An eighty year old African-American female was evaluated for
cough,
chest pain, asymptomatic
anemia and 21 pound
weight loss over a six month period. Computerized tomography (CT) revealed a spiculated 2.8 cm right upper lobe lung nodule, other smaller nodules and
lymphadenopathy.
Gallium scan revealed abnormal uptake of radiotracer in lacrimal, hilar and mediastinal glands. Broncho-alveolar lavage showed CD4/CD8 ratio of 2:1 with 15% lymphocytes. Biopsy of right upper lobe lesion and mediastinoscopic lymph node biopsy showed numerous matured uniform non-caseating granulomatous
inflammation, however stains and culture for
Acid fast bacilli (AFB)/fungal organisms were negative. Patient improved on oral
steroids. Six months later she returned with worsening
dyspnea and chest X-ray showed bilateral
pleural effusions. Thoracocentesis revealed
Thyroid transcription factor 1 (TTF1) positive
adenocarcinoma cells and Video assisted thoracic surgery (VATS) procedure revealed numerous pleural, pericardial, diaphragmatic
metastasis. Biopsy also was positive for TTF1
adenocarcinoma and positive for
Epidermal Growth Factor receptor (EGFR) mutation, however negative for
Anaplastic Lymphoma Kinase (ALK).
Talc pleurodesis was performed. She was treated with
erlotinib while
steroid was kept on hold. Initial
tumor burden decreased but follow-up PET scan six months later showed progression of
tumor with
lymphadenopathy. After discussion with patient and family, patient opted for
hospice care.
DISCUSSION: Oncocentric theory postulates
sarcoidosis as an immunological reaction to dispersal of
tumor antigen. Sarcocentric theory postulates that cell-mediated immune abnormalities induced by
sarcoidosis in CD4 and CD8 cells is involved in the onset of
lung cancer. Thus considerable controversy exists regarding
sarcoidosis and
malignancy. In our case, TTF1
adenocarcinoma cells from thoracocentesis suggest peripheral nodules in right upper lobe and lingula were likely metastatic, presenting as
malignant pleural effusions. However if noncaseating granulomatous
inflammation is expected as an immunological reaction to
tumor antigen, it is very interesting to observe that initial tissue biopsy of primary right upper lobe mass and mediastinal lymph nodes showed matured uniform non-caseating granulomatous
inflammation and no evidence of
adenocarcinoma. This being said, it would be highly unlikely for
sarcoidosis to progress to
lung adenocarcinoma within six months. This adds further controversy to whether granulomatous
inflammation is a precursor to future
malignancy or whether this elderly African-American female was predisposed to develop granulomatous
inflammation in presence of a
tumor antigen. One can also speculate whether repeat tissue sampling from right upper lobe mass would have shown granulomatous
inflammation or TTF1
adenocarcinoma.
CONCLUSION: