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Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is commonly used to evaluate mediastinal lymphadenopathy. Studies focusing on malignant lymphadenopathy have compared 21- and 22-gauge (21G and 22G, respectively) needles and have not identified an advantage of one needle size over the other in terms of diagnostic yield., Research Question: Does the 19-gauge (19G) EBUS needle offer greater diagnostic yield and sensitivity vs the 21G and 22G EBUS needles for a diagnosis of sarcoidosis, lymphoma, or mediastinal lymphadenopathy not yet diagnosed?, Study Design and Methods: This study retrospectively examined records of 730 patients from the Stather Canadian Outcomes Registry for Chest Procedures (SCOPE) database who underwent EBUS-TBNA for a diagnosis of suspected sarcoidosis, lymphoma, or mediastinal lymphadenopathy not yet diagnosed. A propensity score analysis of two groups was performed. One group comprised patients undergoing EBUS-TBNA with a 19G needle, the other with a 21G or 22G needle. Cases for analysis were selected with a 1:2 ratio of 19G vs 21/22G using logistic regression and random matching with all eligible 19G cases included., Results: There were 137 patients (312 targets) in the 19G group and 274 patients (631 targets) in the 21/22G group in the propensity score analysis. The diagnostic yield was 107 of 137 (78.1%) in the 19G group vs 194 of 274 (70.8%) in the 21/22G group (difference, 7.3%; 95% CI, -1.9 to 15.6; P = .116). The sensitivity of EBUS-TBNA for sarcoidosis was 80 of 83 (96.4%) in the 19G group vs 150 of 156 (96.2%) in the 21/22G group (difference, 0.24%; 95% CI, -6.6 to 85.1; P = .93). In patients with a final diagnosis of lymphoma, EBUS was diagnostic in 10 of 13 (76.9%) in the 19G group vs 12 of 12 (100%) in the 21/22G group (difference, 23.1%; 95% CI, -5.4 to 50.3; P = .08)., Interpretation: The study did not identify an advantage of the 19G EBUS needle over the 21/22G EBUS needles for diagnostic yield nor sensitivity for sarcoidosis or lymphoma., (Copyright © 2022 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Introduction: Immune checkpoint inhibitors are becoming a standard treatment for many different cancers. Their toxicities are variable and include organ-specific dysimmune injuries and the development of systemic diseases., Case Report: We report 3 cases of sarcoid-like granulomatosis that occurred during treatment of various types of primary cancer by immune checkpoint inhibitors: lung adenocarcinoma, small cell lung cancer and melanoma. The clinical presentation, radiologic pattern and severity of this toxicity were variable. The diagnosis was made on biopsy with pathological examination and exclusion of differential diagnoses, particularly infection. In such cases, immunotherapy should be discontinued and subsequent rechallenge discussed later. Systemic corticosteroids should be considered depending on the severity of symptoms., Conclusions: Knowledge of this toxicity is crucial as the clinical signs and radiological patterns may suggest tumour progression., (Copyright © 2018 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Noncaseating granulomas are seen surrounding tumors with varying frequency, possibly as part of an immune response to tumor cells. However, data about the association of sarcoid with gynecologic malignancy is sparse. We performed a search of our institutional database for all EBUS-TBNA biopsies conducted within the past five years that revealed granulomatous inflammation. All adult female patients with a history of gynecologic malignancy were included. Patients with a history of sarcoidosis or fungal or mycobacterial infection were excluded. All patients with evidence of malignant cells on TBNA specimen were excluded. Our results revealed 65 patients with histologic diagnosis of a noncaseating granuloma on EBUS-TBNA. Five patients (7.69%) had a history of gynecologic malignancy. Two patients had evidence of PET-positive nodes on surveillance scans, which led directly to the examination. Our findings suggest that distant malignancies may cause granulomatous lymphadenitis, through yet undefined mechanisms. As such, patients with evidence of mediastinal lymphadenopathy could benefit from routine sampling and histologic examination to define the pathology in the correct clinical context.

Background: Conventional transbronchial needle aspiration (c-TBNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) are both valuable diagnostic techniques for the diagnosis of hilar/mediastinal lesions. Although a superiority of EBUS-TBNA over c-TBNA may be expected, evidence-based data on a direct comparison between these 2 procedures are still lacking., Objectives: We aimed to test the superiority of EBUS-TBNA over c-TBNA in a randomized trial and to evaluate the cost-effectiveness profile of a staged strategy, including c-TBNA as initial test followed by EBUS-TBNA, in case of inconclusive results at rapid on-site evaluation., Methods: Eligible patients were randomized 1:1 to either the EBUS-TBNA or c-TBNA group. The primary endpoint was to test the superiority of EBUS-TBNA sensitivity over c-TBNA. The secondary endpoints included the sensitivity of the staged strategy, as well as costs and safety related to each procedure and to their sequential combination., Results: A total of 253 patients were randomized to either EBUS-TBNA (n = 127) or c-TBNA (n = 126), and 31 patients of the c-TBNA group subsequently underwent EBUS-TBNA. The sensitivity of EBUS-TBNA was higher, but not significantly superior to that of c-TBNA (respectively. 92% [95% CI 87-97] and 82% [95% CI 75-90], p > 0.05). The sensitivity of the staged strategy was 94% (95% CI 89-98). No major adverse events occurred., Conclusions: EBUS-TBNA was the single best diagnostic tool, although not significantly superior to c-TBNA. Due to the favorable cost-effectiveness profile of their sequential combination, in selected scenarios with a high probability of success from the standard procedure, these should not be necessarily intended as competitive and the staged strategy could be considered in clinical practice., (© 2017 S. Karger AG, Basel.)

The aim of our work is to promote the awareness about the development of sarcoidosis after antineoplastic therapy in order to avoid diagnostic errors with FDG-PET/CT findings. We report the observation of three women with breast, cervix and stomach treated cancers who developed a sarcoidosis after the end of anti-neoplastic therapy. The utility of FDG-PET/CT is in pinpointing the organs candidates for diagnostic biopsy and not distinguishing between the malignancy and granulomatous or inflammatory diseases., (Copyright © 2014 SEPAR. Published by Elsevier Espana. All rights reserved.)

Background: Histoplasmosis and sarcoidosis are commonly included in the differential diagnosis of mass lesions at lung and mediastinal sites. Once cancer is excluded on aspiration biopsy, further classification is essential for proper treatment., Methods: A search identified patients with histoplasmosis and sarcoidosis for whom the diagnosis was made by clinicopathologic correlation. Cases were reviewed for various cytologic parameters along with patient demographic, clinical, and laboratory data., Results: Fifty-eight cases of histoplasmosis and 44 cases of sarcoidosis were reviewed. Thirty-seven of 58 (64%) Histoplasma cases exhibited abundant, bland necrosis, and 76% of cases contained <2 angular and ragged granulomas per slide. Yeasts were identified in 36 of 37 (97%) specimens with necrosis and in 44 of 58 (76%) cases overall. These cases had an acute (14%) and/or chronic (67%) inflammatory component and uncommonly had a giant cell infiltrate (12%). Sarcoid granulomas were round with crisp, sharp borders: 80% of these granulomas contained >3 granulomas per slide, and 32% contained >10 granulomas per slide. All sarcoid granulomas had a chronic inflammatory background without acute inflammatory cells, and 50% contained giant cell infiltrates., Conclusions: Differentiation between histoplasmosis and sarcoidosis is possible in the majority of cases. Histoplasmosis usually exhibits few angular, ragged granulomas (<2 granulomas per slide) in a background of bland necrosis. Yeasts are identified on special stains performed in aspirate smears. Sarcoidosis typically contains many more granulomas (often >10 per slide) than histoplasmosis and has a rounded morphology with crisp and sharp borders. Typically, there is no necrosis or acute inflammation, and giant cell infiltrates are frequent., (© 2015 American Cancer Society.)

Introduction: Sarcoidosis and sarcoid reactions have been previously reported in association with cancer. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a minimally invasive test for investigating mediastinal lymph nodes, Patients and Methods: We conducted a retrospective review of 54 patients undergoing EUS-FNA in a cancer institute for suspected metastatic mediastinal lymph nodes showed by CT-imaging or positron emission tomography (PET). Patients with non-caseating granuloma identified by EUS-FNA were included, Results: EUS-FNA identified non-caseating granuloma in seven out of the 54 included patients. Most of them had positive PET. One patient had a prior history of sarcoidosis before the diagnosis of cancer. Another patient developed micrometastasis associated with sarcoid-like reaction. There was no adverse outcome associated with the EUS-FNA procedure, Conclusions: Sarcoidosis must be included in the differential diagnosis of patients with a history of malignancy who develop mediastinal lymphadenopathy. EUS-FNA is a safe and minimally invasive test to obtain tissue diagnosis., (Copyright © 2013 Société nationale française de médecine interne (SNFMI). Published by Elsevier SAS. All rights reserved.)

Background: : Bilateral hilar and/or mediastinal lymphadenopathy (BHL±ML) is an important radiographic finding. Since it was examined 38 years ago by Winterbauer and colleagues, better diagnostic techniques have been developed. The purpose of this study was to reexamine the diagnosis of BHL±ML by Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA)., Methods: : We carried out a retrospective analysis of data from 78 consecutive patients with BHL±ML who underwent EBUS-TBNA. Patient's characteristics including age, sex, symptoms, radiographic abnormalities, lymph node size, procedural complications, and the final pathologic diagnosis were recorded., Results: : There were 8 diagnostic categories. Sarcoidosis was the most common diagnosis (73%), followed by lymphoma (10%), and reactive lymphadenopathy (10%). Nonlymphoma malignancy was found in 1 case. Seventy-three percent of the patients with sarcoidosis had stage 1 and 27% had stage 2 disease. The diagnosis was made by EBUS-TBNA in 92.3% of the cases. The diagnostic accuracy for EBUS-TBNA was 95% for stage 1 and 93% for stage 2. Fifty one percent of the patients were asymptomatic. Fifty seven percent of sarcoidosis and 36% of the nonsarcoidosis patients were asymptomatic. There were no significant complications from EBUS-TBNA., Conclusions: : EBUS-TBNA is a safe and minimally invasive procedure with a high diagnostic yield for BHL±ML. Sarcoidosis is still the most common diagnosis but the incidence seems to have decreased over the years. The increase in nonsarcoidosis patients and the evidence that lymphoma does occur in some asymptomatic patients suggests that biopsy confirmation with EBUS-TBNA is warranted.

Approximately 90% of patients with sarcoidosis have thoracic involvement, of the lungs or mediastinum or both, isolated in half of all cases and associated with one or several extrathoracic sites in the other half. Diagnosis is based on a compatible clinical and radiologic history, the demonstration of noncaseous granulomas, and the ruling out of other causes of granulomatosis. Histologic proof is not necessary in cases of Löfgren syndrome, or when documentation shows a sequence of progression from stage I to stage II, or when the radiography shows the typical latent stage I picture. The radiographic stage has major prognostic value. Pulmonary fibrosis is the principal cause of morbidity and mortality in patients with sarcoidosis, especially when pulmonary hypertension is also present. Approximately half of all patients recover spontaneously in less than 2 years, while the other half require a systemic treatment. The official indications for treatment are: symptomatic stage II-III disease with functional respiratory or progressive involvement, stage IV with signs of persistent activity, granulomatous bronchial involvement with obstructive ventilatory disorders or endobronchial stenosis and extrinsic bronchial compression by adenopathies. Systemic corticosteroid therapy remains the reference treatment for thoracic involvement in sarcoidosis., (Copyright 2009 Elsevier Masson SAS. All rights reserved.)

Aim: To evaluate the prevalence of sarcoid-like reaction to malignancy detected using integrated 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography and computed tomography (PET/CT) in patients undergoing staging or restaging of solid-organ malignancy., Materials and Methods: A systematic search was performed using the institutional radiology information system of 2048 consecutive PET/CT examinations performed in cancer patients at a tertiary-referral centre. Cases that were considered suspicious for sarcoid-like reaction were identified from the initial radiological report and were retrospectively reviewed by three experienced PET/CT reporters., Results: Sarcoid-like reaction was initially suspected in 23 of the 2048 (1.1%) FDG PET/CT examinations, with the diagnosis confirmed histologically or by clinico-radiological follow-up in 13 of the 23 cases (57%). Sarcoid-like reaction was more commonly seen in patients undergoing FDG PET/CT for restaging of suspected recurrence rather than for primary tumour staging (77% versus 23%; p=0.05). The mean maximum standardized uptake value (SUV(max)) of confirmed hilar and mediastinal sarcoid-like reaction was 7.3 (range 3.1-13.6). Symmetric hilar uptake was demonstrated in 11 of the 13 (85%) and all 13 had additional mediastinal nodal uptake. Pulmonary uptake was seen in seven of the 13 cases (54%). Extra-thoracic involvement was present in eight of the 13 (61.5%), including nodal, splenic, and hepatic lesions., Conclusion: Sarcoid-like reaction was suspected in 1.1% of cancer patients at FDG PET/CT examination, with confirmation of the diagnosis in 0.6%. With the increasing use of FDG PET/CT in cancer patients, it is important to be aware of the prevalence of this uncommon, but important, disease entity and to consider this diagnosis in appropriate cases in order to avoid a false-positive interpretation of metastatic disease.

Relapse following adjuvant paraaortic radiation therapy in patients with Stage I seminoma is rare, occurring in approximately 4% of men. The majority of relapses are sited in the pelvis but relapse in the mediastinum is also recognised. As such, radiological imaging using chest radiographs remains commonplace in follow-up. However, there are reports of the association of testicular cancers with sarcoidosis and sarcoid-like processes in the mediastinum, emphasising the importance of making histological diagnosis prior to commencement of any treatment. We report on two men treated for testicular seminoma who on follow-up developed mediastinal lymphadenopathy, which was initially assumed to be metastatic seminoma. Both patients underwent mediastinascopy and biopsy prior to commencement of anti-cancer therapy. In both cases, the biopsies showed sarcoidosis, and unnecessary anti-cancer treatment was avoided.

Background: In the presence of a compatible clinical picture, the diagnosis of sarcoidosis requires pathologic confirmation of noncaseating epithelioid granuloma in affected tissues. The standard procedure of choice for most patients is a bronchoscopy with transbronchial biopsy (TBB), which has a diagnostic yield of 40% to 90%. The lowest yield with TBB is in cases that present with predominant mediastinal or intra-abdominal lymphadenopathy (LN) and minimal parenchymal lung involvement., Objective: To study the diagnostic yield of EUS-guided FNA in diagnosing sarcoidosis with predominant LN or masses., Design: Retrospective chart review., Setting: Teaching university hospital., Patients: Analysis of 21 consecutive patients with sarcoidosis and predominant mediastinal and/or intra-abdominal LN or masses who underwent EUS-guided FNA., Results: EUS-guided FNA diagnosed sarcoidosis in 18 of 21 patients (86%). In 3 patients, EUS-guided FNA was either not diagnostic or inconclusive, and patients underwent mediastinoscopy with lymphadenectomy, which established the diagnosis of sarcoidosis. Seven of the 21 patients (33%) had intra-abdominal LN and/or masses, and EUS-guided FNA of the intra-abdominal pathology was diagnostic of sarcoidosis in 4 of the 7 patients (57%). Four of the 21 patients (19%) had a history of malignancy, and use of EUS-guided FNA helped in ruling out the recurrence of malignancy in 3 of the 4 patients (75%)., Limitations: Mycobacterial and fungal culture was not obtained in all patients., Conclusions: EUS-guided FNA offers a practical, minimally invasive technique for the diagnosis of sarcoidosis in patients who present with predominant mediastinal and/or intra-abdominal LN or masses.

Introduction: The spinal localization is rare for neurosarcoidosis (0.43 percent of cases) but can be the inaugural manifestation of the disease. We report two cases of spinal neurosarcoidosis in a 57-year-old man and a 43-year*old woman with uneventful past medical histories. Both presented progressive myelopathic features., Methods: Magnetic resonance imaging (MRI) of the spine demonstrated intramedullary lesions, dorsal in the first case, and cervical in the second case. Serum angiotensin converting enzyme was elevated. Radiographs of the chest revealed bilateral symmetric hilar mediastinal lymphadenopathy in the first patient, and bronchial biopsy demonstrated non caseating granulomas. In the second patient the diagnosis was made on pathological examination of a minor salivary gland biopsy., Results: The patients received corticosteroid therapy with good response in the second patient., Conclusion: The diagnosis of intramedullary sarcoidosis is difficult without a previous diagnosis of systemic sarcoidosis or other apparent symptom(s). Extraneurologic biopsies may be suggestive. We reviewed the literature on the diagnosis and treatment of intramedullary sarcoidosis.

Objective: The diagnostic value of transbronchial/transtracheal fine needle aspiration (TBFNA) cytology in the patients with mediastinal and/or hilar lymphadenopathy has been investigated., Method: Out of 116 patients with mediastinal/hilar lymphadenopathy, the diagnosis of sarcoidosis was established in 88 (75.9%). One hundred and seventy-one TBFNAs from different lymph node stations were performed using a cytological 26-gauge needle. Adequate lymph node samples were obtained in 157 of 171 (91.8%) TBFNA and 14 of 171 (8.2%) TBFNA samples were inadequate., Results: Cytological findings consistent with sarcoidosis were found in 79 of 88 (89.77%) patients and 133 of 157 (84.71%) samples. The sensitivity of TBFNA cytology in sarcoidosis presenting as mediastinal/hilar lymphadenopathy was 78.7%, specificity 92.3%., Conclusions: Overall diagnostic accuracy of TBFNA cytology in the diagnosis of sarcoidosis was 86.2%, and cytological findings consistent with sarcoidosis were the only morphological diagnosis of sarcoidosis in 63.6% of patients.

Several case reports and small case series have described a total of 66 patients with sarcoidosis and testicular cancer so far. This report describes three additional cases. We highlight the association of sarcoidosis and testicular cancer and comment on the potential impact of this connection on the interpretation of the radiological and pathological findings in suspected cancer relapse. Sarcoidosis, a condition that can be combined with testicular cancer, should always be considered in the differential diagnosis.

Mediastinal sarcoidal reaction in follow up for seminoma. Testicular germ cell tumors constitute a model for curable neoplasia. Long-term complications are well-known and follow-up includes not only awareness of relapse, but also of the development of secondary tumors and treatment sequelae. In the last two decades, an increase in sarcoidosis incidence has been described in cured patients, who at follow-up present lung nodules or mediastinal lymph nodes. A 28 year-old patient who, on clinical follow up of a semi-nomatous tumor, presented mediastinal lymph nodes on CT scan and chest x-ray, without evidence of disease in pelvis or abdomen is presented. His other testicle was normal and he had negative tumor markers. Because of this rare presentation, a mediastinoscopy was performed and sarcoidosis like reaction was diagnosed. During follow-up of patients with testicular germ cell tumors, the presence of mediastinal lymph nodes requires a histological diagnosis and sarcoidosis should be considered as differential diagnosis.

Background: Preliminary data show that endosonography guided fine needle aspiration (EUS-FNA) may be an accurate method for diagnosing sarcoidosis. However, these data were obtained in a small selected group of patients with a very high pretest probability of sarcoidosis. This retrospective study reports on the use of EUS-FNA in an unselected group of patients with mediastinal lymphadenopathy of unknown origin., Methods: The EUS database of a single tertiary referral centre was reviewed for patients who underwent EUS-FNA for mediastinal lymphadenopathy of unknown origin. Clinical presentation and imaging studies of each case were carefully reviewed and the diagnosis "sarcoidosis" or "no sarcoidosis" attributed if possible. The diagnoses were compared with the result of EUS-FNA., Results: One hundred and twenty four patients were investigated. In 35 cases EUS-FNA identified granulomas (group 1); in the other 89 cases (group 2) no granulomas were detected. The definite diagnoses in group 1 were sarcoidosis (n = 25), indefinite (n = 7), no sarcoidosis (n = 3). The definite diagnoses in group 2 were sarcoidosis (n = 3), indefinite (n = 9), no sarcoidosis (n = 77). Of the 77 cases with no sarcoidosis, 44 were diagnosed with other diseases. The other 33 showed non-specific changes in the FNA and sarcoidosis was excluded by negative non-EUS pathology (n = 17) and clinical presentation. The sensitivity and specificity for EUS-FNA were 89% (95% CI 82 to 94) and 96% (95% CI 91 to 98), respectively, after exclusion of the indefinite cases in both groups., Conclusions: EUS-FNA is an accurate method for diagnosing sarcoidosis in an unselected group of patients with mediastinal lymphadenopathy. The reported sensitivity and specificity must be appreciated in the context of the difficult and often incomplete clinical diagnosis of sarcoidosis.

A 43-year-old woman presented with a recent history of intermittent dyspnea with wheezing. The chest x-ray evidenced mediastinal nodes. A CT scan showed vascular embolism. Mediastinoscopy was performed and pathology examination of the node confirmed the diagnosis of sarcoidosis. The patient responded to corticosteroid and anticoagulation therapy. Is this a fortuitous association? A vascular localization of sarcoidosis? Thrombosis by compression?

Traction diverticula of the midesophagus result from granulomatous inflammation of mediastinal lymph nodes. Tuberculosis and histoplasmosis are known etiologies of this condition. To the best of our knowledge, this is the first report of a traction diverticulum caused by sarcoidosis.

Sarcoidosis is a systemic disease with many localizations. Thyroid involvement has been often described but rarely confirmed histologically. A common immune mechanism appears to be the cause. Thyroid sarcoidosis should be envisaged in patients with a thyroid nodule and mediastino-pulmonary involvement. We report the case of a 63-year-old woman with no past history who was hospitalized for dyspnea. Explorations evidenced a cold thyroid nodule associated with diffuse interstitial lung disease and mediastinal node enlargement. Pathology examination disclosed the sarcoid nature of the thyroid nodule and the lung lesions.

Background and Study Aims: Sarcoidosis is a chronic multisystem granulomatous disease that is often diagnosed after a finding of hilar and mediastinal lymphadenopathy on a chest radiograph. This often requires further evaluation by transbronchial biopsy or other clinical parameters. The present study is a descriptive, retrospective one using endoscopic ultrasound with fine-needle aspiration (EUS-FNA) of mediastinal lymph nodes in seven patients with sarcoidosis., Patients and Methods: Among 108 consecutive patients who underwent EUS-FNA of mediastinal lymph nodes for various clinical indications between July 1994 and October 1997, seven patients were found to have sarcoidosis on EUS-FNA, and the EUS morphology was studied in these patients., Results: Sarcoidosis was diagnosed in seven patients using endosonographic characteristics and clinical follow-up. EUS with FNA showed cytological evidence of sarcoidosis in six patients. Seven patients were found to have subcarinal lymph nodes, and six patients had abnormally enlarged aortopulmonary (AP) window lymph nodes. The nodes in all patients had three endosonographic criteria for malignancy. The long axis of the largest mediastinal lymph nodes measured 3.44+/-1.42 cm (range 1.8-6.0 cm). The short axis measured 2.50+/-0.69 (range 1.0-4.0 cm). The average number of nodes seen in each patient was 2.80+/-0.75 (range 2-4). The nodes in all seven patients were discrete and well demarcated. A central hyperechoic strand was evident in these nodes in four patients (57%). There were no complications., Conclusions: Mediastinal lymph nodes in patients with sarcoidosis appear to have specific echo characteristics, and EUS-FNA can be used for confirmatory tissue diagnosis.

Objective: To find a effective method for diagnosing tuberculous lymphadenopathy and sarcoidosis of mediastinum., Methods: Mediastinoscopy was conducted in patients who had enlarged mediastinal lymph nodes on chest CT or MRI and were clinically suspected of either tuberculosis or sarcoidosis. Biopsy was done to obtain pathological diagnosis, and make therapeutic program., Results: Of this series of 25 patients, 16 cases were pathologically diagnosed as tuberculous lymphadenopathy, representing 64% (hyperplastic tuberculosis 14 cases; caseous tuberculosis 2 cases); 8 cases were sarcoidosis, representing 32%; one case was difficult to tell tuberculosis from sarcoidosis microscopically, representing 4%. Tuberculosis and sarcoidosis were causes of benign enlargement of mediastinal lymph nodes. They were hard to be differentiated from roentgnologically, sometimes even microscopically; and they might be confused with other malignant diseases, which can also cause the enlargement of mediastinal lymph nodes, such as lymphoma, metastatic malignancies, etc. Thus they were easily resulted in misdiagnosis. Of this series, the initial diagnosis of 21 cases were malignancies, representing 84%, two cases has even undergone chemotherapy at local hospitals., Conclusions: For patients with enlargement of mediastinal lymph nodes, mediastinoscopy is of great value. It was emphasized to make every effort to obtain definite pathological diagnosis before standard treatment.

A patient with a stage II seminoma of the testis was treated with a routine orchidectomy and irradiation. One and a half years later enlarged mediastinal lymph nodes were noted. Additional staging showed no other abnormalities and a mediastinoscopy was performed. The initial histologic examination confirmed the clinically suspected diagnosis of sarcoidosis. However, additional immunohistochemical analysis unexpectedly demonstrated that there was also a microscopic relapse of the testis tumor. The literature concerning the co-incidence of non-caseating granulomas and testis tumors is reviewed. It is not clear, whether the granulomas indicate the presence of genuine idiopathic sarcoidosis or whether they reflect a sarcoid-like reaction against tumor antigens. The immunopathogenesis of sarcoid formation and its possible biologic significance in obtaining a spontaneous tumor remission is discussed.

Sarcoidosis is a systemic disease of unknown etiology with variable presentation, prognosis, and progression. At diagnosis, about 50% of patients are asymptomatic, 25% complain of cough or dyspnea, and 25% have skin lesions (erythema nodosum, lupus pernio, or plaques or scars) or eye symptoms (or develop them during the course of the disease). Bilateral hilar adenopathy is the most common radiographic finding. Other characteristic findings include interstitial lung disease, occasional calcification of affected lymph nodes, and pleural effusions and thickening. Computed tomography is more sensitive than radiography in the detection of adenopathy and subtle parenchymal disease; gallium-67 scintigraphy is useful in identifying extrathoracic sites of involvement, detecting active disease, and assessing response to treatment. The diagnosis is established most securely when clinicoradiologic findings are supported by histologic evidence of widespread noncaseating granulomas. The disease ranges from a self-limited subclinical process to chronic debilitation and death, with the major complications being fibrosis, mycetoma formation, and cor pulmonale. Because the disease so often involves thoracic structures, chest radiography plays a crucial role in the diagnosis, staging, and follow-up of sarcoidosis.

A case report describing persistent paratracheal lymphadenopathy after doxorubicin, bleomycin, vinblastin, and dacarbazine (ABVD) chemotherapy for a patient with Hodgkin's disease (HD) is presented. Mediastinoscopy and biopsy of the paratracheal lymph nodes showed non-caseating granulomas characteristic of sarcoidosis. The authors discuss the relationship between sarcoidosis and HD and hypothesize that the development or progression of sarcoidosis in a patient with HD is a potential consequence of chemotherapy. Two possible mechanisms are proposed. The first includes the immunosuppressive effect of chemotherapy and the second implicates the influence of a specific chemotherapy agent, bleomycin, which is known to have relatively higher lymph node, skin and lung tissue concentrations than other agents included in the ABVD regimen, and a predilection for those tissues that are prone for the development of sarcoidosis. With the incidence of sarcoidosis exceeding that of HD for the general population, the authors emphasize the importance of considering the presence of sarcoidosis in the differential diagnosis of patients who do not respond radiographically to HD chemotherapy.

Five cases of recurrent thoracic sarcoidosis which happened 5.5 years on the average after spontaneous resolution of the disease are reported. Initially, these patients were characterized by the frequency of the presence of a Löfgren's syndrome and the absence of extrathoracic sarcoid localizations. Recurrence of sarcoidosis was potentially severe essentially because of extrathoracic localization which needed oral corticosteroid treatment in 2 patients. Because recurrence of sarcoidosis is rarely observed, the diagnosis should be, in the absence of erythema nodosum, confirmed histologically in order to exclude a lymphoma or one of the various etiologies of diffuse interstitial lung disease. A sustained and regular surveillance of sarcoid patients after spontaneous resolution, particularly those with a Löfgren's syndrome, is suggested.

Authors' clinical observations confirm the opinion of many physicians that nodular erythema is a rather frequent manifestation of pulmonary mediastinal sarcoidosis. They also come to a conclusion that the prediction is favorable for the patients in whom the disease onset was acute. Löfgren's syndrome was effectively treated with steroid hormones.

The authors, following prolonged observation for from one to ten years, on average 5 years, of 60 cases of thoracic sarcoidosis, of lymph node or miliary type, propose a therapeutic attitude which, although not new, is frankly oriented towards therapeutic abstinence in the lymph node forms, and very restricted indications for hormone therapy in the miliary forms. In this respect, they agree with many authors, in particular English language authors, who consider that corticosteroid therapy is only justified in the acute forms, with a disturbance of general health and characteristic functional involvement. Such an attitude may appear shocking to those who tend to prescribe corticosteroids for their immediate efficacy, but in the long-term, it appears justified.

We scrutinized the secondary lysosomal vesicle of the epitheloid cell from 9 patients whose biopsy specimens show multiple non-necrotizing granulomas by light microscopy (LM). In 4 of the 9 patients, we found tadpole-shaped structures (TSS) approximately tenfold larger than the size of the mycobacteriophage by transmission electron microscopy (TEM). In addition, we used a plasma etching method on epon-embedded tissue and successfully demonstrated the stereoscopic appearance of the TSS by scanning electron microscopy (SEM). The identified TSS were further analyzed with an X-ray energy dispersive spectrometer for their microchemistry. The TSS appeared to be integral structures by TEM and SEM and did not contain any nonbiologic elements when analyzed with the X-ray energy dispersive spectrometer. Their location as well as their morphologic features and microchemistry suggested that the TSS are a microorganism and related to the formation of the granulomas in our 4 patients.

Sarcoidosis is a disease defined by two criteria: one quantitative involvement if several organs or tissues showing its systemic character) the other qualitative (presence in all affected organs of giant cell and epitheloid cell granulomas without caseation). The first seems to counter balance the absence of specificity of the second. Unfortunately, the quantitative factor may be lacking in the mediastino-pulmonary forms owing to their apparently localised character. The diagnosis is thus based on a critical study of the clinical context (age, general health radiological appearances) and indirect signs of diffusion (biopsies, immune reactions, Kweim test). The therapeutic indications should take into consideration the tendancy to spontaneous recovery which occurs in 98% of cases. Prolonged corticosteroid therapy may be difficult to stop. No treatment should therefore be given unless there are complications or associated lesions exposing the patient to the risk of severe and permanent sequelae.

The clinical course of (pulmonary) sarcoidosis is difficultly foreseeable with regard to the fate of a given patient. There are some clinical features to get a probably good or probably poor prognosis, but there are only a few presumptions about the correlation between the histologic patterns with the clinical course. Lymph nodes were removed by mediastinoscopy. The authors have the intention with the aid of the histologic picture in these lymph nodes to examine, if 1. micro-cellular reactions and pure epithelioid-cell granulomas may have a better prognosis than 2. central necrosis, hyalinization, and fibrosis, whereas 3. the number of giant cells seems to be without prognostic significance.

The cell population of the liquid of broncho-alveolar lavage of 44 cases of mediastino-pulmonary sarcoidosis was compared to that of 12 normal controls, of 14 controls with a localized pulmonary affection, who underwent lavage in healthy contro-lateral segment, and of 33 patients with various diffuse interstitial pneumopathies, except hypersensitivity ones. In sarcoidosis, the total number of cells is significantly higher than in controls; such is the case for neutrophils. It is also higher for lymphocytes in sarcoidosis: 21.8, than in controls: 7.8, or in patients with other diffuse interstitial pneumopathies: 10.3. It is independent of the disease radiological stage, but closely related to its degree of activity; it showed important variations, going from 3 to 50%. The observation of a normal level of lymphocytes is not enough to exclude the diagnosis of sarcoidosis.

A series of 78 patients, mainly young males, with intrathoracic manifestations of sarcoidosis, found on routine chest X-ray, were examined according to a prescheduled program including different biopsy procedures. In 76% the intrathoracic changes were isolated hilar adenopathy, in 9% isolated pulmonary lesions and in 15% hilar adenopathy plus pulmonary lesions. Lymph nodes containing granulomas were found by mediastinoscopy in 41 of 44 patients and by scalene fat pad biopsy in 20 of 34 patients. In 27 of 76 patients granulomas were found by liver biopsy. Complications to the biopsies were more frequent with mediastinoscopy than with the other two biopsy procedures, but no serious complications occurred. Biopsy through mediastinoscopy is thus preferable in patients of this kind. The necessity of doing biopsies to support the diagnosis of sarcoidosis is discussed on the basis of the literature and our own studies. In younger patients with asymptomatic, bilateral hilar adenopathy without pulmonary lesions it seems justifiable to omit biopsy, whereas biopsy is mandatory in patients with unilateral hilar lymph adenopathy and patients with pulmonary lesions. In all cases the course of the disease should be followed for a rather long period.

A middle-aged man with only slight symptoms of disease of short duration died suddenly. On autopsy he was found to have not only disseminated visceral giant cell vasculitis with involvement of large and medium-sized arteries and veins, but also sarcoid granulomas in many organs, especially in enlarged mediastinal lymph nodes as well as in several vessel walls. Death was caused by myocardial infarction due to granulomatous vasculitis. This combination of diseases has not previously been described, and the question is whether it represents giant cell arteritis and sarcoidosis, separately, or whether it is a manifestation of a broad spectrum of the same disease.