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Sarcoid Reactions after Chemotherapy for Hodgkin's Lymphoma.

Wirk B - Clin Med Insights Case Rep (2010)

Bottom Line: This is particularly true for lymphomas and is known as the sarcoidosis-lymphoma syndrome.A 49 year old Caucasian female presented with mediastinal and axillary lymphadenopathy.An excisional axillary lymph node biopsy showed classical Hodgkin's lymphoma, nodular sclerosis subtype.

View Article: PubMed Central - PubMed

Affiliation: University of Florida College of Medicine, Bone Marrow Transplant Program, Division of Hematology-Oncology, Gainesville, FL 32610, USA.

ABSTRACT

Introduction: There is a reported association between sarcoidosis and malignancy. This is particularly true for lymphomas and is known as the sarcoidosis-lymphoma syndrome.

Case report: A 49 year old Caucasian female presented with mediastinal and axillary lymphadenopathy. An excisional axillary lymph node biopsy showed classical Hodgkin's lymphoma, nodular sclerosis subtype. She received six cycles of conventional chemotherapy achieving a complete remission with no evidence of any lymphadenopathy on restaging imaging. However, one month after completion of chemotherapy, she developed new onset of progressive mediastinal lymphadenopathy. A mediastinoscopy and biopsy was performed showing noncaseating granulomata and the patient was diagnosed with a sarcoid reaction.

Conclusion: Sarcoidosis and sarcoid reactions must be considered in the differential diagnosis when assessing patients with persistent or enlargening masses after chemotherapy treatment for Hodgkin's lymphoma, especially since this is associated with a better prognosis. A tissue biopsy is essential prior to starting chemotherapy for presumed relapsed malignancy or persistent disease so as to avoid inappropriate treatment.

No MeSH data available.


Related in: MedlinePlus

Mediastinal lymph node (H&E, 200×) showing confluent noncaseating granulomata.
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f1-ccrep-2010-021: Mediastinal lymph node (H&E, 200×) showing confluent noncaseating granulomata.

Mentions: A 49 year old woman developed pruritus and progressive axillary lymphadenopathy. Computed tomography (CT) and [18F] fluorodeoxyglucose-positron emission tomography (FDG PET) showed enlarged, FDG avid lymph nodes in the left supraclavicular, left axillary and mediastinal regions. An excisional left axillary lymph node biopsy was performed which showed classical Hodgkin’s lymphoma, nodular sclerosis subtype. Neoplastic Reed-Sternberg cells were positive for CD30 and CD15 but negative for CD20 and CD3. A bone marrow biopsy was normocellular without evidence of Hodgkin’s lymphoma. Stage IIA Hodgkin’s lymphoma was diagnosed. Six cycles of doxorubicin, bleomycin, vinblastine, dacarbazine chemotherapy were initiated. After the fourth cycle of chemotherapy, a PET/CT scan showed no further FDG avidity or any evidence of lymphadenopathy. The patient achieved a complete remission. PET/CT performed one month after completion of chemotherapy, showed new hilar and mediastinal lymphadenopathy with associated FDG avidity. There were no lung parenchymal abnormalities. A mediastinoscopy with biopsy was performed. The lymph node biopsy showed the lymph node to be entirely replaced by confluent noncaseating epithelioid granulomata with focal necrosis on hematoxylin and eosin (H&E) stain. No neoplastic Reed-Sternberg cells were noted. Gomori Methanamine Silver (GMS) and acid fast bacilli (AFB) stains were negative for fungal or mycobacterial organisms. Three months after completion of chemotherapy, another PET/CT continued to show stable mediastinal and hilar lymphadenopathy with associated FDG avidity in these areas. Lymph nodes were less than 2 centimeters in largest diameter. The patient was asymptomatic without constitutional symptoms. Physical exam revealed no peripheral lymphadenopathy or hepatosplenomegaly. The angiotensin converting enzyme (ACE), lactate dehydrogenase, beta 2 microglobulin, liver function, renal function, and calcium were normal. A complete blood count was remarkable only for lymphopenia. Human immunodeficiency virus (HIV) testing was negative. A second mediastinoscopy and biopsy again showed confluent noncaseating granulomata of the lymph node suggestive of a sarcoid reaction (Figs. 1 and 2). GMS and AFB stains were negative for fungi and acid fast bacilli. There was no evidence of Hodgkin’s lymphoma on routine histology. Immunohistochemistry staining for (cluster of differentiation) CD30 and CD15 suggestive of neoplastic Reed-Sternberg cells was absent. Flow cytometry of the lymph nodes was unremarkable. A bone marrow biopsy showed no Hodgkin’s lymphoma or significant pathologic change. Two years after completion of chemotherapy the patient remained asymptomatic with persistent but stable mediastinal and hilar lymphadenopathy on PET/CT and no evidence of relapsed Hodgkin’s lymphoma or systemic manifestations of sarcoidosis.


Sarcoid Reactions after Chemotherapy for Hodgkin's Lymphoma.

Wirk B - Clin Med Insights Case Rep (2010)

Mediastinal lymph node (H&E, 200×) showing confluent noncaseating granulomata.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3046012&req=5

f1-ccrep-2010-021: Mediastinal lymph node (H&E, 200×) showing confluent noncaseating granulomata.
Mentions: A 49 year old woman developed pruritus and progressive axillary lymphadenopathy. Computed tomography (CT) and [18F] fluorodeoxyglucose-positron emission tomography (FDG PET) showed enlarged, FDG avid lymph nodes in the left supraclavicular, left axillary and mediastinal regions. An excisional left axillary lymph node biopsy was performed which showed classical Hodgkin’s lymphoma, nodular sclerosis subtype. Neoplastic Reed-Sternberg cells were positive for CD30 and CD15 but negative for CD20 and CD3. A bone marrow biopsy was normocellular without evidence of Hodgkin’s lymphoma. Stage IIA Hodgkin’s lymphoma was diagnosed. Six cycles of doxorubicin, bleomycin, vinblastine, dacarbazine chemotherapy were initiated. After the fourth cycle of chemotherapy, a PET/CT scan showed no further FDG avidity or any evidence of lymphadenopathy. The patient achieved a complete remission. PET/CT performed one month after completion of chemotherapy, showed new hilar and mediastinal lymphadenopathy with associated FDG avidity. There were no lung parenchymal abnormalities. A mediastinoscopy with biopsy was performed. The lymph node biopsy showed the lymph node to be entirely replaced by confluent noncaseating epithelioid granulomata with focal necrosis on hematoxylin and eosin (H&E) stain. No neoplastic Reed-Sternberg cells were noted. Gomori Methanamine Silver (GMS) and acid fast bacilli (AFB) stains were negative for fungal or mycobacterial organisms. Three months after completion of chemotherapy, another PET/CT continued to show stable mediastinal and hilar lymphadenopathy with associated FDG avidity in these areas. Lymph nodes were less than 2 centimeters in largest diameter. The patient was asymptomatic without constitutional symptoms. Physical exam revealed no peripheral lymphadenopathy or hepatosplenomegaly. The angiotensin converting enzyme (ACE), lactate dehydrogenase, beta 2 microglobulin, liver function, renal function, and calcium were normal. A complete blood count was remarkable only for lymphopenia. Human immunodeficiency virus (HIV) testing was negative. A second mediastinoscopy and biopsy again showed confluent noncaseating granulomata of the lymph node suggestive of a sarcoid reaction (Figs. 1 and 2). GMS and AFB stains were negative for fungi and acid fast bacilli. There was no evidence of Hodgkin’s lymphoma on routine histology. Immunohistochemistry staining for (cluster of differentiation) CD30 and CD15 suggestive of neoplastic Reed-Sternberg cells was absent. Flow cytometry of the lymph nodes was unremarkable. A bone marrow biopsy showed no Hodgkin’s lymphoma or significant pathologic change. Two years after completion of chemotherapy the patient remained asymptomatic with persistent but stable mediastinal and hilar lymphadenopathy on PET/CT and no evidence of relapsed Hodgkin’s lymphoma or systemic manifestations of sarcoidosis.

Bottom Line: This is particularly true for lymphomas and is known as the sarcoidosis-lymphoma syndrome.A 49 year old Caucasian female presented with mediastinal and axillary lymphadenopathy.An excisional axillary lymph node biopsy showed classical Hodgkin's lymphoma, nodular sclerosis subtype.

View Article: PubMed Central - PubMed

Affiliation: University of Florida College of Medicine, Bone Marrow Transplant Program, Division of Hematology-Oncology, Gainesville, FL 32610, USA.

ABSTRACT

Introduction: There is a reported association between sarcoidosis and malignancy. This is particularly true for lymphomas and is known as the sarcoidosis-lymphoma syndrome.

Case report: A 49 year old Caucasian female presented with mediastinal and axillary lymphadenopathy. An excisional axillary lymph node biopsy showed classical Hodgkin's lymphoma, nodular sclerosis subtype. She received six cycles of conventional chemotherapy achieving a complete remission with no evidence of any lymphadenopathy on restaging imaging. However, one month after completion of chemotherapy, she developed new onset of progressive mediastinal lymphadenopathy. A mediastinoscopy and biopsy was performed showing noncaseating granulomata and the patient was diagnosed with a sarcoid reaction.

Conclusion: Sarcoidosis and sarcoid reactions must be considered in the differential diagnosis when assessing patients with persistent or enlargening masses after chemotherapy treatment for Hodgkin's lymphoma, especially since this is associated with a better prognosis. A tissue biopsy is essential prior to starting chemotherapy for presumed relapsed malignancy or persistent disease so as to avoid inappropriate treatment.

No MeSH data available.


Related in: MedlinePlus