Hodgkin's disease with a granulomatous pulmonary presentation mimicking sarcoidosis

Renal sarcoidosis

Renal sarcoidosis (RS) is a rare form of sarcoidosis that results in granulomatous inflammation of renal parenchyma. We describe the epidemiology, pathogenesis, clinical features, diagnostic approach, treatment strategies and outcomes of this condition. RS occurs most commonly at the time of initial presentation of sarcoidosis but can at any time along the course of the disease. The most common presenting clinical manifestations of RS are renal insufficiency or signs of general systemic inflammation. End-stage renal disease requiring dialysis is a rare initial presentation of RS. The diagnosis of RS should be considered in patients who present with renal failure and have either a known diagnosis of sarcoidosis or have extra-renal features consistent with sarcoidosis. A renal biopsy helps to establish the diagnosis of RS, with interstitial non-caseating granulomas confined primarily to the renal cortex being the hallmark pathological finding. However, these histologic findings are not specific for sarcoidosis, and alternative causes for granulomatous inflammation of the renal parenchyma should be excluded. Corticosteroids are the drug of choice for RS. Although RS usually responds well to corticosteroids, the disease may have a chronic course and require long-term immunosuppressive therapy. The risk of progression to ESRD is rare.

The role of mediastinoscopy in the diagnosis of non-lung cancer diseases

BACKGROUND

Mediastinoscopy is a good method to evaluate mediastinal lesions. We sought to determine the current role of mediastinoscopy in the investigation of non-lung cancer patients with mediastinal lymphadenopathy.

MATERIALS AND METHODS

We retrospectively reviewed clinical parameters (age, gender, histological diagnosis, morbidity, mortality) of all patients without lung cancer who consecutively underwent mediastinoscopy in Hospital of Faculty of Medicine of Dicle University between June 2003 and December 2016.

RESULTS

Two-hundred twenty nine patients without lung cancer who underwent mediastinoscopy for the pathological evaluation of mediastinum during the study period were included. There were 156 female (68%) and 73 male (32%) patients. Mean age was 52.6 years (range, 16 to 85 years). Mean operative time was 41 minutes (range, 25 to 90 minutes). Mean number of biopsies was 9.3 (range, 5 to 24). Totally, 45 patients (19.6%) had previously undergone a nondiagnostic bronchoscopic biopsy such as transbronchial needle aspiration or endobronchial ultrasound-guided transbronchial needle aspiration. Mediastinoscopy was diagnostic for all patients. Diagnosis included sarcoidosis (n=100), tuberculous lymphadenitis (n=66), anthracosis lymphadenitis (n=44), lymphoma (n=11) metastatic carcinoma (n=5), and Castleman's disease (n=1); there was a diagnosis of silicosis in one patient and tymoma in one patient. Neither operative mortality nor major complication developed. The only minor complication was wound infection which was detected in three patients.

CONCLUSION

Although newer diagnostic modalities are being increasingly used to diagnose mediastinal diseases, mediastinoscopy continues to be a reliable method for the investigation of mediastinal lesions.

Sarcoid reaction: a rare occurrence associated to colon adenocarcinoma (case report and literature review)

Granulomatous reactions are related to infectious and non infectious diseases, but more rarely, granulomas may occur in association to malignancies. The presence of sarcoid-like granulomas in lymph nodes draining malignant tumors is an uncommon but well known occurrence. However, their presence in the stroma of malignant tumors is much rarer. We have only found two previous cases reported in the Japanese and English literature. In this study we report a well differentiated adenocarcinoma of the right colon associated to a stromal granulomatous sarcoid-like reaction. Lymph nodes were not involved. The patient had a clinical history of tuberculosis treated 15 years ago, but there was no clinical, histomorphological, immunohistochemical or molecular evidence of disease at the moment of these findings. We have reviewed the literature to find the keys and the diagnostic challenges posed by granulomatous sarcoid-like reaction occurring in lymph nodes draining malignant neoplasms, peritumoral stroma and in other organs far from the primary tumor. The diagnosis of granulomatous sarcoid-like reactions associated to malignancies can be challenging and it can only be made after ruling out specific infectious and non infectious causes of granulomatous inflammation. The mechanisms involved in granuloma formation, their relationship with demographic and histopathological features, their possible association with autoimmune disorders, their cytokine profile and, more importantly, their prognostic significance in each type of tumor are still unclear and require studies with larger number of patients.

Malignant and benign lymphoid lesions of the lung

Lymphoid lesions of the lung produce a complex of problems for the practicing pathologist. Although these lesions are eventually referred to hematopathologists, it is still the general surgical pathologist who first encounters them and confronts the problem of formulating an initial diagnosis. Over the last 20 years there has been a revolution in our knowledge of the classification and natural history of the pulmonary lesions, a plethora of information which warrants a thorough review. The purpose of this discussion is to report the clinical features and courses, pathologic features and, when known, etiologies or pathogenesis of the major "primary" pulmonary lymphoid lesions and present a brief approach to differential diagnosis. I will divide the lesions into malignant and benign, discussing each in turn.

Pulmonary sarcoidosis

Pulmonary sarcoidosis is one of the most common causes of idiopathic interstitial lung disease. Clinical presentation can range from asymptomatic to respiratory failure. Although some patients never require therapy, many patients with pulmonary sarcoidosis become symptomatic enough to require therapy. Treatment options include corticosteroids.In the past few years, alternatives to corticosteroids have been developed,especially for patients with a chronic condition.

Sarcoidosis

There have been several new insights into the cause and treatment of sarcoidosis. Studies of genetic variation have shown that specific genetic polymorphisms are associated with increased risk of disease or affect disease presentation. These polymorphisms include variation of MHC and cytokines such as tumour necrosis factor (TNF). Not all investigators have come to the same conclusion, suggesting an interaction of various factors, including the patient's ethnic origin. Treatment of sarcoidosis varies considerably. Patients with symptomatic disease for more than 2-5 years have been of particular interest. Corticosteroids remain the standard of care in such cases, but immunosuppressive drugs have proved steroid-sparing in many patients. New agents, including pentoxifylline, thalidomide, and infliximab have proved useful in selected cases. The effectiveness of these agents seems to lie in their ability to block TNF, especially in the treatment of chronic disease.

A case of resectable lung adenocarcinoma associated with sarcoidosis

A 71-year-old woman with uveitis was referred to our hospital for further examination of the possible underlying diseases. In roentgenological examination with plain X-ray and CT scan, hilar and mediastinal lymphadenopathy and a mass shadow in the right upper lung field was observed, whereas fibrotic changes were not obvious in both lung fields. Transbronchial lung biopsy with fiberoptic bronchoscope revealed granulomatous interstitial pneumonia. CD4-positive lymphocytes were increased in bronchoalveolar lavage. The patient was diagnosed as having sarcoidosis. Subsequently, right upper lobectomy was performed, and Stage I lung adenocarcinoma was diagnosed. The patient is under follow up without medication and the disease has been stable for two years. A relationship between epithelioid granulomatosis and malignant diseases is discussed and a review of the literature is given. Since it is still controversial as to the incidence of malignant diseases in sarcoidosis patients, it is important to accumulate data on these associations.

Mediastinoscopy in patients with presumptive stage I sarcoidosis: a risk/benefit, cost/benefit analysis

STUDY OBJECTIVE

To determine whether persons with asymptomatic bilateral hilar lymphadenopathy (ABHL) and normal results of a physical examination should be observed with a presumptive diagnosis of stage 1 sarcoidosis (S1S) (ABHLps), its most frequent cause, or undergo mediastinoscopy to avoid overlooking an alternative diagnosis (AD) requiring treatment.

DESIGN

We surveyed the English-language medical literature to estimate the proportion of persons with tuberculosis (TB), Hodgkin's disease (HD), and non-Hodgkin's lymphoma (NHL) who present with ABHL and calculated the number of mediastinoscopies required to identify each AD by computing the following ratio: incidence S1S/incidence of each AD presenting as ABHL (I(S1S)/I[ABHL-AD]). Risks of mediastinoscopy and benefits of earlier ascertainment of AD were derived from the published literature. Cost estimates were based on institutional charges. We conducted a regional survey of practicing pulmonologists to ascertain their diagnostic preferences.

RESULTS

We estimate that if 33,000 persons with ABHL underwent mediastinoscopy, 32,982 (99.95%) would be found to have S1S or, very rarely, a disorder not requiring intervention; 407 would require hospitalization for complications at a cost in excess of $1 million; and 204 would experience major morbidity; 8 persons with TB, 9 with HD, and 1 with NHL would be identified at a cost of $100 to $200 million. The benefit for persons diagnosed as having AD would be minimal and likely offset by the procedural mortality. Seventy percent of pulmonologists responding to the survey favored observation over transbronchial lung biopsy or mediastinoscopy in patients with ABHL.

CONCLUSION

A policy of continued observation of patients presenting with ABHL is preferable to diagnostic mediastinoscopy from both the risk/benefit and cost/benefit standpoint.

Benign proliferative lesions mimicking recurrence of Hodgkin's disease

Salvage treatment in patients with recurrent Hodgkin's disease is more effective when tumor burden is minimal. That is why more intensive follow-up strategies, including frequent imaging tests, have been recently developed for the detection of early relapse. However, as screening procedures become more sensitive, there is an increasing risk of false-positive results, demonstrating nonmalignant proliferative disorders. We describe three young patients who had lymphocyte-predominant or mixed-cellularity Hodgkin's disease and were in clinical complete remission for 2.5-3 years after a combined treatment with chemotherapy and radiation. Imaging tests revealed new gallium-avid lymphadenopathy in the chest in two cases. Pathologically enlarged pelvic lymph nodes were identified in another case, after a diagnosis of recurrent disease in axilla. Those findings were interpreted as relapse, and the patients underwent thoracotomy and laparotomy, respectively, for histologic confirmation. The results showed progressively transformed germinal centers and sarcoid-like lesions, two benign proliferative disorders. When patients with Hodgkin's disease in remission show new lymphadenopathy, even with positive gallium scan, it seems mandatory to obtain tissue for histologic examination, even through invasive procedures such as laparotomy and thoracotomy, to avoid wrong diagnosis and unnecessary treatment.

Sarcoidosis following chemotherapy for Hodgkin's disease

A case report describing persistent paratracheal lymphadenopathy after doxorubicin, bleomycin, vinblastin, and dacarbazine (ABVD) chemotherapy for a patient with Hodgkin's disease (HD) is presented. Mediastinoscopy and biopsy of the paratracheal lymph nodes showed non-caseating granulomas characteristic of sarcoidosis. The authors discuss the relationship between sarcoidosis and HD and hypothesize that the development or progression of sarcoidosis in a patient with HD is a potential consequence of chemotherapy. Two possible mechanisms are proposed. The first includes the immunosuppressive effect of chemotherapy and the second implicates the influence of a specific chemotherapy agent, bleomycin, which is known to have relatively higher lymph node, skin and lung tissue concentrations than other agents included in the ABVD regimen, and a predilection for those tissues that are prone for the development of sarcoidosis. With the incidence of sarcoidosis exceeding that of HD for the general population, the authors emphasize the importance of considering the presence of sarcoidosis in the differential diagnosis of patients who do not respond radiographically to HD chemotherapy.