Background/Purpose: Several case reports have suggested that cancer can present occultly as a granulomatous inflammatory disease consistent with sarcoidosis. These cases illustrate a problem of potential misdiagnosis leading to adverse outcomes. However, there has not been a study to examine the frequency and circumstances of this issue.

Methods: A retrospective chart review of all the cases of sarcoidosis presenting to Dartmouth-Hitchcock Medical Center from 10/1/2015 to 9/30/2020 were examined for those patients who subsequently developed a malignancy.

Results: Of 1029 individual cases of sarcoidosis 50 patients had a malignancy diagnosed subsequent to the initial determination of sarcoid. 36 of these patients had pulmonary involvement characterized by pulmonary nodules, hilar, paratracheal or mediastinal lymphadenopathy. Of the 14 without pulmonary involvement 2 had CNS, 5 skin, 2 liver, 1 breast, 1 arthritis, 1 inguinal lymphadenopathy and 2 cardiac. 30 of the 50 had biopsy confirmation and the rest imaging consistent with sarcoidosis. 14 of the pulmonary cases had other organ involvement including bone, lymph nodes, skin, pericardial, liver and spleen. Neither of the two CNS cases were confirmed by biopsy and one had a subsequent change of diagnosis to squamous cell of the head and neck. The other had pachymeningitis with elevated CSF ACE levels and no change in diagnosis. Other possible contributing disorders included tuberous sclerosis, Sjogren’s Syndrome, Celiac Disease, Crohn’s Disease, Lynch Syndrome and Psoriasis. In 36 of the 50 cases the malignancy was unrelated to sarcoidosis primarily breast, thyroid, endometrial, squamous cell, basal cell and melanoma. 7 cases the subsequent diagnosis of cancer might have been related to the therapy for sarcoid including AML after mycophenolate, melanoma after Adalimumab, B cell lymphoma after Adalimumab, CTCL after infliximab and methotrexate, squamous cell and basal cell after methotrexate and adenocarcinoma after methotrexate. In one case treatment for the malignancy (Hodgkin’s) probably resulted in the condition labelled sarcoid but was changed to granulomatous disease associated with CVID.7 cases the diagnosis of sarcoidosis appeared to delay the eventual cancer diagnosis by a range of 1 month to 2 years and included cases of Hodgkin’s Lymphoma, a MALT tumor, lymphomatoid granulomatosis, squamous cell of the head and neck, seminoma, and CTCL. In one case sarcoidosis delayed the correct diagnosis of MAC by about 2 months. In every case where a malignancy was eventually found the original diagnosis of sarcoidosis was confirmed by biopsy.

Conclusion: Cancer can masquerade as sarcoidosis but it is very rare occurring in 7 of our 1029 (0.7%) cases resulting in a delay in diagnosis usually a matter of months but in 2 cases more than 1 year for seminoma and lymphomatoid granulomatosis. Conversely, immunosuppressive therapy for sarcoid may increase risk for malignancy. In both circumstances clinical vigilance rather than biopsy characteristics is the best guarantee for a good outcome.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/does-cancer-masquerade-as-sarcoidosis/