PMC7734188_01
Chest X-rays at presentation. Left subclavian pulmonary thickening associated with patchy bilateral peripheral opacity particularly represented in the left lung where there are also band-like consolidations and pleural effusion.
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F1
Echocardiogram was normal, while on chest X-ray (CXR; Figure 1) parenchymal infiltrates were documented, which were more evident in the left lung.
CT scan at presentation: bilateral parenchymal infiltrates (A) and mediastinal hilar lymph node enlargement (B), suggestive of sarcoidosis but also compatible with malignant origin. Enlarged vascularized pathologic (3 cm) axillar node detected in the right axillary region (red arrow).
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F2
A total body CT scan (TB CT; Figure 2) revealed diffuse parenchymal infiltrates with mediastinal and hilar lymphadenopathies, suggestive of sarcoidosis but also compatible with a malignant origin.
Histologic samples. Surgical sample of lymph node localization of adenocarcinoma, x20 (A), x5 (B,   ), featuring positive staining for cytokeratin 7 (C), and concomitant epithelioid sarcoid-like granuloma, x5 (D). Transbroronchial biopsy x10 (E) and x20 (F) displaying sarcoid non-necrotizing epithelioid granulomas (  ).
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F3
At histologic examination, localization/metastasis of poorly differentiated epithelial neoplasia was found in only one of the resected nodes (Figures 3A-C), whereas in the others giant cell granulomatous epithelioid sarcoid-like reaction was detected (Figure 3D). A transbronchial biopsy (TBB) was then performed, revealing bilateral superior bronchial stenosis in the absence of histologic neoplastic infiltration (Figures 3E,F).
Whole-body positron emission tomography (PET): supra- and subdiaphragmatic pathologic lymphadenopathies in the absence of putative primary mass detection. The red circle shows the pathologic standardized uptake value (SUV) at left hilar lymph node (L10 station).
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F4
To complete the disease stage and/or eventually to detect a distant site of origin of the neoplastic cells, a whole-body positron emission tomography was performed and evidenced supra- and subdiaphragmatic pathologic lymphadenopathies in the absence of putative primary mass detection (Figure 4).
CT scan after treatment: remaining parenchymal fibrosis in upper lobes compatible with sarcoidosis grade IV (A), without mediastinal or extra-thoracic lymph node enlargement (B).
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F5
The TB CT at the end of three cycles of adjuvant chemotherapy confirmed the presence of some fibrotic branches, compatible with stage IV pulmonary sarcoidosis, without oncologic localizations (Figure 5).
Timeline with the most relevant data of the clinical case.
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F6
A timeline with all relevant data from this clinical case is available in Figure 6.