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Journal of Clinical Oncology, Vol 23, No 3 (January 20), 2005: pp. 640-641 © 2005 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.02.089
Benign Lesions in Cancer PatientsCASE 1. Sarcoidosis After Chemoradiation for Head and Neck CancerDepartment of Radiation Oncology, The University of Iowa College of Medicine, Iowa City, IA
Department of Otolaryngology, The University of Iowa College of Medicine, Iowa City, IA
Department of Pathology, The University of Iowa College of Medicine, Iowa City, IA
Department of Radiology (Nuclear Medicine), The University of Iowa College of Medicine, Iowa City, IA A 49-year-old white man presented with a 2-month history of bilateral cervical lymph node enlargement in June 2003. Biopsy of the lymph node revealed squamous cell carcinoma. Direct laryngoscopy revealed a firm area on the left side of the base of the tongue, with biopsies of this area showing well-differentiated squamous cell carcinoma. An [18F] fluorodeoxyglucose positron emission tomography (FDG-PET) scan from his skull base to umbilicus was obtained (Fig 1), showing a focus of increased uptake in the left base of the tongue, with a maximum standardized uptake value (SUVmax) of 9.0. There were multiple foci of increased uptake in the neck bilaterally. There was no abnormal focal uptake in the chest or in the visualized portion of the abdomen. A magnetic resonance imaging scan of the head and neck revealed an enhanced mass in the left base of the tongue, extending superiorly to the level of the soft palate and inferiorly to the level of the pyriform sinuses. This mass extended across the midline to the right base of the tongue and into the anterior two thirds of the tongue. There was confluent lymphadenopathy bilaterally in the neck. He was diagnosed with a stage T3N2cM0 squamous cell carcinoma of the base of the tongue. He received intensity-modulated radiation treatment to a final dose of 72 Gy to the gross tumor and the enlarged lymph nodes, and 59.4 Gy to the adjacent uninvolved neck. The anterior lower neck received 50 Gy with an anterior posterior field. He also received three cycles of cisplatin (100 mg/m2 for each cycle on days 1, 22, and 43) concurrent with radiation. Radiation treatment was completed in September 2003. He had persistent bilateral cervical lymph nodes after completion of radiation treatment. A repeat FDG-PET scan was obtained with a LSO Biograph duo PET/computed tomography (CT; Siemens Medical Systems, Hoffman Estates, IL) scan from skull base to umbilicus 2 months after radiation (5 months after the previous FDG-PET scan). This revealed resolution of abnormal uptakes in the base of the tongue as well as the left neck. There was a focal uptake in the right tonsil with an SUVmax of 5.7 and a focal uptake in a right level II lymph node with an SUVmax of 3.8. There were multiple foci of abnormal uptake in the mediastinum in the right paratracheal node, right hilar nodes, subcarinal nodes, and left hilar nodes, with SUVmax ranging from 3.1 to 6.6. The abnormal FDG uptake foci in the mediastinum correlated to the mediastinal lymph nodes in the CT (Fig 2). These uptakes were suspicious for metastatic disease. A subsequent CT of the chest revealed multiple enlarged lymph nodes in the mediastinum, particularly in the aortopulmonary window, pretracheal region, and the subcarinal space; the largest node measured 1.5 cm, again causing concern for metastatic disease (Fig 3). We obtained a transbronchial aspiration that was nondiagnostic. He underwent cervical mediastinoscopy. Biopsies of the level VII and level IVR lymph node showed granulomatous inflammation with necrosis, consistent with sarcoidosis (Fig 4). There was no malignancy identified. Special stains for fungi and acid-fast bacilli were negative. Subsequently, he underwent bilateral neck dissection.
Sarcoidosis and sarcoid-like reactions have been reported to be associated with malignancies, especially testicular cancer and lymphoma.1,2 They occur either synchronously or metachronously with the diagnosis of cancer; they can also occur after chemotherapy.3,4 Sarcoidosis has significant FDG uptake.5 False-positive results due to sarcoidosis have been reported in staging of testicular cancer6 and melanoma,7 surveillance of thyroid cancer,8 and recurrence detection of colorectal cancer.9 As FDG-PET is used more extensively in oncology, clinicians should be aware of sarcoidosis, which can have the same appearance as diffuse metastasis. Pathological diagnosis should always be obtained. Authors’ Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
REFERENCES 1. Rayson D, Burch PA, Richardson RL: Sarcoidosis and testicular carcinoma. Cancer 83:337-343, 1998[CrossRef][Medline]
2. Hunsaker AR, Munden RF, Pugatch RD, et al: Sarcoidlike reaction in patients with malignancy. Radiology 200:255-261, 1996 3. Merchant TE, Filippa DA, Yahalom J: Sarcoidosis following chemotherapy for Hodgkin’s disease. Leuk Lymphoma 13:339-347, 1994[Medline] 4. Kornacker M, Kraemer A, Leo E, et al: Occurrence of sarcoidosis subsequent to chemotherapy for non-Hodgkin’s lymphoma: Report of two cases. Ann Hematol 81:103-105, 2002[CrossRef][Medline]
5. Lewis PJ, Salama A: Uptake of fluorine-18-fluorodeoxyglucose in sarcoidosis. J Nucl Med 35:1647-1649, 1994 6. Cremerius U, Wildberger JE, Borchers H, et al: Does positron emission tomography using 18-fluoro-2-deoxyglucose improve clinical staging of testicular cancer? Results of a study in 50 patients. Urology 54:900-904, 1999[CrossRef][Medline]
7. Haluska P, Luetmer PH, Inwards CY, et al: Complications of therapy and a diagnostic dilemma case: Case 3, diagnostic dilemma—Sarcoidosis simulating metastatic malignancy. J Clin Oncol 21:4653-4654, 2003 8. Grunwald F, Schomburg A, Bender H, et al: Fluorine-18 fluorodeoxyglucose positron emission tomography in the follow-up of differentiated thyroid cancer. Eur J Nucl Med 23:312-319, 1996[CrossRef][Medline]
9. Kalff V, Hicks RJ, Ware RE, et al: The clinical impact of (18)F-FDG PET in patients with suspected or confirmed recurrence of colorectal cancer: A prospective study. J Nucl Med 43:492-499, 2002
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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