Lung cancer or sarcoidosis: A diagnostic dilemma

Abstract

Background: Small cell lung cancer is a neuroendocrine neoplasm representing about 15 percent of all lung cancers. Sarcoidosis is a multisystem granulomatous disease. The involvement of mediastinal lymph nodes is common in both and makes the diagnosis challenging when these conditions coexist. We report a rare case of a patient with history of sarcoidosis who was diagnosed with small cell lung cancer. Case presentation: 65-year-old African American female with history of sarcoidosis, who presented with right sided shoulder pain for two months. CT thorax showed right upper lobe nodule with mediastinal and bilateral hilar lymphadenopathy. FDG-PET scan showed increased uptake in the right upper lobe and in mediastinal and hilar lymph nodes. She subsequently underwent an EBUS with biopsies of multiple lymph node stations. Pathology of these lymph nodes revealed non-necrotizing granulomas without evidence of malignancy. She underwent a CT guided biopsy of the right upper lobe lesion and pathology was consistent with small cell carcinoma. It was unclear whether the enlarged and active mediastinal and hilar lymph nodes were related to sarcoidosis or small cell cancer. A multidisciplinary meeting was conducted and decided to treat the patient presumably as small cell cancer with nodal disease. She was given 2 cycles of carboplatin and etoposide. Follow-up CT thorax after the second cycle showed decrease in size of the nodule along with mediastinal and hilar lymph nodes. She also underwent radiation therapy including mediastinum in the field of radiation. Discussion: Sarcoid-like reactions have been noted either in the vicinity of the tumor or within the regional lymph nodes draining that particular tumor. This has been described in less than 1 percent of lung cancers and mostly in squamous cell lung cancers. True sarcoidosis may be confused with a sarcoid-like reaction in cancer patients. It was not possible to definitively differentiate if the nodal involvement was from sarcoidosis or small cell cancer metastasis or a sarcoid like reaction in our patient. Given the diagnostic dilemma, we treated her nodal involvement as small cell lung cancer metastasis since under treatment could lead to relapse and compromise survival.

A rare presentation of pulmonary sarcoidosis as a solitary lung mass: a case report

“…Prior case reports described the need for a surgical lung biopsy to obtain sufficient tissue for a definitive diagnosis [ 4 , 6 ], which was the case in our patient. However, the presence of granulomas does not necessarily rule out a malignancy, because non-caseating granulomas have been reported in some instances of small cell lung cancer [ 7 ]. Moreover, the presence of non-caseating granulomas in association with a malignancy, described as a sarcoid-like reaction, has been shown to occur adjacent to the site of the malignancy or around local lymph nodes [ 7 , 8 ].…”

Diffuse Sarcoidosis Masquerading as Widespread Malignant Disease: A Rare Case Report and Literature Review

“…Patients are closely followed-up with chest X-rays, pulmonary function tests, and clinical evaluation. 3 , 7 , 8 , 15 , 16 Corticosteroid therapy is used in patients who have severe symptoms, hypercalcemia, neurologic or cardiovascular or ocular involvement, and progressive pulmonary disease. If patients have refractory disease not responding to corticosteroids with progression, methotrexate may be useful.…”

Sarcoid Like Reaction Confounding the Diagnosis of Pulmonary Adenocarcinoma

“…Wolbech et al first described sarcoid like reactions in two autopsy cases of carcinoma of colon and jaw [15]. A case of small cell lung cancer in lung nodule with sarcoid like reaction in mediastinal and hilar lymph nodes causing diagnostic dilemma regarding lymph node metastasis has been reported [14]. Tan et al reported a case with lung adenocarcinoma who underwent lobectomy and 4 years later developed new mediastinal and hilar adenopathy that revealed sarcoid like reaction in Endobronchial ultrasound (EBUS) guided fine needle aspiration [10].…”

“…Granulomatous inflammation can rarely be seen in lung cancer tumors and regional draining lymph nodes which is called 'sarcoid like reaction' as they do not fulfill the criteria for systemic sarcoidosis [2]. Sarcoid like reaction can coexist with malignancy either at the time of diagnosis or later during follow up after treatment or from oncologic immunotherapy [2,10,14]. It can be challenging at times in such cases when tissue biopsies only pick up sarcoid changes without revealing malignancy because of sampling areas in that particular tumor and further delaying the actual diagnosis which happened in our case.…”