Endobronchial ultrasound-guided transbronchial needle aspiration facilitating diagnosis of sarcoidosis in a breast cancer patient with multiple lymphadenopathy: a case report

Abstract

Background: Sarcoidosis is a benign systemic granulomatous disorder of unknown etiology. Cell-mediated immunity disorder is often found in sarcoidosis patients, and an association between malignant tumors and sarcoidosis has been suggested. Sarcoidosis and malignant disease can occur simultaneously or sequentially, leading to misdiagnosis and mistreatment. Sarcoidosis is diagnosed clinically, radiologically, and histologically. We report herein a case of sarcoidosis diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration from the mediastinal lymph nodes of a breast cancer patient.

Case presentation: The patient was a 70-year-old Asian woman who presented with right breast tumor. A 20-mm movable mass was identified in the inferolateral quadrant of the right breast, and mammography revealed a spiculated mass with calcification. Ultrasonography revealed a mass with internal hypoechogenicity, and biopsy revealed estrogen receptor-positive, human epidermal growth factor receptor 2-positive invasive ductal carcinoma. Positron emission tomography/computed tomography showed multiple lymphadenopathy including mediastinal lymph nodes, with fluorodeoxyglucose accumulation in those nodes suggesting breast cancer metastases. Endobronchial ultrasound-guided transbronchial needle aspiration of a mediastinal lymph node revealed noncaseous epithelioid granuloma. Due to a history of uveitis and elevated soluble interleukin 2 receptor, lymphadenopathy due to sarcoidosis and stage IIA breast cancer were diagnosed. Right partial mastectomy and axillary lymph node dissection were performed after preoperative chemotherapy. No exacerbation of sarcoidosis symptoms has been observed during treatment.

Conclusion: We report a case of breast cancer in which sarcoidosis could be diagnosed based on endobronchial ultrasound-guided transbronchial needle aspiration, a history of uveitis, and elevated soluble interleukin 2 receptor despite fluorodeoxyglucose positron emission tomography/computed tomography suggesting multiple lymph node metastases. This report emphasizes the importance of differential diagnosis of lymph node involvements in cancer patients.

Keywords: Breast cancer; Endobronchial ultrasound-guided transbronchial needle aspiration; Sarcoidosis.

Fig. 1

Preoperative imaging findings. a Mediolateral oblique-view mammogram. b Craniocaudal-view mammogram. A spiculated mass (A) with segmental and linear calcification is recognized in the right breast. c Ultrasonogram. A rough-bordered mass with internal hypoechogenicity is apparent in the inferolateral quadrant of the right breast. d MRI with early gadolinium enhancement. A smooth, round mass with rim enhancement is recognized in the inferolateral quadrant of the right breast. e Positron emission tomography. Accumulation of FDG is evident in the primary mass in the right breast, a right axillary lymph node, and multiple lymph nodes in the right supraclavicular fossa, mediastinum, bilateral hilar, dorsal pancreatic head, abdominal aorta, right common iliac region, and bilateral external iliac regions. f Positron emission tomography/computed tomography. Intense FDG uptake is shown in enlarged paratracheal lymph nodes

Fig. 2

Preoperative histopathological findings. Histopathological findings of the right breast from core needle biopsy [a hematoxylin and eosin (HE) ×200]. Immunohistochemistry study for ER and HER2 (b ER ×200 and ×400, c: HER2 ×200). The cytology of the right axillary lymph node from fine needle aspiration cytology (d Papanicolaou ×400). Atypical ductal cells, ER-weakly positive (1–5%) and HER2-positive, formed solid nest with sheet-like growth. Atypical epithelial clusters with hyperchromatic nuclei were seen in red blood cells and lymphocytes

Fig. 3

EBUS-TBNA findings. a Endoscopic view of the tracheal bifurcation. b EBUS ultrasound image of the lesion at the tracheal bifurcation. c, d Histopathological findings of biopsy samples directly obtained by EBUS-TBNA (HE ×400). A swollen lymph node is recognized at the extratracheal region on ultrasound images despite a normal appearance from the trachea. Lymph nodes have been replaced by noncaseous epithelioid granulomas and multinucleated giant cells