Sarcoidosis with bone involvement mimicking metastatic disease at (18)F-FDG PET/CT: problem solving by diffusion whole-body MRI

Radiographical bony lesions after discontinuation of immunosuppressant therapy: bone involvement in sarcoidosis

We describe a patient who had failed renal transplant after 13 years, eventually requiring a graft nephrectomy and discontinuation of immunosuppressive therapy, including antithymocyte globulin, tacrolimus and mycophenolate while on steroid avoidance protocol. Within a few months of complete discontinuation of the immunosuppressive medications, she developed lower back pain associated with numbness in her right anterolateral thigh. The radiological imaging demonstrated multiple bony lesions throughout her axial and appendicular skeleton with normal pulmonary findings. A computerised tomography-guided bone biopsy from the left iliac crest revealed fragments of bone with granulomatous inflammation, thus making the diagnosis of extrapulmonary sarcoidosis. Initiating treatment with prednisone resulted in near-complete resolution of symptoms. Long-term immunosuppressive therapy is administered to all renal transplant recipients to help prevent acute rejection and loss of renal allograft. This case highlights that immunosuppressants can conceal the presence of underlying conditions in transplant patients.

Imaging Plays a Key Role in the Diagnosis and Control of the Treatment of Bone Sarcoidosis

Sarcoidosis is a multisystem granulomatous disease of unknown origin. The most frequent localizations are thoracic lymph nodes and/or parenchymal lung disease, nevertheless any other organ may be involved. Musculoskeletal sarcoidosis, previously considered a rare manifestation of the disease, is presently recognized with increasing frequency, due to the development of modern imaging modalities. The classical X-ray sign of bone sarcoidosis is the image of lace in the phalanges of the hands. Most other locations present with atypical radiological images. Therefore, they may mimic metastatic neoplastic disease, especially when they are the first sign of sarcoidosis not previously recognized. On such occasions, none of the imaging methods will give the correct diagnosis, histopathological verification, monitoring of lesions or clinical data in a patient with confirmed sarcoidosis are indicated. The article summarizes the current status of knowledge concerning the recognition and therapy of bone sarcoidosis. In addition, an illustrative case of patient with bone and bone marrow sarcoidosis is presented.

Multiple bone lesions in a patient with fatigue: case report of bone sarcoidosis

Bone sarcoidosis is usually considered a rare manifestation of multisystemic sarcoidosis. With the growing use of more sensitive imaging techniques, such as ¹⁸F-FDG PET, the detection rate of bone involvement seems to be increasing. We describe the case of a woman presenting with fatigue and general malaise having multiple bone lesions on ¹⁸F-FDG PET. A broad range of differential diagnoses was considered, including malignancy, infections, metabolic diseases and primary bone tumours, which may have delayed the diagnosis. Diagnostic work-up eventually led to an anatomopathological diagnosis of bone sarcoidosis. Immunosuppressive therapy is often necessary since sarcoid bone lesions - even asymptomatic - generally appear in more extensive forms of the disease with other organ involvement.

Pubic and ischial sarcoidosis: a single bone lesion

Bone sarcoidosis is very rarely indicative of the disease. When bone lesion is associated with lung and lymph node involvement, diagnosis can be made based on clinical and imaging features. When bone lesion is isolated, it is difficult to differentiate it from bone metastases because they both have similar appearance in imaging: in this case, the diagnosis is made by bone biopsy with histological study. We report the case of a 61-year-old male with a lytic lesion of the right ischio pubic ramus which appears to be aggressive whose biopsy revealed bone sarcoidosis.

Sarcoidosis - A review article

Sarcoidosis is a granulomatous disorder of multiple organs, with lungs and lymphatic systems being the most frequently affected sites of the body. It was first reported in 1877 and has continued to engross both clinicians and scientists since that time. Because sarcoidosis being a diagnosis of exclusion, it demands the physician to rule out all the possible diagnosis. Most of the patients remain asymptomatic and this makes the disease remain unnoticed for a prolonged period. Later after years, the disease could be diagnosed after witnessing the patient being symptomatic or suffering from organ failures. It could affect middle aged people of any sexes, often its clinical features correlate with tuberculosis. On immunological and histopathological examination, it reveals noncaseating granuloma in simple terms. Glucocorticoids remain the standard drug now and then. Further research has to be done to know the exact pathogenesis, early detection and betterment in treatment plan of sarcoidosis. The current review article gives a brief knowledge about etiopathogenesis, Clinical features, upgraded diagnostic methods such as biomarkers detection and the organized treatment plan to treat sarcoidosis.

Ossified diagnosis: sarcoidosis masquerading as metastatic breast cancer

A 40-year-old woman was referred to the Breast Unit with a solid lump in her right breast. Investigations revealed an invasive lobular carcinoma. The patient underwent a right-sided mastectomy and sentinel lymph node (LN) biopsy, which confirmed axillary LN involvement. The postsurgery staging CT showed unusual enlargement of mediastinal and hilar LN bilaterally. This was consistent with positron emission tomography/CT and MRI, which further established the presence of several bone lesions. Determining the pathology within the LN and bones was pivotal in providing an accurate diagnosis and deciding subsequent management. However, histopathological analysis of the initial endobronchial ultrasound-guided fine-needle aspiration biopsy of mediastinal LN failed to identify definitive metastatic breast cancer cells. The case was extensively discussed in several multidisciplinary team meetings. Collective evidence, including clinical presentation, comparative imaging analysis, and further biopsies confirmed sarcoidosis with bone involvement-mimicking metastatic disease.

Diffuse lesions secondary to sarcoidosis mimicking widespread metastatic breast cancer: A case report

This case of sarcoidosis mimicking metastatic breast cancer serves as a reminder of the need to consider differential diagnoses even when the clinical scenario and imaging findings are highly suggestive of metastases.

Sarcoidosis and Cancer: A Complex Relationship

Sarcoidosis is a systemic disease of unknown etiology, characterized by the presence of non-caseating granulomas in various organs, mainly the lungs, and the lymphatic system. Since the individualization of sarcoidosis-lymphoma association by Brincker et al., the relationship between sarcoidosis or granulomatous syndromes and malignancies has been clarified through observational studies worldwide. Two recent meta-analyses showed an increased risk of neoplasia in sarcoidosis. The granulomatosis can also reveal malignancy, either solid or hematological, defining paraneoplastic sarcoidosis. Recent cancer immunotherapies, including immune checkpoint inhibitors (targeting PD-1, PD-L1, or CTLA-4) and BRAF or MEK inhibitors were also reported as possible inducers of sarcoidosis-like reactions. Sarcoidosis and neoplasia, especially lymphoma, can show overlapping presentations, thus making the diagnosis and treatment harder to deal with. There are currently no formal recommendations to guide the differential diagnosis workup between the evolution of lymphoma or a solid cancer and a granulomatous reaction associated with neoplasia. Thus, in atypical presentations (e.g., deeply impaired condition, compressive lymphadenopathy, atypical localization, unexplained worsening lymphadenopathy, or splenomegaly), and treatment-resistant disease, targeted biopsies on suspect localizations with histological examination could help the clinician to differentiate neoplasia from sarcoidosis. Pathological diagnosis could sometimes be challenging since very few tumor cells may be surrounded by massive granulomatous reaction. The sensitization of currently available diagnostic tools should improve the diagnostic accuracy, such as the use of more “cancer-specific” radioactive tracers coupled with Positron Emission Tomography scan.

Sarcoidosis: Causes, Diagnosis, Clinical Features, and Treatments

Sarcoidosis is a multisystem granulomatous disease with nonspecific clinical manifestations that commonly affects the pulmonary system and other organs including the eyes, skin, liver, spleen, and lymph nodes. Sarcoidosis usually presents with persistent dry cough, eye and skin manifestations, weight loss, fatigue, night sweats, and erythema nodosum. Sarcoidosis is not influenced by sex or age, although it is more common in adults (< 50 years) of African-American or Scandinavians decent. Diagnosis can be difficult because of nonspecific symptoms and can only be verified following histopathological examination. Various factors, including infection, genetic predisposition, and environmental factors, are involved in the pathology of sarcoidosis. Exposures to insecticides, herbicides, bioaerosols, and agricultural employment are also associated with an increased risk for sarcoidosis. Due to its unknown etiology, early diagnosis and detection are difficult; however, the advent of advanced technologies, such as endobronchial ultrasound-guided biopsy, high-resolution computed tomography, magnetic resonance imaging, and 18F-fluorodeoxyglucose positron emission tomography has improved our ability to reliably diagnose this condition and accurately forecast its prognosis. This review discusses the causes and clinical features of sarcoidosis, and the improvements made in its prognosis, therapeutic management, and the recent discovery of potential biomarkers associated with the diagnostic assay used for sarcoidosis confirmation.

18F-FDG PET/CT in bone sarcoidosis: an observational study

OBJECTIVE

Bone sarcoidosis is usually rare. Imaging procedures such as fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) can reveal bone sarcoidosis with better sensitivity than conventional radiography. We aimed to describe bone sarcoidosis involvement detected with ¹⁸F-FDG PET/CT.

METHODS

This was an observational retrospective study of individuals with pulmonary sarcoidosis who underwent ¹⁸F-FDG PET/CT. According to the ATS/ERS/WASOG criteria, sarcoidosis was diagnosed by the presence of clinical and/or imaging features of sarcoidosis and evidence of non-caseating epithelioid granulomas on a biopsy. We assessed clinical and ¹⁸F-FDG PET/CT characteristics.

RESULTS

Data for 85 patients with sarcoidosis (56.5% female, median age 47 [range 21-80] years) were analyzed. The median follow-up was 4 years. Among 56 patients, sarcoidosis occurred in more than three organs. According to ATS/ERS/WASOG criteria, bone sarcoidosis was diagnosed in 12 (14%) patients. The spine was the most commonly affected location (92%, n = 11), followed by the pelvis (67%, n = 8), sternum (33%, n = 4), humerus (25%, n = 3), and fingers (17%, n = 2). Only peripheral adenopathy was associated with bone sarcoidosis (p = 0.04). Seven patients had a ¹⁸F-FDG PET/CT follow-up, all showing a decrease of bone lesions.

CONCLUSION

Bone sarcoidosis occurred in 14% of patients with sarcoidosis, affecting multiple bones and mostly the axial skeleton. ¹⁸F-FDG PET/CT seems a sensitive tool for diagnosis and follow-up of bone sarcoidosis.

FDG-PET Scan in Sarcoidosis: Clinical and Imaging Indications

BACKGROUND

Sarcoidosis is an unknown etiology multisystem inflammatory disease in which noncaseating granulomas (a collections of inflammatory cells) form and grow in various organs, involving predominantly lungs, intrathoracic lymph node, skin and eyes. It most commonly affects patients between 20 and 40 years old of age but it could be observed at any age (female predominance; rare in Asians).

DISCUSSION

The areas of the body usually affected by sarcoidosis are lungs, skin, or lymph nodes; pulmonary and mediastinal involvement is seen in over of 90% of patients. Less commonly eyes, liver, heart, and brain are involved. Any organ, however, can be affected. Early diagnosis of sarcoidosis can be difficult due to few signs and symptoms in its early stages, and when disease does occur, it may mimic other pathologies, and is made up with chest X-ray, Computed Tomography (CT)-High Resolution CT (HRCT), gallium scans. Fluoro-Deoxy Glucose- Positron Emission Tomography (FDG-PET) is another useful tool to assess the extent of disease and has a potential to evaluate the clinical management of patients responding or not to the treatment.

CONCLUSION

In this review, we would summarize in brief the clinical indications of PDG-PET in sarcoidosis and report the imaging features of the main organs involved in this disease.

Musculoskeletal Manifestations of Sarcoidosis: A Review Article

BACKGROUND

Sarcoidosis is a multisystem inflammatory disease with an etiology that is not clearly understood. Amongst the different organs that may be affected, the lungs are the most common. Musculoskeletal manifestations of the disease are uncommon.

OBJECTIVES

They include arthropathy, bone lesions, or myopathy, all of which may occur as initial symptoms or develop during the course of the disease.

METHODS

Articular involvement my present as arthralgia or arthritis. Skeletal complications usually develop in the chronic state of the disease. Muscular disease is rare and usually asymptomatic. Appropriate imaging modalities including X-ray, MRI, FDG-PET/CT assist in the diagnosis of rheumatic sarcoidosis. However, biopsy is necessary for definite diagnosis.

RESULT AND CONCLUSION

In most cases of musculoskeletal involvement, NSAIDs and corticosteroids are sufficient for symptomatic management. For more resistant cases immunosuppressive drugs (i.e., methotrexate) and TNF- inhibitors are used. Our aim is to review various types of musculoskeletal involvement in sarcoidosis and their existing treatment options.

Bone marrow involvement in sarcoidosis: an elusive extrapulmonary manifestation

Sarcoidosis is a granulomatous disease with various extrapulmonary manifestations. We describe a 51-year-old African American woman with a history of cutaneous sarcoidosis admitted with bicytopenia. Suspicion for systemic sarcoidosis was established after contrast-enhanced computerized tomography of the chest, abdomen and pelvis showed a pulmonary nodule, diffuse lymphadenopathy and hepatosplenomegaly. Cytopenias in sarcoidosis, when present, may reflect bone marrow infiltration. Hence, biopsy was obtained and bone marrow sarcoidosis was diagnosed. This manifestation, in spite of ethnic and gender predilection, is rarely seen. As with other forms of sarcoidosis, treatment comprises of corticosteroids.

Abbreviations: ANCA: Antineutrophil cytoplasmic antibody; BM: Bone marrow; BMS: Bone marrow sarcoidosis; CT: Computerized tomography; HIV: Human immunodeficiency virus; HLA: Human leukocyte antigen; MRI: Magnetic resonance imaging

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.

Emergency Radiotherapy for Spinal Cord Compression due to Bone Sarcoidosis

Sarcoidosis is an inflammatory granulomatous disease that is systemic, but bone involvement is uncommon. A 68-year-old man was referred to our hospital complaining of right shoulder pain with numbness. Computed tomography revealed systemic lymphadenopathy and multiple bone lesions. Because malignant lymphoma with a mass lesion protruding into the vertebral canal was considered, he underwent urgent radiotherapy. Thereafter, a needle biopsy of the left parasternal node was performed and showed epithelioid granulomas, confirming a diagnosis of sarcoidosis. Since his neurologic symptoms improved, the patient was not given systemic corticosteroids. Radiotherapy may be useful for local control of bone sarcoidosis.

Coexistence of sarcoidosis and metastatic lesions: A diagnostic and therapeutic dilemma

Sarcoidosis, a chronic, inflammatory disease that affects various different organs, is characterized by noncaseating epitheloid granulomas. This systemic inflammatory process is associated with an increased risk of cancer. Several cases of sarcoidosis that mimic metastatic tumor progression in radiological findings have been reported so far. However, there are also cases that have presented a coexistence of sarcoidosis and metastasis, which have caused a diagnostic and therapeutic dilemma. Due to inadequate current therapies, a reliable differentiation between benign and malignant lesions is crucial. This review focuses on the residual risk of the coexistence of metastases within radiological suspicious lesions in patients with a history of solid tumors and sarcoidosis, as well as immunological findings, in order to explain the potential associations. Sarcoidosis has the potential to promote metastasis as it includes tumor-promoting and immune-regulating cell subsets. Notably, myeloid derived suppressor cells may serve a pivotal role in metastatic progression in patients with sarcoidosis. In addition, the present review also evaluates the potential novel diagnostic approaches, which may be able to differentiate between metastatic lesions and sarcoidosis. The risk of coexistent metastasis in sarcoidosis lesions must be considered by clinical practitioners, and a multidisciplinary approach may be required to avoid misdiagnosis and the subsequent unnecessary surgery or insufficient treatments.

Clinical characteristics of patients with bone sarcoidosis

OBJECTIVE

To assess the clinical features, diagnosis, and treatment of bone sarcoidosis in the United States.

METHODS

Patients with bone sarcoidosis were identified and matched to sarcoidosis patients based on race, gender, and age. Detailed characteristics were obtained by medical record review.

RESULTS

A total of 64 patients with bone sarcoidosis were enrolled in this study. The female:male ratio was 1.46:1 and the white:black ratio was 3:1. Thirty-eight (59.4%) of 64 patients had bone symptoms. Compared to matched cases, bone sarcoidosis patients have more multi-organ involvement and higher incidence with liver, spleen, and extrathoracic lymph node involvement than controls (P < 0.05). Spine was the most commonly affected bone in 44 (68.8%) of patients, followed by pelvis (35.9%), and hands (15.6%). MRI and PET/CT scan was the common imaging technology, which performed in 36 patients and 32 patients, respectively, and with 97.2% and 93.8% positive bone uptake. Laboratory test indicated anemia was more common in bone sarcoidosis group than controls (P = 0.044). Infliximab was more commonly used in bone sarcoidosis patients than controls (P = 0.009).

CONCLUSION

Bone sarcoidosis was associated with multi-organs affection, and high frequency of liver, spleen, or extrathoracic lymph node involvement. Infliximab should be considered in those patients with aggressive and refractory bone sarcoidosis.

Intrascrotal and osseous sarcoidosis mimicking intrascrotal organ cancer and bony metastasis

We report a case of sarcoidosis with concomitant epididymis, testes, and phalanxes involvement mimicking intrascrotal organ cancer and metastatic bony disease. A 23-year-old man developed blurred vision and hyperemia of the left eye, and was diagnosed as having left iritis. A chest computed tomography scan detected bilateral hilar lymphadenopathy and lung nodular shadows. A transbronchial lung biopsy revealed a non-caseating granuloma and he was diagnosed with sarcoidosis. One year after the onset of his eye symptoms, he noticed enlargement of his right scrotum. Magnetic resonance imaging detected lesions of the right epididymis, bilateral testes, and bilateral phalanxes. A technetium-99m scintigram revealed a high accumulation in the bilateral bones of extremities. These radiological findings mimicked intrascrotal organ cancer and metastatic bony disease. Pathologic evaluation following the right epididymectomy revealed non-caseating granulomas compatible with sarcoidosis. Three and half years after the appearance of intrascrotal and bony lesions, they improved spontaneously. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 373-376).