Figure 1
Post-treatment axial CT and PET-CT image of chest
Previously noted significantly avid mediastinal lymphadenopathy has reduced in size, without any significant FDG uptake on current examination.
Clinical History
We are reporting a case of a 61-year-old female patient who presented with weight loss and fatigue for 6 months. She had palpable cervical nodes.
Imaging Findings
She underwent PET-CT on 26-01-2016 which documented metabolically active extensive pulmonary pleural nodularity with an avid mass in the left upper lobe. There were supraclavicular, mediastinal, paraoesophageal and upper abdominal lymph nodes as well.
Based upon these findings she underwent CT guided biopsy of left apical lung mass.
Based upon these findings she underwent CT guided biopsy of left apical lung mass.
Discussion
Sarcoidosis is a multisystem inflammatory disease which is characterized by chronic non-granulomatous inflammation. The most common sites of involvement are lungs and mediastinal lymph nodes. The most common sites of lymphadenopathy are mediastinal lymph nodes with symmetrical involvement of the right paratracheal and bilateral hilar nodes. It may involve lymph nodes at atypical sites which could be mistaken for other potential causes of lymph node enlargement like lymphoma and tuberculosis. Pulmonary involvement is seen as nodules with perilymphatic distribution. Ill-defined pulmonary opacities are less common [1, 2]. Atypical pulmonary involvement may mimic primary lung cancer. Gold standard for diagnosis is histopathology.
Our case had both typical and atypical imaging features [Fig. 1, 2, 3]. Later it was histopathologically proven as sarcoidosis. There was non-caseating granulomatous inflammation without necrosis. Ziehl-Neelsen and GMS stains and cultures for mycobacteria were negative. She was given steroid treatment. Post biopsy scans documented complete metabolic response with partial morphologic response [Fig. 4, 5, 6].
FDG-PET CT has an emerging role in the evaluation of sarcoidosis as there is increased FDG uptake by inflammatory cells. Simultaneous acquisition of morphological and functional data can identify occult disease sites which are not detected by other imaging techniques. Similarly, FDG PET-CT aids in monitoring treatment response. This is especially useful when the disease remains morphologically stable. In these cases response can still be assessed based on FDG uptake. FDG PET-CT is especially useful to assess active and fibrotic components of the disease [3].
In conclusion, sarcoidosis should always be kept in the differential list in patients having mediastinal lymph adenopathy with pulmonary involvement even with atypical sites of nodal involvement.
Our case had both typical and atypical imaging features [Fig. 1, 2, 3]. Later it was histopathologically proven as sarcoidosis. There was non-caseating granulomatous inflammation without necrosis. Ziehl-Neelsen and GMS stains and cultures for mycobacteria were negative. She was given steroid treatment. Post biopsy scans documented complete metabolic response with partial morphologic response [Fig. 4, 5, 6].
FDG-PET CT has an emerging role in the evaluation of sarcoidosis as there is increased FDG uptake by inflammatory cells. Simultaneous acquisition of morphological and functional data can identify occult disease sites which are not detected by other imaging techniques. Similarly, FDG PET-CT aids in monitoring treatment response. This is especially useful when the disease remains morphologically stable. In these cases response can still be assessed based on FDG uptake. FDG PET-CT is especially useful to assess active and fibrotic components of the disease [3].
In conclusion, sarcoidosis should always be kept in the differential list in patients having mediastinal lymph adenopathy with pulmonary involvement even with atypical sites of nodal involvement.
Differential Diagnosis List
Sarcoidosis
Lung cancer with metastatic lymph adenopathy
Lymphoma
Tuberculosis
Final Diagnosis
Sarcoidosis
References
[1] B H Miller, M L Rosado-de-Christenson, H P McAdams, and N F Fishback (1995) Thoracic sarcoidosis: radiologic-pathologic correlation. Radiographics 15(2):421-37 (PMID: 7761646)
[2] Criado E, Sánchez M, Ramírez J et al (2010) Pulmonary Sarcoidosis: Typical and Atypical Manifestations at High-Resolution CT with Pathologic Correlation. RADIOGRAPHICS 30 (6): 1567-86 (PMID: 21071376)
[3] Soussan, Michael, Augier et al (Feb) Functional Imaging in Extrapulmonary Sarcoidosis: FDG-PET/CT and MR Features. Clinical Nuclear Medicine 39(2):e146-59 (PMID: 23579973)
Case information
| URL: | https://www.eurorad.org/case/13554 |
| DOI: | 10.1594/EURORAD/CASE.13554 |
| ISSN: | 1563-4086 |
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Figure 2
Post-treatment axial CT and PET-CT image
Left supraclavicular lymph node (A, B) and bulky periportal lymph adenopathy (C, D) has also significantly decreased without significant FDG uptake within residual subcentimetre lymph nodes.
Figure 3
Post-treatment axial CT and PET-CT image of chest
Previously noted spiculated opacity in left upper lobe has significantly reduced in size, this currently has a thickness of around 11 mm as compared to 21 mm, with completely resolved metabolic uptake within this mass-like lesion.
Figure 4
Pre-treatment axial CT and PET-CT image (neck and abdomen)
Atypical metabolically active left supraclavicular (A, B) and portal hepatis lymph nodes (C, D).
Figure 5
Pre-treatment axial CT and PET-CT image of chest
Typical sites of lymphadenopathy involving mediastinal and bilateral hilar lymph nodes.
Figure 6
Pre-treatment axial CT and PET-CT image of chest
Metabolically active spiculated opacity in the left upper lobe posterior segment with multiple pulmonary nodules.
Post-treatment axial CT and PET-CT image of chest
Previously noted significantly avid mediastinal lymphadenopathy has reduced in size, without any significant FDG uptake on current examination.
Shaukat Khanam Cancer Hospital Lahore
Shaukat Khanam Cancer Hospital Lahore
Post-treatment axial CT and PET-CT image
Left supraclavicular lymph node (A, B) and bulky periportal lymph adenopathy (C, D) has also significantly decreased without significant FDG uptake within residual subcentimetre lymph nodes.
Shaukat Khanam Cancer Hospital Lahore
Shaukat Khanam Cancer Hospital Lahore
Post-treatment axial CT and PET-CT image of chest
Previously noted spiculated opacity in left upper lobe has significantly reduced in size, this currently has a thickness of around 11 mm as compared to 21 mm, with completely resolved metabolic uptake within this mass-like lesion.
Shaukat Khanam Cancer Hospital Lahore
Shaukat Khanam Cancer Hospital Lahore
Pre-treatment axial CT and PET-CT image (neck and abdomen)
Atypical metabolically active left supraclavicular (A, B) and portal hepatis lymph nodes (C, D).
Shaukat Khanam Cancer Hospital Lahore
Shaukat Khanam Cancer Hospital Lahore
Pre-treatment axial CT and PET-CT image of chest
Typical sites of lymphadenopathy involving mediastinal and bilateral hilar lymph nodes.
PET-CT Shaukat Khanam Cancer Hospital Lahore
PET-CT Shaukat Khanam Cancer Hospital Lahore
Pre-treatment axial CT and PET-CT image of chest
Metabolically active spiculated opacity in the left upper lobe posterior segment with multiple pulmonary nodules.
Shaukat Khanam Cancer Hospital and Research center Lahore, Pakistan
Shaukat Khanam Cancer Hospital and Research center Lahore, Pakistan