diseases. Awareness of overlap syndromes is important for clinicians to avoid diagnostic errors and evaluate for concomitant diagnoses that may impact the management and outcome of sarcoidosis. This article is intended to provide an overview of these presentations and the most commonly associated diseases, with attention to their prevalence, clinical features, and reciprocal impacts on disease outcomes.

Long-term outcomes of clinical and pathological-staged T3 N3 esophageal cancer

Locally advanced esophageal cancer is associated with poor long-term survival. Pre- and post-treatment stages may differ because of neoadjuvant therapy and inaccuracies in staging. The aim of this study was to determine the outcomes of patients staged with clinical T3 N3 and pathological T3 N3 carcinoma of the esophagus and determine differences between the groups. Consecutive patients from a single unit between 2010 and 2018 were included with either clinical (cT3 N3) or pathological (pT3 N3) esophageal cancer. Outcomes were compared between patients that underwent esophagectomy with or without neoadjuvant treatment and those patients staged cT3 N3 treated non-surgically (NSR). Patients were staged using the TNM 8. This study included 156 patients, 63 patients were staged cT3 N3 initially and had NSR treatment, only three of these had radical treatment. Of the remaining 93 patients who underwent esophagectomy, 34 were initially staged as cT3 N3, 54 were found to be pT3 N3 having been staged earlier initially, and five were unchanged before and after treatment. Median overall survival (OS) for surgical cT3 N3 patients was significantly longer than pT3 N3 and NSR (median: NR vs 19 vs 8 months, P < 0.001). Twenty-seven patients with cT3 N3 had lower staging following treatment, while three had a higher stage. T3 N3 disease carries a poor prognosis. Within this cohort, cT3 N3 disease treated surgically has a high 5-year OS suggesting possible over-staging and stage migration due to neoadjuvant therapy. Those not having surgery, have a dismal prognosis. The impact of neoadjuvant treatment cannot be predicted and, current staging modalities may be inaccurate. Clinical stage should be used with caution when counseling patients regarding management and prognosis.

Sarcoid-like reaction in lymphadenopathy associated with superficial esophageal squamous cell carcinoma

Correctly distinguishing metastasis and sarcoid-like reaction in patients with mediastinal lymphadenopathy is clinically important in esophageal cancer. A patient was a 52-year-old Japanese woman with superficial esophageal squamous cell carcinoma and rare case of sarcoid-like reaction. The patient was admitted with pharyngeal discomfort and an upper gastrointestinal endoscopy detected a superficial tumor in the middle thoracic esophagus. Biopsy confirmed a diagnosis of squamous cell carcinoma. Chest computed tomography (CT) showed enlarged lymph nodes around the trachea and in the bilateral hilum of the lung that were found to accumulate label on positron emission tomography CT. One course of chemotherapy in 5-fluorouracil, docetaxel and cisplatin did not affect the lymphadenopathy, which suggested that it was reactive rather than metastatic. The patient had undergone thoracoscopic esophagectomy with lymph node dissection. The pathohistology of the dissected lymph nodes showed noncaseating epithelioid-cell granuloma and no malignant cells. No clinical findings indicative of systemic sarcoidosis were observed, leading to a diagnosis of sarcoid-like reaction with the esophageal cancer. The patient has survived without recurrence for 4 years after beginning the initial treatment. Monitoring the response to chemotherapy may be helpful in distinguishing between metastasis and sarcoidosis-associated lymphadenopathy in esophageal cancer.

FDG-PET/CT Assessment of Pulmonary Sarcoidosis: A Guide for Internists

BACKGROUND

18F-fluorodeoxyglucose positron emission tomography integrated with computed tomography (18-F-FDG-PET/CT) is getting wide consensus in the diagnosis and staging of neoplastic disorders and represents a useful tool in the assessment of various inflammatory conditions.

DISCUSSION

Sarcoidosis is an uncommon disease characterized by the systemic formation of noncaseating granulomas. Lungs are the sites most often affected, and investigation with high resolution computed tomography and biopsy is essential to achieve a correct diagnosis. 18-F-FDGPET/ CT is effective in the assessment of pulmonary sarcoidosis by demonstrating pulmonary and extrathoracic involvement and findings correlate well with pulmonary function in patients affected.

CONCLUSION

This review would illustrate the usefulness and limits of 18-F-FDG-PET/CT in the assessment of pulmonary sarcoidosis.

18F-FDG PET/CT of Multiorgan Sarcoid-Like Reaction During Anti-PD-1 Treatment for Melanoma

We report a case of a 50-year-old woman treated with anti-PD-1 inhibition for metastatic melanoma. During treatment, extensive and transient histopathologically confirmed sarcoid-like reaction was detected in multiple organ systems and at different time points using F-FDG PET/CT imaging. Immune-related adverse events during anti-PD-1/PD-L1 antibody treatment are increasingly being reported. This case report emphasizes the broad spectrum of possible presentations of sarcoid-like reaction detected by F-FDG PET/CT and its evolution in time. For the clinician, awareness of these immune-related adverse events helps to accurately interpret findings on imaging.

Pulmonary lymphangitic carcinomatosis without concurrent liver metastasis from colon cancer detected using 18F-FDG PET/CT: A case report

RATIONALE

The infiltration of tumor cells to pulmonary lymphatic system, as known as pulmonary lymphangitis carcinomatosis (PLC), is a rare presentation of pulmonary metastases.

PATIENT CONCERNS

We reported a case of a 66-year-old man after surgery, chemotherapy, and radiation therapy for colon cancer. Two months after these therapies, the patient complained of nonproductive cough for 1 week.

DIAGNOSES

18F-fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) scanning revealed increased FDG uptake along the thickened bronchovascular bundles, in bilaterally scattered ground-glass opacities and in mediastinal lymphadenopathy. The transbronchial biopsy and pathological study confirmed the diagnosis of PLC.

INTERVENTIONS

Antineoplastic treatment (cetuximab) were administered after the patient was diagnosed with PLC.

OUTCOMES

The patient died of respiratory failure within 3 months after the onset of his symptom.

LESSONS

18F-FDG PET/CT play an important role in identifying PLC, in selecting possible biopsy sites, and in accessing the extent of metastatic disease.

Unusual Imaging Findings Associated with Germ Cell Tumors

Germ cell tumors, because they contain immature and mature elements, can differentiate into different tissue types. They can exhibit unusual imaging features or manifest in a syndromic fashion. The authors describe these features and assign them to one of the following categories: (a) unusual manifestations of metastatic disease (growing teratoma syndrome, choriocarcinoma syndrome, ossified metastases, and gliomatosis peritonei); (b) autoimmune manifestations (sarcoidlike reaction and paraneoplastic syndromes); (c) endocrine syndromes (sex hormone production, struma ovarii, and struma carcinoid); or (d) miscellaneous conditions (ruptured dermoid cyst, squamous cell carcinoma arising from a mature teratoma, Currarino triad, fetus in fetu, pseudo-Meigs syndrome, and pancreatitis). Rare conditions associated with germ cell tumors demonstrate characteristic imaging findings that can help lead to the appropriate diagnosis and management recommendations. When evaluating for potential metastatic disease, alternative benign diagnoses should be considered (eg, growing teratoma syndrome, ossified metastases, ruptured dermoid cyst, gliomatosis peritonei, and sarcoidlike reaction), which may impact management. Germ cell tumors may also lead to life-threatening complications such as extensive hemorrhage from choriocarcinoma metastases or the rupture of mature teratomas, cases in which timely diagnosis is crucial. Autoimmune and endocrine manifestations such as paraneoplastic encephalitis, autoimmune hemolytic anemia, and hyperthyroidism may occur owing to the presence of germ cell tumors and can create a diagnostic dilemma for clinicians. Knowledge of the syndromic and unusual imaging findings associated with germ cell tumors helps guide appropriate management. ^©RSNA, 2019.

Sarcoid-like reaction associated with lung adenocarcinoma: A case report

A 71-year-old woman with a history of left lower lobe lobectomy 4 years ago for adenocarcinoma of the lung presented with new mediastinal and bilateral hilar lymphadenopathy on surveillance imaging, suspicious for disease recurrence. She underwent an endobronchial ultrasound-guided transbronchial needle aspiration of the lymph nodes and histology yielded non-necrotizing epithelioid granulomas with no evidence of malignancy. A diagnosis of sarcoid-like reaction associated with lung adenocarcinoma was made. The significance of this rare condition is discussed.

A nonrandom association of sarcoidosis in patients with gastrointestinal stromal tumor and other sarcomas

In patients with sarcoma, concomitant malignancy is found in 1.2% -2.5% of cases. Previous studies have demonstrated conflicting results in terms of positive or negative effects on cancer prognosis with comorbid sarcoidosis. Additionally, there are no data determining whether an association between sarcoidosis and sarcomas exists. Finding an association between the two entities could prevent inadvertent upstaging of a primary sarcoma based on pulmonary nodularity mistaken for metastatic disease. Here, we will describe eight sarcoma patients with concomitant occurrence of sarcoidosis identified since 2007. Eight patients with diagnosis of both sarcoma and sarcoidosis were identified over the period of 2007 -2016 at a single sarcoma center. Clinical and historical data including presentation, histology, treatment, and outcome was tabulated for analysis. The standardized incidence ratio was calculated for the state of Florida and our hospital catchment area. We compared the observed incidence to the expected incidence if the two entities were to be unrelated. Sarcoma subtype was gastrointestinal stromal tumor in five patients, the remaining three cases were unclassified spindled and epithelioid cell sarcoma, uterine leiomyosarcoma, and myxofibrosarcoma. Sarcoidosis was diagnosed before sarcoma in three patients, after sarcoma in four patients, and at the same time of sarcoma diagnosis in one patient. From our series, three patients have shown no progression of sarcoma, two are alive with sarcoma, two died due to progression of sarcoma, and one was lost to follow up. Statistical analyses showed a standardized incidence ratio of 305 (95% confidence interval: 131 -556) for the state of Florida and standardized incidence ratio of 950 (95% CI: 407 -1727) for our catchment area. This case series points to a statistically robust, nonrandom association between sarcoma and sarcoidosis that has not been previously described. Presumed metastatic sarcoma should be considered for biopsy particularly with demographic characteristics or imaging features suggestive of sarcoidosis.

Sarcoidosis from Head to Toe: What the Radiologist Needs to Know

Sarcoidosis is a multisystem granulomatous disorder characterized by development of noncaseating granulomas in various organs. Although the etiology of this condition is unclear, environmental and genetic factors may be substantial in its pathogenesis. Clinical features are often nonspecific, and imaging is essential to diagnosis. Abnormalities may be seen on chest radiographs in more than 90% of patients with thoracic sarcoidosis. Symmetric hilar and mediastinal adenopathy and pulmonary micronodules in a perilymphatic distribution are characteristic features of sarcoidosis. Irreversible pulmonary fibrosis may be seen in 25% of patients with the disease. Although sarcoidosis commonly involves the lungs, it can affect virtually any organ in the body. Computed tomography (CT), magnetic resonance imaging, and positron emission tomography/CT are useful in the diagnosis of extrapulmonary sarcoidosis, but imaging features may overlap with those of other conditions. Familiarity with the spectrum of multimodality imaging findings of sarcoidosis can help to suggest the diagnosis and guide appropriate management. ©RSNA, 2018.

Sarcoidosis and colon cancer: a possible association

Sarcoidosis is a multisystem inflammatory disease characterized by non-caseating granulomas which mainly affect the pulmonary lymphatic system and lungs; although any organs can be interested. The association between sarcoidosis and cancer is still controversial, but many studies demonstrated an increased risk of cancer in patients with sarcoidosis, whereas few cases of sarcoidosis occurring after cancer have been reported. This report outlines and describes clinical, biologic and radiologic features of 3 patients with a history of surgical treatment and adjuvant chemotherapy for colon cancer, followed by a diagnosis of sarcoidosis some years later. The history of cancer and the lymph nodes positivity found through PET scan induced us to hypothesize a relapsing cancer disease. However, this hypothesis was not confirmed by the lymph nodes biopsy, which is the core method of diagnosis of sarcoidosis. (Sarcoidosis Vasc Diffuse Lung Dis 2018; 35: 376-380).

Multidisciplinary approach and long-term follow-up in a series of 640 consecutive patients with sarcoidosis: Cohort study of a 40-year clinical experience at a tertiary referral center in Barcelona, Spain

Cohort studies of large series of patients with sarcoidosis over a long period of time are scarce. The aim of this study is to report a 40-year clinical experience of a large series of patients at Bellvitge University Hospital, a tertiary university hospital in Barcelona, Spain. Diagnosis of sarcoidosis required histological confirmation except in certain specific situations. All patients underwent a prospective study protocol. Clinical assessment and follow-up of patients were performed by a multidisciplinary team.From 1976 to 2015, 640 patients were diagnosed with sarcoidosis, 438 of them (68.4%) were female (sex ratio F/M 2:1). The mean age at diagnosis was 43.3 ± 13.8 years (range, 14-86 years), and 613 patients (95.8%) were Caucasian. At diagnosis, 584 patients (91.2%) showed intrathoracic involvement at chest radiograph, and most of the patients had normal pulmonary function. Erythema nodosum (39.8%) and specific cutaneous lesions (20.8%) were the most frequent extrapulmonary manifestations, but there was a wide range of organ involvement. A total of 492 patients (76.8%) had positive histology. Follow-up was carried out in 587 patients (91.7%), over a mean of 112.4 ± 98.3 months (range, 6.4-475 months). Corticosteroid treatment was administered in 255 patients (43.4%), and steroid-sparing agents in 49 patients (7.7%). Outcomes were as follows: 111 patients (18.9%) showed active disease at the time of closing this study, 250 (42.6%) presented spontaneous remission, 61 (10.4%) had remission under treatment, and 165 (28.1%) evolved to chronic sarcoidosis; among them, 115 (19.6%) with mild disease and 50 (8.5%) with moderate to severe organ damage. A multivariate analysis showed that at diagnosis, age more than 40 years, the presence of pulmonary involvement on chest radiograph, splenic involvement, and the need of treatment, was associated with chronic sarcoidosis, whereas Löfgren syndrome and mediastinal lymphadenopathy on chest radiograph were indicators of good outcome.Sarcoidosis is a multisystem disease with protean clinical-radiographic manifestations. Although almost half of patients follow a spontaneous resolution or under treatment, a significant number of them may have several degrees of organ damage. This study emphasizes the value of a multidisciplinary approach and long-term follow-up by specialized teams in sarcoidosis.

Granulomatosis after autologous stem cell transplantation in nonHodgkin lymphoma - experience of single institution and a review of literature

Background

Sarcoidosis before and after treatment of malignancy is an important differential diagnosis that has to be distinguished from lymphoma.

Patients and methods

Hodgkin lymphoma, diffuse large B-cell lymphoma and aggressive follicular lymphoma are being staged and treatment effect is evaluated with PET-CT. We report three cases of aggressive lymphoma after high dose therapy and autologous stem cell transplantation with positive lymph nodes on PET-CT, which were histologically diagnosed as sarcoidosis/granulomatosis. In the literature, we found that false positive lymph nodes were more common after allogeneic than after autologous transplantation.

Conclusions

Post-treatment PET-CT positive lymph nodes should always be examined histologically prior to any further treatment decision to avoid unnecessary toxic procedures.

A case of sarcoidosis diagnosed by positron emission tomography/computed tomography

Sarcoidosis is a multisystem granulomatous disorder of unknown cause which may affect any organ or system but primarily involve the lungs and the lymphatic system. Extrapulmonary sarcoidosis represents approximately 30-50% of patients. We report the case of a 51-year-old female who presented with increasing complaints of a cough, weakness, weight loss, and chest pain and who was found to have a suspicious lesion on thorax computed tomography(CT). Fluorodeoxyglucose (FDG) positron emission tomography/CT performed for diagnostic purposes demonstrated increased FDG accumulation at the bilateral enlarged parotid and lacrimal gland and in the reticulonodular infiltration area located in the left lung as well as multiple lymphadenopathies with increased FDG accumulation. There were also hepatosplenomegaly and splenic uptake. Skin biopsy showed noncaseating granulomas, and the patient was diagnosed as stage 2 sarcoidosis.

How are cancer and connective tissue diseases related to sarcoidosis?

PURPOSE OF REVIEW

Several studies have suggested an association between sarcoidosis and cancer, and between sarcoidosis and connective tissue diseases (CTDs). In this review, we discuss the evidence supporting and refuting these associations.

RECENT FINDINGS

In terms of a cancer risk in sarcoidosis patients, the data are somewhat conflicting but generally show a very small increased risk. The data supporting an association between sarcoidosis and CTD are not as robust as for cancer. However, it appears that scleroderma is the CTD most strongly associated with sarcoidosis.

SUMMARY

There are several important clinical and research-related implications of the association of sarcoidosis and CTDs. First, rigorous efforts should be made to exclude alternative causes for granulomatous inflammation before establishing a diagnosis of sarcoidosis. Second, the association between sarcoidosis and both cancer and CTDs may yield important insights into the immunopathogenesis of all three diseases. Finally, these data provide insight in answering a common question asked by sarcoidosis patients, 'Am I at an increased risk of developing cancer?' We believe that although there is an increased (relative) risk of cancer in sarcoidosis patients compared with the general population, that increased risk is quite small (low absolute risk).

[Association of lymphoma and granulomatosis: A case series]

PURPOSE

The sarcoidosis-lymphoma syndrome is a recognised entity. However, the presence of granulomas in patients with a haematological disease should not lead too easily to a diagnosis of sarcoidosis. The presence of granulomatous lesions during the follow-up of these patients raises diagnostic and therapeutic issues.

METHODS

We included 25 patients followed by the department of haematology in a French hospital (Centre Léon-Bérard). These patients presented with granulomatous lesions. Patients with a history of sarcoidosis were excluded. We report the type of haematological disease, the time of onset of the granulomatous disease compared to that of lymphoma, associated symptoms, aetiology and outcome. Patients were divided into three groups according to the time of onset of the granulomatous lesions.

RESULTS

Granulomatous lesions appeared before the haematological disease in 4 cases, was concomitant in 8 cases and appeared later in 13 remaining cases. The two main subtypes of lymphoma encountered were: diffuse large cell lymphoma (36%) and Hodgkin's lymphoma (28%). Granulomatous lesions were related to the progression of the hematological disease in 11 cases, to sarcoidosis in 4 cases, to infection in 3 cases, to drug allergy in one case, to inflammatory bowel disease in one case, to granuloma annulare in one case and was isolated in 4 cases (no identified etiology). In the group where granulomas appeared after the haematological disease, mean SUV was 11 for the haematological disease versus 6.4 for granulomas.

CONCLUSION

Granulomatous diseases in lymphomas can be due to various aetiologies: infection, reaction to the haematological disease, or systemic sarcoidosis. It is an important challenge for clinicians, who can miss the diagnosis of lymphoma and or conclude to a treatment failure or a relapse. Computed tomography scan (CT-scan) or (18)F-deoxyglucose-positron emission tomography scan can help establish a diagnosis but do not replace biopsy.