View Abstract

A6500 - Recurrent Metastatic Disease, or Something More Sarcoid?
Author Block: C. V. Edelson1, J. Woods2, J. C. Edelson1, A. Brown3, M. J. Morris4; 1Internal Medicine, San Antonio Military Medical Center, San Antonio, TX, United States, 2Pulmonary and Critical Care Medicine, SAMMC, Fort Sam Houston, TX, United States, 3Hematology Oncology, Sacred Heart Medical Oncology group, Pensicola, FL, United States, 4Brooke Army Medical Ctr, San Antonio, TX, United States.
Introduction
Recurrent metastatic disease is a significant concern in the evaluation of patients with a history of malignancy and new symptoms compatible with recurrence. When the patient has a history of multiple primary malignancies and allogeneic bone marrow transplant, the differential diagnosis expands significantly to include not only recurrent metastatic disease but the myriad complications of allogeneic bone marrow transplant. We report the first reported case of a patient with a history of two primary malignancies and allogeneic bone marrow transplant who initially presented with profound dyspnea on exertion associated with significant functional and radiographic abnormalities initially concerning for recurrence and found to have a multisystem sarcoid reaction attributed to bone marrow transplant.
Case Report
A 54 year old Caucasian female presented with progressive dyspnea on exertion over several weeks associated with bony discomfort in the right hip and low back. Her pulmonary function demonstrated a moderately reduced DLCO. CT chest demonstrated multifocal bilateral diffuse nodules and increased prominence of right axillary lymph nodes. Six years prior to this episode she was diagnosed with left sided breast cancer treated with bilateral mastectomy with adjuvant radiation therapy and tamoxifen. Four years prior to the current episode, while on tamoxifen, the patient was diagnosed with acute myelogenous leukemia which ultimately required multiple courses of chemotherapy, matched unrelated donor allogeneic bone marrow transplant, and donor lymphocyte infusion for multiple relapse episodes. Initial bronchoscopy with bronchoalveolar lavage and transbronchial biopsy demonstrated numerous small non-necrotizing granulomas without evidence of infection or malignancy. Unsure of the significance of this result, CT PET was ordered which demonstrated FDG-avid pulmonary nodules, mediastinal lymphadenopathy, and multiple bony lesions raising significant concern for metastatic disease. EBUS-guided biopsy of mediastinal lymph nodes demonstrated granuloma formation without evidence of infection or malignancy, and bone marrow biopsy demonstrated similar findings. A diagnosis of sarcoid reaction in the setting of bone marrow transplant was made. The patient had complete clinical, functional, and radiographic resolution after initiation of corticosteroid therapy.
Discussion
We report the first reported case of sarcoidosis arising in a patient with history of two primary malignancies and bone marrow transplant. Sarcoidosis is a rare non-infectious pulmonary complication of bone marrow transplant seen in both autologous and allogeneic transplants and attributed to multiple mechanisms. It is essential to obtain biopsy and aggressively rule out recurrent malignancy in this patient population. Corticosteroid treatment is generally effective.