Breast Cancer and Sarcoidosis: Case Series and Review of the Literature

Hematologic and Oncologic Aspects of Sarcoidosis: Some of the Least Studied but Most Common Dilemmas

The hematologic system is frequently involved in sarcoidosis. Lymphopenia is the most common hematologic manifestation noted, although anemia and thrombocytopenia also occur. The etiology of these common manifestations can be direct granulomatous infiltration of bone marrow, lymph nodes, or spleen or related to immunologic dysfunction. Although not life threatening, these problems can lead to cytopenias requiring close monitoring in patients receiving a variety of disease treatments. The relationship between sarcoidosis and malignancy remains complex. However, some sarcoidosis patients are at increased risk for the development of malignancies, particularly lymphomas and gastrointestinal cancers. Conversely, cancer patients can experience an increase in the likelihood for the development of breast cancer and lymphomas.

Hypermetabolic Pulmonary and Mediastinal Lesions With Elevated Cancer Antigen (CA) 15-3 and CA 27-29 in a Patient With a History of Ovarian and Breast Cancer

Breast cancer affects around 13% of women. Breast cancer gene 1 (BRCA1) carriers are prone to lung and lymph node metastasis, while breast cancer gene 2 (BRCA2) carriers tend to have bone metastasis. Findings of pulmonary nodules, mediastinal lymphadenopathy, and elevated markers such as cancer antigen (CA) 15-3 and CA 27-29 suggest metastatic disease. Here, we present the case of a patient with BRCA1-positive breast cancer in remission and a history of ovarian cancer with mediastinal lymphadenopathy and pulmonary nodules, with avid fluorodeoxyglucose uptake on positron emission tomography (PET) scan and elevated CA 15-3 and CA 27-29. A 70-year-old female with a history of bilateral breast and ovarian cancer and a positive BRCA test presented with pulmonary nodules, mediastinal lymphadenopathy, and elevated CA 15-3 and CA 27-29. Imaging showed mediastinal and hilar lymphadenopathy. A PET scan revealed increased metabolic activity in the lymph nodes and pulmonary lesions. Fiberoptic bronchoscopy and endobronchial ultrasound lymph node sampling demonstrated granulomatous inflammation without malignant cells. The patient underwent a therapeutic trial of steroids with clinical improvement of symptoms and decreased hypermetabolic activity in chest lesions, as well as a decrease in tumor markers. The coexistence of sarcoidosis and breast cancer is rare; sarcoidosis can coexist, precede, or appear after breast cancer. In both conditions, tumor markers and PET avidity are seen, which makes diagnosis and management challenging. In case of ambiguity, biopsy is crucial. This case underscores the importance of integrating clinical, pathological, and imaging data to reach an accurate diagnosis and consider a therapeutic trial of steroids. Furthermore, the early PET response to treatment can be pivotal in differentiating between sarcoidosis and malignancy, especially in complex clinical scenarios. Proper differentiation is paramount to avoid therapeutic missteps and ensure appropriate patient management.

Sarcoid-like reaction in patients with malignant tumors: Long-term clinical course and outcomes

Background

The development of non-caseating epithelioid cell granulomas in cancer patients who do not fulfill the systemic sarcoidosis criteria is termed sarcoid-like reaction (SLR). Little is known about this condition's natural course and impact on the prognosis of malignancy. We aimed to investigate the natural course and prognostic value of cancer-associated SLR.

Methods

Clinical data were retrospectively analyzed in 32 patients with biopsy-proven cancer-associated SLR. Among patients with non-small cell lung cancer (NSCLC), SLR cases (n = 8) were matched with non-SLR cases (n = 78) for survival analysis.

Results

Among the included patients, the mean age was 59.7 years, and 68.8% were female. The median follow-up period was 35.6 months [interquartile range (IQR): 14.0–61.4 months]. Of all the included malignancies (n = 32), breast cancer (25.0%) and NSCLC (25.0%) were the most common, with stage I being the most frequent tumor stage (59.4%). During follow-up, SLR progression to overt sarcoidosis was not observed. In the 28 patients with available follow-up computed tomography images (median interval: 24.9 months; IQR: 14.4–41.7), 4 patients received corticosteroids (n = 4), resulting to a decrease of SLR lesions. Meanwhile, among those who did not receive treatment (n = 24), the extent of SLR decreased or did not change in 85.7% of them, whereas 3.6% had increased SLR extent. Furthermore, among patients with NSCLC, SLR was not associated with overall survival [hazard ratio (HR) = 1.28, 95% confidence interval (CI): 0.02–67.71, P = 0.882] and recurrence of malignancy (HR = 1.27, 95% CI 0.21–7.51, P = 0.793) in the Cox proportional hazard regression model.

Conclusions

During the follow-up of cancer-related SLR, we found no further evidence for systemic sarcoidosis, and most of the lesions decreased or did not change. Development of SLR was also not associated with overall survival or disease-free survival in patients with NSCLC.

A Rare Case of Sarcoidosis Involving Male Breast Tissue

Sarcoidosis is a multisystem, inflammatory granulomatous disease that rarely involves breast tissue. The pathophysiology of this chronic granulomatous condition is not well understood but is thought to be multifactorial, involving environmental influences causing an amplified immune response. A key histomorphology feature in sarcoidosis is the presence of non-necrotizing granulomas. In this case, we report a 41-year-old African-American man with a known history of sarcoidosis of the lung who presented with gynecomastia and bilateral breast tenderness with palpable nodules. Subsequent biopsy and microscopic examination of the breast nodules revealed diffuse involvement with non-necrotizing granulomas in both breasts. A final diagnosis of extensive sarcoidosis involving breast tissue was rendered after excluding other causes of non-necrotizing granulomas. The patient underwent a bilateral mastectomy to remove the breast nodules. This case discusses sarcoidosis involving an unusual site.

Sarcoidosis Presenting as Late Seroma Mimicking Breast Implant-Associated Anaplastic Large Cell Lymphoma

ABSTRACT

Late seroma related to breast silicone implants is a rare complication. Interest for its characterization has grown after its association with the recently described breast implant-associated anaplastic large cell lymphoma. The differential diagnosis includes infectious diseases, mechanical and traumatic causes, tumors, postpartum seroma, and inflammatory, allergic, or idiopathic causes.Sarcoidosis has been associated with breast silicone implants over the last decades, but it has never been reported as a cause of breast effusion. We describe a rare presentation of sarcoidosis as a late breast implant seroma simulating the clinical features and radiologic findings of breast implant-associated anaplastic large cell lymphoma and highlight that sarcoidosis can be suspected by the presence of nonnecrotizing epithelioid granulomas in the cytology, with a characteristic inverted ratio of CD4/CD8 T cells.The aims of this article are to review the current evidence about sarcoidosis related to silicone implants and breast cancer, provide a new alternative in the differential diagnosis of late seroma, and advise the scientific community how early implant removal can improve the disease.

Sarcoidosis and maligancy: the chicken and the egg?

PURPOSE OF REVIEW

There is a complex interaction between sarcoidosis and malignancy. Since tumors can elicit a granulomatous reaction, the presence of granulomas alone is insufficient to diagnose sarcoidosis in a patient with cancer. In addition, check point inhibitors can also lead to a granulomatous reaction which can be misdiagnosed as sarcoidosis. These issues need to be considered when exploring the relationship between sarcoidosis and malignancy. Despite these limitations, a growing amount of evidence supports the potential interaction of sarcoidosis and malignancy.

RECENT FINDINGS

Several large epidemiologic studies of patients from Europe, the USA, and Japan reveal an increased relative risk for cancer in sarcoidosis patients. The highest relative risks are seen in patients with lymphoma and breast cancer. New criteria have been developed to standardize the diagnosis of sarcoidosis, which should further clarify the association.

SUMMARY

The diagnosis of sarcoidosis may precede or occur after malignancy. In a sarcoidosis patient with an atypical lesion, such as a breast mass, a biopsy should be considered.

Pulmonary sarcoidosis masquerading as metastatic breast cancer: a case report

Pulmonary lesions on imaging are presumed to be metastatic lesions in patients with breast cancer. Here, we report an interesting case of a 63-year-old lady with breast carcinoma showing pulmonary lesions on imaging suggestive of pulmonary metastases. Detailed evaluation of pulmonary lesions confirmed the presence of co-existing pulmonary sarcoidosis. Modern diagnostic methods like 18-flurodeoxyglucose positron emission tomography (18-FDG PET) are unable to clearly differentiate metastatic disease from granulomatous diseases like sarcoidosis. Thus, histological confirmation is needed for accurate staging and determining response to treatment and rarely, in non-responders, detecting any co-existing disease. This case emphasizes the need for detailed histopathological examination of lymph nodes in patients with non-responsive disease or recurrent disease despite adequate chemotherapy.

Breast sarcoidosis: Clinical features, imaging, and histological findings

Breast sarcoidosis is an extremely rare entity (about 1%). Conventional imaging significantly contributes to the detection of breast lesions, but it has been unable to establish a definite diagnosis. Histological examination should be mandatory, over imaging assessments, in order to confirm an early diagnosis and to avoid unjustified treatments. Malignancy should be excluded as a primary differential diagnosis. However, in the presence of granulomas, it is important to recognize other granulomatous disorders such as tuberculosis, Wegener's granulomatosis, or idiopathic granulomatous mastitis, since therapeutic strategies differ. This report clarifies the current clinical assessments and differential diagnosis of breast sarcoidosis.

Sarcoidosis and breast cancer: A retrospective case series

Background

Sarcoidosis and breast cancer co-incidence is reported in the literature in the form of case reports.

Aim

To describe our experience from a single large sarcoidosis clinic.

Methods

Retrospective chart review of 1000 sarcoidosis cases seen in our clinic from 2003 to 2008.

Results

429/1000 female sarcoidosis cases were identified. Among them 20/429 had a history of sarcoidosis and breast cancer. In 12/20 breast cancer preceded sarcoidosis by 52 months, in 4/20 sarcoidosis preceded breast cancer by 200 months and in 4/20 they presented concurrently. Mean age of sarcoidosis diagnosis was 53.9 (±12.4) years. Majority were of European decent (16/20), 3 were African-Americans and 1 Asian. Scadding radiography stages distribution was (n) 4/11/3/2/0 for stages 0/I/II/III/IV respectively. They had 3.4 (±1.3) organs involved, mainly with intrathoracic involvement. 10/20 were asymptomatic and 11/20 received chronic treatment. Compared to 409 cases of sarcoidosis sine breast cancer (mean age 46.7 ± 13.1), sarcoidosis-breast cancer cases had sarcoidosis diagnosed at a significantly later age (p = 0.01). Histological diagnosis applied in all co-incidence cases, in 5 via mediastinoscopy.

Conclusions

Older females with breast cancer may develop sarcoidosis, with features indistinguishable from stand-alone sarcoidosis. When sarcoidosis is suspected histological diagnosis is mandatory.

[Adenopathy and mammary carcinoma: It is sometimes in the details that one encounters hypersensitivity pneumonitis!]

INTRODUCTION

Hypersensitivity pneumonitis (HP) is an interstitial lung disease due to an immunological reaction to exposure, by inhalation, to a large variety of antigens. The patho-physiological mechanism remains poorly understood. The diagnosis can be challenging and requires a detailed medical history taking especially when the clinical presentation is atypical or when the causal agent remains unknown.

CASE REPORT

We report the case of a 75-year-old woman with a history of mammary carcinoma who presented with recently identified intramammary adenopathy. Biopsy of the adenopathy revealed non-necrotising, giant cell epithelioid granuloma. A diagnosis of hot tub lung with extra-pulmonary granulomatous lymph node involvement was made based on the clinical, functional, radiological and microbiological investigations. The evolution was favorable following antigen avoidance.

CONCLUSION

Extrapulmonary lymph node involvement is rare in HP, suggesting a systemic inflammatory involvement.

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.

Case Report: Sarcoidosis in the lymph nodes of a breast cancer patient

Background: Sarcoidosis is an inflammatory disease that affects multiple organs in the body, especially the lungs and lymph nodes. The coexistence of sarcoidosis and breast cancer has been reported, but the coexistence of both diseases in the same patient often leads to misdiagnosis.

Case: We report a case of a 36-year-old woman who presented with concerns of a lump in her left breast along with pain and discharge from the nipple. On examination a 3-cm hard and tender mass was noted in the upper medial quadrant of the left breast with no palpable axillary lymph nodes.

The patient was diagnosed with an infiltrating ductal cell carcinoma of the left breast with T2N0M1 Stage IV disease, due to positive mediastinal lymphadenopathy on positron emission tomography scan. The biopsy of mediastinal lymph nodes allowed us to diagnose sarcoidosis and correctly stage her disease as T2N0M0 Stage IIA breast cancer. The patient underwent lumpectomy followed by adjuvant chemo radiotherapy and hormonal therapy - corticosteroids given for sarcoidosis up to 1 year. The patient is doing well 18 months later without recurrence of disease.

Conclusion: The simultaneous occurrence of both diseases in the same patient is the risk for misdiagnosis and mismanagement, therefore it is of utmost importance to correctly stage the disease with appropriate investigations and histologic confirmation prior to initiate the treatment for breast cancer.

Emerging phenotypes of sarcoidosis based on 18F-FDG PET/CT: a hierarchical cluster analysis

Objectives: In sarcoidosis, the definition of organ involvement with traditional means appears laborious and somewhat controversial, and phenotyping by the above overlapping. ¹⁸F-FDG PET/CT defines disease extent by activity more precisely, and may result in a better understanding of sarcoidosis disease behavior and phenotypes expression. We hypothesized that ¹⁸F-FDG PET/CT could add in the phenotyping of sarcoidosis patients by unveiling in detail sites of involvement even in clinically and physiologically silent disease.Methods: This study was designed to investigate the role of ¹⁸F-FDG PET/CT in phenotyping sarcoidosis using cluster analysis by adding this new means in the routine work-up of 195 sarcoidosis patients of a single academic center.Results: ¹⁸F-FDG PET/CT succeeded to identify despite the random distribution of the disease, an ordered stratification into 4 phenotypes: I) thoracic nodal hilar-mediastinal, II) thoracic nodal hilar-mediastinal and lungs, III) an extended thoracic and extra-thoracic only nodal phenotype including inguinal-abdominal-supraclavicular stations, and IV) all the above plus systemic organs and tissues such as muscles-bones-spleen and skin.Conclusion: Though further studies are necessary to confirm findings as patterns of disease behavior; the proposed phenotypes may prove useful in the design of future studies with homogeneous cohorts facilitating in sarcoidosis patients a personalized medicine approach.

Cardiac sarcoidosis in a patient with testicular seminoma

Sarcoidosis is a multisystem disorder characterised by non-caseating granulomas that typically affect the lungs, skin and lymph nodes. Sarcoidosis has been associated with various cancers, and we describe the case of a patient with systemic sarcoidosis associated with testicular seminoma. This was originally diagnosed as stable sarcoid-like reaction. He subsequently presented with ventricular tachycardia. Cardiovascular MRI suggested cardiac sarcoidosis, which was confirmed by myocardial biopsy. This case highlights the association between some types of cancer and sarcoidosis. In addition, it highlights the importance of close follow-up for patients with a history of malignancy to monitor for sarcoid-like reactions and sarcoidosis, which are often difficult to differentiate clinically.

Concurrent Diagnoses of Cutaneous Sarcoidosis and Recurrent Metastatic Breast Cancer: More than a Coincidental Occurrence?

Sarcoidosis is a rare, chronic, multisystem disease of unknown aetiology, characterised by non-caseating epithelioid cell granulomas. Its association with internal malignancy, in particular haematological cancers has been strongly documented in the literature, while its link with solid organ malignancies is less extensively reported. We present an atypical case of cutaneous sarcoidosis occurring in association with breast cancer recurrence in a 49-year-old female. Physician recognition of this link between sarcoidosis and internal malignancy is vital because many cases of sarcoidosis in association with neoplasia present initially, or even exclusively, with cutaneous sarcoidal lesions that may precede the development of cancer by several years, or as in our case, present as a cutaneous marker of concomitant underlying malignancy. Our case highlights the importance of age-appropriate cancer screening in additional to a routine work-up for systemic sarcoidosis in a patient with cutaneous sarcoidosis.